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Study Triggers New Enthusiasm 
for Diet in Age of Statins

Plant-Based Diet Lowers ‘Bad’ Cholesterol

At a time when doctors are recommending lower and lower cholesterol levels to reduce heart disease (and stroke) risk--data suggests that lowering LDL ‘bad’ cholesterol by 30 points lowers the risk of coronary heart disease by about 30 percent--the role of diet has been losing favor. Low-fat, low-cholesterol diets have proven only moderately successful, while statins reduce LDL-Cholesterol by 30% to 40% for a large proportion of patients, with few side effects. “The effect of diet on lowering cholesterol has been really minimized and undermined by a lot of clinicians and researchers saying, Yes, it has an effect but it’s really trivial. It would be better to put you on drugs to control cholesterol,” Christopher D. Gardner, director of nutrition studies at Stanford University’s Prevention Research Center, told the Associated Press when his study appeared in Annals of Internal Medicine (3 May 2005).

Gardner and colleagues showed that a low-fat, low-cholesterol diet with lots of vegetables, fruits, beans and whole grains reduced LDL (bad) cholesterol twice as much as the typical low-fat diet without these plant-based foods.

Cholesterol-lowering diets have traditionally focused on fat and cholesterol intake. Nutrition guidelines in the United States call for about 30% of calories to come from fat, with 10% or less saturated fat (and no more than 300 mg. cholesterol). Lowering fat intake to this level can be done with or without a high proportion of plant foods. We know that a diet high in plant-based foods is good for us, but it was not clear whether it is superior for lowering cholesterol. Dr. Gardner and his colleagues undertook to find out. (As regular visitors will remember, the 2005 USDA Dietary Guidelines and the recently unveiled food pyramid call for more vegetables, fruits and whole grains than ever before; see article 149 in our Diet & Nutrition category.)

  Study Details

The study involved 120 healthy non-obese people 30 to 65 with LDL cholesterol from 130 to 190, who get at least 10% of their calories from saturated fat. The subjects were randomly assigned to one of two diets (Low-Fat or Low-Fat Plus) with the same amounts of total fat, saturated fat, carbohydrate and cholesterol. The Low-Fat diet included  foods such as reduced-fat cheese, low-fat frozen lasagna, and low-fat snack foods. The Low-Fat Plus diet contained large amounts of vegetables, fruits, beans, soy, nuts, seeds, and whole grains; butter, cheese, and eggs were added to this diet to bring the saturated fat and cholesterol content up to the level in the Low-Fat diet.

Before and after the four-week study, researchers measured each participant’s total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides. In the plant-based diet group, LDL cholesterol dropped 9.4%, while bad cholesterol in the prepared-food group dropped 4.6%. Total cholesterol also dropped significantly more in the Plus group, but the change in HDL cholesterol and triglycerides was not significantly different.

The researchers concluded that the emphasis on avoiding saturated fat and cholesterol in previous dietary guideline probably short-changed the potential of diet to reduce cholesterol. “In this study, emphasis on including nutrient-dense plant-based foods, consistent with recently revised national guidelines, increased the total and LDL cholesterol-lowering effect of a low-fat diet.”

  Editorial Says Diet Powerful Strategy

An accompanying editorial by a Dr. David Jenkins and colleagues suggests that diet can be considerably more powerful than the Gardner study suggests. “The success of diets that combine foods containing cholesterol-lowering components make diet relevant in the age of powerful drugs like statins,” David J.A. Jenkins, MD, PhD, DSc, of the University of Toronto Clinical Nutrition and Risk Factor Modification Center, told the AP.

“The study by Gardner and colleagues is an important reminder that diet, in addition to drugs, can play a role in achieving cholesterol targets,” Jenkins et al wrote. The reduction in LDL shown by the plant-based diet group was large enough “to reduce all-cause mortality if sustained over time.” The reduction, however, could have been more substantial, according to Jenkins.

Obviously, adding butter, cheese and eggs to the plant-based diet to equalize the diets was like going into battle with one hand tied behind your back. But that’s only the beginning.

The fiber and plant protein in the Gardner-study Plus diet probably caused the greater reduction in total and LDL cholesterol. Jenkins suggests that greater amounts of fiber (especially viscous fiber as found in oats and psyllium), soy protein and other vegetable proteins, along with plant sterols, and nuts could have brought about a much greater reduction in cholesterol. Some of these foods reduce the production of cholesterol by the liver and others block the absorption of cholesterol. “In effect, a combination of these food ingredients is the dietary equivalent of combining a statin and ezetimibe [Zetia],” Jenkins writes.

“It may require the use of specific foods containing concentrated sources of cholesterol-lowering ingredients [such as Benecol],” Jenkins writes, but studies using a combination of such foods have “achieved 30% reductions in LDL cholesterol, much larger than that seen in Gardner and colleagues’ study, [and] similar to the LDL cholesterol reductions seen in the statin trials, which reduced coronary heart disease events by 25% to 30%.”

What’s more, combining cholesterol-lowering plant foods and statins, Jenkins writes, “could reduce the amount of drugs required to achieve therapeutic goals and thereby avoid the rare potential side effects that are more likely to occur at higher statin doses.”

“Perhaps the most obvious significance of Gardner and colleagues’ paper,” Jenkins concludes, “is the injection of new enthusiasm into the dietary management of hyperlipidemia.”

  A Personal Note

Carol and I debated whether to discuss my use of Lipitor and now Zetia in last month’s update of my article on coronary calcium (#105, Health & Fitness category). She finally came around to my view that it would be helpful for people to know that sometimes even the best lifestyle isn’t good enough. As Dr. Arnie Jensen wrote in my report: “I wish we knew why some people develop calcification in the arteries in spite of a wonderful lifestyle like you have, or why some people can completely ignore lifestyle and have a zero calcium score."

Arnie probably saved my life by finding the calcium in my arteries when there was still time to do something about it. He was as surprised--shocked--as me to find the calcified plaque in my arteries. Still, he didn’t immediately prescribe statins. My cholesterol was within the normal range and we thought lowering my homocysteine by adding supplemental folic acid might slow or reverse the process (article 17, Health & Fitness category). It was only after that didn’t work (it lowered my homocysteine, but the calcification process continued) that he recommended that I try the lowest dose of Lipitor.

Lipitor lowered my total and LDL cholesterol, and the progression of the calcification slowed with each check-up (a year or more apart), but not enough. That’s when Dr. McFarlin suggested that I add Benecol (article 132, Health & Fitness category). After a year of using Benecol Spread, a delicious butter substitute, it appeared that the soft plaque in my arteries might actually be receding (soft plaque becomes calcified plaque, which is permanent). We couldn’t be sure, however. That’s when Dr. McFarlin suggested that I add Zetia, to insure that we finally have the process under control.

I’ve never let up on my diet and exercise program. If anything, finding the calcified plaque in my coronary arteries strengthen my resolve. It took a combination of lifestyle and drugs to (hopefully) get my situation under control. Arnie Jensen says we can do more for ourselves than any doctor can do for us. I believe that and I’m doing all I can to help myself. Still, sometimes it takes you and the doctor working together to get the job done.

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