Nutrition with focus High cholesterol also known as hypercholesterolemia.

Part 1:
Introduction to cholesterol:
Those with high cholesterol, usually along with other factors such as high blood pressure, are at an increased risk of atherosclerotic cardiovascular disease (ASCVD) which can cause cardiovascular incidents such as Myocardial Infarction. Hence those with high total cholesterol readings or high LDL (low density lipoproteins) are often recommended to go on a low cholesterol diet (usually reducing saturated fat) and/or put on medication such as statins (Ibrahim and Jialal, 2020). This seems limited.
Contrary to what I had presumed, a diet which supports lowering of cholesterol is not one which is itself is low in cholesterol but high in foods which support the body's functioning and promotes cardiovascular health. Dietary cholesterol does not seem to present a problem unless one is a hyper absorber, as it is maintained by balancing the amount produced with the amount absorbed, known as cholesterol homeostasis (Antoni, 2023). Being overweight, however, can increase cholesterol synthesis (Mc Auley, 2020).
While this essay will primarily focus on dietary advice it would be ineffective in isolation. A lifestyle including exercise, relaxation and joy is also essential. Chronic stress has been found to affect endothelial function and increase chances of ASCVD (Meng et al., 2021). Diets to lower cholesterol can be controversial. NHS advice is lower all saturated fats, while others think a low inflammation diet, reducing carbohydrates and sugar, with moderate fat is the route to go (nhs.uk, 2019), (Dong et al., 2020). Others think inflammation is inevitable with aging and so a diet which lowers cholesterol. I think a strategy which includes some of the Mediterranean and Portfolio diets along with being low in inflammatory foods such as carbohydrates and sugar would be most useful where hypercholesterolemia is a serious concern.
Cholesterol is an essential part of our body. It's used in the formation of steroid hormones, vitamin D, cell membrane structure, nerve function and skin hydration. It is carried by lipoproteins and is transported in plasma to deliver cholesterol, triglycerides, and fat-soluble vitamins to the respective cells as needed. Low density lipoprotein cholesterol (LDL-C) delivers cholesterol to tissues and high-density lipoprotein (HDL-C) recycles it to the liver (Paxton, 2015, p.106).
Cholesterol readings can be high due to lifestyle choices, genetic factors (familial hypercholesterolemia), and are of serious concern especially with other risk factors such as complications or previous cardiac incidents. In some situations, such as with hyper-absorbers of dietary cholesterol who have a higher incidence of atherosclerotic CVD, they would benefit from significantly reducing total cholesterol (Antoni, 2023). Secondary causes need to be ruled out as several pathophysiology’s such as diabetes, hypothyroidism, nephrotic syndrome and more can cause hypercholesterolemia (Ibrahim and Jialal, 2020)
The measuring of cholesterol:
One problem surrounding the cholesterol debate is that a simple lipid profile which at most measures' high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C), triglyceride levels and homocysteine levels is not informative enough. Normally high cholesterol is defined as an LDL-C greater than 190 mg/dL, greater than 160 mg/dL with one major risk factor, or greater than 130 mg/dL with two cardiovascular risk factors. The important risk factors include age, family history, hypertension, diabetes, smoking, low HDL-C (less than 40 mg/dl in male and less than 55 mg/dl in a female) (Ibrahim and Jialal, 2020). Where small LDL-C levels are high, raised triglyceride levels along with low HDL-C levels are often seen. Individuals with metabolic syndrome, obesity or insulin resistance are also at risk (Feingold and Grunfeld, 2000). Studies show that LDL-C particle number and size are important factors to indicate potential heart attacks (Dildy, 2015). Critically small dense LDL-C and high triglycerides treble the risk of heart disease which can be caused by high carb, low fat diets. Studies indicate that saturated fat increases LDL-C but improves the quality of the LDL-C and increases its size along with raising HDL-C which sugar drops (Dildy, 2015).

Why are small denses LDL-C considered a problem?
LDL is essential in the function of cholesterol in the body. And really calling LDL-C, ‘bad’ cholesterol is misleading but high volumes of dense small LDLs can be a problem. It is thought atherosclerosis starts with damage to the endothelium (Paxton, 2015, p.108). One potential cause could be high blood pressure, especially at junctions. Small dense LDL-C particles are extra likely to permeate the vascular intima and get trapped by proteoglycans in the intima. In the intima, LDL build up is oxidatively modified, this causes an inflammatory, fatty streak formation and an immune response in the intima. Macrophages and smooth muscle cells ingest oxidized cholesterol and enlarge to become foam cells. Chronic inflammation can cause this fat streak to grow into a complex lesion called atheroma covered by a fibrous cap which if exposed to chronic inflammation can break it down causing a clot to form (Paxton, 2015, p.108) (Ibrahim and Jialal, 2020).

Part 2:
Next this essay will look at NHS guidelines and review the advice under macro and micronutrient headings. Then I shall present my advice which incorporates some elements of the Mediterranean diet, Portfolio diet and low inflammation diet along with other advice.
NHS Guidelines: Ways to lower your cholesterol include
- Eat less fatty food, especially saturated fat. unsaturated fat is ok.
- Eat more:
· oily fish, like mackerel and salmon
· brown rice, wholegrain bread and wholewheat pasta
· nuts and seeds
· fruits and vegetables
Try to eat less:
· meat pies, sausages and fatty meat
· butter, lard and ghee
· cream and hard cheese, like cheddar
· cakes and biscuits
· food that contains coconut oil or palm oil

Exercise more
Aim to do at least 150 minutes (2.5 hours) of exercise a week.
Stop smoking, Cut down on alcohol.
(NHS, 2019)
Briefly, the advice to exercise more and to stop smoking are important parts of a healthy lifestyle and improve cardiovascular health.
Alcohol, a contensionus topic but cutting down on alcohol if the person drinks more than advised is important for a healthy lifestyle. While the effect of alcohol on an individual is complex, blanket recommendations are not possible (Boston and Ma, 2022). It seems light-to-moderate alcohol intake, usually defined as <30 g/d, could be protective for the development of hypertension, CHD including atherosclerosis and incident Type 2 diabetes. It affects a whole range of factors including HDL-C, LDL- C, plasma apolipoprotein(a) levels, platelet aggregability, blood fibrinolytic activity, insulin sensitivity, estrogen levels, and stress (Minzer, Losno and Casas, 2020), (Agarwal, 2002).
Specific diets for managing high cholesterol:
I do not have space to write in dept about all the facets of a diet for overall health and the wider food politics I feel I must mention some. I have focused on the points I felt were most saliet to ASCVD with the Mediterranean and Portfolio diets being a major influence.
The section called ‘try to eat less of’ on the NHS advice references many processed foods. Unhelpfully these foods are dominant. A healthy diet is one of whole grains, minimally processed. It can take more effort to source good food and prepare it. And while being too dogmatic could cause its own food stress, it should be what influences our choices.
Diet:
Fats:
Saturated fat: This is a much-debated topic as studies have not been unanimous and it seems it depends on what type and where the saturated fat is. One meta-analysis showed a 21% reduction in cardiovascular events when saturated fats were reduced for at least two years. It explored macronutrient substitution and found replacing saturated fat with polyunsaturated fats was more protective of CV events than replacing with carbohydrates (Hooper et al., 2020).
Dairy:
Whereas others fail to find an association, especially when looking at saturated fat in specific foods such as dairy. This may be due to nutrient substitution not being accounted for and other factors interacting, collectively known as the food matrix. These factors influence absorption, digestion and bioactive nature of nutrients and may have cardioprotective elements.
Full fat dairy, especially fermented dairy, such as yogurt, kefir and cheese have been shown to improve cardiometabolic health (Astrup, Geiker and Magkos, 2019). One meta-analysis found dairy yogurt consumption may improve weight and cardiovascular outcomes (Sayon-Orea et al., 2017). It is thought the combined action of short chain fatty acids, protein, calcium, vitamin D, and probiotics present in the matrix of some dairy foods results in powerful beneficial health effects regardless of the saturated fat content. (Astrup, Geiker and Magkos, 2019), (Schmidt et al., 2021).
Butter and cream, which is purely the fat element of dairy should only be consumed in very small amounts.
If people want some butter but a healthier version, one can blend a block of butter with an equal amount of cold pressed olive oil and use as a spreadable butter.
Coconut oil is good cooking oil in moderation due to its high smoke point. While has saturated fat, they are short chain fatty acids and it also contains unsaturated fat. It raises both HDL and LDL, while improving the profile of LDL’s to the preferable large and fluffy (Dreon et al., 1998), (Hewlings, 2020), (Chinwong, Chinwong and Mangklabruks, 2017). Choosing a high quality, ethically traded oil is important (Crumbie, 2018).

Unsaturated fat:
Unsaturated fats can help keep cholesterol numbers low, these include monounsaturated fats such as found in nuts and olive oil and polyunsaturated fats such as fish.
Virgin olive oil, abundant in Oleuropein, hydroxytyrosol, and their derivatives are polyphenolic compounds. They are powerful antioxidants and are found to modulate the human immune system Along with improving HDL (Katerina Sarapis et al., 2022). Studies show promising results in the prevention and treatment of cancer or cardiovascular and neurodegenerative diseases (Gorzynik-Debicka et al., 2018).
The NHS advice is too vague, recommending reducing saturated fat, replacing it with unsaturated fat. Sunflower and vegetable oils (which can be highly processed) are unsaturated fat. However they are high in Ω-6 polyunsaturated fats and without simultaneously increasing Ω-3 fatty acids can leads to an increased risk of death (Ramsden et al., 2010). They are also unstable at high temperatures, resulting in high aldehydes, known to be bad for health (Peng et al., 2017).
Trans-fatty acids: Are made from manufactured hydrogenated unsaturated fatty acids and always to be avoided (Soliman, 2018). Trans fat increases LDL, triglycerides and insulin levels and reduces beneficial HDL (Dhaka et al., 2011).
A criticism of low-fat options is that it can often mean more sugar, less feelings of satiety leading to consumption of excess calories along with inflammatory factor (Nguyen, Lin and Heidenreich, 2016). Along with possible danger of being deficient in fat soluble vitimins A, D, E and K.
Carbohydrates:
Studies show reducing refined carbohydrates which includes sugar, as opposed to fat, seems to have more favorable effects on atherogenic dyslipidaemia, inflammation, thrombogenic and atherosclerotic surrogate markers (DiNicolantonio, 2014). This is because refined carbohydrates lower HDL, increase triacylglycerol levels and are inflammatory (Ma et al., 2006).
Like the Mediterranean and portfolio diet I would recommend a diversity of whole grains such as buckwheat, oats, spelt, quinoa (British grown is available) and whole meal breads. They have high amounts of fiber, including soluble fiber β-glucan which is effective at reducing cholesterol levels, especially unprocessed oats (Grundy et al., 2018)
Beans, whole fruits and vegetables are also a healthy source of carbohydrates. The whole meal grain element being no more than ¼ of the plate (Boston and Ma, 2012). Some ideas include using a spiralizer and using spiralized vegetables along with whole meal spaghetti, or adding small, chopped vegetables and/or cooked beans to brown rice (which has been soaked in advance to reduce phytic acid) near the end of its cooking. Have a smaller portion of potatoes. Cooked and cooled potatoes which can be warmed again have higher levels of resistance starch which can reduce LDL as they are digested in the colon and produce among other things beneficial short chain fatty acids (Yuan et al., 2018). Studies show carbohydrate restriction has been associated with reduction in total HDL cholesterol ratio, apolipoprotein B, and the mass of small, dense LDL particles. (Wylie-Rosett et al., 2012). I would advise no simple, carbohydrates and low complex carbohydrates with a limit on added sugars, sugar lowers HDL (Schaefer, Gleason and Dansinger, 2009).

Protein:
Protein,35 grams:
Beans and pulses such as various peas, chickpeas, kidney, black, white cannellini, pinto, lentils and tofu. Beans are high in soluble fiber, which binds to cholesterol in the blood and moves it out of the body. Studys have shown 180 g of beans a day can lower LDL-C in those with raised levels (Doma et al., 2021).
If eating fish or meat, Oily line caught wild fish, grass fed local red meat or free-range organic poultry. Grass fed is a lot better as it is higher in omega 3’s. Most livestock in the UK is fed GMO soy and corn along with other welfare concerns (Provenza, Kronberg and Gregorini, 2019).

Nuts: One handful a day, or about 23 almonds, walnuts (especially high in omega 3s, pecans and brazil nuts. A handful of nuts has been shown to have positive cardiovascular effects along with lowering LDL-C (Del Gobbo et al., 2015). Walnuts have been shown to be particularly helpful as they contain linoleic acid and alpha-linolenic acid (Duke and Castleman, 2001, p.430). These polyunsaturated fats elicit cardioprotective effects by decreasing lipid and lipoprotein levels and by eliciting vascular anti-inflammatory effects. (Zhao et al., 2004)

Soluble fiber: 57 grams of foods with B-glucan and other viscous dietary fiber (oats, barley, okra, eggplants and fruits such as apples and pears, citrus and berries) Eating 5 to 10 grams of soluble fiber a day can help lower total and LDL-cholesterol by 5 to 11 points (National Lipid Association, n.d.). It is important to increase water intake along with fiber. Psyllium suppliements can be useful extra support is needed.
Plant sterols: 2 grams, a tbs of sesame seeds, a ¼ cup of sunflower seeds, or ½ of an avocado are all rich in plant sterols.Phytosterols compete with cholesterol for absorption in the digestive tract. Plant sterol suppliments are also available.

Lifestyle: Stress and exercise
Studies show that phycological stress can cause high cholesterol and that exercise can improve it, High levels of cortisol from chronic or long-term stress can cause high blood cholesterol, along with other heart disease risks.
Stress also triggers inflammation that lowers your HDL which helps clear out extra LDL (Assadi, 2017).

Conclusion:
While I agree with David J. Jenkins that there is no healthy diet on a dead planet we have come to different conclusions. The recommendations are contrary to our current ‘convenient’ western diet and food systems which has in part created this epidemic. A diet of whole foods, chosen and prepared with thought as to their origins and content is good for all round cardiovascular health and the health of the planet and the people working within the food system.
While I mainly looked at the recommendations from the NHS that I felt needed elaborating I would have loved to have discussed loads of other helpful foods such as beetroot or hawthorn berry ketchup and herbal teas such as hawthorn leaf and flower which would be beneficial to cholesterol levels and overall cardiovascular health (Wu et al., 2020).

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