This month, we feature a four-part series on cholesterol to commemorate National Cholesterol Education Month. This third article focuses on the nutritional supplements that promote healthy cholesterol levels.
The amount of evidence supporting cholesterol-lowering supplements is varied but the best evidence is for phytosterols, soy protein and niacin (which at high levels is available as a prescription). Below provides more information on these and other lipid altering supplements.
Inconsistent studies have shown that garlic may provide small reductions in total cholesterol, LDL and triglycerides. Garlic is often formulated in heart health supplements because it aids in maintaining arterial elasticity by stimulating the body’s production of nitric oxide, a natural muscle relaxant.
A number of companies offer garlic supplements; however, Kyolic offers the broadest range of products using aged garlic extract.
Garlic containing supplements promote thinning of the blood and should be used with caution when taking medications with the same action (e.g., Coumadin) and discontinued prior to surgery.
This compound which comes from the resin of the guggul plant (Commiphora mukul), claims to reduce LDL and triglyceride levels but the evidence is weak. Some labels list the active ingredient as guggulipid and others as guggulsterone. Recommended dosing is 75 to 100 mg per day of the E znd Z forms of guggulsterone (divided into three doses daily).
A number of companies offer guggul containing supplements, ranging in price from $10.00 – $23.00, but based on the scant evidence; it may not be worth purchasing them.
Guggulsterone containing supplements may cause skin rash and other mild side-effects.
The evidence is very strong that this B-vitamin, when taken in high doses, can elevate HDL levels. Niacin can also decrease LDL and triglyceride levels but to a lesser extent.
Niacin containing supplements are available either as niacin (nicotinic acid or nicotinate) or niacinamide (nicotinamide). It is the nicotinic acid form that is effective as a reducer of blood cholesterol levels.
A common side-effect of niacin is a temporary flushing of the skin. However, this effect is minimized at lower doses and if taken with food. If the dosing is pushed beyond 500 mg a day, then cholesterol levels and liver function should be checked periodically.
The Omega-3 polyunsaturated fats docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) are found in certain types of fish and their oil. Solid evidence exists for the benefits of taking these Omega-3s for heart health. Their primary benefit is in lowering triglycerides but they also may increase HDL or “good” cholesterol levels.
In the U.S., there is no official recommended daily intake for EPA and DHA in healthy people. However, the American Heart Association (AHA) recommends that healthy individuals consume 500 mg daily of EPA/DHA. For patients with documented cardiovascular disease, the AHA recommends about 1 gram daily of EPA/DHA. For patients trying to lower trigylceride levels, the AHA recommends 2 to 4 grams daily of EPA/DHA.
With increased ocean pollution, a concern with fish oil supplements is contamination. However, according to a recent Consumer Labs survey, most fish oil supplements are free of mercury, PCBs and other contaminants. Supplements like VitaMedica’s Super EPA/DHA Fish Oil which use only small, oily fish that are low in the food chain (e.g., anchovy and mackerel) and a molecular distillation process, further ensure that the fish oil is contaminant-free.
Although fish oil supplements are widely available, the amount of EPA and DHA per serving can vary by as much as ten fold. Better quality brands like VitaMedica, Barry Sears and Nordic Naturals concentrate their fish oil so that fewer capsules need to be taken.
Fish oil supplements promote thinning of the blood and should be used with caution when taking medications with the same action (e.g., Coumadin) and discontinued prior to surgery.
Although this compound can be extracted from a variety of sources, the best evidence for lowering cholesterol is policosanol from sugar cane. However, the supplement is not well-studied and the evidence is inconsistent. An independent study published in the Journal of the American Medical Association in 2006 did not find any benefit of policosanol, even at high doses, on cholesterol profile.
To be effective, a product should contain at least 60% octacosanol by weight. The typical recommended dose is 5 – 10 mg twice daily.
A number of companies offer policonsanol containing supplements, ranging in price from $10.00 – $23.00, but based on the scant evidence; it may not be worth purchasing them.
Red Yeast Rice
Red yeast rice is formed by fermenting the red yeast, Monascus purpureus, on rice. Red yeast rice has been used for centuries by the Chinese in cooking and making rice wine.
A decade ago, a supplement called Cholestin (Pharmanex) was marketed with red yeast rice. Red yeast rice contains monacolin K, a naturally occurring form of lovastatin – the same active ingredient used in the statin drug Mevacor. Not surprisingly, studies conducted at UCLA confirmed that a preparation of red yeast rice reduced total cholesterol, LDL cholesterol and trigylceride levels but had no effect on HDL levels.
The FDA – with the help of the pharmaceutical industry which had a vested interest in the outcome – determined that Cholestin had drug-like effects. As a result, in the U.S., the FDA ruled that it is illegal to sell red yeast rice supplements that contain more than trace amounts of cholesterol lowering substances. In addition, red yeast rice supplements can not be promoted for cholesterol lowering. A key concern by the FDA was that these supplements could exert the same side-effects associated with statin drugs including muscle pain and liver problems.
A number of red yeast rice supplements are available today, typically with 600 mg of red yeast rice per capsule. However, the supplement facts provide no indication as to how much lovastatin each product delivers. As Consumer Labs pointed out, a major concern is that lovastatin levels vary 100-fold among brands. For these reasons, it seems prudent to avoid red yeast rice supplements to improve cholesterol levels.
Soy protein is very low in fat and contains no cholesterol. As a plant based protein, soy contains phytochemicals – the key ones which include isoflavones, saponins and phytochemicals.
A meta-study conducted in 1995 and published in the New England Journal of Medicine, demonstrated that the consumption of soy protein rather than animal protein significantly decreased blood levels of total cholesterol, LDL cholesterol and triglycerides without significantly affecting HDL levels.
Based on this study, the FDA allowed a health claim on all soy protein foods. The claim applies to foods with intact soy protein and not to isoflavones extracts (e.g., isoflavones supplements). In order to qualify for the claim, the food must contain (per serving):
- 25 gram of soy protein
- Less than 3 grams of fat; with less than 1 gram of saturated fat
- Less than 20 mg of cholesterol
- Less than 480 mg of sodium
Soy protein is now available in many food products – it is added to soups, vegetarian foods and meat imitations to increase the protein content. Soy protein is also available in powder. Relative to whey protein, soy protein does not mix as well, and is higher in salt (average is about 300 mg per serving). The industry leader, Genisoy, offers soy based bars, shakes, powders and snacks; Jarrow’s Iso-Rich Soy is available in a powder.
Phytosterols, or plant sterols, is the umbrella term for both plant sterols and stanols. Sterols are naturally present in a variety of plants including fruits, vegetables, nuts, seeds, legumes, and vegetable oils. Stanols occur in many of these same plants but in much lower quantities.
The function of phytosterols in plants is similar to that of humans. Because they are similar to the chemical structure of cholesterol, phytosterols block the absorption of cholesterol in the gut by mimicking cholesterol. If enough plant sterols are consumed, less cholesterol is absorbed and returned to the liver which ultimately lowers cholesterol levels.
According to the National Cholesterol Education Program, “daily intakes of 2 to 3 grams per day of plant sterol/stanol esters will reduce LDL cholesterol by 6 to 15 percent”. Studies have also demonstrated that stanol/sterol esters do not affect HDL or “good” cholesterol levels.
A challenge with consuming sterols and stanols for cholesterol reduction is that they are poorly absorbed in the human intestinal tract. In addition, plant sources of stanols/sterols are low. Corn oil – the best source of naturally occurring stanols – provides just 0.13 grams per tablespoon.
Food scientists were able to solve this problem by developing new compounds called sterol and stanol esters. Initially, foods fortified with stanol/sterol esters were primarily found in spreads and salad dressings. But, advances in food technology allowed for a wider variety of foods to include these beneficial plant compounds including bread, cereal, low-fat milk, and fruit juice.
The FDA allows a health claim on plant sterol/stanol esters which is: “Diets lows in saturated fat and cholesterol that includes at least 1.3 grams of plant sterol esters or 3.4 grams of plant stanol esters, consumed in two meals with other foods, may reduce the risk of heart disease”.
In order to meet the health claim, the food must also be low in saturated fat (1 gram or less), low in cholesterol (20 mg or less per serving) and contain no more than 13 grams of total fat per serving.
The best place to find foods fortified with phytosterols is in your local grocery store. The margarine aisle includes well-known brands like Corowise, Benecol and Promise Activ. In the juice section, Minute Maid offers a Heart Wise product. In the snack aisle, Corazonas offers a complete snack line that is heart healthy.
In the supplement aisle, you might find a small selection of products that contain phytosterols. Given that at least 2 grams of phytosterols need to be consumed per day to obtain a cholesterol lowering effect, most supplements are not a good source. As an example, Bayer Heart Health Advantage – an aspirin free-product – is formulated with 400 mg of phytosterols per caplet. Five caplets per day are required to obtain just 2 grams of phytosterols.
In addition to diet and lifestyle, nutritional supplements can play a role in managing healthy cholesterol levels. However, if you’re already taking a drug to lower your cholesterol, you should speak with your doctor before taking a nutritional supplement.
David H. Rahm, M.D. is the founder and medical director of The Wellness Center, a medical clinic located in Long Beach, CA. Dr. Rahm is also president and medical director of VitaMedica. Dr. Rahm is one of a select group of conventional medical doctors who have education and expertise in functional medicine and nutritional science. Over the past 20 years, Dr. Rahm has published articles in the plastic surgery literature and educated physicians about the importance of good peri-operative nutrition.