Oops! Take It From Me - Half Dietary Measures to Lower Your Cholesterol Will Result in Half Measure Improvements

"The first thing I do when people tell me that they can't reduce their cholesterol to 150 ml/dL or less is press them on precisely what they eat on Friday or Saturday nights, or what they might have consumed at that seemingly endless weekday meeting where there was "nothing else to eat."

Often, under my questioning, they reveal tiny deviations from the nutrition program--lapses so small that they didn't even take them into account.

--Dr. Caldwell B. Esselstyn, Jr., Prevent and Reverse Heart Disease--

If you've received this via email, click here to get to the web version with all the links.

Let this be a cautionary tale!

I thought I was doing everything right with my diet. I'm eating loads of vegetables, fruits, beans, and whole grains.  I feel wonderful.  I've accrued countless benefits.  But I didn't cut out oil or nuts or avocados.

• Two years ago I "mostly" cut out all dairy, eggs, and meat.  And yes, that includes, cheese, yogurt, chicken, my beloved turkey sandwiches, and fish.
• About one year ago I "mostly" cut out sugar--ditching desserts that deliciously combine butter, oil, flour, and sugar.  But, I didn't cut out super dark chocolate every once-in-awhile.
• I limited my cooking oils to just canola or olive oil, and cut down the amounts considerably.
• I still ate nuts, including almond butter, and my fave Larabars--and I ate them in moderation.
• I still ate avocados. 
• Occasionally, I'd eat humus or baba ganoush that were store-bought or restaurant-ordered & of course they're made with fat-heavy tahini.
• I ordered vegan dishes whenever I ate out--but didn't think too much about the oil used back in the kitchen.  Deep-fried falafel?  Fried onions on top of the Mujadara?  Indian vegetable curries?  You get the picture.  And I never asked the chef for "special orders" made without oil
• Maybe every other month I might eat fish at a friend's house, or at a restaurant. 

I figured I was healthy.  No diagnosed heart disease.  I've exercised for over 35 years.  My weight's fine, even though I'd love to drop a few pounds.  I figured I could successfully follow the Esselstyn/Engine 2/McDougall/Fuhrman plant-based diet-thing "my way"--not exactly "their way"!   Unknowingly, I chose to eat plant-based with moderate fat intake--which isn't exactly what they're prescribing.  Oops on me!

Boy was I in for a surprise!

The Cholesterol Test - Did I Ace It?

My last cholesterol test was 2 1/2 years ago, taken five months before I started eating plant-based.  And because I had squeaked in as "healthy" after my last cholesterol test--I still didn't need any statins--and my health plan wouldn't "authorize" a new cholesterol test for me for 2 1/2 years!  I certainly was curious to see how eating plant-based was affecting my cholesterol--but I was going to have to wait 2 more years to find out.

But, when a new "Employee Wellness/Shape Up" initiative began this year at the medical center where I work--all that changed.  Now--all of sudden I was required to retake the cholesterol test, and all the other tests needed to qualify for a health insurance discount.

Here's the deal:  If you want to "Lock Into" 2009 health insurance rates for 2010 & 2011 you have to prove:

• Your weight is healthy--a BMI below 27 (which is actually overweight). 
• Your blood pressure is normal at 120/80 or below
• You are diabetes-free
• Your cholesterol levels are in the normal range.
• If you flunk any of these tests--you have to "enroll" in a "special help" program to lose the weight, lower the cholesterol, control the diabetes, and lower the blood pressure--before you can get an insurance rebate. 

I was sure I would Ace the cholesterol test that I took on May 6th.  The blood pressure test was the one I was a bit worried about.  I knew I'd pass the weight test.

So, imagine my disappointment when I got back my cholesterol test.  I thought for sure the total would be between 150-170.   Boy, was I mistaken.  Yes, my tests were good enough to be in the so-called "normal range".  I passed the test and I'll get my health insurance discount--but now I know I need to kick it up a notch if I want to beat the family "stroke and heart disease curse".

The results were good enough to still keep me "statin-free".   But, now that I'm eating plant-based, ingesting nary a speck of dietary cholesterol I was expecting a STRAIGHT-A LIPID TEST.  Nope, didn't happen. 

Here are my 2007 & 2010 scores--the bad, and the better.  According to my doctor, I'm one of those people whose cholesterol is affected to a large degree by what they eat. 

The Cholesterol Report Card

                        9/28/07        11/08/07        5/6/10

Total CHO          269                198                209

LDL CHO            157                 117               111

HDL CHO             96                   72                77

Triglycerides       84                   44               103

LDL:HDL Ratio    1:64                                    1:44

**Please note:  Total Cholesterol = LDL + HDL + triglycerides divided by 5.  That why a high HDL will falsely inflate the total.

Half-Measures Bring Half the Expected Results.  Oops!

So I was good enough to get my discount, and stay off of statins--but I wanted to know why my scores hadn't dropped more.  What was I doing wrong?  What was I missing?

The next day I decided to email Dr. Caldwell Esselstyn to get his opinion.  Sending this email felt totally presumptuous, an imposition, and nervy on my part--but I hit the send button before I could talk myself out of it.

• I told him I ate dark chocolate the night before the test
• I let him know I had eaten out the previous weekend
• I told him that I use spray oils, some canola & olive oil
• I let him know I ate nuts, and nut butters
• I asked him why he thought my triglycerides had increased so much.  I was only eating  whole grains & hardly any sugar.

But of course the night before my test I ate an Indian chutney made with sugar.  And a piece of chocolate. And I drank a glass of red wine.  No one had told me that it would also be a good idea to avoid alcohol for 24 hours before the test.  Only later did I find out that alcohol can significantly increase triglyceride levels.  I don't drink often--who knows why I decided to have a glass of wine that night?

The next day was Saturday and I headed out of the house early because I had to work.  As I'm driving to the hospital my cellphone rings at 8:00 am.  I figured it was either my husband trying to find something--or my sister, who was visiting from out-of-town.

Turns out it was Dr. Esselstyn, calling in reply to my email.  As he says, a few people can get away with eating foods like avocados, nuts, and some oil and it won't affect their cholesterol at all.  But, for most people, the least little addition of one of these offenders can keep the cholesterol up, and arteries inflamed.  I'm one of those people.

Dr. E:  I don't know what kind of restaurants you go to, or what you order.  What did you order the last time you went out to eat?

Me:  It was a Turkish restaurant.  I had a salad, without cheese, topped with 4 fried falafels--a bit of salad dressing--and a couple pieces of pita bread with baba ganoush.   White flour, tahini, salad oil, fried foods.  Duh?  What was I thinking?  Funny how easy it is to ignore what is going into your mouth when you're eating out--and thinking, "This is vegan. It will be OK."

Me:  And what about those triglycerides?  Why would they be so much higher than before?  I'm only eating whole grains  (except when I'm not--like the restaurant pita bread)

Dr. E:  For one thing, you can't keep eating chocolate, avocados, and nuts--and cooking with olive oil--and expect stellar cholesterol scores.  And what about dried fruits.  Are you eating those?

Me: Uh, yeah.  My morning steel cut oats are loaded with dates, and raisins, and dried cherries.  Dr. E informed me that these are the most concentrated sugars--I should avoid them--or eat smaller quantities.

I went on to express my concerns about eating too little oil, and asked him if a cholesterol under 150 could ever have negative effects.  Not if you're doing it naturally, through your diet, he told me--like many disease-free native communities have done for years.  And don't worry getting enough fat to absorb vitamins--there's fat in almost all vegetables, beans, and grains.

But, the best part...  Dr. Esselstyn generously invited me to join his next small group 5 1/2 hour appointment that would be meeting in mid-June, where I would get a first-hand understanding of how I could kick up my "healthy eating" a notch, and learn why it's in my best interest to do so.  Like ditching those added oils at home--and lurking in restaurant meals.  And I'll get the chance to have all my questions answered.

I thought I would be able to skip the "no-added-oil-no-nuts-no-avocado" requirement of the Esselstyn diet  But I guess My Way wasn't enough.  Click here to read:  I'm Going to Miss My Olive Oil.  Who Knew It Wasn't So Healthy After All?  Drs. Esselstyn, Ornish, Vogel, and Rudel Did.

Dr. Esselstyn's Heard This All Before

"The first thing I do when people tell me that they can't reduce their cholesterol to 150 mn/dL or less is press them on precisely what they eat on Friday or Saturday nights, or what they might have consumed at that seemingly endless weekday meeting where there was "nothing else to eat."

Often, under my questioning, they reveal tiny deviations from the nutrition program--lapses so small that they didn't even take them into account.

One example: by the time you hold down the nozzle on a popular cooking spray long enough to coat a wok or pan, you'll build up about a tablespoon of oil.

Such transgressions can easily be enough to injure the endothelium's capacity for producing nitric oxide, which in borderline cases can mean the difference between success and failure.  It is the kind of attention to tiny details that makes my program work.

It is true that there are some people without heart disease who strictly adhere to a plant-based diet--no lapses at all--and even so, cannot reduce their cholesterol below 165-170 mg/dL.  (Some researchers have suggested that years of eating fat and cholesterol may compromise the body's natural capacity to reduce cholesterol levels.)

For these people, a modest dose of a cholesterol-lowering medication under physician supervision should take care of the problem.  It is worth noting, however, that anyone who achieves a cholesterol level of 165-170 mg/dL by eating a strictly no-fat, plant-based diet is already doing wonders for his or her health, even without reaching the optimal level.

That person is, by definition consuming large quantities of natural antioxidants, which prevents the body from oxidizing LDL cholesterol into its most dangerous, artery-clogging form."

--from Esselstyn, Dr. Caldwell B.  Prevent and Reverse Heart Disease.  New York: Penguin Group, 2007--

Reconsidering the So-Called Healthy Oils

Drs. Matt Lederman and Alona Pulde appear in the upcoming documentary, Forks Over Knives--they're the physicians who were responsible for turning around the health of writer/director Lee Fulkerson and Joey A. of Tampa.  On their web site they provide an excellent explanation of why oils need to go:

Question: Do you prohibit the use of vegetable oils?  Does this include Olive Oil?

Answer: Thank you for your question and your interest. Our feeling about oils is that they are processed forms of foods high in calories and low in nutrients.  The more a food is processed the less healthy it is! 

Furthermore, vegetable oils including olive oil are NOT health foods! These oils suppress the immune system (increasing risks of infections and cancer), promote atherosclerosis (clogging of the arteries), increase bleeding, cause insulin resistance, and lead to obesity.

With regards to olive oil, we have been misinformed of its “benefit” from observations that people on the Mediterranean diet are healthier than people on the American diet. This is so because their diet consists largely of fruits, vegetables, and grains with little animal products...not because of the olive oil. In fact, they are healthier DESPITE the olive oil in their diet and not because of it! 

That being said, although we highly recommend against the use of vegetable oils, we don’t like to use the word prohibited. So if you feel you have to use a little bit of olive oil or else you will go back to cheeseburgers, milkshakes, and fries...then by all means, use that bit of olive oil. 

However, it might be helpful to know that there are many healthier forms of fat to use out there.  Ground up, unsalted olives are much healthier than the extracted olive oil and still add the wanted olive flavor. 

When you are frying something you can use a fat substitute like juice or vegetable broth to cook with rather than oil. Then you can add a healthier unprocessed form of fat if you want that particular flavor...such as ground up cashews, seeds, or avocado. 

The benefit of using a ground up whole food is that you then also get things like fiber, vitamins, and minerals that are discarded when you extract the oil from the whole food. These nutrients are not only important for your health but also help shut off your hunger signals, ultimately preventing you from overeating.

Finally, we don’t like to use the term “okay” like you are doing something wrong if you don’t follow these rules. Certain oils/fats (olive, canola, peanut, avocado) are less saturated and better for your heart than others (palm kernel, coconut, butter) but we would never say olive oil is a health food.

Also, remember that the most important thing is that we do our best. Meaning, if you are out and wind up eating some oil because there is no alternative and you didn't prepare for the situation...it's not the end of the world or your health.  Rather, just be better prepared for next time. Any move closer towards a low fat plant based diet is not only healthier for you, but will prevent more disease and give you more energy.  So in the end, please don't be too hard on yourself as you do the best that you can!

Cleaning up my kitchen act:  I've already started sauteing with vegetable broth, or other flavored liquids instead of with oil or oil sprays.  It wasn't such a big deal. I'm using parchment paper or a Silpat to roast vegetables, or for "stick-free" baking.  Just yesterday I found a delicious tahini & oil-free red pepper humus.  I've also discovered a fat-free whole grain pizza crust made by Kabuli.  I can do this!

I'd really appreciate any tips, advice, or experiences that you can offer to help me with this new adventure in going oil-free--or almost-oil-free.

Comments

[The50besthealthblogs.blogspot.com]

Olive oil, canola oil, butter, no oil ...

Ornish, Atkins, Esselstyn ...

Why can't all the experts agree on anything?

Jim Purdy

[Chris]

I'm sorry to hear about your cholesterol numbers. That must have felt like a setback for you after all your efforts you kindly post. But, just think, it might have been much worse if you weren't as strict as you already are.

But, as usual, something adverse also brings something good and you now have that invitation from Dr.Esselstyn.

What I found very surprising in you article was the fact you weren't "allowed" to have a cholesterol test for 2.5 years!

For all the criticism of our (wonderful) NHS both here in the UK and recently from some in the US, this is not a problem we face here. I'm not saying one system is better than another, nor that ours does not have its problems. But, maybe the prevention message is a little stronger here.

Keep up the good work!

[Steven at Positive Massage Therapy]

As a pure speculation, I would blame the eating out more than what you have at home.

One unproven opinion I hold is that eating out is nutritional Russian roulette. No matter what the server says, assume what you order has high quantities of everything you want to avoid. Even knowing what's in the food, there's a psychological disconnect between that knowledge and the finished dish on your plate that is avoided when you prepare your own food.

My diet has large amounts of nuts, seeds, and olive oil, and yet my cholesterol is in the 120's. Of course, as you mention, everyone is different.

Positive Massage Therapy

[Ken Leebow]

Yes, eating out is one of the worst. Even when you get vegetables, they are loaded with butter, salt, and other assorted mystery toppings.

Please give Dr. Esselsytn my regards. He was the first doctor who I have ever heard discuss getting total cholesterol down to 150. My doc certainly did not. My doc told me it was mostly related to genes. Oops, got mine from 202 to 155 in less than six months.

Thank you Dr. Esselstyn! And good luck to you...Debby.

Ken Leebow
http://www.FeedYourHeadDiet.com

[Michelle]

It seems that European cultures feel that there must be some form of fat in everything. I have struggled with that and my solution is eat Asian food -- noodles in broth is good. So is pasta in Tomato sauce which you can buy with very little fat added -- though not zero.
Try Japanese Soba (Buckwheat noodles) cooked in broth and served in dipping sauce. Or Udon cooked the same. It is possible to make a vegan broth, though that is not the most common kind.
The best source for this that I have seen is:
http://www.justhungry.com/basics-cold-soba-noodles-dipping-sauce
It has a couple of truly delicious fat-free recipes. I find those very hard to find. And these are easy to make.

[Gael in Vermont]

I, too, was feeling quite cocky going into my lipid profile last month. Yes, indeed, my total cholesterol numbers came down but my LDL went up! And I am eating a full force vegan-plant-based-gluten free diet. Who thought about the fat in nuts and avocados and the good-for-you olive oil on a diet like this? I agree with Jim above when he says "why can't the experts all agree?" Of course, they can't. I just listened to a podcast from the author of Bone Vitality talking about how wonderful dried fruits are for my bones! What's a girl to do? I have seen the benefits of a plant-based diet...no doubt about it, but I need to adjust my own thinking about fats-oils. So, last week, I gave up on my beloved avocados and handfuls of walnuts and almond butter and Earth Balance and olive oil (except for a bit in my salad dressing). Yikes, what's next? I'm going to try this throughout the summer and get re-tested and see what happens. It's a tough road to travel, but in the end, everyday, I feel SO much better than I ever have in my life. I can't go back now. Good luck Deb. Can't wait until your 5 hour consult.

[Fran]

I have been reading your blog for several months and have learned a lot about health and nutrition, but I think you're going overboard on the cholesterol and I think the medical profession has led us to be cholesterol phobic. Personally, I would rather live fewer years and eat foods that I enjoy such as cheese, pasta and bread. We rarely eat out and I cook everything from scratch. We eat a lot of vegetables,but I cannot imagine cooking them without olive oil and garlic. From the research I've done, I learned that half of those who have heart attacks DO NOT have high cholesterol. My father-in-law died of a massive heart attack. He was on statin medication for years. He had a complete check-up and was given a clean bill of health by his cardiologist two weeks earlier. There's still a lot we don't know about heart disease.

[Kiki Ohio]

I would not lose heart as this information about your total cholesterol profile is showing you where you need to go. I gave up using oil to saute foods and now only use H2O or veggie broth and my taste buds adjusted just fine. However, the comment about restaurant food is right on: always assume that you are getting loads more fat than you realize. I have minimized eating out and have gotten to the point that I eat before going out so that I can nibble around the plate without eating more than is good for me. This might be "weird" to some, but in my business I must eat out with others several times a week and this would wreck my waistline and cholesterol levels in short order. I do not care for nuts so that is not a problem for me. I know a *lot* of people think nuts are "healthy" but they pack an unbelievable caloric wallop and can drive up my cholesterol in short order as well. I think overall it is just consistency: figuring out where there are gaps in your eating plan and plugging the holes! :-)

[Lora]

The last time I had my cholesterol checked, about a year and a half ago at age 51, my total was 124 (starred as just below the reference range of 125-200). I attribute this result largely to my diet. However, I find that it is extremely difficult to eat as I think I should when socializing. Hence, eating healthily pushes me toward being somewhat of a hermit. I read convincing research reports indicating it is much healthier not to live like a hermit, so I feel like I'm in somewhat of a Catch-22 situation. I sometimes use the strategy Kiki mentions above, eating healthier food ahead of time so that I can just nibble at social occasions. Also, at times I bring healthier foods to non-restaurant social occasions. Last year I took expensive organic apples when we went to my mother-in-law's home for several days beginning on Christmas Eve. That night she gave most of them away along with some leftovers to a departing guest who had no concern about organic food or healthy eating!! I try to be diplomatic and low profile about my eating preferences, but I think I looked horrified as the apples I had paid a premium price for and counted on as healthy snacks during our visit went out the door! I also find, as Kiki mentions, that my taste buds adjust if I stick to my diet. However, even a nibble of some foods that I'd rather avoid sets off cravings for them. And we often have such foods around the house due to my husband's preferences. Fortunately, those have started to shift since his doctor talked to him recently about his cholesterol numbers!

I'll be very interested in any upcoming tips on maintaining a healthy diet while socializing!

[Suzanne]

My last five cholesterol screenings (from 3 different sources) always include a "Risk Ratio", determined by dividing total cholesterol level by HDL level. The desirable number is <4, borderline 4.0-4.9, and High Risk 5.0+.
So even though my total cholesterol was 239 in one test, my HDL was a nice high 114, so my risk ratio was 2.0. My most recent test was 204/80=2.5.
Using risk ratios, your numbers look fine. 209/77=2.7
Congratulations!
Suzanne

[claire]

i love your blog...
as a longtime vegan - and as someone who prepares fresh food daily - delicious 'no-oil added' food, without sacrificing taste, is not that big of a deal. An fast and easy alternative for dressing salads is to use some ripe avocado pieces(either smashed or pureed), water, and dijon mustard (all according to taste and preference). throw in some raw sunflower seeds (also can be smashed to better integrate), optional herbs and seasonings(ie dill, ground pepper, etc) and your salad will be fully 'dressed'!
good luck....claire

[Charlie]

If you've gone completely plant based and removed most fats from you diet, you have likely increased your intake of carbohydrates (and perhaps protein to a lesser extent) to maintain the same caloric intake and satiety. And it is the excess carbohydrates, along with the glycemic load they present your body, which can raise triglycerides. Moral of the story: when removing an entire macronutrient class from your diet, you have to pay attention to what you are replacing it with. If you remove all fats from your diet and end up replacing a lot of those fat calories with carbs, that may not necessarily be a good thing, even if they are whole grains as eating too many of them will still present your body with a high glycemic load.

[Kiki Ohio]

I have to disagree with Charlie regarding carbohydrates driving up triglyceride levels. While *refined* carbohydrates will definitely drive up triglyceride levels, complex carbs such as those found in brown rice and vegetables are not absorbed as quickly and affect triglyceride levels far differently. I know that John McDougall encourages some patients with severe heart disease to limit their fruit intake to 2 pieces or less per day to avoid spiking triglyceride levels but I do not see any evidence in the research literature to show empirically that complex carbs drive up triglyceride levels.

The only caveat to this I can think of is for people who have been diagnosed with Metabolic Syndrome X. Individuals who have become, or are becoming, insulin resistant respond to glucose differently and can experience spikes in both glucose and triglyceride levels with even complex carbs. However, I believe that research by Neal Barnard clearly shows that reducing fat intake can effectively heal insulin resistance allowing the cells to move dietary sugar appropriately. Research out of Italy on morbidly obese patients who had gastric bypass surgery was the impetus for this finding. These patients, who were insulin resistant, became well within weeks of gastric bypass surgery. And this was *not* due to weight loss as they had only lost 20-30 pounds by that time (meaning that many of them still had 100+ pounds to lose). However, due to the way gastric bypass shunts dietary fat, the patients could not absorb the fat they ate and their cells began to "de-gunk" and allow sugar in and out of the cells to enter the bloodstream as necessary.

In addition, refraining from adding oil to food does *not* mean that a person has removed all fat from their diet thereby constituting "removing an entire macronutrient class from your diet". Quite the contrary. Raw oats are 16% fat without the butter that many people add to them after cooking. All fruits and vegetables contain trace amounts of fat in them. It is virtually impossible to remove all fat from your diet. However, removing *added* fat from your diet is a different proposition all together and one that increases heart health on every level.

[Kiki Ohio]

I agree with Lora that avoiding "just a taste" or "just a bite" of rich foods helps keep my taste buds and cravings for those foods in check. Caldwell Esselstyne cites a study on this that showed that the less that people ate of high fat foods, the less they wanted them. However, this took about 15 weeks to occur. Esselstyne urges his patients to eat clean with no slip-ups for 3 months. That three month period is the time it takes to reset the taste buds and it is well worth it in my experience.

I lived abroad for several years in East Asia and found that children there *loved* vegetables and whole soy foods. East Asians, at that time, ate fruit as their dessert and it was rare to serve cakes, pastries, or sweets after a meal. Fruit cleanses the palate, is satiating, and delicious (not to mention healthy). It was an adjustment at the time (I ate sweets several times a day) but one that I am grateful to have acquired.

The truth is that our taste buds are 100 % trainable. That is why children in East Asia love vegetables while U.S. kids want potato chips, french fries, and sugary soft drinks. We train ourselves (or our parents do) to eat and therefore enjoy certain types of foods. That means that we can re-train our taste buds and reap the benefits from it.

[Joan]

Cooking without oil tips: http://lechateausoleil.blogspot.com/2010/02/cooking-basics-pan-frying.html

[NaomiF]

Very enlightening post! I've noticed a lot of people here have pointed out that East Asian diets are very healthy and low in cholesterol. I can attest to this- I lived in Tokyo for four months and quickly lost almost 15 pounds almost effortlessly because of the local diet and the amount of activity in my daily life- going up and down stairs all day, walking everywhere, jumping from subway to subway, that type of thing. I had a good time in Asia and I'd love to return.