By Guest Contributor Justin Groce MSN, AGNP-BC, CVNP-BC, CSCS
“Your cholesterol is high; you need to take this (insert drug) along with and diet and exercise” followed by a succinct “see ya in 4 weeks” and an abrupt exit from your medical provider. Sound familiar?
I think we can all relate to having experienced a similar encounter with our primary care provider (PCP). Unfortunately, it’s not your PCP’s fault for such a brief medically-trite quip. After all, many insurance providers are switching from paying your doc on a fee-for-service basis to paying when the patient meets their “lab goals.”
So, what do you, the patient, do when your PCP says to “diet and exercise?”
Well, there’s the classic class of drugs known as the statins. Statins have received a bad reputation and have been the center of litigations in the past. However, these were the first generation statins and aren’t prescribed anymore. The statins currently on the market have pleiotropic effects including having antioxidant properties (especially on the vascular level), anti-inflammatory properties, and overall mortality reduction.
However, some people can’t tolerate statins while others simply refuse to take them. But alas, there are other options. Here’s where integrative medicine comes into play.
Integrative medicine is the integration of both conventional medical practices with non-conventional practices.
Conventional practices of improving your lipids is rather straightforward – your PCP pretty much puts you on a statin and says to “eat better and exercise.” Unfortunately, it pretty much ends there. On the contrary, integrative medicine focuses on educating you WHY your lipids are poor and what you can do to improve your lipid profile.
In this first installment I’ll discuss some nutraceuticals that you can implement to help improve your lipid profile. Without further ado…
1. Probiotics – yep…probiotics. Nothing sexy here; just simple gut bacteria. I try to get virtually every patient to start taking probiotics. At some point in your life you’ve taken antibiotics. Everyone with a sniffle seeks antibiotics. Antibiotics have, for some unknown reason, been given the almighty title of being a panacea of sorts; this is most likely due to old-school medical practices in which they were handed out like Halloween candy for anyone that comes through the clinic doors.
Your gut flora is actually a naturally occurring defense against invading pathogens. Also, your gut flora serves in a multitude of functions including aiding in digestion, regulating your bowel movements, and have even been implicated in the management of diseases such as diabetes, irritable bowel syndrome, fatty liver disease, and even cardiovascular diseases (the other implications are beyond the scope of this article).
In regards to lipid health your gut flora is involved in the metabolic processes of fatty acid digestion/regulation and the redistribution of your lipids. Your gut flora (via probiotics) can improve your lipids by diverting the foods you consume to bile acid excretion via your stool. Just how efficacious it is, we don’t know. As of now it is only speculative how well probiotics may improve your lipids.
2. Plant sterols – Plant sterols are the plant’s equivalent of cholesterol. These are commonly found in nuts, seeds, vegetable oils, and leafy greens. The chief sterols are beta-sitosterol, campesterol, and stigmasterol. Plant sterols work similarly to the prescription medication ezetimibe.
These work by blocking cholesterol absorption. Typically, you only need about 2.0-2.5g of plant sterols a day to get good efficacy. A dose of this nature could reduce your cholesterol upwards of 10-15%. The biggest concern for taking plant sterols is that they could possibly block the absorption of fat-soluble vitamins (A,D,E,K). Also, a rare condition, sitosterolemia, is a contraindication to taking plant sterols. In this condition the patient is a hyperabsorber of plant sterols, thus consuming plant cholesterols can actually do more harm than good.
3. Fish oils – Fish oils belong to a group of fats called omega-3 fatty acids. The primary fatty acids involved in improving lipids are eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Literature has shown that a combination of 3-4g daily EPA + DHA can lower triglycerides upwards of 50% in a dose-dependent fashion. Greater reductions are seen by those with higher starting triglycerides. Studies of diets involving the Japanese and the Inuit, both involving high consumption of marine animals, is what piqued the interest of scientists to investigate EPA and DHA.
The mechanism of action of EPA and DHA is that they lower triglycerides both blocking the production of very-low density lipoproteins (VLDL) and/or increase the clearance of VLDLs. VLDLs are the primary vehicle that carries triglycerides throughout the body. Furthermore, omega-3 fatty acids ehances the activity of lipoprotein lipase (LPL). LPL is responsible for breaking down triglycerides.
4. Viscous fiber – viscous fiber, which falls under the umbrella of soluble fiber, has been implicated to have cholesterol-lowering ability. These include plant pectins and gums. Viscous fiber exerts these effects by physically entrapping cholesterol and diverting it bile acid synthesis (rather than chemically-binding the cholesterol). It’s ability to entrap cholesterol is due to the viscosity itself hence the name viscous fiber.
Some studies have reported reductions in LDL of 7-9%. Other studies have reported reductions of up to 12.5% with 15g per day of viscous fiber. Effective doses that mitigate possible side effects lie in the 5-10g per day range.
Sources of viscous fiber include guar gum, oat bran, psyllium, and konjac mannan. Other sources include eggplant, okra, tomatoes, oat bran, barley, flaxseed, and persimmon. The biggest problem that many people face when consuming viscous fiber is the flatulence and/or bloating it may cause from colonic fermentation.
5. Pulses (AKA non-oilseed legumes) – Pulses, or dried legumes, include chickpeas, peas, beans, lentils, and lupini beans. At doses of simply 1 cup per day (2 servings) have demonstrated reductions in LDL by 5-8%. Although, these may be considered modest reductions the regular consumption of these foods have beneficial effects merely beyond LDL reduction.
Due to their relatively low glycemic index they tend to not cause large excursions in the post-meal glycemic index. Some literature has shown that pulses can even lower the a1c as well as blood pressure. A simple way to incorporate these into your diet is to simply switch out one meal a day with a canned lentil soup. I like Campbell’s Well Yes heart healthy lentil soup as well as Progresso’s canned lentil soup.
6. Tocotrienols – tocotrienols are derivatives of tocopherols (vitamin E) and are often obtained from palm oil or rice bran. Similar to tocopherols the tocotrienols also have the same four isomers (alpha, beta, gamma, and delta). Tocotrienols have greater antioxidant capabilities than do tocopherols. Furthermore, delta- and gamma-tocotrienols have the ability to lower your lipids.
Tocotrienols lower lipids in two ways: 1) they inhibit the conversion of farnesyl into farnesol; since farnesyl in the precursor to cholesterol the production of cholesterol goes down and; 2) they upregulate the LDL receptor (LDLR), which is responsible for disposal of LDLs.
When choosing tocotrienols choose either a delta- or gamma-tocotrienol product (delta is more potent). Reductions of LDLs of 8-27% have been observed with 200mg/day however do not exceed 200mg per day as the effectiveness goes down due to conversion to alpha-tocopherol, which competes with proteins that carry both tocotrienols and tocopherols. Lastly, the product should contain <20% alpha-tocopherol.
References:
Ballantyne, C (2015). Clinical Lipidology: A Companion to Braunwald’s Heart Disease (2e). Philadelphia, PA: ElSevier Saunders.
Grundy et al (2018). Guideline on the Mgmt of Blood Cholesterol: Executive Summary. JACC. 73(24).
(multiple authors) (2012). Guide to Anti-Aging & Regenerative Medicine. Chicago, IL: A4M.
Rakel, D (2018). Integrative Medicine (4e). Philadelphia, PA: ElSevier Saunders.