Hello Plants, Goodbye Cholesterol
Repeat after me, “Cholesterol matters, cholesterol matters.” There may be confusion in the media about how cholesterol is “no longer a target” for disease prevention, but poppycock. Over the years, I have seen so many patients suffer major heart attacks, and the only abnormality even after an advanced evaluation was an elevated total and elevated LDL (low-density lipoprotein) cholesterol, an elevated LDL cholesterol particle number (an advanced measure of LDL cholesterol), or perhaps a low HDL (high-density lipoprotein) cholesterol. I would add that an elevated Lipoprotein(a), or Lp(a), cholesterol level is particularly common in families and should be a number you know. You might read that butter is back, meat is a treat, coconut oil is the new kale, high cholesterol is good for you, your brain needs lots and lots of fats, and . . . STOP! This is not science but rather media hype that we have been hearing more and more about.
After intense discussion and debate, the USDA’s 2015–2020 Dietary Guidelines for Americans made it crystal clear when it stated that “people should eat as little dietary cholesterol as possible. In general, foods that are higher in dietary cholesterol, such as fatty meats and high-fat dairy products, are also higher in saturated fats (which should be limited to 10 percent of total calories per day). The primary healthy eating style described in the Dietary Guidelines is limited in saturated fats and thus, dietary cholesterol (about 100–300 mg across the various calorie levels).”1 Plants have no cholesterol. Only animal products have cholesterol. Adopting the Plant-Based Solution is a proven way to lower or eliminate your dietary cholesterol load and at the same time decrease foods richest in saturated fats, like cheese, chicken, meats, and eggs.
Some plant-based foods, while free of cholesterol, are high in saturated fats. None is higher than coconut oil. Coconut oil is not a whole food because it has been processed to remove the water and meat. It is left with a whopping 92 percent of calories from saturated fat. There is no data that coconut oil is good or even safe for heart arteries. (Other coconut-based foods such as milk, yogurt, or sugar are not 100 percent fat and may be acceptable for many people.) Even olive oil is a highly processed food that may have 15–20 percent of calories from saturated fat. Oils are not WFPB but are processed, and important nutrients are ripped out. All the fiber and minerals are gone. Poof! Beware of them and the hype around them.
Cholesterol by the Numbers
CASE STUDY
Cholesterol and Thirty Days of the Plant-Based Solution
Adam is a lovable guy with a huge following in the business community. His giant smile attracts many to him on social media, and he was known for his posts calling his friends to meet for a late-night food orgy centered on burgers and bacon. He was the most meat-oriented person I had ever met, and I have little doubt he had bacon-scented deodorant and a full-body bacon suit to wear on Halloween.
I was pleased, therefore, when he texted me to say he wanted to try a change, maybe for just thirty days. Then in his late forties, he felt his diet high in processed foods, meat, and fats could not work long term, even though he felt okay. The fact that he ate almost every meal out made it a bit more challenging, but he said he was up to a thirty-day immersion into the Plant-Based Solution. I was stoked.
To document his status at baseline, I arranged advanced labs of his blood and urine. On the first of the month, he was ready to go. I admired his energy and enthusiasm to do this right. He switched out eggs and bacon for oatmeal and fruit. Lunch became soups and vegetable plates. Dinner might be baked potatoes, stir-fries with tofu, or a rare plant-based frozen meal. He posted pictures on social media of our grocery tours where I showed him hundreds of plant-based options. He actually shunned the processed meat substitutes and wanted to concentrate on whole foods.
Adam pretty much stuck to the program for the entire month. He noticed energy, regular bowel frequency with ease, and greater brain clarity. He had never eaten so many fruits and vegetables in his life as in those thirty days. After a month, I repeated his laboratory testing, unsure whether enough time had passed to see changes. However, there were important improvements already: His high-sensitivity C-reactive protein, a measure of dangerous inflammation, fell dramatically from 6.1 mg/l to 0.7, back to the normal range. His body was no longer being irritated by his food choices. A urine test called the MACR, or microalbumin-to-creatinine ratio, fell from 8.5 (a high level, indicating protein was leaking from damaged arteries into his kidneys) to undetectable, indicating a major healing process. Finally, his total cholesterol fell from 224 mg/dl to 196, his LDL cholesterol from 142 to 115, and his LDL particle number (an ideal level being <1,000 mg/dl) from 1,714 mg/dl to 1,474. These improvements lowered his calculated risk of heart attack and stroke significantly and all in just thirty days!
Adam is continuing his journey mixing some of the older habits with many of his new ones. He is single and finds that dating plant-based women keeps him focused. Whatever works, because he is healthier and happier too! 
Study In-Depth: Cholesterol Medication Versus a Plant-Based Diet
Could a plant-based diet loaded with foods known to lower cholesterol ever compare to a prescription cholesterol-lowering statin medication to control your cholesterol? That is exactly the question asked in a carefully done study published in a prestigious medical research journal.2
Forty-six healthy adults with high cholesterol levels (twenty-five men and twenty-one postmenopausal women) were randomly assigned to undergo one of three interventions on an outpatient basis for one month: (1) a diet very low in saturated fat, based on milled whole-wheat cereals and low-fat dairy foods (the non-vegan control group); (2) the same diet plus the powerful cholesterol-lowering medication Mevacor (lovastatin); or (3) a diet high in plant sterols via supplements, soy protein, plant-based fiber, and almonds, all known to lower cholesterol (the “dietary portfolio” group).
The study went on for four weeks. The non-vegan control group, the Mevacor statin group, and the dietary portfolio group all had decreases in LDL (“bad”) cholesterol of 8 percent, 31 percent, and 29 percent, respectively. Reductions in the C-reactive protein, a measure of dangerous inflammation, were 10 percent for the control group, 33 percent for the Mevacor group, and 28 percent for the dietary portfolio group. There were no significant differences in efficacy between the Mevacor statin and dietary portfolio treatments even though the dietary portfolio group was not using any prescription medication. That is amazing.
Five Tips for Lowering Your Cholesterol
1. Begin with a WFPB diet low in salt, oils, fats, and added sugars, rich in fruits and vegetables.
2. Take 2 grams of plant stanols daily. Plant stanols block cholesterol absorption in the GI tract and can be found in the supplement section of natural grocery stores.
3. Eat about two dozen or 30 grams of almonds a day. Almonds are rich in minerals, vitamin E, and fiber. Try substituting margarine or peanut butter with almond butter spread on whole-grain breads (but be careful with the amount if you are trying to lose weight).
4. Aim for 20 grams of soluble fiber a day, which binds cholesterol in the gut. Two big bowls of oatmeal, lentils, chickpeas, barley, or beans a day, whether alone or added to soups or salads, will meet this goal. Five servings of fruits and vegetables can add half of the target amount of soluble fiber.
5. Finally, soy is high in fiber, low in saturated fat, and a good complete protein source. The goal is 50 grams of soy a day. Organic soy milk, tofu, and edamame are good choices. Soy nuts can be a good snack or added to salads, but buy organic and unsalted.
My patients who embraced this diet to lower their cholesterol have seen good results and enjoyed the challenge of fitting these special foods in daily. As always, inch by inch it is a cinch, so go slow.
Science Corner: Proven Cholesterol-Lowering Effects of the Plant-Based Solution
There has been great interest in diet and cholesterol management for a variety of reasons: Heart disease is so common and serious; the medications used have been quite expensive in the past and the new ones (PCSK9 inhibitors) are even more expensive; and some people encounter side effects (muscle aches and weakness, memory loss, blood sugar elevation) on statin medication. If lowering your cholesterol is a goal you want to achieve naturally, the following studies will be important to you.
Data from the EPIC-Oxford study is important to understand. Researchers in the United Kingdom looked at a sample of over 424 meat eaters, 425 fish eaters, 423 vegetarians, and 422 vegans matched for sex and age.3 Vegans had the lowest body mass index, the highest intakes of polyunsaturated fat, and the lowest intake of saturated fat. Vegans had the lowest serum concentrations of total and non-HDL cholesterol and apolipoprotein B (ApoB)—all bad cholesterol fractions that you want to be low. The authors concluded that total cholesterol concentrations were lower in vegans compared with meat eaters, fish eaters, and vegetarians. Vegans were also on average thinner, as eating a WFPB diet has multiple benefits.
Some criticize studies like the EPIC-Oxford analysis because while it observed differences in groups—in this case a much lower cholesterol in vegans—it is not a randomized trial comparing two diets. There is one study that fits that bill and may inspire you to choose a WFPB diet to lower your cholesterol.
As I mentioned in chapter 3, Dr. Neal Barnard approached the insurance company GEICO about doing a study of plant-based nutrition for its employees.4 It was set up as a randomized study in the workplace. Employees from ten sites were randomized to either follow a low-fat vegan diet, with weekly group support and work cafeteria options available, or make no diet changes for eighteen weeks. At intervention sites with cafeterias, low-fat vegan menu options, such as oatmeal, minestrone, lentil soup, and veggie burgers, were among the daily offerings. The low-fat vegan menu options were highlighted in the cafeteria, but the daily vegan options varied depending on the individual cafeterias. All the study subjects were either overweight or had a diagnosis of type 2 diabetes mellitus. Measurements were made before and after the study period.
At the end of eighteen weeks, weight fell only in the vegan group, on average seven pounds. Total and LDL cholesterol fell 8.0 and 8.1 mg/dl in the intervention group and 0.01 and 0.9 mg/dl in the control group. This difference was significant, and clinically would be important. Additional benefits were lower blood pressure and blood-sugar measurements at the end of the study period. This randomized study shows the power of the effects of a low-fat WFPB diet on cholesterol levels.
Another piece of evidence is a recent analysis comparing followers of a vegan diet to similar-aged omnivores. Their cholesterol levels were the main focus of the study.5 Compared to the omnivores, the vegan subjects had lower total cholesterol, LDL cholesterol, non-HDL cholesterol, and ApoB. Concentration of HDL cholesterol was similar between groups. The study concluded that a vegan diet may have a beneficial effect on the serum lipid profile and cardiovascular protection. Not a bad outcome for eating WFPB diets: less risk for heart disease, the nation’s top killer. You can get the same result.
Plant Rant
There is a war going on for your mind and wallet by confusing you about the health aspects of eating foods high in fats, particularly animal saturated fats. For example, a British cardiologist recommends putting butter in coffee and eating full-fat dairy. He even gained international attention with an editorial in the British Medical Journal titled “Saturated Fat Is Not the Major Issue.”6 He relies heavily on a meta-analysis in 2010 on the topic of saturated fat and also on a randomized trial examining different versions of a Mediterranean diet on coronary artery disease (CAD) outcomes like heart attack and heart deaths.7
I have many issues with doctors who recommend increasing fats like butter in the diet while also telling the public to avoid whole grains. This combination produces a low-carbohydrate, high-fat mix. This is worrisome because the LCHF diet is associated with an increase in all-cause and CAD mortality in large databases.8 Meat, dairy products, and processed foods high in saturated fat remain the main felon in CAD, with added sugars an obvious accomplice. When you plan your meals, I would strongly recommend you ignore advice from outliers like this particular British physician and remain loyal to the proven Plant-Based Solution.
THE PLANT-BASED PLAN Have a Smoothie a Day
Increase your daily fruit and vegetable servings by having a smoothie a day. Smoothies don’t have to be limited to breakfast. They’re great with lunch, as a snack, or for dessert, and they are simple to prepare. I love the NutriBullet blender because it makes one serving at a time, it’s powerful, and it’s easy to clean, but you can use any blender.
SMOOTHIE
INGREDIENTS
1½ cups liquid (any plant milk or juice or a combination)
1 banana or ½ avocado
1 cup fresh or frozen fruit
OPTIONAL ADD-INS
1 handful of kale or spinach
¼ cup oats
1–2 tablespoons chia seeds or ground flax seeds
1–2 tablespoons nuts or 1 tablespoon nut butter
INSTRUCTIONS
1. Blend all ingredients until smooth.
2. Add more liquid if needed.