Ashlee Williams, MD (Host): Did you know nearly 40% of adults in the United States have high cholesterol? Elevated cholesterol levels put you at an increased risk for heart attack and stroke. But fortunately, there are lifestyle changes you can make to get your cholesterol numbers back to healthy levels.

Welcome to the Healthier You podcast. I am Dr. Ashlee Williams. And today, I am talking with Dr. Ameya Kulkarni, a cardiologist at Kaiser Permanente, about simple ways that you can lower cholesterol without medication. Welcome, Dr. Kulkarni.

Ameya Kulkarni, MD: Thanks, Dr. Williams, for having me.

Host: Glad to have you here. So, what is cholesterol? And who is at risk of having high cholesterol?

Ameya Kulkarni, MD: Yeah, great questions. So, cholesterol is actually a really important part of our body's work, right? So, cholesterol is a little lipid molecule, a little fat molecule that's used in a bunch of functions of our body. It has core functions in the cells, it's used to make hormones, it helps with brain function.

So in its essence, cholesterol is actually really, really important. But like everything that's important, you know, cholesterol is important in moderation. And what we're faced with now is that because of diet, genetics, and a variety of other things, the amount of cholesterol we're intaking is more than the amount we need, and that excess cholesterol can present a risk.

Host: Okay. So, what do cholesterol numbers mean and what should I do if I have high cholesterol?

Ameya Kulkarni, MD: This is like probably the most common question that I get asked. You probably get asked exactly very commonly. And I think one of the reasons we get asked this question is because when you look at your lab results, there's those high values and we sort of worry about them right away. So, I think it's useful to sort of break down what the cholesterol individual components are and how we think about each of them.

So, total cholesterol is the first number that you see on your cholesterol report. That's sort of all the cholesterol in your body. Now traditionally,, we want that number to be on average under 200, but I'd say let's call that an old school way of looking at cholesterol. I think most people now almost ignore that total cholesterol number unless it's very, very high, much above 200.

The component cholesterols are actually the things that matter. And there's two that we think about a lot. One is the HDL. Now, the HDL or the high-density lipoprotein is the good cholesterol. You know, it's the stuff that we think is protective when it comes to heart disease and stroke. And that is sort of elevated by two things, genetics and exercise. So, we want that to be higher is better. Above 40 we think is sort of in the normal range. But the higher you are, that means you're exercising more and that genetics are better.

The second cholesterol component to think about is the LDL. Now, that's the bad guy. That's the one we think about as being not good for you. It's the thing that causes all the sort of plaques in your arteries. The bad cholesterol, in general, in a person who doesn't have any disease, we want that number to be under 160. Now you'll often see on the lab values that you see the number as under 100. And so, there are certain populations, if you're at higher risk of heart disease or you have heart disease, we want that number to be under 100. But if you're an average risk person, you know, you're somebody who's testing your cholesterol because you're sort of trying to be proactive about your health. If that number is under 160 or ideally under 140, then you're probably in okay shape.

The key thing here, Dr. Williams, is you and I always talk about is, we want these conversations to be sort of with your doctor. You know, your doctor knows you better than anybody else. And so, rather than a random number assignment, that you're talking to your doctor about your individual risk.

Host: Exactly. Personalized care. Thank you.

Ameya Kulkarni, MD: Exactly right.

Host: So, should people with high cholesterol change their diets?

Ameya Kulkarni, MD: Yeah. Short answer is yes. So if your LDL number is elevated, even if it's not quite at that 160 level where we're thinking about other stuff, but it's elevated, the simplest tool to try to get that number down and to improve your health is to change your diet. And there's lots of different ways in which you can change your diet. But I think that I like to eat in principles and I think that I like to tell people how to eat in principles rather than these specific diets. So, the principles for me is focus on fruits and vegetables. So, the green leafy vegetables are better. The high-fiber fruits are better. But fruits and vegetables in general, we want more than 50% of our calories to come from fruits and vegetables.

Then, minimize the sort of the high-fat meats like lamb, beef, and pork. And if you're going to eat meat, then focus on meats that are leaner like chicken and fish, and minimize the sort of carbohydrate intake. Now, you probably have seen something. So, there's lots of sort of fad diets that talk about a super low-carb diet. And in reality, you get benefit by reducing your carbohydrate intake if you shift it from being over 60% of the calories you take to less than 50%. So, it's not a huge leap. It doesn't mean you got to be like no carb, none of the time, you know. But, you know, sort of reducing the amount you eat is really important.

And then, the last thing that's important is minimizing the processed food. Anytime you're eating a processed food or an ultrprocessed food, you can guarantee they're making it taste good by either adding fat or salt, and both those things are not great. So if you sort of focus on reducing that, that's a good place to start.

Host: So, do you have any suggestions for food swap?

Ameya Kulkarni, MD: I do. One of my favorite questions that my patients ask is, "How do I get this started?" Right? And so, food swaps are a simple way to really start to try something today. And I have three, but I hope that your listeners will use these as sort of principles to think about other swaps as well.

So, the first one is potato chips. So, potato chips are delicious, but they're deep fried, they're high in starch, and they're high in fat. They're sort of all the bad things. And so, what I suggest is switch potato chips for kale chips. And the reason why that's a good substitution is because when you make kale chips, you buy kale already torn up, you put it on a flat sheet and you put olive oil and salt on it and you put it in either an air fryer or you can use an oven as well to roast them. If you think about what are the things that people like about potato chips, what they like about them is the crunch, and the sort of taste of salt in your mouth. If you ask people why they like potato chips, that's really the two things they like. And so, kale chips actually meet those substitutions, but the fat content is way lower. You're switching bad fat for good fat and you can use a lot less salt to get that salty taste. And so, that's like an easy substitution and a good place to start.

Host: And you can probably buy those over-the-counter, right, just at the store. You don't even have to make them.

Ameya Kulkarni, MD: Yeah, you can buy them from the store as well. Yeah, if you don't have time, it's right there. They're a good on-the-go snack. The only trick is that if you buy them in the store, you want to check the salt content. Sometimes they add a lot of salt. But otherwise, yeah, that's an easy substitution. You know, potato chips for kale chips.

A second substitution I suggest is switching soda for sparkling water. Now, soda is interesting because soda doesn't have any cholesterol in it. So, you're saying, "Well, why are we talking about it in the conversation about cholesterol?" most sodas have a lot of sugar in them. And if sugar, if you have a lot more sugar than you need, that will convert to fats as well. So, that sort of becomes a bad actor eventually. Switching out soda for sparkling water, that's again, an easy substitution. If you ask most people what they like about sodas is they like the fizz and they like a little bit of flavors. So, you take lemon and mint and you put it in a sparkling water, and you sort of achieve the same goal with significantly less cholesterol.

And then, the third one, which takes a little bit getting used to, but I have proof of it with my kids, is switching out candies for fruits. Now, that sounds crazy. I know, Dr. Williams, that sounds crazy. But what's interesting is that when you think about what is it about a candy that when you bite into it that you like, it is that you like that sudden rush of sweetness and a little bit of tanginess, right? So, that flavor profile is what we're looking for. And switching to like a juicy peach or a plum, you can get that same sort of mouth feel. And because fruit sugars are more easily processed than the processed sugars in candies, it's actually a very healthy substitution as well.

So, those are three sort of easy tricks, I think, to get you started. And then, just use the same principle. When you're encountering a food that you just can't give up, think about what about it that gives you joy, and try to find that joy in other foods that are healthy. I think that's the trick to sustainability.

Host: Yeah, those are great tips and probably just like everything in moderation, right? And slowly making these transitions will probably make you more successful.

Ameya Kulkarni, MD: That's like the best lesson anyone can learn about food switches. Don't try to suddenly become-- if you're, you know, a meat and potatoes person, go into vegan immediately, you're never going to get there, right? You're going to be miserable. Your family's going to be miserable. And so, just sort of figuring out small things incrementally that you can do over days and weeks and months to go from an unhealthy diet to a healthy one will have pretty significant impacts. And, you know, what you really want is when your cholesterol is high and you're trying to reduce it, you're looking for things you can do forever, right? Because really these changes need to be forever changes. And so, a lot of small changes are far superior to sort of these drastic changes you're going to do for 30 days.

Host: So, what are your thoughts on exercise?

Ameya Kulkarni, MD: I love exercise. So, exercise is interesting, because I think that there is a lot of value in exercise in controlling your cholesterol and controlling your cardiovascular risk. I sort of started to talk about it and didn't quite finish talking about why cholesterol matters in terms of cardiovascular risk. And the reality is when your cholesterol levels are high for a long period of time, that cholesterol gets trapped into these plaques in your arteries. And when those plaques rupture, they can cause a heart attack or a stroke, depending on where the plaques are.

We use a bunch of tools to figure out when you have high cholesterol, what is your risk of having one of those events happen? And so, one of the tools we use is called the ACVSD risk score. There's lots of them. You know, everyone has it. I'm sure, Dr. Williams, you have your own risk score that you use. So, we just sort of use this risk score to guide somebody's risk of an event. And what we know about exercise is that in addition to lowering your bad cholesterol and increasing your good cholesterol, when you do enough aerobic exercise in a week is we know that that ACVSD risk goes down independent of those risk factors, because there's a bunch of other things that exercise does, even if you don't lose any weight, even if you don't change your cholesterol, you're changing your risk in a positive way. So, I think that aerobic exercise done four times a week is sort of a great medicine to prevent heart disease.

You know, people also ask about, you know, what kind of exercise do I need to do? And think any exercise is good exercise as long as it's the kind you can do for a long time and the kind that you don't injure yourself doing. You know, the American Heart Association recommends 150 minutes a week of exercise. That's sort of 30 minutes, five times a week. I think most people who are doing no exercise now would have a lot of trouble getting to 150 minutes a week right away. So, I say search for the moments when you can do sort of surreptitious exercise. So if you are driving to the mall, instead of parking as close as possible, look for the furthest parking spot and walk that distance. You know, that's five minutes of exercise that you weren't getting that you're going to get now. And if you just sort of just build habits like that, taking the stairs instead of the elevators, over time, you'll start to acquire some activity. Now over the longterm, that's not going to be enough, but that's a good place to start. You know, that's little activity pockets that you didn't have before.

And then after that, you got to sort of start doing some sustained aerobic exercise. But the sustained exercise, it doesn't have to be going to the gym and sweating buckets. You know, you can do things like taking a brisk walk. What we know is that once you get your heart rate more than 30% from your baseline, you're getting some cardiovascular benefit. So, you know, you don't have to boil the ocean right away. You can really just start with these small increments of change that can have you on your way.

Host: Right. More about the marathon, not the sprint, right?

Ameya Kulkarni, MD: That's right. Exactly right. That's right.

Host: Are there any other lifestyle changes that you can think of that can help lower cholesterol?

Ameya Kulkarni, MD: For the most part, bad cholesterol comes from three things. One is your genetics, which you can't control at all. The second thing is the foods you intake, which we've been talking about. And the third is your environment. By your environment, what I mean is sort of, are you active or not active? Are you in a place that has more air pollution, things like that? So, some of those things you can control and some of them that you can't. But if you really want to focus on things that have the highest value in terms of lowering your cholesterol and your risk, the diet and exercise is one and two.

I do want to say one thing about stress, because stress is one of those things that we're all experiencing and worse than the last three to four years than ever before, probably, right? And so, stress is a factor in cardiovascular risk. Now, thankfully, stress, for the most part, doesn't affect cholesterol. So, it's sort of specifically about how can you lower your cholesterol. It's not as important a factor. But it certainly is important in your cardiovascular risk. And certainly, if you are a person who stress eats, so when you're high stress, you tend to eat to sort of help that stress reduce, that's something that you want to pay attention to.

Along the lines of stress as well is alcohol. So, there's lots of controversy about whether alcohol helps your cholesterol or hurts your cholesterol. I think that we don't have a clear answer right now. I don't think that we ever will, because of the way that alcohol is processed differently in different people. I think right now most cardiologists will say mild or moderate amounts of alcohol are probably okay. Anything more than a little bit is probably not okay in terms of cholesterol, but that's sort of the other thing to think about.

Host: Okay. And what about smoking to handle stress?

Ameya Kulkarni, MD: Oh, yeah. How could I forget about smoking? So, smoking is a universally bad thing, I think is the best way to describe. It definitely can increase your cholesterol. It definitely increases your risk of heart disease, independent of your cholesterol. And then, it does all the other bad things like damages your lungs and your peripheral vascular disease and increases your risk of stroke and kidney disease. And it badly affects every organ in your body. But yes, cholesterol, it is certainly a bad actor with cholesterol.

Host: So, are there any over-the-counter supplements that we can use to lower our cholesterol?

Ameya Kulkarni, MD: So, the thing about supplements as we know them now is that there have been randomized clinical trials that have demonstrated the value of any supplements with regards to lowering cholesterol and cardiovascular risk. So, there are a bunch of things that we know that lower cholesterol. So red yeast rice extract, that was popular a couple of years ago. People talk about ginger as a natural agent to lower cholesterol or turmeric. So, there's a lot of sort of these claims made about natural agents and their ability to lower cholesterol and reduce cardiovascular risk. Some of those things do reduce cholesterol actually. So, some of those things, we have seen reductions in cholesterol with some of those agents in enough of a randomized fashion where we think, yes, they're cholesterol-lowering agents.

Interestingly though, none of them have shown that second part, which is a reduction in cardiovascular events. And cholesterol is really complicated, right? It's not just about if your cholesterol is lower, then your risk is lower. There is some other things at play that we think the medications that we know reduce cholesterol do that just purely lowering your cholesterol may not do. And so, what I would say is that if you want to take a supplement to try to reduce your cholesterol, I think that as long as it doesn't interact with any of your other medications or it doesn't cause you any problems, I don't think that that is inherently a bad thing. I think you want to be cautious about, one, claiming that it will reduce your risk of having a heart attack, because there's nothing shown that it does. And two, if it's at the expense of something that could potentially help, I think that that's where we get into risky territory. But of course, like all of these things, it should be a good conversation with you and your doctor who knows you the best and understands your needs and limitations the best. I think that's where you get to the best solutions for you.

Host: Okay. So, I've stopped smoking, I don't drink alcohol, I'm exercising five days a week, 30 minutes a day, I'm eating everything my doctor recommends, and my cholesterol is still elevated. Now what?

Ameya Kulkarni, MD: Now what? Now it's time for medication. So, I think, you know, people, one of the worst things about cholesterol is that there is this belief that it's all our fault, right? That if only I eat better and exercise like crazy, that I will get my cholesterol to a normal rate. The reality is that some component of cholesterol is genetic, and it's impossible to outrun it. You can run away from your genetics, but you can't outrun it. And so, I think that, at some point, your cholesterol may be higher than is acceptable for your risk. And in order to lower your risk of having a heart attack or stroke, we got to use medications.

So, the statin medications are the most commonly used medications to reduce cholesterol. They are fantastic tools. We have now, I think, almost 40 years of data on them. So, we know what they are and what they do and what they aren't and what they don't do pretty well. I think there's been a billion patient years of data collected on statins. So, we understand what they are. There's also new medications that have come out that work in a variety of ways, and that have specific use cases. But, you know, I think that if I could sort of help my patients understand one thing is that statins are not a waving the white flag. You know, it's not a surrender to your limitations. It's just some people's bodies can't process cholesterol, even at normal intakes and they need medications, and that's okay. That's what you and I are here for, right? That's why we're here to help our patients.

Host: Thank you, Dr. Kulkarni, for this amazing and great information. There are a few key takeaways for anyone looking to lower their cholesterol. One, make sure your diet includes lots of high fiber fruits and vegetables such as berries, avocados, leafy greens, broccoli, and cauliflower. Avoid fatty, fried, and processed foods. Cut back on red meat as much as possible. Three, swap refined grains like white bread and white rice for whole grains such as oatmeal, quinoa, brown rice, and whole wheat bread. Four, exercise regularly. Aim for 30 minutes a day, 5 days a week, and start slow. And five, cut back on alcohol, smoking, and find healthy ways to manage stress.

For more tips from our doctors and other healthy living advice, visit kp.org/doctor and listen to more episodes of Healthier You wherever you get your podcast. If you enjoyed this episode, be sure to share it with others who may find it helpful. Thank you and, from all of us at Kaiser Permanente, be well.