High Cholesterol

What is Cholesterol?

Cholesterol is an animal sterol that was first discovered in the human gallbladder in the 1700s. The prefix “chole” is regarding anything to do with bile. Sterol, is the name of a molecule with a specific structure.

Cholesterol generally is used in the production of cell membranes. Cell membranes are composed of lipids and cholesterol. Cholesterol gives the cell membrane more fluidity. Because of this, cholesterol has a significant importance for our bodies and it is important that the circulating pool of cholesterol is sufficient for cellular needs. We see great risk in those who have low cholesterol, where their cholesterol is below range.

Cholesterol is also used in the production of sex hormones such as progesterone, estrogens and testosterone. These hormones rely on cholesterol as a backbone.

There is also a risk when cholesterol is too high. Unfortunately cholesterol can deposit in arteries that have injury or inflammation known as endothelial dysfunction. If we have high cholesterol, we want to focus on supporting the good cholesterol called High Density Lipoprotein (HDL) which acts somewhat as a vacuum cleaner bringing bad cholesterol back to the liver to be eliminated through the bile in the gallbladder. We also want to look at how we can lower bad cholesterol, namely, Low Density Lipoprotein (LDL), which is often done holistically through dieting and exercising.

We can also lower cholesterol with the use of statins. There are pros and cons when it comes to taking a statin medication, which will be discussed in a later section.

As someone who likes to look at the root cause of disease, I want to know for sure what is causing the high cholesterol whether it is a genetic cause, a thyroid imbalance or a lifestyle imbalance. From there, we can begin to heal the body at the root cause, in an intelligent step by step process, rather than using prescription medications (if possible).

Common Causes of Elevated Cholesterol

1. Poor Diet and Lifestyle – Poor diet includes processed meats, sausages, hotdogs, bologna, salami, too much sugar and fried foods. Also, lack of exercise can lower the LDL receptors in the liver, making it more difficult to reduce LDL levels in the blood. When you are active there is an enzyme that can convert LDL into HDL. If you are sedentary, it can reduce this conversion into HDL cholesterol by 95%! It’s important to get up from your desk every 30 minutes or go for a walk every hour, even if its 5-10 minutes.
2. Familial hypercholesterolemia – This is an inherited defect in how the body recycles LDL (bad) cholesterol. Specifically, it is usually a defect in the LDL receptors. As a result, LDL levels in the blood remain very high. People have high cholesterol at a young age and increases as they age. Other mutations can include the PCSK9 gene and the gene for Apolipoprotein B. Usually these people will need some sort of medication and strict lifestyle changes to prevent heart attacks that occur 10-20 years younger than the general population.
3. Nonalcoholic Fatty Liver Disease (NAFLD) – this is when extra fat is stored in your liver. It affects almost 1 in 4 adults. It causes the function of the liver to be impeded and your liver may not be able to process excess circulating cholesterol. This can be treated with lifestyle, diet and herbal medicine. If it goes untreated, it can lead to cirrhosis of the liver and can be deadly.
4. Kidney Disease – some kidney diseases can raise cholesterol
5. Excessive Alcohol Consumption – this can lead to damage to the liver and causes the function of the liver to be impeded and your liver may not be able to process excess circulating cholesterol. This can be treated with lifestyle, diet and herbal medicine. If it goes untreated, it can lead to cirrhosis of the liver and can be deadly.
6. Type II Diabetes – this can cause lower HDL and your body won’t be able to vacuum away bad LDL cholesterol.
7. Menopause – When the sex hormone estrogen begins to drop, your cholesterol can increase (it is no longer being used to make estrogens). However, I’ve read that it doesn’t take too much of the circulating pool of cholesterol to make estrogens and some attribute this rise in cholesterol to reduced exercise as you age and weight gain.
8. Low Thyroid or Hypothyroid – this can cause LDL cholesterol levels to increase. This can be corrected in a variety of ways through either a low iodine diet for a period of time or through thyroid medication. If you have fatigue, dry skin, eyebrow thinning, weight gain, weakness and aches you may want to get a blood test to screen for hypothyroid (TSH, T3, T4).
9. High Consumption of Caffeine – shown in a 2018 study that high levels of diterpenes in coffee can raise LDL.
10. Chronic Psychological Stress – elevations of cortisol can raise LDL cholesterol in the body while lowering HDL (good cholesterol). Meditation, herbal medicine, stress relief can help
11. Cigarette Smoking – nicotine causes the release of catecholamines which increase fat breakdown which increases LDL production
    
12. Certain Medications – antihypertensive drugs, beta-blockers, danazol, retinoids, antipsychotics, anticonvulsants, immunosuppressants, antiviral drugs, interferons, some depression and anti-psychotic medications due to weight gain
13. Pregnancy – has a temporary rise in cholesterol
14. Rapid Weight Loss – leads to temporary elevation of LDL due to the fat breakdown in the body, but then returns to normal

Diagnosis Requirements: Blood Testing

To determine whether or not you have high or low cholesterol, a blood test must be taken.

Blood markers that your physician may test are the following:

1. Total Cholesterol (TC)
2. Low Density Lipoprotein (known as LDL or c-LDL) – This type of cholesterol, known as “bad cholesterol,” can collect in blood vessels, become oxidized through inflammation and develop atherosclerosis.
3. High Density Lipoprotein (known as HDL) – This type of “good cholesterol” helps reduce the buildup of LDL.
4. Triglycerides (TG) a type of fat that is associated with heart disease and pancreatic inflammation when in excess.

If your doctor determines that you have high cholesterol, your doctor may run other testing to determine the root cause of high cholesterol, or they may want to determine whether or not you are at a high risk for cardiovascular disease or stroke. Additional testing is discussed in the next section.

Further Testing:

Determining the Root Cause and How to Approach Treatment

1. Testing for Cardiovascular Risk

• Blood tests: homocysteine, hs-CRP, Lipoprotein(a), VLDL-C, Cholesterol/HDL ratio, Lipid Particle Testing, ApoA-I, Apo B, APOE Genotyping, MTHFR Mutation
• EKG, Holter Monitor, Stress Testing

2. Testing for Familial Hypercholesterolemia

• Genetic Testing: LDLR, Apo B, PCSK9

3. Testing for Liver Disease

• Blood tests: ALT, AST
• Imaging: liver ultrasound, biopsy

4. Testing for Hypothyroidism

• Blood Tests: Thyroid Stimulating Hormone (TSH), T3, T4
  

Approach to Treating the Root Cause

First is to determine if any of the above are a leading cause of high cholesterol. If you have identified one or more causes, talk to your doctor about how to approach lowering cholesterol.

If cholesterol is high in conditions like liver and kidney disease, it is best to work with your specialist as well as a nutritionist who is specifically trained in those conditions.

If cholesterol is high in pregnancy, work closely with your doctor on what is the best approach.

If cholesterol is high due to a genetic cause like hypercholesterolemia, it is usually recommended to take a more aggressive lifestyle, diet and medication approach as this condition can lead to a premature mortality from coronary events.

If you are taking blood thinners, your diet (especially your vitamin K intake) must be kept consistent and stable or you can have complications. Talk to your doctor before attempting any dietary or supplement changes.

General Information on Lowering Cholesterol

In general, lifestyle and dietary changes need to be made to lower your cholesterol. If you lead a predominately sedentary lifestyle, then you may want to begin to incorporate more walks and light exercise. Eventually you would want to increase your exercise to a more vigorous athletic lifestyle to successfully lower your cholesterol.

Exercise helps to increase the LDL receptor in the liver to help to clear LDL from the blood.

Your dietary choices are also very important for lowering cholesterol. In most of the plans below, there is an emphasis on lean proteins and whole foods. Here are several diets that are highly researched and shown to reduce elevated cholesterol:

1. Mediterranean Diet: fruits, vegetables, whole grains, fish, lean meats, olive oil and 1/2 glass of red wine is optional (preferably organic without sulfates and also don’t overdo the wine!)
2. DASH (Dietary Approaches to Stop Hypertension) Diet: This diet is LOW in salt and RICH in fruits, vegetable, whole grains, low-fat dairy, and lean protein like beans, and fish. You’ll cut your sodium and sugar and red meats significantly down. This diet has been proven to lower blood pressure. It can also lower cholesterol.
3. Vegetarian or Vegan Diet if done the healthy way with healthy protein and minimal sweets and fats can help to lower cholesterol. If you do this long term, you may need to supplement with B12, iron, calcium and zinc.
4. Weight Watchers can help manage weight and it is also satisfying and flexible.
   
5. Dean Ornish’s Diet is a strict diet that is vegan and low in fat. This diet can lower cholesterol by more than 30%.

Supportive Foods, Herbs and Supplements for Reducing Cholesterol and a Healthy Endothelium

Popular Supplements

• Omega-3 Fatty Acids
  • Dosage: 1000-2000 mg a day with food. The best source has a balance of DHA and EPA
  • Contraindications: Discontinue prior to any major surgeries. Pregnancy requires a prenatal version with a different balance of DHA and EPA for the baby. Note that in pregnancy cholesterol will naturally raise and then lower again a few months after the baby is born.

• CoQ10
  • Benefits: strengthens the heart, repletes heart and muscles with CoQ10 anti- oxidant. Used for older women to improve egg quality and fertility.
  • Dosage: between 50-100 mg / day
  • Contraindications: Discontinue prior to any major surgeries. Low doses are usually okay in pregnancy, ask your doctor first.

• Alpha Lipoic Acid
  • Dosage: 600 mg, taken 1-2x/day
  • Benefits: Potent antioxidant, reduces insulin resistance, lowers risk of diabetic neuropathy and retinopathy. Its primary role is to convert blood sugar into energy using oxygen, a process referred to as aerobic metabolism.
  • When is it used? type 2 diabetes, diabetic neuropathy, diabetic retinopathy, hypertension, carpal tunnel syndrome, PCOS, Multiple Sclerosis, Alzheimer’s Disease, dementia, brain fog, neuroinflammation from infections.
  • Contraindications: Alpha Lipoic Acid should be used with caution in people of East Asian and Native American origin; thiamine deficiency and alcoholics; patients with cancer, high homocysteine, liver impairment, thyroid disorders; people treated for diabetes or glycemic impairment. There are also several drug interactions that should be considered before use. A 2017 observational study found that it is not harmful to take during pregnancy, however, always ask your doctor about whether or not it is safe in your case to take it and at what dosage.

• Resveratrol
  • Benefits: antioxidant, helps promote weight loss
  • Dosage: 20 mg / day. This is the equivalent of the resveratrol in 40 glasses of wine. Higher doses between 500-1000 mg a day are used in Alzheimers and other conditions and should be monitored by a doctor.
    
  • Contraindications: surgery, blood thinners, pregnancy (can harm the fetus), breastfeeding, young children

• Beta Carotene
  • Benefits: prevents LDL oxidation
  • Dosage: It is best to get from your vegetables: orange, yellow and dark green veggies

• Lutein
  • Benefits: lutein may slow down the development of early arteriosclerosis, may improve insulin resistance, potent anti-oxidant, especially for the eyes
  • Dosage: 5 mg/day. Can take up to 10-20 mg/day. Taken with food (specifically fat)
  • Contraindications: Unknown if safe in pregnancy or breastfeeding. Refrain from excessive lutein intake if you have a liver or kidney problems. Possible contraindication with certain medications, speak with your doctor. It is contraindicated in allergies to carotenoids.

• Astaxanthin
  • Benefits: This is a carotenoid just like beta carotene, lycopene and lutein. It is a very strong anti-oxidant, stronger than the other carotenoids. Prevents low- density lipoprotein (LDL)-cholesterol from oxidative damage. Can cross blood brain barrier and used in Parkinson’s and Alzheimers.
  • Dosage: 4-12 mg daily taken with food (specifically fat)
  • Contraindications: It should not be used by pregnant or lactating women, it is contraindicated in allergies to carotenoids.

• L-Arginine
  • Benefits: may improve athletic performance around 1-2 grams / 2-3x a day, helpful in angina
  • Dosage: Can range between 1-20 grams a day. Talk to your doctor before taking higher doses especially if you’re on medications. Always start small!
  • Contraindications: L-arginine is not recommended in patients following an acute heart attack. Higher dosages can lead to high levels of nitric oxide which may be unsafe. Stick to the recommended dosage of your doctor or practitioner.

Vitamins & Minerals

• Always double check all your supplements to make sure you are not over consuming any of the following vitamins, amino acids or minerals.

• All dosages below are for adults, not for children.

• Dosages below are not for pregnancy and some of these supplements may not be safe in pregnancy – ask your doctor or midwife before taking.

• Vitamin A
  • Dosage: 700 mcg female; 900 mcg male
  • Contraindications: ~Discontinue prior to any major surgeries. Contraindicated in pregnancy, unless in your prenatal vitamin.
    
• Vitamin D
  • Dosage: 1000-4000 IU / day ideally with food; for higher doses consult with your doctor and monitor blood calcium. Higher doses should always be monitored by a physician with appropriate blood work checking calcium and vitamin D levels.
  • Contraindications: certain kidney diseases, certain liver diseases
• Vitamin C
  • Dosage: 2000 mg daily
  • Contraindications: Discontinue prior to any major surgeries. Could be contraindicated in kidney stones.

• Vitamin E
  • Dosage: 200-400 IU / day. Lower doses have a therapeutic effect. Higher doses taken continuously are dangerous.
  • Benefits: inhibits the oxidation of LDL cholesterol, thereby inhibiting atherosclerotic plaques
  • Contraindications: May thin the blood. Ask your doctor if you can use it especially with blood thinners, warfarin, Vitamin K, Aspirin, NSAIDS, Discontinue prior to any major surgeries. Do not take long term with prescription estrogens due to risk of thrombophlebitis. Do not take with digoxin, digitalis and neomycin. Higher doses increase risk of hemorrhagic stroke, reproductive dysfunction, and becomes pro- oxidative at high doses.

• Magnesium Citrate
  • Dosage: 100-400 mg at bedtime. For some people, higher doses will cause loose stool. Just lower the dose if this occurs. Some people like to take magnesium in the daytime and evening to help them relax as well.
  • Benefits: May also improve blood pressure, mood, sleep, bowel movements, migraines.
  • Contraindications: slow heart rate (bradycardia), intestinal blockage, certain gastrointestinal conditions, certain kidney conditions, on a low magnesium diet. Higher doses can cause nausea, abdominal cramping, gas and diarrhea.

• Zinc
  • Dosage: Male: 11 mg (Upper intake limit: 34 mg) Female: 9 mg (Upper intake limit: 34 mg) Pregnancy: 12 mg (Upper intake limit: 40 mg) Lactation: 13 mg (Upper intake limit: 40 mg)
  • Contraindications: taking high doses of zinc over a period of time can deplete copper. Do not take if you have a known copper deficiency.

• Selenium
  • Selenium deficiency is not common, but can happen in chronic bowel malabsorption. Selenium is incorporated into selenoproteins in the body. It is a cofactor in the production of glutathione peroxidase and helps to minimize oxidative damage. It is also needed as a cofactor to transform the less active thyroid hormone T4 into T3.
  • Dosage: 45 mcg daily; in pregnant women stick to your prenatal vitamin and do not add more selenium. For children ages 1-13 the recommended daily allowance is 20 mcg which is found in their food and multivitamin. No need to supplement higher than that.
  • Contraindications: Caution in renal diseases and renal failure. May cause stomach upset.

• Folic Acid (Vitamin B9)
  • Dosage: 800 mg a day to help to reduce homocysteine levels. Pregnancy requires about 400-800 mcg daily. Methylated folate may need to be used for those with an MTHFR mutation.
  • Contraindications: Only supplement with methyl folate if you have MTHFR. Any other folate will not help. If megaloblastic anemia due to low B12 or pernicious anemia is present, folate is not the suitable treatment because it can mask megaloblastic anemia caused by low B12. In pernicious anemia, the body cannot absorb B12 due to a lack of intrinsic factor in the stomach. These people need injections of B12.

Botanicals

• Always double check all your supplements and herbal blends to make sure you are not over consuming any of the following vitamins, amino acids or minerals.

• All dosages below are for adults, not for children.

• Dosages below are not for pregnancy and some of these supplements may not be safe in pregnancy – ask your doctor or midwife before taking.

• Always talk to your doctor before consuming botanicals, particularly if you are being treated for a condition or are on medication.

Green Tea (Camellia sinensis)

• Dosage: 1-2 cups daily
• Contraindications: Too many cups of tea can lead to high levels of caffeine. This can cause: symptoms such as high blood pressure, vomiting, diarrhea, headaches and dizziness, arrhythmias, insomnia and nervousness.

Hawthorn berry/flower (Crataegus spp.)

• Benefits: reduces blood pressure, reduces cholesterol, reduces inflammation of the heart
• Dosage: 50 mg 3x/day; can be dosed higher with herbalist or doctor supervision
• Contraindications: if using it for a heart condition, ask your doctor first as it can be contraindicated.

Gum Guggul gum (Commiphora mukul)

• Benefits: Anti-inflammatory effects, lipid lowering
  
• Dosage: 500 mg 3x/day of gum guggul OR 75 mg of standardized guggulsterones, talk to a doctor or professional about which brand to take and how much to be safe.
• Contraindications: Does interact with some medications, so ask your doctor. Guggul may stimulate thyroid hormone production, specifically the conversion of T4 (less active)—> T3 (more active) ; dosage adjustment of thyroid medication may be required only with proper lab testing and done by a medical doctor.

Bergamot (Citrus bergamia)

• Dosage: 500-1000 mg per day taken with food for 4-6 weeks (ask your doctor)
• Contraindications: Do not use the oil in pregnancy or breastfeeding. Do not use the oil on your skin as it can cause a rash, especially when in the sun. Some medications might make the skin more sensitive to sunlight. Bergamot might also make the skin more sensitive to sunlight. Using these products together might increase the risk of sunburn, blistering, or rashes when the skin is exposed to sunlight. Be sure to wear sunblock and protective clothing when spending time in the sun. Bergamot might lower blood sugar and interfere with blood sugar control during surgery. Stop using bergamot at least 2 weeks before a scheduled surgery.

Ashwagandha (Withania somnifera)

• Benefits: Neuroprotective, antiinflammatory, reduces stress
• Dosage: 500 mg daily
• Contraindications: Pregnancy, sensitivity to nightshade plants, certain intestinal disorders, hyperthyroidism, hemochromatosis, hormone sensitive prostate cancer, if you are taking benzodiazepines, barbiturates, or anticonvulsants. Could cause low blood sugar in some individuals. May be contraindicated during chemotherapy, during certain autoimmune flares.

Culinary Herbs

Rosemary herb (Rosmarinus officinalis) Sage herb (Salvia officinalis)

Turmeric rhizome (Curcuma longa)

• Dosage: If taking the powdered turmeric, less than 6 tablespoons daily.
• Contraindications: High doses are contraindicated in pregnancy, blood thinners, previous allergic reaction, hypotension (low blood pressure), hypoglygemia (low blood sugar). Can also cause stomach upset, nausea.

Ginger Rhizome (Zingiber officinale)

• Dosage: Added to taste in food
• Indications: Anti-inflammatory, can help with lowering blood glucose, lowers cholesterol, helps with weight management, helpful for healthy blood flow.
  
• Contraindications: Contraindicated when under anticoagulant treatment or when any medication and high doses of naproxen, ibuprofen, aspirin which are also known to thin the blood.

Cinnamon bark (Cinnamomum spp.) Garlic bulb (Allium sativum)

Foods

Foods with carotenoids like orange, yellow and dark green vegetables Leafy Greens

Olive Oil

• 1-2 tsp daily
• Look for organic olive oil coming from one country (not 2 or more countries)
• Do not cook with olive oil, it ruins the properties. Apply on food after it is cooked.
• Rich in polyphenols, plant sterols, triterpenes

Red Wine in moderation

• Dosage: 1/2 glass or organic red wine, sulfate free, once a day or less
• In moderate levels, it helps to lower risk of cardiovascular disease and high cholesterol. In high levels, it has a negative effect on the body and raises cholesterol.
• Contraindications: Do not use red wine if you have fatty liver disease, liver disease, formerly or currently suffering from alcohol abuse (alcoholism), currently trying to become pregnant, pregnant or breastfeeding

Blueberry Solid Extract (Vaccinium spp.)

• Dosage: 1/4-1/2 tsp twice daily, delicious
• Contraindications: Blueberry allergy

Pomegranate (Punica granatum)

• Dosage: 8-12 ounces a day (basically a cup a day)
• Contraindications: pomegranate allergy

Organic Dark Chocolate

• Purchase organic very dark chocolate high polyphenols
• One small square a day
• Contraindications: Chocolate allergy, difficulty with caffeine or methylxanthines

Pineapple

• Anti-inflammatory properties
• Useful in patients with kidney disease
• Careful with high blood sugar
  
• Contraindications: Pineapple allergy

Medications for Lowering Cholesterol

Statins

• What is it? – It blocks the enzyme HMG CoA reductase which is responsible for making cholesterols.
• Pros: Lowers cholesterol, may reduce cardiovascular risk
• Cons: Depletes or reduces the body’s ability to produce: CoQ10, Vitamin K2, selenoproteins, vitamin D, sex hormones causes muscle pain.
• Taking CoQ10 can help reduce muscle pain
• Dosage: Determined by your doctor

PCSK9 Inhibitor (injection)

• What is it? – Proprotein convertase subtilisin/kexin type 9 (PCSK9) is an enzyme that binds to low-density lipoprotein receptors (LDL receptors) and stops LDL being removed from the blood, leading to an increase in blood levels of LDL. Studies have shown that if you have naturally high PCSK9, you are more likely to have high cholesterol. This is often used in familial hypercholesterolemia.
• Pros: Very effective at lowering cholesterol, sometimes up to 70%. Lowers LDL up to 50%. It can reduce the risk of heart attack by 1/3.
• Side-effects: Fatigue, muscle pain, soreness, swelling near injection site. May increase risk of kidney and liver problems.
• Contraindications: Possible contraindication in kidney and liver disease.