This website uses cookies so that we can provide you with the best user experience possible. Cookie information is stored in your browser and performs functions such as recognizing you when you return to our website and helping our team to understand which sections of the website you find most interesting. We do not share any your subscription information with third parties. It is used solely to send you notifications about site content occasionally.

Typography
  • Smaller Small Medium Big Bigger
  • Default Helvetica Segoe Georgia Times

Heart and blood vessel (cardiovascular) disease is the number one killer of Americans, and study after study points to elevated cholesterol as a major contributor to the problem. Some authorities have indicated that for every one-percentage point that cholesterol levels are reduced, the risk for cardiovascular disease is reduced by two points. In addition, most people with diabetes have increased risk for heart disease and stroke, due in part to high cholesterol and triglyceride levels, which can result in death. In fact, more than 65 percent of people with diabetes die from heart disease or stroke. By managing diabetes, and blood lipids (cholesterol and triglycerides), however, diabetics can greatly reduce this risk.1

The current conventional medical treatment is cholesterol- lowering prescription drugs, along with low saturated fat diets. In addition, it makes sense to work with your doctor in trying one or more of the following relatively risk-free dietary supplement approaches as part of your total program for lowering cholesterol and reducing risk of cardiovascular disease.

Plant Sterols And Stanols
Plant sterols are natural substances found in small quantities in many fruits, vegetables, nuts, seeds, cereals, legumes, vegetable oils, and other plant sources. Research has demonstrated that taking plant sterols orally significantly reduces total and low-density lipoprotein (LDL) cholesterol levels, but has little or no effect on high-density lipoprotein (HDL) cholesterol levels. LDL is considered to be the “bad cholesterol,” while HDL is considered to be the “good cholesterol.” The way it works is that plant sterols block cholesterol absorption in the intestines, which in turn results in lowered LDL cholesterol in the bloodstream. Plant sterols has been reported to decrease LDL cholesterol levels nine to 20 percent, and usual doses have ranged between 800 mg to six grams per day and given before meals. Plant sterols are typically given in conjunction with a low-fat diet.2,3,4,5,6,7,8,9,10,11 Orally, plant sterols are usually well tolerated. Ezetimibe (Zetia), a medication used to lower cholesterol levels, inhibits intestinal absorption of plant sterols.

Similar to sterols, plant stanols are natural substances that occur in even smaller quantities in many of the same sources. Like sterols, stanols block the absorption of cholesterol in the intestines. Taking plant stanols orally is effective for reducing total and LDL- cholesterol in about 88 percent of adult patients when used alone or in combination with a low-fat diet or statin drug (drug that inhibits the production of cholesterol in the body).12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27 When used alone it can reduce total and LDL cholesterol levels by 10 to 15 percent. When added to statin drugs, sitostanol reduces total cholesterol and LDL cholesterol by an additional three to 11 percent and seven to 16 percent, respectively. Clinical studies have used from 800 mg to four grams per day.28 Orally, plant stanols seem to be very well tolerated. Plant stanols can reduce absorption and blood levels of beta-carotene, so it should be used at a different time if you are taking beta-carotene supplements.

Inositol Hexanicotinate High amounts (several grams per day) of niacin lower cholesterol; an effect recognized in the approval of niacin as a prescription medication for high cholesterol.29 At such intakes, however, acute symptoms (flushing, headache, stomachache) may be severe. In an attempt to avoid the side effects of niacin, alternative health practitioners increasingly use inositol hexanicotinate (aka, “no-flush niacin”), recommending 500 to 1,000 mg, taken three times per day, instead of niacin.30,31 This special form of niacin has been reported to lower serum cholesterol but so far has not been found to cause significant toxicity.32

Omega-3 Fatty Acids From Fish Oil Including fish as a regular part of the diet has been shown to increase HDL cholesterol33 and is linked to a reduced risk of heart disease in the majority of studies.34 One reason that it has this effect is its oils contain the omega-3 fatty acids (O3FA) which appear to protect against heart disease.35 When used supplementally, however, there is contradictory evidence about the effects of fish oil on blood fat levels. Some clinical research shows fish oil supplementation can decrease elevated triglyceride levels, and decrease LDL cholesterol and increase levels of HDL cholesterol.36,37,38 However, other clinical research did not show beneficial effects on cholesterol levels.39 Nevertheless, fish oil from supplements or from dietary sources has been shown to reduce triglyceride levels by 20 to 50 percent. This effect appears to be dose-dependent.40,41,42,43 Fish oil preparations providing 465 mg of eicosapentaenoic acid (EPA) and 375 mg of docosahexaenoic acid (DHA) is particularly effective in conjunction with dietary modifications.44

In addition, research suggests that fish oil supplementation may be superior to the cholesterol-reducing drug rosuvastatin (Crestor®) for patients with heart failure. In a study published in The Lancet,45 researchers gave 1,000 mg of omega-3 fatty acids from fish oil to about 3,500 patients with heart failure, while another 3,500 heart failure patients received a placebo. After four years researchers found that those taking the omega-3 fatty acids had a nine percent relative risk reduction of dying, and an eight percent relative risk reduction for being hospitalized. The researchers concluded their study demonstrated that long-term administration of 1,000 mg daily omega-3 fatty acids effectively reduced all-cause mortality and admissions to hospital for cardiovascular reasons.

The same researchers conducted a parallel study, giving rosuvastatin to 2,285 heart failure patients, and placebos to 2,289 heart failure patients. After four years researchers found little difference in heart failure rates between those given omega-3 fatty acids and those given rosuvastatin. In comparing the results, the researchers concluded that the omega-3 fatty acids were slightly more effective than rosuvastatin.46

Dietary Considerations
I would be remiss if I did not briefly recount the incredibly important role that diet plays in cardiovascular health. Specifically, the Mediterranean diet has extensive patient-oriented outcome data showing a significant risk reduction in mortality rates and in rates of fatal and nonfatal heart attack.47 Strong evidence support Mediterranean dietary patterns, including intake of vegetables and nuts, as protective against coronary heath disease.48


The Mediterranean Diet

The Mediterranean diet is based upon the diets of at least 16 countries that border the Mediterranean Sea. Although there are many differences in culture, ethnic background, religion, economy and agricultural production which result in variations in food intake among the population groups, there is still a common Mediterranean dietary pattern which includes:

  • High consumption of fruits, vegetables, bread and other cereals, potatoes, beans, nuts and seeds
  • Olive oil is an important monounsaturated fat source
  • Dairy products, fish and poultry are consumed in low to moderate amounts, and little red meat is eaten
  • Eggs are consumed zero to four times a week
  • Wine is consumed in low to moderate amounts

In addition, there is strong evidence for the protective effect of monounsaturated fatty acids and prudent dietary patterns.49 Research clearly demonstrates that the people at low risk for CVD eat lots of vegetables, fruits, beans, whole grains and fish: a prudent diet.

Those at high risk for CVD eat the typical Western pattern diet loaded with red meat, processed meat, refined grains, sweets and desserts, fried foods and high-fat dairy products.50,51 Furthermore, strong evidence has also shown a clear and harmful relationship between CVD and the intake of trans-fatty acids and foods with a high glycemic index or load.52

In 2006 the American Heart Association released guidelines that integrate recommendations from a variety of diets into a single plan. The emphasis should be on diets that are rich in fruits, vegetables, and healthful fatty acids and that limit saturated fat intake. A stepwise individualized approach may be a practical way to help reduce your cardiovascular disease risk.53 Visit www.americanheart.org for more information.

Conclusion
There are many dietary supplements that may be used as part of your total program for lowering cholesterol and/or otherwise help in reducing risk of cardiovascular disease. Good choices include plant sterols/stanols, inositol hexanicotinate, and omega-3 fatty acids from fish oils. In addition, a healthy dietary program such as the Mediterranean diet should be the first line of defense for reducing the risk of cardiovascular disease.

References:

  1. Diabetes: Heart Disease and Stroke. American Diabetes Association. Retrieved October 4, 2008 from http://www.diabetes.org/diabetes- heart-disease-stroke.jsp.
  2. Becker M, Staab D, Von Bergmann K. Treatment of severe familial hypercholesterolemia in childhood with sitosterol and sitostanol. J Pediatr 1993;122:292–6.
  3. Oster P, Schlierf G, Heuck CC, et al. [Sitosterol in familial hyperlipoproteinemia type II. A randomized, double-blind, cross-over study]. [Article in German]. Dtsch Med Wochenschr 1976;101:1308–11.
  4. Schlierf G, Oster P, Heuck CC, et al. Sitosterol in juvenile type II hyperlipoproteinemia. Atherosclerosis 1978;30:245–8.
  5. Schwartzkopff W, Jantke HJ. [Dose-effect of beta-sitosterin in type IIa and IIb hypercholesterolemias]. [Article in German]. MMW Munch Med Wochenschr 1978;120:1575–8.
  6. Becker M, Staab D, Von Bergman K. Long-term treatment of severe familial hypercholesterolemia in children: effect of sitosterol and bezafibrate. Pediatrics 1992;89:138–42.
  7. Weststrate JA, Meijer GW. Plant sterol-enriched margarines and reduction of plasma total- and LDL-cholesterol concentrations in normocholesterolaemic and mildly hypercholesterolaemic subjects. Eur J Clin Nutr 1998;52:334 –43.
  8. Anon. FDA authorizes new coronary heart disease health claim for plant sterol and plant stanol esters. FDA. 2000. Available at: www. fda.gov/bbs/topics/ANSWERS/ANS01033.html.
  9. Lichtenstein AH, Deckelbaum RJ. Stanol/sterol ester-containing foods and blood cholesterol levels: a statement for healthcare professionals from Nutrition Committee, Council on Nutrition, Physical Activity, Metabolism of American Heart Association. Circulation 2001;103:1177–9.
  10. Matvienko OA, Lewis DS, Swanson M, et al. A single daily dose of soybean phytosterols in ground beef decreases serum total cholesterol and LDL cholesterol in young, mildly hypercholesterolemic men. Am J Clin Nutr 2002;76:57–64.
  11. Neil HA, Meijer GW, Roe LS. Randomised controlled trial of use by hypercholesterolaemic patients of a vegetable oil sterol-enriched fat spread. Atherosclerosis 2001;156:329–37.
  12. Nguyen TT, Dale LC, von Bergmann K, Croghan IT. Cholesterollowering effect of stanol ester in a US population of mildly hypercholesterolemic men and women: a randomized controlled trial. Mayo Clin Proc 1999;74:1198–206.
  13. Vuorio AF, Gylling H, Turtola H, et al. Stanol ester margarine alone and with simvastatin lowers serum cholesterol in families with familial hypercholesterolemia caused by the FH-north karelia mutation. Arterioscler Thromb Vasc Biol 2000;20:500–6.
  14. Weststrate JA, Meijer GW. Plant sterol-enriched margarines and reduction of plasma total- and LDL-cholesterol concentrations in normocholesterolaemic and mildly hypercholesterolaemic subjects. Eur J Clin Nutr 1998;52:334 –43.
  15. Gylling H, Miettinen TA. Cholesterol reduction by different plant stanol mixtures and with variable fat intake. Metabolism 1999;48:575–80.
  16. Gylling H, Puska P, Vartiainen E, et al. Serum sterols during stanol ester feeding in a mildly hypercholesterolemic population. J Lipid Res 1999;40:593–600.
  17. Gylling H, Radhakrishnan R, Miettinen TA. Reduction of serum cholesterol in postmenopausal women with previous myocardial infarction and cholesterol malabsorption induced by dietary sitostanol ester margarine: women and dietary sitostanol. Circulation 1997;96:4226–31.
  18. Gylling H, Miettinen TA. Serum cholesterol and cholesterol and lipoprotein metabolism in hypercholesterolaemic NIDDM patients before and during sitostanol ester-margarine treatment. Diabetologia 1994;37:773–80.
  19. Gylling H, Miettinen TA. Effects of inhibiting cholesterol absorption and synthesis on cholesterol and lipoprotein metabolism in hypercholesterolemic non-insulin-dependent diabetic men. J Lipid Res 1996;37:1776–85.
  20. Gylling H, Puska P, Vartiainen E, et al. Retinol, vitamin D, carotenes and alpha-tocopherol in serum of a moderately hypercholesterolemic population consuming sitostanol ester margarine. Am J Cardiol 1999;145:279–85.
  21. Hallikainen MA, Uusitupa MI. Effects of 2 low-fat stanol estercontaining margarines on serum cholesterol concentrations as part of a low-fat diet in hypercholesterolemic subjects. Am J Clin Nutr 1999;69:403–10.
  22. Jones PJ, Ntanios FY, Raeini-Sarjaz M, et al. Cholesterol-lowering efficacy of a sitostanol-containing phytosterol mixture with a prudent diet in hyperlipidemic men. Am J Clin Nutr 1999;69:1144 –50.
  23. Gylling H, Siimes MA, Miettinen TA. Sitostanol ester margarine in dietary treatment of children with familial hypercholesterolemia. J Lipid Res 1995;36:1807–12.
  24. Miettinen TA, Puska P, Gylling H, et al. Reduction of serum cholesterol with sitostanol-ester margarine in a mildly hypercholesterolemic population. N Engl J Med 1995;333(20):1308-12.
  25. Vanhanen HT, Kajander J, Lehtovirta H. Serum levels, absorption efficiency, faecal elimination and synthesis of cholesterol during increasing doses of dietary sitostanol esters in hypercholesterolaemic subjects. Clin Sci (Colch) 1994;87:61-7.
  26. Plat J, van Onselen EN, van Heugten MM, Mensink RP. Effects on serum lipids, lipoproteins and fat soluble antioxidant concentrations of consumption frequency of margarines and shortenings enriched with plant stanol esters. Eur J Clin Nutr 2000;54:671–7.
  27. Hallikainen MA, Sarkkinen ES, Gylling H, et al. Comparison of the effects of plant sterol ester and plant stanol ester-enriched margarines in lowering serum cholesterol concentrations in hypercholesterolaemic subjects on a low-fat diet. Eur J Clin Nutr 2000;54:715–25.
  28. Law M. Plant sterol and stanol margarines and health. BMJ 2000;320:861–4.
  29. Guyton JR, Blazing MA, Hagar J, et al. Extended-release niacin vs gemfibrozil for the treatment of low levels of high-density lipoprotein cholesterol. Niaspan-Gemfibrozil Study Group. Arch Intern Med 2000;160:1177–84.
  30. Head KA. Inositol hexaniacinate: a safer alternative to niacin. Alt Med Rev 1996; 1:176–84.
  31. Murray M. Lipid-lowering drugs vs. Inositol hexaniacinate. Am J Natural Med 1995; 2:9 –12.
  32. Dorner Von G, Fisher FW. Zur Beinflussung der Serumlipide undlipoproteine durch den Hexanicotinsaureester des m-Inositol. Arzneimittel Forschung 1961; 11:110–3.
  33. Santos MJ, Lopez-Jurado M, Llopis J, et al. Influence of dietary supplementation with fish on plasma total cholesterol and lipoprotein cholesterol fractions in patients with coronary heart disease. J Nutr Med 1992;3:107–15.
  34. Kromhout D, Bosschieter EB, Coulander CdL, The inverse relation between fish consumption and 20-year mortality from coronary heart disease. N Engl J Med 1985;312:1205–9.
  35. Albert CM, Manson JE, O’Donnoell C, et al. Fish consumption and the risk of sudden death in the Physicians’ Health Study. Circulation 1996;94 (suppl 1):I-578 [abstract #3382].
  36. Petersen M, Pedersen H, Major-Pedersen A, et al. Effect of fish oil versus corn oil supplementation on LDL and HDL subclasses in type 2 diabetes. Diabetes Care 2002;25:17048.
  37. Chan DC, Watts GF, Barrett PH, et al. Regulatory effects of HMG CoA reductase inhibitor and fish oils on apolipoprotein B-100 kinetics in insulin-resistant obese male subjects with dyslipidemia. Diabetes 2002;51:2377–86.
  38. Friedberg CE, Janssen MJ, Heine RJ, Grobbee DE. Fish oil and glycemic control in diabetes. A meta-analysis. Diabetes Care 1998;21:494–500.
  39. Balestrieri, G. P., Maffi, V., Sleiman, I., Spandrio, S., Di Stefano, O., Salvi, A., and Scalvini, T. Fish oil supplementation in patients with heterozygous familial hypercholesterolemia. Recenti Prog Med 1996;87(3):102–5.
  40. Roche HM, Gibney MJ. Effect of long-chain n-3 polyunsaturated fatty acids on fasting and postprandial triacylglycerol metabolism. Am J Clin Nutr 2000;71:232S–7S.
  41. Deslypere JP. Influence of supplementation with N-3 fatty acids on different coronary risk factors in men--a placebo controlled study. Verh K Acad Geneeskd Belg 1992;54:189–216.
  42. Simons, L. A., Hickie, J. B., and Balasubramaniam, S. On the effects of dietary n-3 fatty acids (Maxepa) on plasma lipids and lipoproteins in patients with hyperlipidaemia. Atherosclerosis 1985;54(1):75–88.
  43. Nikkila, M. Influence of fish oil on blood lipids in coronary artery disease. Eur J Clin Nutr 1991;45(4):209–13.
  44. Reliant Pharmaceuticals. Omacor package insert. Liberty Corner, NJ; December, 2004.
  45. Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebocontrolled trial. Lancet; Published online ahead or print, 31 August 2008, doi:10.1016/S0140-6736(08)61239–8.
  46. Effect of rosuvastatin in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. Lancet; Published online ahead or print, 31 August 2008, doi:10.1016/S0140-6736(08)61240–4.
  47. Walker C, Reamy BV.Diets for cardiovascular disease prevention: what is the evidence? Am Fam Physician 2009;79(7):571–8.
  48. Mente A, de Koning L, Shannon HS, Anand SS. A systematic review of the evidence supporting a causal link between dietary factors and coronary heart disease. Arch Intern Med 2009;169(7):659–69.
  49. Mente A, de Koning L, Shannon HS, Anand SS. A systematic review of the evidence supporting a causal link between dietary factors and coronary heart disease. Arch Intern Med 2009;169(7):659–69.
  50. Hu FB, Rimm EB, Stampfer MJ, Ascherio A, Spiegelman D, Willett WC. Prospective study of major dietary patterns and risk of coronary heart disease in men. Am J Clin Nutr 2000;72(4):912–921.
  51. Liu S, Manson JE, Lee IM, Cole SR, Hennekens CH, Willett WC, Buring JE. Fruit and vegetable intake and risk of cardiovascular disease: the Women’s Health Study. Am J Clin Nutr 2000; 72(4):922–928
  52. Mente A, de Koning L, Shannon HS, Anand SS. A systematic review of the evidence supporting a causal link between dietary factors and coronary heart disease. Arch Intern Med 2009;169(7):659–69.
  53. Walker C, Reamy BV.Diets for cardiovascular disease prevention: what is the evidence? Am Fam Physician 2009;79(7):571–8.

Gene Bruno, MS, MHS

Gene Bruno is the Dean of Academics and Professor of Dietary Supplement Science for Huntington College of Health Sciences (a nationally accredited distance learning college offering diplomas and degrees in nutrition and other health science related subjects. Gene has two undergraduate Diplomas in Nutrition, a Bachelor’s in Nutrition, a Master’s in Nutrition, a Graduate Diploma in Herbal Medicine, and a Master’s in Herbal Medicine. As a 32 year veteran of the Dietary Supplement industry, Gene has educated and trained natural product retailers and health care professionals, has researched and formulated natural products for dozens of dietary supplement companies, and has written articles on nutrition, herbal medicine, nutraceuticals and integrative health issues for trade, consumer magazines, and peer-reviewed publications. Gene's latest book, A Guide to Complimentary Treatments for Diabetes, is available on Amazon.com, and other fine retailers.