The Cost of Corporate Cholesterol

America’s cholesterol levels are too high making us at risk for heart attacks and strokes. It’s expensive. And it’s almost entirely preventable.

We likely all know someone who has suffered from a heart attack. Heart disease is the number one killer in the United States.¹ Annually, it costs approximately 200 billion dollars.² The single most potent risk factor for heart disease is high cholesterol. The good news is: high cholesterol is almost entirely preventable.

What’s the big deal about cholesterol anyway?

Just imagine. You’re making dinner and fry hamburger for a spaghetti sauce. As you’re stirring the sauce, you see your son getting ready to pour the hamburger grease directly down the sink drain. You make a mad dash to stop this from happening. Why? Because that grease will clog up your drain creating an expensive, messy problem you’ll have to fix.

Well, “bad” cholesterol does the same thing to our blood vessels. Cholesterol is a fatty substance made in the liver. It’s part of the outer coating of each of our cells and is the backbone for some hormones like estrogen and testosterone.³ LDL cholesterol is considered “bad” cholesterol because it gets deposited in our blood vessels forming fatty plaques just like grease in the kitchen sink. HDL is considered “good” cholesterol because, like a garbage truck, it picks up the bad stuff (LDL cholesterol) and removes it from the blood stream. If cholesterol plaque becomes too thick, all blood flow will stop and the plaque bursts open. Rapid damage to the heart or brain can immediately occur creating an expensive, life-threatening problem you may not be able to fix.

When do greasy plaques of cholesterol begin to build up?

Cholesterol build up starts early and progresses through life. In 1953, 300 American soldiers, who were casualties of the Korean war, underwent medical autopsies. Among these men, averaging 22-years of age, 77% already had signs of plaque build-up and hardening of the arteries. Some arteries were already 90% blocked.⁴

Another study of American children and young adults who died from accidental causes showed nearly all, by the age of 10, had the first signs of cholesterol build up. Those children with higher blood cholesterol levels had more fatty streaks in their arteries.

Where’s the Silver Lining?

The average cholesterol of an American is around 200mg/dL and 78 million have LDL levels high enough a cholesterol medication would be recommended.¹ Our current target range of LDL cholesterol (90-130mg/dL — depending on risk factors) is misleading as 75% of patients had LDL cholesterols that fell into their recommended target range when they had a heart attack.^{7, 8} However, in some places like rural China or Uganda, heart disease is almost non-existent. In Ugandan men who were 65 or younger, 0.2% died from a heart attack. Compare that to 22% among age matched men from St. Louis.⁹ What were the average cholesterol levels in those Ugandan men? They had total cholesterol averages of less than 150mg/dL and LDL averages between 40-80mg/dL.^{10, 11}

When total cholesterol levels are less than 140mg/dL and LDL levels less than 50-70 mg/dL, development of cholesterol fatty plaques or progression of heart disease ceases to exist. Even as a smoker, with high blood pressure or diabetes, or inactive or obese.¹² The optimal cholesterol levels of the Ugandans and rural Chinese, have been attributed to their diets comprised of vegetables, whole grains, and plant-based proteins. Compared to the United States, their diets have about half the fat, one-tenth of the meat intake, and three times the fiber.^{11, 9} Except in rare cases of genetic conditions, diet is the main driver of everyone’s cholesterol level.

How do we bring cholesterol levels into the ideal range?

The most common way to get cholesterol levels to an ideal range in America is by using a group of medications called “statins.” “Statins” are among the top three medications prescribed at a physician’s office.¹³ Though many have become generic, these medications are prescribed daily for the rest of one’s life, creating large costs for patients and employers. Statins can help reduce the risk of heart attacks, but much less than people think. Statins also have several undesirable side effects including muscle aches and pain, liver damage, and increased risk of diabetes and breast cancer.

The newest class of cholesterol medications are called PCSK9 inhibitors and can lower LDL cholesterol up to 60%. They are options for individuals who cannot tolerate statin medications or need a greater reduction in cholesterol levels despite statin use. Treating all eligible patients with this new class of medications could increase annual health spending in the U.S. by 2.8 trillion dollars.¹⁴ According to Dr. Dexter Shurney, prior chief medical and executive director of Global Health and Benefits at Cummins, Inc., “If just 100 of our 55,000 employees use lifestyle as medicine and eliminate the need for high cost cholesterol medications (PCSK9s), it saves our company over $1.5 million a year.”

There is something you can do.

As Dr. Shurney mentions, lifestyle is another option besides medication and it’s recommended as the first line therapy for high cholesterol by the American College of Cardiology.¹⁵ Unfortunately, most physicians under prescribe lifestyle changes and the true impact is not seen. This would be like changing the oil in your car, but instead of changing all the oil, you simply add 1 quart of new oil. The potential benefits of the new oil is lost in all the old oil. Small healthy lifestyle changes can go unnoticed because of stronger unhealthy habits that remain unchanged.

A high-risk individual who’s already had a heart attack and takes a statin every day for 6 years has an 3% lower absolute risk of a second heart attack than someone in the same situation who isn’t taking the medication.¹⁶ However, one study following high-risk patients who already had heart attacks but made lifestyle changes and began eating an unprocessed plant-based diet every day, had within 4 years close to a 60% lower absolute risk of a second heart attack.¹⁷

A study on the effects of a very-high-fiber, unprocessed plant-based diet on cholesterol levels showed this diet was equivalent to lowering cholesterol as a moderate dose statin medication in just 2 weeks. The greater the dietary changes, the greater the cholesterol reduction. The side effect profile of eating a plant-rich diet is well known. Patients benefit from less constipation, increased weight loss, lower blood pressure, improved blood sugar control, and long term lower risks of cancer and heart disease.¹⁸

How do I start lifestyle change and an unprocessed plant-based diet?

To help lower total cholesterol and “bad” LDL cholesterol:

• Avoid eating trans fats, saturated fats, and cholesterol.
• Our bodies will take the fats we eat and make them into types of cholesterol and triglycerides. If our fat intake is low and we are eating healthy carbohydrates, the ingredients needed to make excess amounts of cholesterol are not available and cholesterol levels remain lower. Trans fats are found mostly found in solidified plant oils (like Crisco), processed foods (most packaged snack foods and sweets), and naturally in some meats and dairy products. Saturated fats are naturally found in meats, dairy products, eggs, processed and fried foods, and oils (including coconut and palm oil). Foods high in dietary cholesterol include meat (especially liver), eggs, and dairy products.
• Eat at least 40 to 45 grams of fiber per day.

Soluble fiber may bind to cholesterol causing it to be removed more from the body. Fiber may indirectly lower cholesterol by causing people to feel fuller leading them to eat less food.

Foods that are high in soluble fiber include:

• Legumes: beans, lentils, garbanzos, peas
• Vegetables: eggplant, okra, sweet potatoes, broccoli, leafy greens
• Fruits: figs, pears, raspberries, apples, citrus fruits
• Whole grains: barley, psyllium, wheat, oats
• Eat a handful of nuts each day (almonds, walnuts and pecans)¹⁹
  Nuts are a high nutrient, high calorie food. Studies consistently show they help protect against cardiovascular disease and may contribute to weight loss. A handful a day is all that’s needed. 4-8 Brazil nuts once a month may help keep cholesterol levels down for 30 days
• Eat more plant sterols and stanols²⁰
  Plant sterols and stanols are similar to cholesterol in structure. They compete with cholesterol in the gut for absorption into the blood stream; therefore, less cholesterol is absorbed. Foods high in plant sterols and stanols include soybeans, green peas, legumes, nuts and seeds, sprouts, avocado, wheat germ and Brussels sprouts

To help increase “good” HDL cholesterol:

• Achieve or maintain a healthy body weight for your height
• Quit using any tobacco products
• Exercise regularly for 30 minutes a day, 4-6 times a week
• Eat foods high in vitamin C like peppers, broccoli, snow peas, cauliflower, kale, guava, papaya, kiwi, oranges, strawberries, pineapple, grapefruits, cantaloupe and mangoes

Take heart, when the above changes in the diet are made even for a few weeks, cholesterols levels can drop rapidly into an optimal range.

These changes can safely be made in an outpatient setting with the comfort of knowing the side effects of an unprocessed plant-based diet will be lowering the risk of other chronic diseases like diabetes, cancer, and high blood pressure.

Sources

1. CDC. High Cholesterol Facts. Cholesterol 2017 October 31, 2017; Available from: https://www.cdc.gov/cholesterol/facts.htm.
2. CDC. Multiple Cause of Death 1999-2015. 2016; Available from: http://wonder.cdc.gov/mcd-icd10.html.
3. Berg JM, T.J., Stryer L. , Biochemistry. 5th edition. . Important Derivatives of Cholesterol Include Bile Salts and Steroid Hormones. . 2002, New York: : W H Freeman
4. Enos, W.F., R.H. Holmes, and J. Beyer, Coronary disease among United States soldiers killed in action in Korea; preliminary report. J Am Med Assoc, 1953. 152(12): p. 1090-3.
5. Berenson, G.S., et al., Association between multiple cardiovascular risk factors and atherosclerosis in children and young adults. The Bogalusa Heart Study. N Engl J Med, 1998. 338(23): p. 1650-6.
6. Napoli, C., et al., Fatty streak formation occurs in human fetal aortas and is greatly enhanced by maternal hypercholesterolemia. Intimal accumulation of low density lipoprotein and its oxidation precede monocyte recruitment into early atherosclerotic lesions. J Clin Invest, 1997. 100(11): p. 2680-90.
7. Javed, U., et al., Use of intensive lipid-lowering therapy in patients hospitalized with acute coronary syndrome: An analysis of 65,396 hospitalizations from 344 hospita participating in Get With The Guidelines (GWTG). Am Heart J, 2011. 161(2): p. 418-424.e1-3.
8. Horwich, T.B., et al., Cholesterol levels and in-hospital mortality in patients with acute decompensated heart failure. Am Heart J, 2008. 156(6): p. 1170-6.
9. Higginson, J. and W.J. Pepler, Fat intake, serum cholesterol concentration, and atherosclerosis in the South African Bantu. II. Atherosclerosis and coronary artery disease. J Clin Invest, 1954. 33(10): p. 1366-71.
10. Shaper, A.G. and K.W. Jones, Serum-cholesterol, diet, and coronary heart-disease in Africans and Asians in Uganda*. International Journal of Epidemiology, 2012. 41(5): p. 1221-1225.
11. Campbell, T.C., B. Parpia, and J. Chen, Diet, lifestyle, and the etiology of coronary artery disease: the Cornell China study. Am J Cardiol, 1998. 82(10b): p. 18t-21t.
12. Benjamin, M.M. and W.C. Roberts, Facts and principles learned at the 39th Annual Williamsburg Conference on Heart Disease. Proc (Bayl Univ Med Cent), 2013. 26(2): p. 124-36.
13. CDC. Therapeutic Drug Use. 2017 May 3, 2017; Available from: https://www.cdc.gov/nchs/fastats/drug-use-therapeutic.htm.
14. Szabo, L. New cholesterol drugs could add $120 billion to annual U.S. health costs. 2016 Aug 17, 2016; Available from: https://www.usatoday.com/story/news/2016/08/16/new-cholesterol-drugs-could-add-120-billion-annual-us-health-costs/88820936/.
15. SS, P.V.H.D.A.M.B.R.M. Major Dyslipidemia Guidelines and Their Discrepancies: A Need for Consensus. 2018 April 24, 2018; Available from: https://www.acc.org/latest-in-cardiology/articles/2018/04/24/08/56/major-dyslipidemia-guidelines-and-their-discrepancies.
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18. Jenkins, D.J., et al., Effect of a very-high-fiber vegetable, fruit, and nut diet on serum lipids and colonic function. Metabolism, 2001. 50(4): p. 494-503.
19. Ros, E., Health benefits of nut consumption. Nutrients, 2010. 2(7): p. 652-82.
20. Ras, R.T., J.M. Geleijnse, and E.A. Trautwein, LDL-cholesterol-lowering effect of plant sterols and stanols across different dose ranges: a meta-analysis of randomised controlled studies. Br J Nutr, 2014. 112(2): p. 214-9.