Muscle Mag Fitness spoke with health and nutrition expert Jeff Behar to get his advice about regarding heart disease and ways to lower cholesterol naturally. We sat down with Jeff at his facility in Los Angeles California.

Jeff Behar: Cholesterol is a type of fat (lipid) found in foods from animal sources. The body (the liver) also produces about 1,000 milligrams of cholesterol a day. Because cholesterol can't travel alone through the bloodstream, it has to combine with certain proteins so that they are able to be transported to different parts of the body. When this happens, the cholesterol and protein form what is called a lipoprotein.  

The two most important types of lipoproteins are high-density lipoproteins (or HDL) and low-density lipoproteins (or LDL). You've probably heard people call LDL cholesterol "bad cholesterol" and HDL cholesterol "good cholesterol" because of their very different effects on the body. Most cholesterol is LDL cholesterol, and this is the kind that's most likely to clog the blood vessels, keeping blood from flowing through the body the way it should. Only about one third to one fourth of the total amount of cholesterol is HDL cholesterol. HDL cholesterol carries cholesterol back to the liver, where it can be processed and sent out of the body; therefore HDL is often referred to as "good cholesterol". 

Muscle Mag Fitness: Why is it important to try to lower cholesterol if it is high and maintain healthy cholesterol levels?

Jeff Behar:  When you have too much cholesterol, it can be dangerous to your health. When LDL cholesterol levels are high, cholesterol is deposited on the walls of arteries and forms a hard substance called plaque. Over time, plaque causes the arteries to become narrower, decreasing blood flow and causing a condition called atherosclerosis or hardening of the arteries.  When atherosclerosis affects the coronary arteries (the blood vessels that supply the muscles of the heart), the condition is called coronary artery disease, which puts a person at risk for having a heart attack. When atherosclerosis affects the blood vessels that supply the brain, the condition is called cerebral vascular disease, which puts a person at risk of having a stroke.

Atherosclerosis may also block blood flow to other vital organs, including the kidneys and intestines. This is why it's so important to start paying attention to cholesterol levels as a teen - you can delay or prevent serious health problems in the future. Based on the biggest cholesterol study to date (Lancet 2007), if you lower cholesterol even by about 4 mg/dL at age 40-49, you reduce the risk of a fatal heart attack by half; at age 50-69, by a third; and at age 70-89, by a sixth. This applies to both men and women. This is quite significant considering that heart disease is one of the leading causes of death in the U.S and throughout the developed world.

Although lowering cholesterol is important in reducing the risk to heart disease it is just one part of an important health management plan to reduce risks to heart disease. Eating a healthy diet, exercising daily, managing stress, maintaining your ideal weight, and restraining from smoking are also equally important when managing your risks for heart disease. All of these factors can have a huge positive impact on health. 

Muscle Mag Fitness: What Causes High LDL Cholesterol Levels?

• Heredity - If cholesterol problems or heart disease run in your family, you are at a higher risk for having problems.
• Diet - Avoid foods that are high in cholesterol, saturated fat, and trans fat, all of which increase cholesterol levels and your risk of developing heart disease.
• Bodyweight - Excess weight has been linked with high cholesterol levels.
• Physical activity - Exercise tends to increase HDL levels, which lowers your chance of developing heart disease.
• Age - The risk of high cholesterol increases as you get older.
  

Muscle Mag Fitness: Are there natural ways to lower cholesterol levels?

Jeff Behar: You don't have to settle for prescription medications with life-long dependency and undesirable side effects to lower cholesterol levels. There are many preventative measures you can take and natural ways to lower cholesterol. Many ways are simple, yet still very effective. Some very simple yet effective approaches for lowering your cholesterol levels include:

• Improve Your Diet.  The first step to lowering cholesterol should be an effort to improve your diet.  This means each and every day making sure you get at least 5 to 7 servings of the freshest possible fruits and vegetables.
  
• Learn to Read Food Labels.  Choosing foods wisely is one significant way to lower cholesterol without prescription drugs. By making a practice of reading and understanding food labels, you can make more informed choices for your low cholesterol diet. If a food product contains cholesterol it will list the number of milligrams per serving and the percent of your daily total. Note, for whole, fresh foods such as fresh eggs the seller doesn't have to list nutritional facts, therefore it is important to find a good resource that gives the nutritional breakdown of fresh foods.
• Avoid Foods With Saturated Fats.  The fact is that cholesterol is mostly produced by the body and only about ¼ of the cholesterol in the blood comes from foods. However, someone trying to lower cholesterol intake will have difficulty in two ways when they consume foods high in saturated fats (which includes trans fats).Trans fats, also called trans fatty acids, raise overall blood cholesterol. Trans fat is the worst of all fats, far more damaging to cholesterol levels than even saturated fats. Not only do they raise the low density lipoprotein (LDL), which is the bad cholesterol, but it also lowers the good cholesterol, known as high density lipoprotein (HDL). By lowering your intake of trans fats, you can lower your blood cholesterol significantly. Foods that contain the highest amounts of trans fats are the typical junk foods: snack crackers, fast food, fried foods that are commercially prepared, etc.
• Start Exercising. The benefits of exercise in lowering cholesterol cannot be overemphasized. To see some of the evidence behind the positive effects of exercise in reducing cholesterol see this link: http://www.ncbi.nlm.nih.gov/pubmed/18645633
• Reduce Stress.  Stress can make reducing cholesterol difficult because of the physiological process stress initiates. When you feel emotional stress, the body initiates a hormone to fight the stress called cortisol. Cortisol triggers the release of fat into the bloodstream creating extra fuel for the body. Fat in the blood stream equals higher cholesterol levels including the Low Density Lipoprotein (LDL), which is the bad type of cholesterol that causes plaque to build up in the arteries. This process also causes many people to crave foods high in saturated fat. The greater intake of fatty foods means higher cholesterol entering the body through food sources - in addition to the cholesterol naturally created by the body. Since stress can raise LDL cholesterol, controlling stress can reduce cholesterol. A good health plan for anyone, especially those trying to reduce cholesterol, is to therefore control the stress and the automatic responses it triggers. Ways to do this is to be mindful and aware of how stress can make you crave certain types of foods you can more consciously avoid the foods. Another way to combat stress is to head it off at the past and work into your daily routine ways to combat stress. Ways may include exercising, adding hobbies that make you feel more relaxed (meditation, yoga), getting a massage, etc.
• Start a natural Supplementation Program. Natural supplements like, lecithin, policosanol (a natural substance derived from sugar cane alcohols, primarily octacosanol) and Omega 3 fatty acid (found in most varieties of fish) can help significantly lower cholesterol. These supplements have been studied extensively and show great promise for people who want to lower cholesterol as quickly and effectively as prescription drugs, but without the side effects.
• Add Fiber to your Diet.  Soluble fiber been shown to significantly lower cholesterol and help prevent the heart disease that can result from high cholesterol levels. Soluble fiber actually washes away the bad cholesterol that clings to the inner walls of the arteries. You can increase the amount of soluble fiber in your diet through supplementation or by adding certain foods that contain soluble fiber such as oat bran (which contains Psyllium), and certain fresh fruits and vegetables are a great source of soluble fiber. Apples and carrots, for instance contain generous amounts of pectin. Adding a few servings a day or better yet, following the recommended 5 servings of fruits and vegetables daily, will help in lowering cholesterol. Psyllium, you can also take a supplement. Pysllium comes in capsules or granules that can be dissolved in water or juice. Also consider eating your fruits and veggies in the rawest form for increased amounts of fiber.  Another simple change that is easy to make is to switch from white bread to a whole grain, high fiber bread. Not only will it help in lowering cholesterol, but also this type of bread will help you feel full longer. Feeling full helps you maintain a healthy weight, which is another key ingredient in lowering cholesterol.
• Increase Your Water Intake. Water is good for your overall health.  Increasing your water intake can also help cleanse the body.  

Muscle Mag Fitness: What is HDL Cholesterol and Why are their Levels So Important?

Jeff Behar:  High-density lipoproteins (HDL), aka "good cholesterol",  is one of the 5 major groups of lipoproteins (chylomicrons, VLDL, IDL, LDL, HDL) which enable lipids like cholesterol and triglycerides to move within the water based solution of the blood stream. Studies show that HDL cholesterol, aka "good cholesterol", appears to scour the walls of blood vessels, cleaning out excess cholesterol.

HDL cholesterol then carries that excess cholesterol -- which otherwise might have been used to make the "plaques" that cause coronary artery disease -- back to the liver for processing. When a person's HDL cholesterol level is measured it is used to estimate how vigorously his or her blood vessels are being "scrubbed" free of cholesterol. In healthy individuals, about thirty percent of blood cholesterol is carried by HDL. 

Muscle Mag Fitness: What levels of HDL Cholesterol are considered good?

Jeff Behar:  HDL levels between 40 and 60 mg/dL are considered "normal." HDL levels greater than 60 mg/dL may actually protect people from heart disease.

HDL levels below 40 mg/dL result in an increased risk of coronary artery disease, even in people whose total cholesterol and LDL cholesterol levels are normal. Bottom line, the medical community has known for years that when it comes to HDL levels, the higher the better.  

*mg/dL = milligrams per deciliter

Muscle Mag Fitness: Are there natural supplements one can take to help lower cholesterol?

Jeff Behar: There are many natural supplements that have shown promise with lowering cholesterol levels. If most of your excess cholesterol is made by your body, B vitamins such as vitamin B3 (niacin) and pantethine have evidence to support their use.

Niacin (AKA Nicotinic Acid, B3). Niacin is also another popular natural agent used to lower LDL cholesterol and increase HDL. Well-designed studies have found that niacin lowers LDL cholesterol by approximately 10%, lowers triglycerides by 25%, and raises "good" HDL cholesterol by 15% to 30%. Niacin also appears to significantly lower levels for another risk factor for atherosclerosis, lipoprotein  Note, Niacin can increase the effect of high blood pressure medication or cause nausea, indigestion, gas, diarrhea, gout, and worsen peptic ulcers, or trigger gout, liver inflammation, and high blood sugar. It can also cause skin flushing or hot flashes, which is caused by widening of blood vessels. Although high doses of niacin showed promise in combination with drugs to lower cholesterol (called "satins"), there are concerns that combining them could result in a potentially fatal condition called rhabdomyolysis, therefore they shouldn't be combined unless under the close supervision of a physician.

Pantethine. Pantethine is the biologically active form of pantothenic acid (Vitamin B-5) and the fundamental component of Coenzyme A. Pantethine participates in the metabolism of carbohydrates, amino acids, fatty acids and dozens of other important chemical reactions. Pantethine has been used for the past 30 years in Japan, where it is approved as a pharmaceutical agent for the purpose of increasing HDL-C.  In the US, pantethine is sold as a supplement without a prescription in the United States. Pantethine works by slowing production of cholesterol in the liver and boosting the rate at which your metabolism uses fats. It significantly reduces levels of TC and LDL-C while raising HDL-C. It is the most effective natural product against serum TG levels. Pantethine is not known to cause significant side effects, has no known drug interactions, and may be the best choice for diabetics. It has not been known to cause birth defects.

Jeff Behar: If you think most of your excess blood cholesterol is from the diet, there are additional natural alternatives that may also help lower your LDL and increase your HDL.

Plant Sterols/Stanols.  If you think most of your excess blood cholesterol is from the diet, plant sterols (such as beta-sitosterol and sitostanol) and/or stanols can help prevent the absorption of dietary cholesterol. These naturally-occurring substances found in certain plants. Stanols are also found as dietary supplements or are added to margarine, orange juice, and dressings have been given an FDA nod for their use in decreasing heart disease risk. Studies have found that stanols significantly reduced total cholesterol and LDL cholesterol, but had no significant effect on HDL cholesterol or triglycerides. Stanols and sterols appear to enhance the effects of other methods to lower cholesterol. In studies, people taking the statin drugs to lower cholesterol had an additional improvement in their cholesterol levels with stanols/sterols.

Soluble Fiber. Soluble fiber also reduces LDL cholesterol by reducing cholesterol absorption in the intestines. Soluble fiber binds with cholesterol so that it is excreted. Five to 10 grams a day of soluble fiber has been found to decrease LDL cholesterol by approximately 5%. Soluble fiber can be found as a dietary supplement, such as psyllium powder, or in foods such as: oats, rye, barley, legumes (peas, beans), certain fruits (e.g., apples, prunes, and berries), certain vegetables (e.g., carrots, broccoli, yams, etc.)

Jeff Behar: There are other supplements such as guggulipids, artichoke extract (Cynara scolymnus), policosanol, red yeast rice, Coq, and garlic - but the evidence is mixed.  

Guggulipids.  Guggulipids is a natural ingredient derived from the mixture of plant chemicals (ketonic steroids) from the gum resin of commiphora mukul, called guggulipid, and is an approved treatment of hyperlipidemia (high cholesterol) in India. It has been a mainstay of traditional Indian herbal medicine (Ayurveda) approaches in preventing high cholesterol and atherosclerosis. It is believed that guggul helps reduce high cholesterol, because it lowers harmful LDL (low-density lipoproteins) while elevating the beneficial HDL (high-density lipoproteins). Studies have also shown that LDL oxidation, which is the main cause of plaque build in the arteries, can be prevented or at least decreased by the antioxidant activity of guggul. Guggul also has anti-inflammatory activity and reduces the levels of C-reactive protein. It helps prevent blood platelet aggregation and breaks up blood clots. Therefore there are practioners that believe that guggul can be used not only to lower bad cholesterol but can be used as a preventative against heart disease and stroke.

Policosanol. Policosanol is a natural substance derived from sugar cane alcohols, primarily octacosanol.  Millions of people needing to lower cholesterol in other countries have been using policosanol for years. It has just recently been introduced into U.S. markets. People are turning to this natural substance because of concerns over the safety statin drugs. There are limited studies indicating that those taking policosanol can expect up to a 25% reduction in LDL cholesterol.

Artichoke leaf extract.  Artichoke leaf extract may work by limiting the synthesis of cholesterol in the body. Artichokes also contain a compound called cynarin, believed to increase bile production in the liver and speed the flow of bile from the gallbladder, both of which may increase cholesterol excretion. A double-blind, placebo-controlled German study found that 1,800 mg of artichoke extract per day for six weeks significantly lowered total cholesterol by 18.5% compared to 8.6% in the placebo group and lowered LDL cholesterol by 22.9% compared with 6% in the placebo group. The ratio of LDL to HDL decreased by 20% in the artichoke group compared with 7% in the placebo group. There were no adverse effects associated with artichoke use.  Larger clinical trials over longer periods are needed.

Red Yeast Rice. Red yeast rice also has been used in China for over 1,000 years for medicinal purposes, most notably for improving blood circulation and for alleviating indigestion and diarrhea. Recently, red yeast rice has been developed by Chinese and American scientists as a product to lower blood lipids, including cholesterol and triglycerides. Although small scale studies using pharmaceutical-grade red rice yeast have demonstrated efficacy and safety, it is no longer legal to sell supplements containing red yeast rice in the United States. The main reasons the Food and Drug Administration (FDA) removed red yeast rice from the market in the United States were because  there is concern that patients who take statin drugs when combined with red yeast rice products may increase their risk of muscle or kidney injury. The FDA also considers the products containing red yeast rice to be new, unapproved drugs for which marketing violates the Federal Food, Drug, and Cosmetic Act.

Coenzyme Q10. Coenzyme Q10 is a fat-soluble nutrient also known as CoQ10, or ubiquinine primarily found in the mitochondria. The mitochondria are small bodies within cells that produce energy for the body. CoQ10 provides energy to the cells, stabilizes cell membranes and acts as an antioxidant (a substance that reduces damage that results from oxygen, such as is caused by free radicals). As for lowering cholesterol there are some reports that this supplement may have some benefit in ischemic heart disease, which occurs when there are already blockages in the coronary arteries. This claim is not yet proven. Co Q 10 has no effect on lowering cholesterol.

Garlic. While some individual studies have shown that garlic can be effective in reducing "bad" cholesterol (LDLs), the overall body of evidence is inconclusive. A recent study conducted in 2007, appears to shed serious doubt on the reality behind garlic's reputation in this area. The researchers tested raw garlic and two different garlic supplements on nearly 200 adults with moderately high levels of LDL ("bad") cholesterol. After six months, the patients showed no improvements in their average cholesterol or other blood fats (lipids), no matter what kind of garlic they had consumed. SOURCES: Gardner, C. Archives of Internal Medicine, Feb. 26, 2007; vol 167: pp 346-353. Charlson, M. Archives of Internal Medicine, Feb. 26, 2007; vol 167: pp 325-326. National Heart, Lung, and Blood Institute: "How is High Blood Cholesterol Diagnosed?" News release, Stanford University Medical Center. Haru Amagase, PhD, director, research and development, Wakunaga of America. 

Muscle Mag Fitness: What diet changes can one make to help support a lower cholesterol level?

Jeff Behar: There are many changes that can be made to the diet that can help lower cholesterol. 

On a big-picture level, eat more natural, whole foods rather than processed foods; eat enough protein, lots of vegetables, complex carbohydrates and adequate amounts of healthy oils (which means no trans-fats, but more omega-3 fatty acids and monounsaturates like extra virgin olive oil). In terms of specifics, aim for at least 25 grams of fiber daily - through oatmeal, vegetables, whole grains and other fiber sources like psyllium husk. Try to have cold water fish like salmon (wild only) on a regular basis (studies say two servings a week) - if this is not possible, a reputable source of fish oil or omega-3 fatty acids is highly recommended.

There are studies to support a Mediterranean diet which is generous with vegetables, fruits, beans, and whole grains, moderate amounts of fish and chicken, and low amounts of red meat, and olive oil as the main oil. Side note, extra virgin olive oil is high in polyphenols or plant pigments, which have been shown by themselves to improve cholesterol.

And as always, don't overeat. If you're overweight, eat less and choose foods that have more nutrients per gram, such as vegetables, instead of empty calories from sugar, soda or white bread.

It can take up to 6-12 months to see the effects of diet on cholesterol levels, so be patient, and be consistent. But you will feel better on so many levels, it's worth it. 

Muscle Mag Fitness: What are some lifestyle changes one can make to try to lower cholesterol naturally?

• Lose weight. If you are overweight, reducing your weight should decrease your LDL levels. Losing weight is especially important if your excess weight is stored in your abdominal area; your weight-to-hip ratio is particularly important in determining whether you ought to concentrate on weight loss.
• Exercise daily.
• Start a Heart Healthy Diet. Even if you have been eating poorly for years, making a few changes in your diet can reduce cholesterol and improve your heart health in just a few short months. A heart healthy diet includes:
• Increasing soluble fiber in the diet. Soluble fibers found in oats, fruits, vegetables, and legumes, can result in both a reduction in LDL cholesterol and increase HDL cholesterol.
• Choosing healthier fats. Saturated fats, found in red meat and dairy products, raise your total cholesterol and low-density lipoprotein (LDL) cholesterol, the "bad" cholesterol. As a general rule, you should get no more than 10 percent of your daily calories from saturated fat. Instead, choose leaner cuts of meat, low-fat dairy and monounsaturated fats - found in olive, peanut and canola oils - for a healthier option.
• Eating foods rich in omega-3 fatty acids. Omega-3 fatty acids can help lower your LDL ("bad") cholesterol. Some types of fish - such as salmon, mackerel and herring - are rich in omega-3 fatty acids. Other good sources of omega-3 fatty acids include walnuts, almonds and ground flaxseeds.
• Eliminating trans fats. Trans fat can be found in fried foods and many commercial baked products, such as cookies, crackers and snack cakes. But don't rely on packages that are labeled "trans fat-free. You can tell if a food has trans fat in it if it contains partially hydrogenated oil.
• Limiting cholesterol intake. Aim for no more than 300 milligrams (mg) of cholesterol a day - less than 200 mg if you have heart disease. The most concentrated sources of cholesterol include organ meats, egg yolks and whole milk products. Use lean cuts of meat, egg substitutes and skim milk instead.
• Limiting processed food.
• Adding anti-oxidants to the diet. The antioxidant qualities of vitamin E with beta carotene can raise the good or HDL cholesterol levels, cleansing the body of free radicals. Green tea can be consumed each day also because of the antioxidant properties in the tea.  In addition to lowering LDL cholesterol and raising HDL, green tea can also regulate blood sugar and reduce high blood pressure.
  

Muscle Mag Fitness: Are there natural supplements available to increase HDL?

Jeff Behar: Most evidence supports the use of niacin to increase HDL - up to 35%. The beneficial effect is dose dependent. Niacin can cause flushing which people don't like - in these cases, it makes sense to start at a low dose and slowly build up. If people end up taking large doses of niacin, it is important that they ask their doctor about checking for liver enzymes because liver injury is a potential side effect at high doses. There is evidence supporting the use of exercise, red wine, polyphenols in berries in increasing HDL too. 

Muscle Mag Fitness: Are there other natural ways to increase HDL?

Jeff Behar: Most evidence supports the use of niacin to increase HDL - up to 35%. The beneficial effect is dose dependent. Niacin can cause flushing which people don't like - in these cases, it makes sense to start at a low dose and slowly build up. If people end up taking large doses of niacin, it is important that they ask their doctor about checking for liver enzymes because liver injury is a potential side effect at high doses. There is evidence supporting the use of exercise, red wine, polyphenols in berries in increasing HDL too.

• Start on a Mediterranean diet. A Mediterranean diet emphasizes mono unsaturated fats (e.g., canola oil, avocado oil, or olive oil) over saturated fats, emphasizes the consumption of fish over meat, includes heart healthy oils, and emphasizes moderate consumption of alcohol. This approach has shown to increase HDL cholesterol levels without increasing the total cholesterol, and lowers the risk for heart disease.
• Removing trans fatty acids from the diet. Trans fatty acids are currently present in many of your favorite prepared foods -- anything in which the nutrition label reads "partially hydrogenated vegetable oils" -- so eliminating them from the diet is not a trivial task. But trans fatty acids not only increase LDL cholesterol levels, they also reduce HDL cholesterol levels. Removing them from your diet will almost certainly result in a measurable increase in HDL levels.
• Reducing fat in the diet. Limiting intake of dietary fat to 30-35% of total calories can lower cholesterol dramatically.
• Weight loss. Obesity results not only in increased LDL cholesterol, but also in reduced HDL cholesterol. If you are overweight, reducing your weight should increase your HDL levels. This is especially important if your excess weight is stored in your abdominal area; your weight-to-hip ratio is particularly important in determining whether you ought to concentrate on weight loss.
• Smoking cessation. If you smoke, giving up tobacco will result in an increase in HDL levels. Within 30 minutes after quitting, your blood pressure decreases. Within 24 hours, your risk of a heart attack decreases. Within one year, your risk of heart disease is half that of a smoker. Within 15 years, your risk of heart disease is similar to someone who never smoked. Quitting smoking does a body good!! So, QUIT TODAY!!!
• Increasing aerobic exercise. Consistent moderate physical activity can help raise high-density lipoprotein (HDL) cholesterol, the "good" cholesterol. With your doctor's OK, work up to 30 to 60 minutes of exercise a day. Exercising does not have to be in a gym. Take a brisk daily walk. Play tennis. play with your kids or your dog in your yard. just get up and move!!
• Drink wine. One drink of alcohol a day or less yields higher HDL-C levels, more so in women than men. HDL transports cholesterol to the liver and cholesterol is known to have a protective effect on the cell membrane. It is likely that this reflects the liver's need for more cholesterol to protect itself from the alcohol.
• Adding soluble fiber to diet. Soluble fibers found in oats, fruits, vegetables, and legumes, can result in both a reduction in LDL cholesterol and increase HDL cholesterol.
• Adding anti-oxidants to the diet. The antioxidant qualities of vitamin E with beta carotene can raise the good or HDL cholesterol levels, cleansing the body of free radicals. Green tea can be consumed each day also because of the antioxidant properties in the tea. In addition to lowering LDL cholesterol and raising HDL, green tea can also regulate blood sugar and reduce high blood pressure.

About Jeff Behar 

Jeff Behar, MS, MBA