Cholesterol and heart disease: The role of diet Your diet clearly plays a role in determining your cholesterol levels, but if you're like most people, the most important factor isn't how much cholesterol-rich food you eat. Rather, it's what else you eat. Figuring this out has been a learning process. Initially, the news that cholesterol in the bloodstream was linked to heart disease prompted an all-out war on cholesterol in food. From the 1960s on, people were advised to stay away from foods rich in cholesterol, like eggs, dairy foods, and some types of seafood. But today, the science suggests that, for most people, dietary cholesterol (the cholesterol in foods) has only a modest effect on the amount of cholesterol in the bloodstream. In fact, the 2015–2020 Dietary Guidelines for Americans eliminated an earlier recommendation to limit dietary cholesterol to 300 milligrams (mg) per day—although they still suggest caution on overall intake. Get your copy of Managing Your Cholesterol   Managing Your Cholesterol offers up-to-date information to help you or a loved one keep cholesterol in check. The report spells out what are healthy and unhealthy cholesterol levels, and offers specific ways to keep cholesterol in line. It covers cholesterol tests and the genetics of cholesterol. The report also focuses on treatments based on the latest scientific evidence, including the pros and cons of statins and other medications, and provides the lowdown on other substances advertised to lower cholesterol. Managing Your Cholesterol can also help you work with your doctor to individualize your treatment. Notably, the guidelines did not change the recommendation on saturated fat, which is found mainly in animal-based foods such as meat and dairy—and is often found in high-cholesterol foods. Saturated fat in the diet clearly does raise LDL by a significant amount and should still be consumed in limited quantities. And although some research has cast doubt on the conventional wisdom that saturated fat is linked with heart disease, other research upholds the link. Foods high in fiber, low in saturated fat can lower cholesterol While saturated fat and dietary cholesterol both play a role in your cholesterol level, experts stress that the most important dietary change you can make to lower your cholesterol numbers is to adjust the overall pattern of your diet. Best is a diet rich in fruits, vegetables, fish, and whole grains. This helps in two ways. First, the more of these healthful foods you eat, the less you generally consume of foods that are high in saturated fat and highly refined carbohydrates, which both damage the cardiovascular system. Second, high-fiber foods help reduce your cholesterol level by making unhealthy dietary fats harder to absorb from the gut. This doesn't work for everyone, however. For people at high risk of heart disease, dietary efforts don't come close to lowering cholesterol enough. Other people are genetically predisposed to having high blood cholesterol regardless of what they eat. To learn more about cholesterol and heart disease, read Managing Your Cholesterol, a Special Health Report from Harvard Medical School. Share this story:

Cholesterol-lowering medications: PCSK9 inhibitors In the summer of 2015, the FDA approved two new cholesterol- lowering drugs, alirocumab (Praluent) and evolocumab (Repatha). They belong to a novel category of medications called PCSK9 inhibitors. To understand what these drugs are and how they work, it's helpful to know a little bit about PCSK9 and why you might want to inhibit it. PCSK9 is a protein that targets and breaks down a certain class of receptors in the liver. Those receptors remove LDL from the blood as it passes through the liver. By reducing the number of these receptors, PCSK9 effectively increases the level of LDL in the blood. Studies have shown that people with excess PCSK9 have higher LDL and tend to suffer early heart disease, while those who are lacking PCSK9 (either entirely or partially) have low LDL and less heart disease. That's where the PCSK9 inhibitors come in. By hampering PCSK9's ability to work, they allow more LDL receptors to remain in the liver—and with more receptors available to sweep away LDL, a person's blood levels of LDL plummet. What the drug trials revealed Three trials published in The New England Journal of Medicine demonstrated the LDL lowering ability of these new drugs, which are given by injection under the skin. In all three trials, all of the participants took a statin to lower cholesterol. In addition, half were given a PCSK9 inhibitor (either evolocumab or alirocumab) by injection every two to four weeks; the other half got a dummy injection (placebo). After a year, LDL levels were 40% to 60% lower in the PCSK9-inhibitor groups. In those treated with evolocumab, the average LDL after one year of treatment was 48 milligrams per deciliter (mg/dL), the lowest LDL ever seen in the experimental arm of a cholesterol-lowering trial. Some participants' LDL levels even fell below 25 mg/dL—arguably lower than needed. But both PCSK9 inhibitors have similar effects. To learn more about cholesterol and heart disease, read Managing Your Cholesterol, a Special Health Report from Harvard Medical School. Share this story:

Featured in this issue

Managing Your Cholesterol Featured content: • Cholesterol: Good, bad, and indifferent • Cholesterol and heart disease • Understanding your cardiovascular risk • Why treat cholesterol? • Your cholesterol test • Making sense of the statin guidelines • Special Section: Lifestyle changes to improve your lipid levels Click here to read more »