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K E Y P O I N T S

Cholesterol is a lipid or fat. It plays a vital role in the body, but too much can increase the risk of coronary heart disease (CHD). Cholesterol is present in animal foods, but not plant foods.

Low-density lipoproteins (LDLs) are known as "bad" cholesterol. LDLs carry cholesterol from the liver to the body's cells, but if there's too much it gets deposited in the blood vessels and can cause heart disease.

High density lipoproteins (HDLs) are known as "good" cholesterol. HDLs return unneeded cholesterol to the liver.

One in 500 people have high cholesterol levels due to an inherited disorder called familial hyperlipidaemia.

A small Canadian study suggests that a vegetarian diet can reduce cholesterol and may reduce the need for medication with statins.

Experts agree that diet plays a key role, but say it's also possible to lower cholesterol without being vegetarian.

Statins are very helpful but, theoretically, their use could be minimised by diet and lifestyle changes for some people.

Could a vegetarian diet lower cholesterol?

Bupa investigative news - 20 December 2002
written by Rachel Newcombe, Bupa health news reporter

Coronary heart disease (CHD) is the single biggest killer in the UK, claiming up to 125,000 lives each year. High cholesterol, together with other factors, increases the risk of heart disease. To combat high cholesterol, middle-aged people are frequently prescribed drugs called statins. Other measures include lifestyle changes, including eating healthily and being active. And reports now suggest that adopting a vegetarian diet could also substantially lower cholesterol, reducing the need for medication.

What were the headlines?

Reports throughout early December were featured by various media sources in the UK and worldwide. The main area of coverage focused on the idea generated from a tiny study in Canada that a vegetarian diet may offer cholesterol-lowering powers and that a dietary approach could eventually be used as an alternative to medication.

Headlines of stories included, "New hope for non-drug cholesterol treatment", "Vegetarian diet 'cuts heart risk'" and "Combination vegetarian diet as good as cholesterol-lowering drugs" and many reports promoted the idea that being vegetarian may be healthier.

What is the bigger picture?

The reports stemmed from research conducted in Canada, published in the journal Metabolism and led by Professor David Jenkins, from the University of Toronto and St. Michael's Hospital. The team recruited 13 people who had the inherited form of hyperlipidemia, making them prone to high cholesterol, and put them on a vegetarian combination diet for one month.

The diet consisted of four main components:

soy proteins
nuts
viscous fibres (found in oats and barley)
plant sterols (found in vegetable oils and leafy green and non-starch vegetables).

Each of the above components has been found to reduce blood cholesterol levels by 4-7 per cent on their own. One participant also completed two extra diet periods - a low-fat control diet and a control diet plus statin medication.

By combining the foods the researchers discovered that LDL cholesterol levels were reduced by 29 per cent - a similar effect to that achieved with medication. Based on this, they suggest the diet may be as effective as statins.

According to Professor David Jenkins: "This opens up the possibility that diet can be used much more widely to lower blood cholesterol and possibly spare some individuals from having to take drugs."

Dr Cyril Kendall, another researcher, says: "There's still an important place for statin therapy, particularly for individuals with very high cholesterol levels or those who find it difficult to follow this type of dietary approach." However, he also points out that "dietary approaches may be effective if their use enables individuals to use lower doses of statins".

The researchers admit the study was extremely small, and some people found the foods bland, but they are planning further investigations.

"It's been known for a long time that a high-fibre diet can help lower cholesterol. A high-fibre vegetarian diet, including plenty of foods such as pulses instead of animal protein foods, certainly could be beneficial for reducing cholesterol levels. Whether diet alone can replace statins or reduce the dose needed would depend, in part, on how high the cholesterol was to begin with. But, theoretically, it is possible."

Rhoda Sutherland,
consultant clinical genetic oncologist
state-registered dietician at Bupa Southampton hospital

What does this mean?

The idea that some foods reduce cholesterol levels isn't new and fits into existing knowledge.

"Foods such as porridge are known to be particularly good at binding the cholesterol," says Rhoda Sutherland, state-registered dietician at Bupa Southampton hospital. This might explain why oats featured widely in the study. Other beneficial foods, as used in the study, are beans, pulses and high-fibre foods.

Dr Sarah Schenker, a state-registered dietician from the British Nutrition Foundation, agrees: "Replacing fatty meats with low-fat vegetarian alternatives, such as beans and pulses, could help lower cholesterol."

However, Dr Schenker is keen to stress that being vegetarian isn't necessarily the key - what's important is eliminating sources of saturated fat. "You could quite easily get the same effect by replacing fatty meat products, such as pork pies and fried chicken, with lean meat products, such as skinless chicken and virtually fat-free ham," she says. The British Heart Foundation agrees, adding that the "most common cause of high blood cholesterol is having too much saturated fat in the diet".

Liz O'Neil, a spokesperson for the Vegetarian Society, was pleased to hear of the study. "We welcome the report and would be keen to see the research verified," she said.

A C T I O N P O I N T S

Cholesterol is measured by a blood test. HDL and LDL are measured in units called millimols per litre of blood - mmol/l. The ideal total cholesterol level is less than 5 mmol/l (although the average in the UK is about 5.5 mmol/l) and an LDL level of less than 3 mmol/l.

If you have one test that gives a high reading, don't panic. Levels of blood cholesterol and other blood fats vary from day to day, so doctors are unlikely to prescribe medication on the basis of just one reading.

A balanced vegetarian diet, say the Vegetarian Society, consists of the following daily portions - five portions of fruit and vegetables, five carbohydrates, two to three high protein foods, two to three milk or dairy products and a small amount of sugar and fatty foods.

What does this mean to me?

If you're currently taking statins, don't stop taking them the British Heart Foundation advises. Instead, use your diet to help with the overall process of lowering your cholesterol.

Foods that will help to increase fibre and lower cholesterol include items such as beans, peas, lentils and oats, explains Rhoda. To increase these foods in your diet, Rhoda suggests trying the following foods:

lentil curries
chickpea salads
vegetable stews with pulses
porridge
bran-type cereals
oat flapjacks.

If you would like to start this diet, Rhoda does have one word of warning. If you don't currently eat a lot of fibre suddenly increasing the amount you eat could cause abdominal pain. Rhoda advises gradually increasing the amount of fibre you eat over time and drinking more water. "More fluids are essential, as fibre soaks up fluid," she says.

Rhoda was also keen to point out that other lifestyle issues are also really important for reducing cholesterol; for example, exercising and losing weight.

The British Cardiac Patients Association believe it's useful to have regular cholesterol checks. As well as being good for ascertaining heart health, if the level is slightly high it "offers people a practical chance to take steps to increase their health and reduce the risk of developing heart disease".

For those who do wish to try a vegetarian approach, the Vegetarian Society has the following advice. "It's not complicated to get a balanced diet," said Liz O'Neil. "It's about thinking practically, getting the proportions of the different foods right and having lots of variety."

Summary

High cholesterol is a known risk factor for heart disease, but high levels can be reduced. Statin drugs help many people, but dietary and lifestyle approaches are beneficial, too. Whether a vegetarian diet could completely remove everyone's need for medication, though, is debatable.