The New Cholesterol Guidelines

Bringing the Science to your Dinner Table

Cholesterol is a waxy substance produced by the body and found in foods that come from animals. Cholesterol is needed by your body to make hormones, skin oils, digestive juices and vitamin D. You could not live without some cholesterol in your body.

However, too much cholesterol is a major risk factor for heart disease, particularly LDL (low density lipoprotein) cholesterol. LDL causes the build-up of fatty deposits within your arteries, reducing or blocking the flow of blood and oxygen to your heart.

It is estimated that millions of people are at much greater risk for heart disease than previously realized. This means more and more people will be walking away from their doctor’s office with a cholesterol-lowering drug prescription in hand. Medications aside, the new guidelines also vividly illustrate the growing epidemic of poor dietary habits, obesity, hypertension, hyperlipidemia and sedentary lifestyles that lead to the number one killer in the “Civilised World” today.

Measure your LDL and other blood lipids

Everyone age 20 and older should have their cholesterol checked at least every five years through a blood test. The guidelines recommend you have a complete “lipoprotein profile” that measures total cholesterol, LDL, high-density lipoprotein (HDL, the good cholesterol that may help prevent heart disease), and triglycerides, another type of fat in the blood stream. The test should be performed after fasting.

Low density lipoprotein (LDL) goal values:

  • Less than 70 mg/dL for those with heart or blood vessel disease and for other patients at very high risk of heart disease (those with metabolic syndrome,(obese, diabetes, hypertension)
  • Less than 100 mg/dL for high risk patients (for example: some patients who have diabetes or multiple heart disease risk factors)
  • Less than 130 mg/dL otherwise

Total cholesterol (TC) goal values:

  • 75-169 mg/dL for those age 20 and younger
  • 100-199 mg/dL for those over age 21

High density lipoprotein (HDL) goal value:

  • Greater than 45 mg/dl (the higher the better)

Triglyceride (TG) goal value:

  • Less than 150 mg/dl

Should I take cholesterol-lowering medication?

Drugs to reduce LDL include the “statins,” bile acid sequestrants, nicotinic acid and fibric acid. If your LDL and heart-disease risk are both high, doctors may prescribe medications at the same time as lifestyle changes. For others, medication may be added if six to 12 weeks on the TLC plan fail to adequately reduce LDL. Those who are started on a cholesterol-lowering medication will need to continue lifestyle changes.

Identifying those with metabolic syndrome

A group of specific risk factors, known as the metabolic syndrome, raise your risk for coronary disease at any LDL cholesterol level. If you have three of the following risk factors, you may have metabolic syndrome, and need more rigorous cholesterol lowering:

  • Abdominal obesity (a waistline over 35 inches in women and 40 inches in men)
  • Triglycerides of 150 of higher
  • Low HDL (lower than 40 in men and lower than 50 in women)
  • Blood pressure of 130/85 mm Hg or higher
  • Fasting glucose of 110 mg/dL or higher

Middle-aged men (age 35-65) are predisposed to abdominal obesity and the metabolic syndrome. As a result, they carry a relatively high risk for heart disease. For those with high risk, intensive LDL reducing strategies should be followed.

Because of all the above the guidelines for nutrition, physical activity and weight control in the treatment of elevated cholesterol have been modified and called the “Therapeutic Lifestyle Changes” (TLC) treatment plan. Even if you come out with a gold star on your cholesterol level and overall risk for coronary heart disease, most of us would surely benefit from implementing these guidelines.  Why the word therapeutic in the TLC guidelines?, because if you would stick to it you probably have a better effect than taking medications.
The following table can help you implement the guidelines into practical terms you and your family can enjoy and reap heart-healthy benefits:

New TLC guidelines

Why?  What does this mean?
Examples
Why?: Saturated Fat – less than 7% of total calories
What does this mean? Saturated fats are thought to have the most potent cholesterol raising potential.
Examples: Fatty cuts of meat, skin on poultry, egg yolks, lard, butter, palm oil, coconut oil, desserts and sweets, fried foods and most snack foods and fast foods.
Why?: Trans Fat – as little as possible
What does this mean? Trans fatty acids are formed when a liquid fat is turned into a solid one; a process called hydrogenation.
Examples: Limit foods with the following ingredients: partially hydrogenated oil, hydrogenated oil, stick margarine and shortening. Limit your intake of fried foods, cakes, pies.

Why?: Polyunsaturated Fat – up to 10% of total calories
What does this mean? Diets moderate in polyunsaturated fats are generally recommended. .
Examples: Margarine, soybean, safflower, sunflower, cottonseed and corn oils, pumpkin and sunflower seeds, most salad dressings and mayonnaise.

Why?: Monounsaturated Fat – up to 20% of total calories
What does this mean? Most desirable source of fat in the diet.
Examples: Olive and canola oils, nuts, nut butters and oils (e.g. peanut butter, almond oil), avocados and olives.


Total Fat – 25% – 35% of total calories

All of the fat you consume on a daily basis should not exceed 35% of total calories.
All of the sources of fat noted above.
Dietary Cholesterol – less than 200 milligrams each day
Excesses in dietary cholesterol have been linked to increases in coronary heart disease.
Cholesterol comes from two sources – that which your body creates and that which is found in animal products (meat, poultry, fish, egg yolks and dairy contain dietary cholesterol)


Carbohydrates – 50% of total calories

Why?: Carbohydrates are the building blocks of a heart-healthy diet.

What does this mean? Choose complex carbohydrates (instead of refined ones with white flour) to get the maximum nutritional benefit from these foods.
Examples: Whole grain or oat based breads, crackers, pastas and cereals, other whole wheat/grain based flour products; brown or wild rice; couscous, quinoa, barley, buckwheat; lentils, split peas and beans; fruits and vegetables.

Fiber – 20-30 grams per day

Why?: Dietary fiber, specifically the viscous (soluble) form, is associated with a decrease in cholesterol and contributes to a host of other health benefits.
What does this mean? All of the above complex carbohydrate food sources.

Examples: Aim for a minimum of 10 or more grams of viscous (soluble) fiber each day by increasing oats, barley, lentils, split peas, beans, fruits and vegetables


Protein – Approximately 20% of total calories

Dietary protein can come from both plant and animal sources and is an essential nutrient to good health. The problem is, many protein sources (especially animal sources) contain a lot of saturated fat and cholesterol so choose your protein sources wisely.
Major sources of protein in the diet: beef, veal, pork, fish, chicken, legumes like lentils and beans, dairy products, nuts, seeds and soy foods.
Total Calories – balance energy intake with output to achieve or maintain a desirable body weight
Excessive calories, regardless of the source, results in weight gain.

General advise: Aim to consume 4-6 small meals and snacks daily. Avoid skipping meals and eating late at night.

You may wonder HOW it is you can incorporate these guidelines into your and your families hectic lifestyle. Take the following steps one day at a time and focus first on the foods in your diet that are high in saturated fat and cholesterol. Start making simple substitutions for saturated fats with mono and polyunsaturated fats, couple this with a focus on fruits, vegetables and whole grains, some physical activity and you are well on your way towards reaching your nutritional goals. Below is an example of how the TLC guidelines would be implemented for someone on a 1,800-calorie diet. You may require more or less calories for weight loss or maintenance, see your registered dietitian or physician for more information on your caloric needs.

Nutrient

For a 1,800-calorie diet

  • Saturated fat, <7% of calories
  • 14 grams or less per day

Polyunsaturated fat, up to 10% of calories

  • Up to 20 grams per day

Monounsaturated fat, up to 20% of calories

  • Up to 40 grams per day

Total fat, 25% to 35% of calories

  • Between 50 and 70 grams per day

Carbohydrate, 50% to 60% of calories

  • Between 225 and 270 grams per day

Protein, about 15% of calories

  • Around 67 grams per day

Cholesterol

  • Less than 200 milligrams per day

Fiber

  • 20-30 grams per day with a focus on viscous (soluble) fiber

If the above is still to difficult to implement in your dietary habits, the statins are for most people a effective strategy to maintain or even regain better cardiovascular health and lower their risks for heart attack and stroke.