Diet and the Risk of Heart Disease

The Cholesterol Connection

If you want to know about your risk of heart disease, the first thing you need to do is get a blood test to check your cholesterol level. The test will measure the amount of cholesterol in your blood, which is an extremely important indicator of your risk for heart disease. 

While it is normal to have some cholesterol in your blood, it can be dangerous to have too much. This can happen if you eat a diet that is too high in cholesterol or in the saturated fats that can increase your cholesterol level.

How high is too high? How low should you go? The answers are pretty clear-cut.

Cholesterol Levels
 

High	240 or more
Borderline-high	200-239
Desirable	Below 200

A high cholesterol level is a huge risk factor for CHD. According to the results of the famous Framingham study, which tracked cholesterol levels of 5,000 men and women over 20 years, men with average blood cholesterol levels of 260 had three times more heart attacks than men with average blood cholesterol levels of 195.

If your cholesterol level is high, here are some ways to lower it.

• Reduce your saturated fat intake to less than 10 percent of the total fat in your diet.
• Reduce the amount of dietary cholesterol you eat. 
• Reduce your fat intake to less than 30 percent of your total diet.
• Eat more soluble fiber.
• Maintain your ideal weight.

Your total cholesterol level includes two different types of cholesterol in your blood: HDL and LDL cholesterol. HDL and LDL are both lipoproteins, or protein-containing packages in which cholesterol travels through the bloodstream. The acronyms stand for High Density Lipoprotein and Low Density Lipoprotein. HDL cholesterol is considered beneficial, but LDL cholesterol is considered undesirable; read on to find out why.

HDL Cholesterol

• Think of this as the cholesterol that is taken out of your arteries, or the detergent that sweeps cholesterol away.
• Your HDL level is a key factor in your risk of heart attack. For example, if your HDL level is low (below 35), you are at risk even if your total cholesterol is only 200. But if your HDL level is up around 80, your risk is lower -- even through your total cholesterol may be as high as 250.
• A good general rule is, the higher your HDL cholesterol, the better. 
• Women's HDL levels tend to be above 45, a good protective start against heart disease.

It is not exactly clear how to raise your HDL, but high HDL has been associated to some extent with the following factors.

• plenty of exercise
• modest alcohol intake
• low fat consumption 
• low saturated fat consumption
• low consumption of trans fatty acids

• This is the cholesterol that clogs your arteries.
• The lower your level of LDL cholesterol, the better for your heart health.
• In the US, more than half of men over 35 and women over 45 have high levels of LDL.
• LDLs can be small or large; small LDLs have been linked to undesirably low levels of HDL (good) cholesterol and to high levels of triglycerides. 
• One of three men and one of six post-menopausal women have more small LDLs than large ones and may therefore be at higher risk for CHD.

If you need to lower your LDL, try taking these steps.

• Take the steps described earlier to lower total cholesterol and increase HDL cholesterol.
• Stay as close as possible to your ideal weight.
• Keep your fat intake down.

Triglycerides

Triglycerdides are a type of fat found in the bloodsteam. Triglycerides only recently have begun to be considered important in cardiovascular health. High levels of triglycerides are now generally associated with a high risk of CHD.

Triglyceride Levels
 

Very High	1000
High	400-1000
Borderline	200-399
Normal	Below 200

High triglycerides are often attributable to excess weight or to heredity. In some cases, however, they may be associated with the carbohydrates in a very low-fat diet. They are not associated with all carbohydrates, however. Simple sugars and refined flours (such as those in a diet that is high in sugar and in low-fat products such as cookies, pretzels and pasta) tend to raise triglyceride levels in some people. On the other hand, whole grains and fruit do not seem to pose a large problem. Here is what you can do to lower your triglyceride level.

• Reduce total fat and saturated fat intake.
• Eat less sugar.
• Avoid alcohol.
• Eat more fish high in Omega-3 fatty acids. 

Lp(a) is a form of LDL cholesteral, or "bad" cholesterol. It is emerging as another risk factor for CHD, and elevated levels of Lp (a) in your blood should be of concern. However, it is not clear how to lower a high Lp (a) level. Some preliminary findings point to aspirin, red wine and Omega-3 fatty acids from fish as possibly lowering Lp (a) levels. More research is needed before specific dietary recommendations can be made, but following a heart-healthy diet is a good start.

Fifteen Ways to Lower Your Cholesterol Through Diet

1.Cut your total fat intake.

The risk of heart disease falls sharply if you reduce fat to less than 30 percent of total calories (as opposed to the 34-54 percent that is typical in the United States). When you lower fat consumption, you also reduce your saturated fat intake, cut calories and lose weight.

Exactly how much of your diet should come from fat is a matter of controversy. Too little fat may be as bad as too much, although this idea is somewhat controversial. It probably depends on your specific health profile. Two very different programs have proven track records:

• Dr.,Dean Ornish, a cardiologist, has published a number of books about his program, which has been proven to reverse heart disease. His plan includes exercise, meditation, support groups, an almost-vegetarian diet, and fat intake of only 10 percent. Ideal weight is also a goal of this plan. Overweight people with high cholesterol and Type A personalities will greatly benefit from Dr. Ornish's program. It is rigorous, rigid and effective.

• Advocates of the Mediterranean Diet, on the other hand, promote a diet of 30 percent fat. The recommended sources of fat, though, are largely olive oil, fish and nuts. People on this diet eat a good deal of cheese and yogurt, but they rarely eat red meat and pork and drink wine only in moderation. People of the Mediterranean have a lower incidence of heart disease and stroke than Americans.

2. Eat less cholesterol-rich food. 

Your daily cholesterol intake should be 300 milligrams or less. Certain animal foods are rich in cholesterol, but no plant foods contain cholesterol. Keep these food facts in mind.

• A single egg yolk has 255 milligrams of cholesterol; if you are healthy, you should eat no more than two egg yolks per week. (If you already have heart disease, you may be advised otherwise.)
• Egg white has no fat or cholesterol, so you might consider eating egg whites and egg substitutes frequently. Egg white is also an excellent form of protein. 
• Organ meats and certain seafoods -- shrimp, lobster and calamari -- have high levels of cholesterol. 

3. Avoid saturated fats. 

In terms of heart health, there is nothing good to be said for saturated fats! They are to blame for increasing total cholesterol, LDL cholesterol and triglycerides.

• Less than one-third of your fat intake should come from saturated fat.
• You find saturated fat in dairy fats such as cream, butter and cheese.
• Saturated fat is also in animal fats like chicken skin, visible fat on meat, and lard.
• The chemical structure of saturated fats makes them solid at room temperature. 

The tropical oils are palm, palm kernel and coconut oil. They are highly saturated. Many prepared foods contain them, so check labels for ingredients. You are likely to find tropical oils in these products.

• non-dairy coffee creamers
• whipped toppings
• baked goods
• cookies
• chocolate candy

Transfatty acids are compounds that occur when foods are chemically modified by partial hydrogenation. The safety of transfatty acids has been a controversial subject. Recent studies have helped resolve the issue; for instance, a US Department of Agriculture study showed that transfatty acids from partially hydrogenated vegetable oil raise cholesterol as much as saturated fats do. Fatty acids may also reduce HDL cholesterol (good cholesterol) and raise Lp (a). 

6. Increase your use of monounsaturated fats within your total allotment for fat. 

Monounsaturated fats lower blood cholesterol and will reduce your risk of heart disease.

• Monounsaturated fats are liquid at room temperature. 
• They are the main fatty acids in olive oil and canola oil.
• Use olive and canola oil in your cooking and in salad dressings to promote heart health. 

Polyunsaturated fats are the major fat source in vegetable oils such as safflower oil and corn oil. They generally lower total cholesterol, although they may also lower HDL cholesterol (good cholesterol). 

• Try to use less hydrogenated margarine; liquid and tub margarine are better than stick margarine. 
• Some less hydrogenated products may contain trans fatty acids, but you can avoid them by reading labels. The newest types of margarine are labeled "without transfats."

8. Get your Omega-3 fatty acids. 

Omega-3 fatty acids are polyunsaturated fats from plant and marine sources. Omega-3 is an essential fatty acid, linolenic acid. The richest sources are fish that swim in cold waters, such as those listed here; try to eat them 3-4 times a week.

• salmon
• bluefish
• mackerel
• tuna
• herring
• sardines

• significant reductions in high triglyceride levels
• slower blood clotting
• prevention of abnormal heart rhythms
• enhanced immune function
• improved eye and brain development

• walnuts 
• walnut oil
• flaxseed oil

9. What about shellfish? 

• Shrimp, although moderately high in cholesterol, is a very low-fat protein. Eaten once or twice a month it will not affect cholesterol levels. 
• All other shellfish are also acceptable, except squid (calamari) and roe (caviar). 
• Mollusks such as clams, mussels and scallops are all fine. 
• Be sure shellfish are from reputable sources and are cooked well.
• Have your seafood baked, broiled, steamed or boiled -- but not fried.
• Use only acceptable oils in preparing shellfish recipes which call for oil. 

Remember the oat bran craze? Well, there is nothing crazy about eating a lot of soluble fiber-which is found in oat bran, in abundance-if you want to lower your cholesterol. 

The soluble fiber in oats, called beta-gluca, has specifically been proven to reduce blood cholesterol. A high daily intake of soluble fiber, through generous servings of oat- and bean-based foods, helps to eliminate cholesterol-laden bile acids and fats from your body. 

Soluble fiber is found primarily in these foods.

• oats
• legumes
• apples
• pears
• plums
• carrots
• okra
• barley

11. Be sure to get enough folic acid, vitamin B6 and vitamin B12.

Low levels of folic acid and other B vitamins can cause excessive homocysteine to be produced in the body, and high homocysteine levels are an independent risk factor for heart attack and stroke. 

You need 400 micrograms of folic acid a day to prevent heart disease. A multivitamin will provide the recommended amount. Foods that will also do the job include the following.

• Total cereal
• Product 19
• lentils
• asparagus
• spinach
• kidney beans
• orange juice

12. Try more soy protein. 

A number of studies have shown that soy protein lowers cholesterol. Soy has isoflavones, called daidzein and genistein, which are the plant estrogens that play a role in cholesterol metabolism. Soy protein is a good protein that can be substituted for animal protein in your diet. Here are some sources of soy protein.

• tofu
• tempeh
• veggie burgers made with textured vegetable soy protein
• soy milk

13. Get more anti-oxidants. 

Anti-oxidants retard the development of "free radical" cells that are implicated in heart disease and cancer. Oxidized LDL (bad cholesterol) is damaging to the arterial wall. Certain vitamins and other compounds provide anti-oxidant effects.

• Vitamin E is an anti-oxidant; doctors recommend 400-800 IU daily for heart patients.
• Vitamin C is recommended as an anti-oxidant at 350-500 mg a day.
• Beta-carotene is recommended at 15 micrograms a day.

14. Go beyond vitamins -- and get your phytochemicals.

Phytochemicals are plant chemicals that may help prevent not only CHD, but also other chronic diseases and conditions such as diabetes, cancer and hypertension. 

• Fruits and vegetables are chock-full of them; eating five servings a day is a good start on the road to better health.
• Garlic may help reduce blood cholesterol, LDLs and triglycerides; garlic pills are being studied now, but the results so far are inconclusive. It appears that raw garlic is the active ingredient.

• Get a lot of exercise. It will help you lose weight, increase your HDL (good) cholesterol and lower your triglycerides.
• Lose weight if you need to. Losing just 10 pounds can make a difference in your cholesterol level, especially if your body is an "apple shape." 
• Your waist measurement divided by your hip measurement should be less than 0.9 for men and less than 0.8 for women. 
• If you smoke, stop.

Oils and fats are usually a mixture of the three kinds of fatty acids -- monounsaturated, polyunsaturated, and saturated. For heart -- healthy eating, keep these guidelines in mind.

• Choose food products with more monounsaturated and polyunsaturated fatty acids
• Reduce your use of saturated fats
• Refer to this chart to make healthier choices.

How to Reduce the Saturated Fat in Your Diet

Try these suggestions for replacing saturated fat in your diet with improved fat choices.
 

Food High in Saturated Fat	Lower Saturated Fat Alternative
Cream Cheese	Light cream cheese in a tub
Butter	Whipped margarine
Spray margarine	Butter Buds or Molly McButter
Egg	2 egg whites or egg substitutes
Chocolate	Cocoa with margarine
Ground Beef	Lean ground turkey, soy protein crumbles
Mayonaise	Light mayonaise
Shortening (1 cup)	Margarine (1 cup) or canola oil (3/4 cup)
Sour cream	Non-fat yogurt or non-fat sour cream
Cooking oil	non-stick pan, Pam cooking spray
Powdered coffee creamer	Non-fat dried skim milk

Sharon Howard, R.D.
Date Published: December, 1998
Date Reviewed: December, 1998

This information is not intended to be a substitute for professional medical advice. You should not use this information to diagnose or treat a health problem or disease without consulting with a qualified healthcare provider. Please consult your healthcare provider with any questions or concerns you may have regarding your condition.