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Preventive Medicine

Keys to Lower Cholesterol


COPYRIGHT 2005, SAUDI ARAMCO. All rights reserved.
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may be reproduced for educational purposes provided that Saudi Aramco is credited.
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C H O L E S T E R O L

What is cholesterol?
Cholesterol is a waxy, fat-like substance found
in the bloodstream. Our body needs cholesterol
to make hormones, vitamin D, and bile (for
digestion); to build cells; and for proper
functioning of our brain and other organs.

Cholesterol comes from two sources. Our liver


manufactures about 80% of the cholesterol
we need. We get the rest from dietary sources,
e.g., meat (especially liver and other organs),
egg yolks, butter, whole milk and its products,
and some seafood.

What causes high cholesterol?


In many individuals high blood cholesterol
comes from a diet that is high in trans and
saturated fats and cholesterol. See p. 10 for
more information. Some people are born
with a genetic condition that causes them to
produce too much cholesterol; such individuals
have high blood cholesterol despite what they
eat.

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C H O L E S T E R O L

What are the effects


of high blood cholesterol?
High blood cholesterol significantly increases
your risk for heart disease by contributing to
Atherosclerosis atherosclerosis (a build-up of fatty deposits
inside arteries) which in turn causes poor blood
flow. These deposits can break off, travel in the
bloodstream, block the blood flow, and cause a
heart attack or stroke.

What are LDL and HDL?


LDL (low-density lipoprotein) and HDL (high-
density lipoprotein) are compounds that help
cholesterol travel in the blood.

LDL carries cholesterol to wherever the body


needs it. Since the need for cholesterol is
limited, any excess amount being carried by LDL
is deposited on the walls of the arteries. Over
time these deposits accumulate, leading to
atherosclerosis. This is why LDL is called “bad”
cholesterol.

HDL is referred to as “good” cholesterol because


it carries the excess cholesterol to the liver where
it is destroyed.

Thus individuals who have high levels of HDL and


low levels of LDL are less likely to develop heart
disease.

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C H O L E S T E R O L

Measuring cholesterol
High cholesterol produces no symptoms and
can only be detected through a blood test (lipid
profile) after fasting for 12-14 hours. The test
measures total cholesterol, HDL, and triglycerides
(another form of fat in the blood). LDL is
calculated by applying the following equation:
LDL = Total cholesterol - [HDL + (Triglycerides/5)]

Classifications of Cholesterol
and Triglycerides (mg/dL)
Desirable Borderline Undesirable
Total 240 and
Below 200 200 - 239
Cholesterol above
160 and
LDL Below 130 130 - 159
above
200 and
Triglycerides Below 150 150 - 199
above
HDL: Optimal level is 40 or higher
Source: National Heart, Lung and Blood Institute

This chart represents a general guideline. Values


will vary according to certain factors such as age,
gender, family history, and medical conditions,
i.e., diabetes. Consult your physician to identify
your individual target levels.

How often should cholesterol


be checked?
Men aged 35 years and older and women aged
45 years and older should have their cholesterol
checked every five years. Those with other risk
factors for heart disease should start at age 20.
If you have high cholesterol your physician may
advise you to check it more frequently.

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C H O L E S T E R O L

What are the risk factors?


Certain factors increase our chance or risk of
developing high blood cholesterol. There are
two types of risk factors: those beyond our
control and those within our control.

Uncontrollable risk factors

Heredity
Some people are born with a tendency to
handle cholesterol abnormally.

Age and Gender


Cholesterol levels rise with age in both men
and women. Before menopause, women
have lower total cholesterol levels than men.
Estrogen reduces a woman’s risk of heart
disease by raising HDL levels and decreasing
LDL levels. After menopause, women’s LDL
levels tend to rise.

Having two or more risk factors


(e.g., high cholesterol, high blood
pressure and diabetes) multiplies
the risk for heart attack and stroke.

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C H O L E S T E R O L

Controllable risk factors


Diet
A high-fat diet increases the levels of cholesterol
in the blood. Saturated and trans fats raise
cholesterol levels even more than dietary
cholesterol itself because they stimulate the
liver to produce more LDL. See p. 10 for more
information on fats.

Medical conditions
High cholesterol occurs in some people with
diabetes, high blood pressure, under-active
thyroid, and disorders of the liver or kidney.

Smoking
Smoking can decrease your HDL and increase
your LDL. It also damages the lining of the
blood vessels, making them more susceptible to
atherosclerosis (see p. 2). Additionally, smoking
increases the tendency for blood to clot,
increases blood pressure, and decreases exercise
tolerance. All these factors increase your risk
for heart attack or stroke.

Physical inactivity
Lack of exercise may lower your level of HDL.

Obesity or overweight
Excess weight may increase your levels of
cholesterol and triglycerides and lower your
HDL.

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C H O L E S T E R O L

How can you control


high cholesterol?
Individuals with high cholesterol should work
with their physician and dietician to develop a
plan to control it. The following measures and
lifestyle practices can help prevent and control
high cholesterol.

Maintain a healthy diet


Choose foods low in saturated fat, trans fat
(hydrogenated or partially hydrogenated oils)
and cholesterol, and high in fiber. Select whole
grains, fresh fruits and vegetables, nonfat or
low-fat dairy products, fish, poultry (skinless)
and legumes. Limit added sugar and salt.

Limit saturated and trans fats as these cause


your body to produce more LDL. Trans fats also
lower your HDL. See p. 10 for more information
on fats.

Limit foods containing cholesterol, especially


concentrated sources such as organ meats,
egg yolks, butter, and whole-milk products.
Cholesterol is found only in animal products.
Fruits, vegetables, grains, legumes (dried beans
and lentils), nuts, and seeds are all cholesterol-
free.

Choose lean cuts of meat and trim all visible


fat before cooking.

Note: Dietary fat is needed in early childhood


to ensure proper development. Children may be
given low-fat products beginning at age three
and non-fat products beginning at age five,
unless instructed otherwise by a physician.

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C H O L E S T E R O L

Eat foods with soluble fiber. There are two


forms of dietary fiber: soluble and insoluble.
Soluble fiber forms a gel when mixed with
liquid, while insoluble fiber does not. Although
both types of fiber are important, soluble fiber
is the one that can help lower your total blood
cholesterol level. Eat 20 to 30 grams of dietary
fiber daily. Foods such as oats, barley, beans,
peas, brown rice, citrus fruits, apple pulp,
strawberries, and carrots are good sources of
soluble fiber.

Eat fish more often. Some fish - particularly


fatty types found in cold water, such as salmon,
mackerel and herring - contain high amounts
of omega-3, a polyunsaturated fat, which may
lower cholesterol and triglycerides. Young
children, pregnant women, women who are
breast-feeding and women who plan to become
pregnant in the next several years, should not
eat king mackerel, shark, swordfish or tilefish,
and should limit their intake of albacore tuna
due to increased mercury. Salmon, canned light
tuna, pollack, shrimp and catfish are generally
low in mercury.

Eat soy products. Soy proteins can reduce your


levels of total cholesterol, LDL, and triglycerides,
and may also raise your HDL.

Choose wisely when eating out. Avoid fast


food restaurants as these foods are usually high
in trans and saturated fats. Choose restaurants
that carry “heart healthy” selections. Ask
about ingredients and how foods are prepared;
request smaller portions.

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C H O L E S T E R O L

Control medical conditions


Individuals with diabetes, high blood pressure,
and elevated triglycerides should follow the
instructions of their physicians and dieticians,
take medications as prescribed, and keep clinic
appointments.

Quit smoking
To successfully quit smoking: set a quit date;
study your smoking habit (ask yourself where,
when and why you smoked; identify what
you could have done instead); list ways to deal
with barriers that have kept you from quitting
before; and tell everyone you know that you
are quitting.

Quitting often requires several attempts.


Many smokers benefit from a combination of
counseling and nicotine replacement therapy.
Consult your physician for more information.

Maintain healthy weight


Losing weight can help lower your LDL,
triglycerides, and total cholesterol levels, as
well as raise your HDL levels. Those who are
overweight are advised to increase physical
activity and reduce calorie intake by eating
smaller portions, avoiding high-sugar foods,
and using nonfat or low-fat products.
Quick weight loss methods (i.e., diet pills or
prepackaged foods) don’t provide lasting
results. To maintain weight loss, set realistic
goals and lose weight gradually. If you join a
weight-loss program, select one that promotes
a balanced diet and emphasizes changing your
eating habits.

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C H O L E S T E R O L

Be physically active
Physical activity can help lower LDL cholesterol
and raise HDL cholesterol levels. It also helps
control weight, lower blood pressure, control
diabetes, and manage stress.

If you’ve been inactive for a long time, begin


with a low to moderate level activity, i.e.,
walking. Increase slowly until you can sustain
a level that increases your heart and breathing
rates for at least 30 minutes on four or more
days per week. Whether you choose to run,
swim, attend an exercise class, or play tennis,
the important thing is to find something that
you enjoy.

Most healthy people can safely engage in


moderate levels of physical activity, i.e., walk-
ing. Middle-aged or older persons who are
inactive and at high risk for heart disease or
who have a medical condition should seek
medical advice before increasing their physical
activity. If in doubt, check with your physician.

A healthy lifestyle should begin


in early childhood and continue
throughout life.

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C H O L E S T E R O L

Fats in the diet


To reduce blood cholesterol levels, it is especially
important to limit saturated and trans fats.
Check nutrition facts labels for information on
fat content.

Unsaturated fats (polyunsaturated and


monounsaturated) are liquid at room
temperature. Found mostly in plants, these are
less likely to raise blood cholesterol levels. In
fact, there is evidence that monounsaturated
fats (olive, peanut, or canola oils) may even
help lower cholesterol. Thus, most dietary fat
should be unsaturated.

Saturated fats are solid at room temperature.


They are found mainly in meats, butter, and
dairy products made with whole milk. Cocoa
butter, palm oil, and coconut oil are plant
sources of saturated fats found in commercially
prepared baked goods. Saturated fats should
be limited.

Trans fats (hydrogenated or partially


hydrogenated oils) are produced during food
processing when (unsaturated) vegetable oil is
converted into a solid or semi-solid. Since these
fats have a longer shelf life they are used in
baked goods and snack foods, e.g., cookies,
cakes, and crackers. Shortenings and some
margarines are also high in trans fat. Trans fats
should be limited.

Trans and saturated fats increase


blood cholesterol levels.

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C H O L E S T E R O L

Tips to reduce dietary cholesterol

Complex Carbohydrates
Category Choose Limit

Whole grain breads


and rolls; low-fat or
Butter or cheese rolls and
homemade muffins,
breads; commercial biscuits,
pancakes, waffles,
muffins, pancakes, pastries,
Bread and biscuits using
sweet rolls, donuts, croissants;
unsaturated oil or tub
ready-made mixes with trans
margarine, and non-fat
and/or saturated fats
milk; use egg whites or
egg substitutes

Dishes prepared with whole


Whole wheat noodles
milk, egg yolks, cream,
(spaghetti, macaroni);
Pasta and Rice and cheese sauces; canned
rice (preferably brown or
or boxed noodle dishes
wild rice)
(macaroni, spaghetti)

Cooked or dry oats


Cereals and bran, barley Highly sweetened cereals
(preferably unsweetened)

Fried snack foods; snacks


Snacks (e.g., crackers,
or crackers containing trans
pretzels, popcorn)
and/or saturated fats; cheese
Snacks prepared with mono/
crackers or snacks; potato
polyunsaturated oil;
chips; corn chips; tortilla chips;
air popped popcorn
commercial buttered popcorn

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C H O L E S T E R O L

Meats and Protein


Category Choose Limit
Lean meats: Beef Fatty meats: Mutton, ribs,
(round, sirloin, chuck, luncheon meats (e.g., corned
loin, super lean ground beef, pastrami), beef bacon,
beef); lamb (leg, arm, beef sausage, frankfurters,
loin); veal (all trim cuts canned meats, sandwich
Meats except commercially spreads
ground)
Organ meats: Liver,
Limit meat to one 3 oz brain, kidney, heart, tripe,
serving, five meals per sweetbreads, gizzards,
week. Trim visible fat. stomach, all other organ meats
Fried poultry; self-basted
poultry; duck; processed poultry
Chicken and turkey with
Poultry products (chicken or turkey
skin removed
franks / turkey ham, bologna or
bacon)

No more than two egg yolks


Egg whites and egg
Eggs per week, including yolks in
substitutes
cooked or prepared foods

Caviar
Seafood All fish Limit shrimp, oysters and squid
to 2 oz per week.

Whole fat dairy products,


Skim or low-fat milk and
sour cream, heavy cream,
dairy products (yogurt,
Dairy coconut milk, milkshakes,
buttermilk, labneh and
cream cheese; processed
cheese)
cheese and cheese spreads

Dried beans, peas,


lentils; tofu; peanut
Legumes Added saturated fats
butter - limit to 2 Tbsp
a day

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C H O L E S T E R O L

Fruits and Vegetables


Category Choose Limit

Fresh or frozen Creamed, breaded, or deep


Vegetables Canned (rinse with fried vegetables; vegetables in
water) cream sauces

Fresh, unsweetened
dried fruits; canned or Canned or frozen packed
frozen packed in water, in heavy syrup, sweetened
Fruit
own juice or light syrup dried fruits, coconut,
preferred; all fruit juices fried fruit snack chips
(unsweetened preferred)

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C H O L E S T E R O L

Fats
All fats should be limited when weight is a concern.
Category Choose Limit

Unsaturated

Monounsaturated:
Canola, olive and
peanut oils
Saturated: Coconut, palm
Oils
Polyunsaturated: and palm kernel oils
Sunflower, safflower,
corn, soybean,
cottonseed and
sesame oils

Saturated: Butter, meat


drippings, animal fat,
Tub margarine in cocoa butter
Other Fats
moderation
Trans fats: Stick margarine,
shortenings

Made with saturated


Made with
Salad Dressings oil (e.g., palm oil)
unsaturated oils
and/or egg yolk

Unsalted pumpkin
seeds, ground flaxseed,
sesame seeds,
Seeds and Nuts None
sunflower seeds,
almonds and other
nuts

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C H O L E S T E R O L

Miscellaneous
Category Choose Limit

Homemade baked
Homemade baked goods
goods made with
made with whole milk,
unsaturated oils or
butter, stick margarine,
tub margarine, nonfat
shortening, cream,
or low-fat milk, and
chocolate, and egg yolk;
egg whites or egg
commercially prepared cakes,
Desserts substitutes; gelatin;
pies, cookies, pastries; ice
angel food cake; low-
cream and other frozen
fat frozen desserts;
desserts; cake, brownie and
puddings or custards,
other commercial dessert
made with non-fat
mixes; chocolate and candies
milk and egg whites or
made with cream fillings
egg substitutes

Low-fat or fat-free;
Soup made with whole milk
broth, consommé, and
or cream; broth containing
bouillon; homemade
Soups and fat; canned soups; gravy and
soup skimmed of fat;
Sauces sauces made with butter,
cream soup and sauces
margarine or animal fat,
made with nonfat milk
and whole milk
and unsaturated oils

Spices, herbs, pepper,


lemon juice, garlic
and onion powder,
Mayonnaise, croutons,
Tabasco, catsup,
Other commercially fried foods,
mustard, vinegar,
i.e., french fries
relishes, jam, jelly,
marmalade (preferably
unsweetened)

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C H O L E S T E R O L

Medications
Oftentimes lifestyle changes aren’t enough
to bring the desired reduction in cholesterol.
In such cases your physician may prescribe
medication, especially if you have a family
history of high cholesterol or other risk factors
for heart disease.

People respond differently to medications.


Thus, most patients go through a trial period
to find out which medications and doses are
most effective, with the fewest side effects.
It may be necessary to take a combination of
medications. Always report unpleasant side
effects to your physician.

Once you have lowered your cholesterol to the


desired level, your physician will advise you
how to maintain results. It may be necessary
to stay on the medication indefinitely and you
should not stop taking it unless your physician
advises you to do so.

Individuals taking cholesterol-reducing


medication should have their levels checked
every four to six months and their liver enzymes
checked regularly.

Individuals taking cholesterol


medication should continue to
follow a diet that is low in trans and
saturated fats and cholesterol.

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Remember:
Always follow your physician’s instructions.
Take medications as prescribed.
Keep clinic appointments.
Report any problems to your physician without delay.
Keys to Lower Cholesterol

Keys to Lower Cholesterol L0049E Revised in 2005


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Preventive Medicine

Keys to Lower Cholesterol

Cholesterol