Part of managing your diabetes is knowing and becoming very familiar with what are often called your “diabetes numbers” or “ABCs:” these include A1C, blood pressure, and cholesterol. Staying on top of your cholesterol levels and getting them into range are key goals, as there is a link between dyslipidemia (lipid levels that are out of range) and a higher risk of heart disease and stroke among people who have diabetes. There’s also a link between diabetic dyslipidemia and insulin resistance, which is a risk factor for Type 2 diabetes. People who have diabetes are more than twice as likely to have heart disease than people without diabetes. And according to the American Heart Association, 68 percent of people with diabetes age 65 and older die from heart disease, while 16 percent die from a stroke. As grim as those facts and figures sound, the good news is that there’s a lot you can do to lower your cholesterol and, consequently, lower your risk of heart disease.
Know your lipid profile
The American Diabetes Association recommends that most adults with diabetes who are not taking cholesterol-lowering medication have a lipid profile done at the time of diabetes diagnosis, at an initial medical evaluation, and then every five years after if under the age of 40, or more frequently, if needed. A lipid profile measures HDL, LDL, and total cholesterol, as well as the level of triglycerides (a type of blood fat) in the blood. HDL cholesterol above 50 mg/dl, LDL cholesterol below 100 mg/dl (or below 70 if you have heart disease), and triglycerides below 150 mg/dl are levels considered to pose a low risk of cardiovascular problems.
The bad guy: LDL
Your LDL, or “bad,” cholesterol is the culprit when it comes to raising the risk of heart disease. LDL stands for low-density lipoprotein, and if you have too much of it in your blood, it can build up along the insides of your artery walls, leading to the formation of fatty deposits called plaque. Plaque makes it harder for blood to flow through your arteries, which means that less blood can get to vital organs, such as your heart, brain, and kidneys. Sometimes this can lead to a heart attack or a stroke. Plaque can also rupture, triggering the formation of blood clots, which can also block the arteries, leading to a heart attack or stroke. So, it makes sense to keep your LDL level low. If you’re not sure what your LDL is or what your target is, ask your health-care provider, and make sure you get your LDL checked every year.
Some of the steps you can take to help lower your LDL cholesterol level include reducing your intake of saturated fat, dietary cholesterol, and trans fat (which is present in foods that contain partially hydrogenated oils), maintaining a healthy weight, and engaging in regular physical activity.
The good guy: HDL
HDL, or high-density lipoprotein, is known as “good” cholesterol. HDL is like the body’s drain cleaner, scooping up the LDL-ridden plaque in the arteries and bringing it to the liver for disposal. The higher your HDL level, the greater your protection against heart disease. If you’re a woman, aim for an HDL of 50 mg/dl or higher; men should aim for an HDL of 40 mg/dl or higher. Quitting smoking, losing excess weight, and getting regular exercise are proven ways to raise your HDL cholesterol.
There’s another player to consider when it comes to heart health, and that’s triglycerides. Triglycerides are a kind of fat found in your blood and also stored in the body for fuel. But, as with LDL cholesterol, if you have too high a level of triglycerides in your blood, your heart disease risk goes up (especially if your LDL cholesterol is also high). The goal for triglycerides is less than 150 mg/dl.
Lifestyle and dietary measures that can help to lower triglycerides include losing excess weight, exercising regularly, avoiding refined carbohydrates such as white flour, lowering saturated fat intake, and increasing your intake of omega-3 fatty acids and fiber.
When you have your cholesterol checked, your lab report may also have your total cholesterol number, which is made up of your LDL, HDL, and triglycerides. The goal for total cholesterol is a number less than 200 mg/dl. But don’t assume that all is OK if your total cholesterol is under 200: it doesn’t mean your other lipid numbers are within range. Make sure your provider has ordered a complete lipid profile and informs you about your results.
Many people with high cholesterol are prescribed one or more medicines to lower their LDL cholesterol and/or triglycerides or to raise their HDL cholesterol. Statins are one of the more common types of medicines used, but there are others that work well, too, including bile acid resins, niacin, and a newer class of drugs called PCSK9 inhibitors. Evolocumab (brand name Repatha) is an example of a PCSK9 drug. Fibrates are a type of medicine that can help lower triglycerides and raise HDL cholesterol. There’s also a medicine that blocks the absorption of cholesterol in the intestines.
However, as with all drugs, side effects can occur, and the medicines can be expensive. Lifestyle measures can be effective at helping you meet your lipid goals. In fact, you may be able to avoid or delay taking medication by making dietary and physical activity modifications. And if you do need medication? Lifestyle changes are still an important part of helping you reach and maintain all of your diabetes numbers.
Nature’s cholesterol reducers
There’s strong evidence that making dietary changes and staying physically active can help with cholesterol management and lower the risk of heart disease. Some dietary supplements may also be helpful in lowering cholesterol, although it’s important to remember that dietary supplements are not regulated by the Food and Drug Administration (FDA), so there are no guarantees as to their safety or effectiveness.
Here are some of the more popular foods and supplements for which cholesterol-lowering claims have been made. Of those that may have a positive effect, some may work to lower LDL cholesterol while others lower triglycerides. Keep in mind that any decisions about taking cholesterol-lowering supplements or making significant dietary changes should be made in conjunction with your health-care team, who can best guide you toward the therapies that are likely to help and caution you about any possible side effects.
When most people think of fiber, they think of a bowl of bran cereal or a slice of whole wheat bread. These foods are high in insoluble fiber, the type of fiber that helps to move food through the intestinal tract and prevent constipation. But insoluble fiber is not the only kind of fiber found in food.
Soluble fiber, or viscous fiber, is found in certain foods, including oatmeal, oat bran, and other oat products, dried beans and peas (black beans, chickpeas, lentils), barley, flaxseed, nuts, apples, oranges, prunes, carrots, Brussels sprouts, and psyllium (seed husks found in some fiber supplements and bran cereals). Soluble fiber works differently than insoluble fiber: It takes up water in the digestive tract, forming a gummy, gel-like substance. While it, too, may help prevent constipation, a unique feature of soluble fiber is that it can help lower LDL cholesterol by binding to cholesterol in the intestines. The evidence for soluble fiber’s cholesterol-lowering abilities is pretty strong and is supported by fairly extensive research.
How much soluble fiber does you need to lower LDL? Aiming for 5–10 grams of soluble fiber each day can lower your LDL cholesterol by 3–5 percent. You can meet this fiber goal by eating at least 5 servings of fruits and vegetables a day, as well as 6 servings of grains.
What about soluble fiber supplements? Taking psyllium-based fiber supplements, such as Metamucil, or supplements of beta-glucan (a substance found in barley and oats) may also help lower LDL, particularly if you’re unable or unwilling to eat a lot of foods high in soluble fiber. But fiber supplements can cause gasiness, bloating, cramps, and diarrhea, and may decrease the absorption of the fat-soluble vitamins A, D, E, and K. Also, some people may be allergic to psyllium, so caution is necessary. (The incidence of psyllium allergy appears to be higher among health-care workers.) Signs of psyllium allergy may include rash, itching, and shortness of breath.
Plant stanols and sterols
Distant cousins to cholesterol (they share a similar chemical structure), phytosterols, or plant stanols and sterols, are natural substances found in plant cell membranes that compete with cholesterol for absorption in the intestinal tract. End result? A lower LDL cholesterol level. You can lower your LDL cholesterol by up to 15 percent by consuming at least 2 grams of phytosterols every day.
Natural sources of plant stanols and sterols include fruits, vegetables, vegetable oils, nuts, legumes, and whole grains. However, it can be challenging to consume much more than 500 milligrams (mg) of phytosterols daily from these food sources.
A number of foods are fortified with phytosterols, including certain brands of vegetable oil spread (Benecol, Promise Activ), juice, yogurt, soy milk, rice milk, snack bars, and even chocolate. Over-the-counter phytosterol supplements are also available. Read the label carefully if you decide to go this route. You may need to take phytosterol supplements twice a day.
Plant stanols and sterols are quite safe. However, check with your doctor if you take a cholesterol-lowering medication and are thinking of taking a phytosterol supplement.
Polyunsaturated and monounsaturated fats are sometimes called “heart-healthy” or “good” fats because they can improve your lipid profile. These come from plant foods and fish. Chemically, they have a different structure than saturated fat, which is why they’re liquid at room temperature.
When either of these fats replace saturated fat and highly refined carbohydrate foods, cholesterol levels drop, as does the risk of heart disease. Polyunsaturated fats can also lower triglyceride levels.
Examples of polyunsaturated fat include corn oil, sunflower oil, safflower oil, and soybean oil. Omega-3 fatty acids (such as those found in fish oil) are another type of polyunsaturated fat. Monounsaturated fats include olive oil, canola oil, peanut oil, avocados, nuts, and seeds.
Speaking of omega-3 fatty acids: these fats are found in fatty fish such as salmon, tuna, mackerel, and sardines. Plant sources of omega-3s include flaxseed, walnuts, canola oil, and soybean oil. Omega-3 fatty acids help lower triglyceride levels, lower blood pressure, and regulate heart rhythms. To boost your omega-3 fatty acid intake, try to eat fatty fish at least twice a week. Also, grind up flaxseed and sprinkle it on cereal or mix it into yogurt.
Whey protein, one of two proteins found in dairy foods, is a popular dietary supplement among body builders and athletes. Studies show that along with helping to building muscle, whey protein provides other health benefits, such as lower blood sugars, blood pressure, and cholesterol. In one study, subjects who consumed 54 grams (about 2 scoops) of whey protein every day for 12 weeks significantly lowered both total and LDL cholesterol.
Whey protein powder is available in drug stores, health-food storesm and some grocery stores. A good way to include it in your diet is to add it to a smoothie or stir it into hot cereal or yogurt. However, keep in mind that it contains calories, so watch your portions. Also, check with your doctor about using whey protein if you have liver or kidney disease.
Back in the 1990s, researchers thought that soy was another tool in the cholesterol-buster’s arsenal. At the time, a meta-analysis of 38 studies appeared to show that consuming at least 25 grams of soy protein daily could help lower total and LDL cholesterol and triglycerides.
But in 2006, a second look at the research cast doubt on the magnitude of soy’s benefit in this area. The American Heart Association announced that eating soy had much less of an effect on LDL than previously thought, lowering it only by about 3 percent. The other catch is that most Americans don’t eat that many soy foods on a daily basis, so few are likely to consume 25 grams of soy protein per day. However, the evidence of some benefit is still there, so if you’re willing to eat a few soy-based meals a week, soy may be of some help in lowering your LDL.
Soy protein is found in tofu, tempeh, miso, edamame (green soybeans), soy nuts, soy milk, soy cheese, and soy-based meat substitutes (such as veggie burgers, soy hotdogs, and “bacon” strips).
Soy foods are generally considered to be safe, but another component of soy, called isoflavones, are natural, estrogen-like substances that may reduce thyroid function in some people (although these findings are not consistent). Women who have had estrogen-sensitive breast cancer and are taking either a selective estrogen receptor modulator (such as tamoxifen [Nolvadex, Soltamox], raloxifene [Evista], ospemifene [Osphena], toremifene [Fareston], or toremifene [Fareston]) or an aromatase inhibitor (such as anastrozole [Arimidex], exemestane [Aromasin], or letrozole [Femara]) should probably not eat soy foods until treatment has been completed.
Niacin, or nicotinic acid, is a B vitamin that the body needs to help turn food into fuel. The recommended dietary allowance (RDA) for niacin for men is 16 mg per day, and for women it is 14 mg per day. The Upper Tolerable Limit (UL) for niacin is 35 mg per day if niacin is consumed either in supplement form or in niacin-fortified foods. Key food sources of niacin include dairy foods, lean meat, poultry, fish, nuts, and eggs.
Niacin is also sometimes prescribed in much larger doses — up to 3 grams per day — to increase HDL cholesterol (by 15–35 percent), with secondary effects of lowering LDL and triglycerides. Prescription niacin can be taken along with a statin or a bile acid resin for further LDL reduction. Some common brand names of prescription niacin are Niacor, Niaspan, and Slo-Niacin.
While consuming the RDA for niacin in foods or vitamin supplements is safe (but will likely have no effect on your HDL cholesterol level), you should never take large doses of niacin on your own without checking first with your doctor. Side effects of prescription-strength niacin can include flushing (redness of the face and neck), stomach upset, itching, high blood glucose, and liver damage.
Red yeast rice
Red yeast rice is a fungus that grows on rice. It’s been used in Asian countries both as a medicine (for various ailments) and as a food coloring (for Peking duck, for example) for hundreds of years.
Interest in red yeast rice in the United States has grown in recent years because of its ability to block the production of cholesterol by the liver. This ability is due, in part, to a substance called monacolin K, which is a “natural” form of lovastatin, a prescription drug used to lower LDL cholesterol. Red yeast rice is essentially a lower-dose type of statin. As a result, many people who cannot tolerate the side effects of prescription statins or who do not want to take them for other reasons have turned to red yeast rice.
The catch is that red yeast rice is sold as a dietary supplement in the United States, not as a drug, and it raked in about $49 million in the United States in 2015, according to Nutrition Business Journal. The FDA does not regulate it for quality, safety, or effectiveness; in addition, the amount of red yeast rice in supplements can vary from brand to brand. And given the fact that red yeast rice is essentially a low-dose statin (it’s identical, chemically, to the drug lovastatin), possible side effects are similar to those of statins, including muscle pain or tenderness that can lead to kidney damage, flu-like symptoms, dark-colored urine, difficulty with urination, upset stomach, bloating, and headache. In addition, red yeast rice supplements may contain a substance called citrinin, which is a toxin that may cause liver damage.
As tempting as it can be to take something that’s natural and effective, it’s wise not to take this supplement without first talking with your doctor. People who decide to take red yeast rice should have their liver enzymes checked about six weeks after starting it and then every six months thereafter. If you take this supplement and experience any of the above side effects, call your doctor right away.
Ground flaxseed contains a type of omega-3 fatty acid called alpha-linolenic acid (ALA). Studies have shown that ALA is linked with a lower risk of heart attack, heart disease, and stroke. And in animal studies, ALA from flaxseed prevented cholesterol deposits and reduced inflammation in arteries.
The fiber in flaxseed is also beneficial in that it can help lower cholesterol levels. One study found that people with high cholesterol lowered their LDL cholesterol by almost 20 percent after consuming 3 tablespoons of ground flaxseed every day for 3 months. Flaxseed may also help increase HDL cholesterol: in a separate study, people who had diabetes had a 12 percent increase in HDL after consuming 1 tablespoon of ground flaxseed for one month.
Flaxseed is quite safe, although nausea, bloating, and diarrhea are possible side effects. It’s best to take flaxseed separately from any medicines to prevent drug absorption problems because flaxseed can slow the movement of food (and medicines) from the stomach to the intestines.
Lower your carbs…with caution
Low-carb and keto (ketogenic) diets are all the rage these days and they may be something you’re considering trying (if you haven’t already). There’s evidence that a low-carb diet can lower triglycerides and raise HDL cholesterol. However, when it comes to LDL cholesterol, the research is a bit murky. In some studies, a low-carb diet lowered LDL, whereas in others, it raised LDL. Proponents of a low-carb diet argue that it’s the particle size of cholesterol that determines heart disease risk: the smaller the particles, the greater the risk of heart disease. Advanced lipoprotein testing can measure the size and number of LDL particles; it’s a more detailed version of a lipid profile, and it’s also more expensive. Your insurance plan may not cover the cost, either.
Bear in mind, too, that some people may have high cholesterol levels for reasons other than dietary factors, and it’s important to talk with your doctor. However, if your low-carb diet is high in saturated fat from, say butter, fatty meats, coconut oil, or Bulletproof coffee, for example, it may be worthwhile switching to more heart-healthy, unsaturated forms of fat in your diet to see if that helps to improve your lipid profile.
Physical activity is another way to improve your lipids and your heart health. Regular physical activity can boost HDL cholesterol and lower triglyceride levels. The American Heart Association recommends aiming for at least 150 minutes of physical activity each week (or 30 minutes of activity, 5 days per week) to improve heart health; for lowering cholesterol, the goal is to aim for 40 minutes of aerobic exercise at a vigorous intensity 3 to 4 times per week.
But what if you’re not a big fan of going to the gym? No worries. Physical activity is anything that you do that makes you move and burn calories. This means that walking, biking, dancing, playing sports, climbing stairs, or doing housework or yard work all count! And if finding time to do 30 or 40 minutes seems next to impossible, break it down into smaller time segments, such as doing 10 minutes, 3 times a day. The point is to move as much as you can.
If you’re not currently very active, it’s a good idea to get the OK from your doctor before you get started with a physical activity program. In the meantime, starting off with a walking program is generally safe for most people. And if you can go walking with your spouse, partner, or friend, you’re more likely to stick with it. Setting a steps goal and using a pedometer or fitness tracker to track your progress is another great way to keep you motivated.
Following a heart-healthy eating plan is one of the best ways to help you reach your blood lipid goals. A heart-healthy plan has the following characteristics:
• It is low in saturated and trans fat (especially trans fat!). This means limiting fats that are solid at room temperature such as butter, some stick margarines, shortening, and lard, and consuming less red meat, cheese, whole milk, and fast food.
• It contains heart-healthy fats, such as olive, peanut, canola, corn, and sunflower oils; trans-fat–free tub vegetable oil spread; nuts and seeds; and omega-3 fatty acids, which are found in fatty fish, walnuts, and flaxseed.
• A heart-healthy plan is rich in both soluble and insoluble fiber from fruits, vegetables, whole-grain breads, cereals, and pasta, and dried beans and peas.
• It contains no more than 2400 milligrams of sodium daily, primarily for blood pressure control. Canned or processed foods, such as canned soups and vegetables, frozen meals, fast foods, and lunch meats tend to be high in sodium. Eating less of such foods and seeking out low-sodium (containing no more than 140 mg sodium per serving) or “no salt added” varieties of them can help you cut back on your sodium intake.
A registered dietitian can help you develop an individualized eating plan that’s good for both your heart and your blood glucose control. If you choose to try dietary supplements to lower your cholesterol — or for any other reason — tell your health-care provider, and keep him updated on your usage from one appointment to the next.
(Click here for more information about choosing foods that can help you lower your cholesterol.)
Finally, take a holistic approach to improving your cholesterol. What you eat, of course, has a big impact on your lipids, but other factors do, too, including your level of physical activity, whether you’re overweight or obese, and if you smoke (smoking lowers HDL cholesterol). High cholesterol can also run in the family, as does heart disease. While you can’t change your genes, you can change your lifestyle.
Work with your health-care team and learn about your options. And if you need medication to help you reach your lipid goals, don’t give up on lifestyle changes, as they can help to keep your medication dose on the low side.
Want to learn more about improving your cholesterol profile? Read “HDL: Nine Ways to Raise Your Good Cholesterol” “Lifestyle Habits for Lipid Management,” “Lowering Cholesterol: What Works and What Doesn’t (Part 1),” and “Lowering Cholesterol: What Works and What Doesn’t (Part 2).”