Sunday, 31 August 2014

Cholesterol - the heart of the matter

Someone dies from heart disease or stroke every seven minutes in Canada (Statistics Canada 2011c in Statistics Heart & Stroke Canada). Does anyone else find that alarming? The Conference Board of Canada says that Canada spends $20.9 billion dollars every year on health care services, hospital costs, lost wages and decreased productivity for heart disease and stroke. In 2010 Canadian hospitals saw 2.8 million hospitalizations for cardiovascular disease (Statistics, Heart & Stroke Canada).  

The statistics are endless. The bottom line is that our cardiovascular health status is in the crapper. As a population we are definitely failing in the heart and vascular department. And heart disease is almost exclusively categorized as a "lifestyle disease". In other words our diet, exercise, and smoking habits are killing our cardiovascular systems and us. 

Today I am writing about cholesterol. Cholesterol is a panel of tests measured in your blood. High levels of blood cholesterol (and inflammation) can lead to atherosclerosis, or the lining and clogging of our arteries, that ultimately causes heart attacks and strokes (Mayo Clinic). In Canada 40% of Canadians have high cholesterol levels (Statistics Canada 2011 in Statistics Heart & Stroke Canada) and that's just the people that we know about who have had their blood checked. Canadian obesity rates are phenomenal (obesity correlates with high cholesterol) - 60% of adults and 31.5% of children are overweight or obese (Statistics Canada 2012 in Statistics Heart & Stroke Canada). 

I could write at length about how extensive heart disease is and how much it is costing us as a nation and in our personal lives. But today I'd like to focus on nutrition and how to eat to reduce cholesterol. There's a lot of mythology out there and if I had to guess I would say that about 99% of the patients I see have incorrect information about how to lower their cholesterol with food. 

The reason we are so grossly misinformed about what makes up a heart healthy diet is that past recommendations offered by the medical community, the Canadian government, and disease agencies turn out to be….well… wrong. Existing guidelines have not reduced heart disease, obesity, or for that matter diabetes, cancers and other "lifestyle diseases". In fact in the fifty or so years that we have been eating this way (think Canada Food Guide or Heart & Stroke Diet) our rates of lifestyle diseases have shot up (J. of Nutrition).

The Low Fat Myth
The high carbohydrate low fat diet that was rolled out far and wide around the world simply doesn't work. We were told to reduce dietary fat as much as possible and that fundamental recommendation was apparently based on theory not evidence. Nevertheless food companies quickly developed a plethora of low fat and fat free products. The problem is that in order to remove fat from food and keep it edible and have a long shelf life, food engineers had to add in lots of sugar, salt, refined grains, and preservatives. As a nation our fat consumption went way down and our sugar/salt/carbohydrate intake shot up (Harvard School of Public Health, Liz Wolfe in Huffington Post).

The problem with the low fat diet is two-fold. First, it turns out that the amount of fat in our diets does not impact the cholesterol levels in our blood. What's important is the kind of fat that we eat and the balance of the fats that we eat. Trans fats and an overload of saturated fat can be damaging to cholesterol levels. But saturated fat eaten in balance with good fats (monounsaturated and polyunsaturated) is essential and reduces the risk of heart disease (NHS, UK; Harvard School of Public Health). Our hearts and other body parts (brains, hormones, immune systems, cells) need fat to properly function. When we took all fat out of our diets we stopped giving our bodies an essential macronutrient (Harvard School of Public Health).

The second problem with the low fat diet is all the sugar and carbohydrates that are used to replace fat.  Sugar and carbohydrates are rapidly absorbed by the body which causes blood sugar to shoot up and insulin levels to rise rapidly. Ultimately the system gets burnt out and we develop insulin resistance and diabetes which is toxic to most organs including hearts and vessels. Additionally sugar and carbs are stored in the body as fat. Fat crowds out our organs and cells and reduces insulin sensitivity which also leads to diabetes and heart disease. It is also sugar (not fat) that directly elevates serum triglycerides which leads to atherosclerosis and heart disease (Harvard School of Public Health).

What We Are Supposed To Eat: The Big Picture

In general terms it's pretty easy to figure this out. We make it hard for ourselves because we cannot imagine a diet without sugar or our favourite crackers. What's life without sugar? Longer.

The diet that we should be eating to reduce the risk of high cholesterol and heart disease is the same diet we should be eating to lose body fat, control diabetes, reduce cancer risk, and enhance mental health. Balanced healthy fats in the context of a nutrient rich whole foods diet.

If you know the words sing along. If you don't please see click here to see our Starting a Healthy Diet Tool or click here to see The Fridge List Tool. Don't rely exclusively on my blog. There are some great websites out there Diet Doctor: Real Food for your HealthPrecision Nutrition Blog) or register for a nutrition course or coaching (Nutrition Coaching with Cait Lynch @ 

You will definitely notice that there is a difference of opinion in the health care community about what to eat to lower your cholesterol (Can J. Cardiology, J of Nutrition). Some agencies are still pumping out the message to eat low-fat and high carbohydrate. They haven't updated their information. But do a little research and you will see that much of the information coming from reputable research sites, journals, and nutrition specialists are talking about a whole foods diet (Berardi & Andrews). And the proof is in the pudding, so they say. If your cholesterol isn't controlled with the old way of eating (high carbs & sugar and low fat) - try eating a whole foods diet and see what happens.

What's Out: 
  1. Sugar. It drives up our triglycerides which are toxic to vascular health. Sugar is a calorie rich but low nutrient food & is stored as fat, growing waistlines & taxing heart & organ function.
  2. Low fat intake: See above - we need healthy fats. And low fat products are high sugar and high carbohydrate so that means more calorie rich, low nutrient food. 
  3. High intake of processed & refined foods that emphasize carbohydrates. Crowding your plate with processed carbs means you aren't getting enough nutrient rich foods. It's one or the other. Fill up on fillers and you get….filler. Dump the processed and high carb foods and power your plates with healthy fats, whole proteins, vegetables and fruit. Consider the following: 
    • Both traditional Asian and Mediterranean diets seem to work well for low rates of heart disease. But these diets are quite opposite to each other. The Asian diet is high in carbohydrates and low in fat and the Mediterranean diet is high in fat and low in carbohydrates. Why do they both work? The solution seems to be in what they share. Both diets have a very low intake of processed and refined foods, include very high vegetable and fibre intake, and are very low in glycemic index. In other words they eat whole foods and don't eat processed food and sugar. 
    • Nutrients provided by half an avocado (healthy fats 14.7g, carb 8.6g, fibre 6.7g, protein 2g, sugars 0.7g, calories 160, vitamins C, E, K, & the B's) (California Avocado) beat the heck out of 2 slices of whole wheat bread (healthy fats 2g, carb 32g, fibre 4g, protein 7g, sugars 2g, calories 170, vitamins & minerals - primarily derived from additives) (Dempster's).  The avocado is made by mother nature. The bread is made by a company that adds "glucose-fructose/sugar" (3rd ingredient on the list) (Dempster's). 
What's In: 
  1. Whole foods. Replace processed with produce. More greens less grains. Food on your plate should look like it did on the farm. Eat like your grandmother did. The best foods don't have labels. You've heard them all. Get real about what you are eating.
  2. Healthy and balanced fat intake. Fat intake should be balanced equally between saturated: polyunsaturated: monounsaturated and Omega 6 should be balanced with Omega 3. What does all that mean? It's perfectly healthy to eat saturated fat (fat from animal products) in the context of consuming the other healthy fats (olive oil, vegetable oils, coconut oil, nuts, avocados, oily fish, flax seed) (Berardi & Andrews).
  3. Fibre: Up up and up a bit more (Berardi & Andrews). I guarantee you don't eat as much fibre as you think you do. Choose vegetables, chia seeds, flax, & raw nuts every day. Include power house veggies like broccoli and avocados and legumes and beans (Can J Cardiology). Make sure to drink lots of water when you eat a high fibre diet. 
  4. Vegetables vegetables and more vegetables: most sources are recommending 10 to 12 half-cup servings of vegetables per day (Berardi & Andrews). We need a mix (think different colours) and should have lots of leafy greens as well as solid and cruciferous vegetables. That kind of intake means you want to have vegetables with most meals including breakfast and your snacks. It's easy once you get going. Again - most of us think we eat enough vegetables but don't. According to Statistics Canada seven out of ten children and 56% of adults consume fewer than five servings of vegetables and fruit per day (Statistics, Heart & Stroke Canada). 

Sample Menus:
Don't be fooled by the marketing on packages. As discussed above get processed food and sugar out of your diet. That includes all those cereals, store-bought juices, and bread products. Manufacturers tell you that they are "healthy" but you will benefit far more from the nutrients and fibre in whole foods not the filler and calories in packaged food (Can J Cardiology, Harvard Medical School, Heart & Stroke Fnd Ont, J of Nutrition, Liz Wolfe in Huffington Post)

Sample Day 1
BF: 1/3 c oats, 1tbsp each chia, hemp seeds, flax, walnuts, almonds + almond milk or Greek yogurt.
LU: grilled chicken w/ field greens, avocado, alfalfa sprouts, purple onion, pumpkin seeds, homemade dressing
DI: Mahi Mahi pan fried tsp butter, cooked broccoli, asparagus, grilled portabello mushroom & orange pepper w/ o.oil
Snack: 4 tbsp hummus with raw zucchini, carrots, mushrooms + cup of green tea
Snack: 1.5 oz cheese, slices of tomato, 5 olives
Water: 16oz water with all meals and snacks.

Sample Day 2
BF: kale or Swiss chard or spinach pan fried in coconut oil with 2 eggs, slices avocado, tomato & 1 oz cheese
LU: grilled wild salmon w/ salad of arugula, cucumber, shallots, pistachios, homemade dressing 
DI: 4 oz grilled steak, 1/2 baked potato w/ 1tsp butter, grilled zucchini & beets w/ o.oil,  
Snack: 1/2 cup strawberries & blueberries with 1/3 cup plain Greek yogurt or 3 tbsp full fat cream, palmful almonds
Snack: 1.5 tbsp organic peanut butter mixed w/ 1.5 tbsp chia seed & 1 tbsp pumpkin seeds
Water: 16oz water with all meals and snacks.

Portion sizes depend on individual needs and health goals. Meal timing should be based on personal preference and activity. It is best to eat carbohydrate rich foods after exercise. Eat organic produce whenever possible. These are sample menus only. To obtain nutrition recommendations tailored to individual needs consult a nutrition coach or registered dietitian. For recipe and menu ideas see Real Fast Food & Wholesome Weekend recipes on this blog.
One Size Does Not Fit All:
I have many patients who come into the clinic and tell me that they want to do what their friend is doing to manage cholesterol because it's working for him so why can't they try? This gang tend to be the ones that stop medications because the lady at the bowling club said she had a friend of a friend that got a tumour when she was taking a Statin. I'm off topic.

Each person needs an individualized plan of action for managing high cholesterol. There are many factors that need to be taken into consideration - your age, gender, level of activity, body weight, family history, diet, smoking, health status (blood work results, blood pressure readings, cardiac tests) and personal history of disease. How we manage your cholesterol might be more or less aggressive than someone else's because there are quite different targets depending on your individual picture. And your action plan may change over time as you age or your family or personal medical history changes.

It is very important for you to have, and keep having, conversations about cholesterol with the people that provide your health care. This may include your family physician, nurse practitioner, cardiologist, registered dietitian, health and fitness specialist, and naturopath. Each professional will likely have expertise in a specific area of your care.

A heart healthy diet is helpful for virtually everyone. Exercise is appropriate for most (provided you are healthy enough to do it). Medications are necessary for some. And smoking is good for no-one. Quit. Immediately. Not all smokers get cancer but most get heart and lung disease. It's not fun. Trust me on that one.

Thanks for reading Getting Healthy with NP Sam. Comments welcome - click the pencil icon below.

Functional Foods to Increase the Efficacy of Diet in Lowering Cholesterol (Cdn J or Cardiology)
11 Foods That Lower Cholesterol (Harvard Medical School)
Top cholesterol-lower foods (Heart & Stroke Foundation of Ontario)
Lower Your Cholesterol (National Health Service UK)
Fats & Cholesterol: Out with the Bad, In with the Good (Harvard School of Public Health)
Statistics (Heart & Stroke Fnd Canada)
Arteriosclerosis/Atherosclerosis (Mayo Clinic)
Avocado Nutrients (California Avocado)
100% Whole Wheat Bread Nutrient Info (Dempster's)
Dietary carbohydrate restriction as the first approach in diabetes management (J. of Nutrition)
Are egg whites or whole eggs healthier? (Liz Wolfe in Huffington Post)
Berardi, J. & Andrews, R. The Essentials of Sport and Exercise Nutrition (Precision Nutrition)

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