High Cholesterol and Triglycerides: Which Supplements to Support Diet Therapy?
Cholesterol and high triglycerides: which supplements to support diet therapy?
The cardiovascular diseases are the main causes of death in the Italian population. Yet intercepting their risk factors is possible and, consequently, it is possible to put into practice effective preventive strategies that reduce the probability of facing potentially fatal events such as heart attack and stroke.
Among these risk factors are altered blood levels of cholesterol and triglycerides. Managing them and bringing them, if possible, within intervals considered healthy requires paying particular attention also to nutrition. However, diet therapy is not always as effective as desired, also due to difficulties patients encounter in adhering to the dietary plans proposed to them.
Dietary supplements can represent a valid help both in the most resistant cases to diet therapy – those in which, despite apparent adherence to the prescribed dietary plan, cholesterol and triglycerides do not decrease as much as desired – and to increase the patient’s adherence to diet therapy itself, motivating them in light of the results obtained on altered blood parameters.
But which supplements to choose to support the hypolipidemic diet?
Fighting cholesterol with supplements
Regarding cholesterol, it is first of all good to remember the thresholds below or above which the concentration of the different forms in which it is present in the bloodstream is considered optimal:
- Total cholesterol: not exceeding 200 mg/dL
- LDL (Low Density Lipoprotein, or “bad” cholesterol): not exceeding 100 mg/dL
- HDL (High Density Lipoprotein, or “good” cholesterol): not less than 50 mg/dL (men) or 40 mg/dL (women)
The possibility of resorting to treatment with statins (the gold standard in pharmacological management of hypercholesterolemia) depends on the patient’s age and their 10-year risk of atherosclerotic diseases. Moreover, the Italian Medicines Agency (Aifa) recognizes statin prescriptions covered by the National Health Service (SSN) only in cases where elevated hypercholesterolemia cannot be corrected with diet therapy alone, attempted for at least 3 months, and in polygenic hypercholesterolemia.
The scope of action of the nutrition professional in the fight against high cholesterol is therefore quite broad. Any patient should consider changes in their eating habits regardless of statin prescription; moreover, in many cases before moving to pharmacological treatment it is necessary to attempt reduction through diet therapy.
Supplements based on red yeast rice have long supported hypocholesterolemic diets. Today, however, the possibility of exploiting their properties has been limited because they are sources of a true natural statin and, therefore, concerns about their possible side effects exist. This has led many companies to reformulate their products, focusing on active ingredients different from monacolins of red yeast rice. Among these stands out artichoke dry extract (Cynara cardunculus) standardized in chlorogenic acid and luteolin.
The traditional medicinal use of artichoke was supported in the 20th century by research demonstrating, among other things, its ability to reduce blood lipids and oxidative stress (a phenomenon contributing to atherosclerosis). Today, the Ministry of Health also recognizes the antioxidant effects and lipid metabolism modulation of artichoke leaf extract. However, to benefit from these properties, it is necessary to use high doses of the extract’s active ingredients. For this reason, it is essential to rely on supplements based on extracts standardized in:
- chlorogenic acid and derivatives (10-12%): for inhibitory action on cholesterol synthesis, fatty acid synthesis, and digestion of dietary fats;
- luteolin-7-glucoside and derivatives (2-4%): for inhibitory action against cholesterol synthesis and intestinal absorption and antioxidant protection of LDL.
In overweight individuals diagnosed with metabolic syndrome not treated with statins, taking 150 mg daily of this type of artichoke extract for 6 months was associated with improved levels of total and LDL cholesterol and cardiovascular profile (evaluated in terms of flow-mediated vasodilation and carotid intima-media thickness).
By inhibiting cholesterol synthesis via mechanisms similar to statins (it inhibits the enzyme HMG-CoA reductase), artichoke extract could raise concerns about reduced Coenzyme Q10 synthesis (and thus muscle problems). For this reason, it is advisable to choose supplements that also contain this active ingredient.
The addition of other ingredients able to control blood cholesterol (such as monacolins from red yeast rice, at concentrations currently allowed), antioxidants, and nutrients promoting good cardiometabolic health is an added value not to be underestimated.
Supplements in triglyceride management
The same treatment that demonstrated the ability of standardized artichoke extract to reduce total and LDL cholesterol also produced a lowering of triglycerides, in which case, however, the most potentially useful supplements are undoubtedly those based on Omega 3. The efficacy of these polyunsaturated fats in controlling hypertriglyceridemia is now beyond doubt, so much so that the European Food Safety Authority (EFSA) has authorized a nutritional claim precisely regarding this property. Moreover, some drugs based on high doses of Omega 3 are used precisely in cases of hypertriglyceridemia.
Under optimal conditions, blood triglyceride concentrations do not exceed 150 mg/dL. Levels between 150 and 199 mg/dL deserve attention but are not yet considered high enough to induce prescription of drugs. Above 250 mg/dL the situation becomes more dangerous; if 500 mg/dL is exceeded, the pancreas is also seriously at risk. Referring to the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) guidelines, triglycerides can be classified as slightly high (between 150 and 199 mg/dL), high (between 200 and 499 mg/dL) and very high (starting from 500 mg/dL).
The European Society of Cardiology (ESC) suggests considering pharmacological treatment only starting at concentrations of 200 mg/dL. However, slightly high triglycerides are enough for cardiovascular risk to increase. For this reason, the nutrition professional intervenes well before drugs. Their first, fundamental task is to suggest changes in eating habits that can help correct hypertriglyceridemia – a task in which Omega 3 supplements can be particularly helpful.
As mentioned, EFSA authorizes the use on labels of the nutritional claim that «DHA contributes to maintaining triglyceride levels within normal range». For correct use, however, it is necessary to remember that the dosage needed to hope for this benefit is a full 2 grams per day of a combination of EPA + DHA.
It is precisely this high dosage, difficult to reach with diet alone, that makes Omega 3 supplements valuable allies of diet therapy. For correct use, it is good to remember that:
- the supplement chosen for managing the problem must contain DHA in combination with EPA;
- the product must be able to provide 2 grams of EPA + DHA per day without requiring the intake of too many capsules;
- a total daily intake exceeding 5 grams of EPA + DHA should never be exceeded.
Finally, it is always worth remembering the importance of relying on products of certified quality, concentration, and purity. In the case of marine-origin Omega 3s, the best certification to base one’s choice on is that issued by the IFOS program (International Fish Oil Standards). To learn more about this aspect, it is possible to listen to episode 10 of “Pearls of Wellness”, the podcast on the world of Omega 3 produced by Omegor. It is entitled “Which supplement?” and is available at this link.
Bibliographic references
2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce
cardiovascular risk. European Heart Journal (2020) 41, 111188. doi:10.1093/eurheartj/ehz455
Italian Medicines Agency. Update of AIFA Note 13 pursuant to AIFA determination no. 191 of 06/05/2022
American Heart Association. Prevention and Treatment of High Cholesterol (Hyperlipidemia). Last viewed April 4, 2023
Castellino G et al. Altilix® Supplement Containing Chlorogenic Acid and Luteolin Improved Hepatic and Cardiometabolic Parameters in Subjects with Metabolic Syndrome: A 6 Month Randomized, Double-Blind, Placebo-Controlled Study. Nutrients. 2019 Nov; 11(11): 2580. doi: 10.3390/nu11112580
European Commission. Food and Feed Information Portal. Health Claims. Last viewed March 15, 2023
Harvard Health Publishing. Harvard Medical School. Understanding triglycerides. March 1, 2020. Last viewed March 15, 2023
Karanchi H et al. Hypertriglyceridemia. 2022 Aug 22. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID: 29083756
MedlinePlus. Cholesterol Levels: What You Need to Know. https://medlineplus.gov/cholesterollevelswhatyouneedtoknow.html. Last viewed April 4, 2023
MedlinePlus. Triglycerides. https://medlineplus.gov/triglycerides.html. Last viewed March 15, 2023
Ministry of Health. Attachment 1 to DM August 10, 2018, on the regulation of the use in dietary supplements of substances and plant preparations as updated by Decree January 9, 2019.
NHS. Cambridge University Hospitals. Dietary advice for management of High Triglycerides. https://www.cuh.nhs.uk/patient-information/dietary-advice-for-management-of-high-triglycerides/. Last viewed March 15, 2023
Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Executive Summary. https://www.nhlbi.nih.gov/files/docs/guidelines/atp3xsum.pdf
Visseren FLJ et al. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J. 2021 Sep 7;42(34):3227-3337. doi: 10.1093/eurheartj/ehab484
