Supporting Healthy Lipid Balance*
Beyond Red Yeast Rice Extract
Elevated serum cholesterol is an established factor influencing cardiovascular health. Total cholesterol, low-density lipoproteins (LDL), high-density lipoproteins (HDL), and triglycerides all influence cardiovascular health. Guidelines from the U.S. National Cholesterol Education Program identify LDL cholesterol levels as the most important of these factors, suggesting that an optimal level of LDL should be less than 100 mg/dL.
A variety of dietary supplements have been shown to support healthy lipid balance.* Here are seven well-researched supplements to consider.
RED YEAST RICE
Red yeast rice extract is made by culturing rice with various strains of the yeast Monascus purpureus. This culturing process can produce a variety of compounds, including 14 active monacolins.
Numerous clinical trials have evaluated red yeast rice for lipid metabolism support. A 2015 meta-analysis reviewed 20 randomized, controlled trials of red yeast rice extract involving 6,663 participants. The amount of red yeast rice taken per day ranged from 1,200 to 4,800 mg, with levels of naturally occurring Monacolin K in the products ranging from 4.8 to 24 mg per day (averaging 10.8 mg). The analysis concluded that red yeast rice, taken for four months, supported healthy LDL cholesterol levels.*
Niacin (nicotinic acid) was used as early as 1955 to support healthy cholesterol levels, but its mechanisms have only recently become understood. Niacin is thought to decrease mobilization of triglycerides from fat stores and inhibit triglyceride synthesis. It’s also believed to influence HDL metabolism. These benefits have been demonstrated with daily intakes of 1,200 to 2,000 mg of nicotinic acid.*
However, many people don’t want to take niacin because of the flushing reaction that can occur when a large amount is ingested at once. Depending on the sensitivity of each individual, even doses as low at 50 mg may cause flushing. Sustained-release niacin ameliorates the flushing reaction, but has a higher risk of damaging the liver. It’s also important to note that no-flush niacin (inositol hexaniacinate) has not been shown to have the same cardiovascular benefits as nicotinic acid.
Another key point is that although niacin/nicotinic acid supports healthy lipid metabolism, those benefits may not translate to reduced cardiovascular risk. Two large, randomized, controlled trials (AIM-HIGH and HPS2-THRIVE) found that niacin supported healthy HDL cholesterol levels but didn’t affect the risk of cardiovascular events.
Fish oils contain the omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). These essential fatty acids boast many health supporting benefits, including their ability to modulate eicosanoid metabolism to support healthy inflammatory response.* When it comes to supporting healthy cholesterol levels, however, the data on fish oils aren’t as clear.
Studies consistently show that fish oils support healthy triglyceride levels but not overall cholesterol levels. Moreover, the amount of EPA and DHA correlates with the ability to support triglycerides. A 2009 meta-analysis of 47 studies reported that daily consumption of 3.25 grams of EPA or DHA supported healthy triglyceride levels but didn’t affect total or LDL cholesterol.
Plant sterols and stanols are naturally occurring compounds in fruits, vegetables, grains, and oils. They’re also now found in fortified margarine, cooking oils, orange juice, and other functional foods. Examples include beta-sitosterol, campesterol, and stigmasterol. Plant sterols are similar in molecular structure to cholesterol and compete for absorption from the digestive tract.
The current interest in plant sterols stems from epidemiological studies that suggest people who consume more dietary plant sterols have healthier cholesterol levels. In recent years, more than 200 clinical trials have lent credence to the ability of plant sterols to support healthy LDL levels.*
Most studies of plant sterols have evaluated an intake of 2 grams per day from functional foods. Meta-analyses of these studies suggest that this amount supports healthy LDL cholesterol levels.* Based on this evidence, the National Cholesterol Education Program recommends that people with elevated cholesterol consume at least 2 grams of sterols or stanols per day.
Policosanol is an extract from Cuban sugarcane wax that contains octacosanol and other alcohols. Some dietary supplement companies source policosanol from rice or wheat germ, but most clinical trials have evaluated policosanol from sugarcane. In addition to its well-known ability to support healthy lipid levels, policosanol also supports healthy platelet function and blood pressure.*
Policosanol was recently evaluated in a 2018 meta-analysis of 22 clinical trials. The pooled results from 1,886 participants showed that policosanol supported healthy levels of total cholesterol, LDL cholesterol, and HDL cholesterol.*
In a 2005 meta-analysis, researchers asked whether policosanol or plant sterols had a more pronounced effect on lipid levels. The analysis included 23 studies on plant sterols and 29 studies on policosanol. The researchers concluded that both plant sterols and policosanol supported healthy lipid levels, but that policosanol had a stronger effect.*
Policosanol’s mechanism of action is not well defined, but it appears to have a good safety profile. Long-term studies of more than three years suggest it’s safe to take policosanol in amounts up to 20 mg per day.
Garlic (Allium sativum) has been shown in studies to support cardiovascular health due to its antioxidant activity and ability to support healthy blood pressure, lipid levels, and platelet function.*
Not all clinical trials show that garlic supports healthy cholesterol levels, but the most comprehensive and recent meta-analysis suggests it does. This analysis, published in Nutrition Reviews in 2013, concluded that garlic taken for two or more months supports healthy total cholesterol, LDL cholesterol, and HDL cholesterol.* The analysis didn’t find that garlic affects triglyceride levels.
Most clinical trials use 500 to 1,500 mg of dried garlic powder, equating to about one to two cloves per day. Alliin is the most abundant organosulfur compound in garlic, and many dietary supplements are standardized for this compound.
Hawthorn berries (Crataegus oxyacantha) grow on a thorny tree that’s a member of the Rosaceae family. Rich in flavonoids and other nutrients, hawthorn has a long history of use as a “heart tonic”. The berries have antioxidant effects, support normal contractility of the heart muscle, and support healthy blood pressure.*
So far, only animal studies offer evidence that hawthorn might support healthy lipid metabolism. Studies in mice that were fed a high-cholesterol diet found that hawthorn supports healthy LDL cholesterol and triglyceride levels. Mechanistic studies suggest that hawthorn supports lipid metabolism by regulating fatty acid synthesis and degradation.
THE POWER OF SYNERGY
These supplements are just a few of the dietary compounds that might support healthy lipid balance. Soluble fiber abundant in vegetables and grains, for example, binds to cholesterol in the digestive tract and supports healthy cholesterol levels. Foods, herbs, and dietary supplements (such as coenzyme Q10, astaxanthin, and vitamin E) that are rich in antioxidants also support healthy lipid metabolism.*
Lastly, we need to acknowledge the power of synergy. Some combination supplement formulas have demonstrated a benefit for supporting healthy lipid metabolism in clinical trials. One of these combos includes red yeast rice, berberine, policosanol, astaxanthin, coenzyme Q10, and folic acid.* Another combines berberine, policosanol, and red yeast rice.*
Supporting healthy lipid metabolism with supplementation is one piece of the puzzle when it comes to cardiovascular health.* Choosing to use or recommend any of the supplements discussed above should be done in the context of the overall health, diet, and lifestyle of any given patient. Weigh the risks and benefits of each supplement, and always check for nutrient and drug interactions.
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*These statements have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure, or prevent any disease.