Diet and High Cholesterol

The March 28, 1991 edition the New England Journal of Medicine printed a letter from the physician who had made a very unusual observation about diet and cholesterol. An 88-year-old man who lived in a retirement community complained only of loneliness since his wife’s death. He was in excellent health, articulate, well educated, and ate 20-30 soft-boiled eggs a day, as he had done for the past 65 years. His blood cholesterol levels measured between 150 and 200 mg/deciliter for 15 years. Clearly, in this man’s case, a high-cholesterol diet did not result in high cholesterol in the bloodstream. And if you think that case was unique consider this one.

I spent several years studying the research of an internationally renowned cardiologist, Demetrio Sodi-Pallares, who preferred to be called “Dr. Sodi.” Among Dr. Sodi’s more controversial concepts was his idea that high cholesterol was caused by too much salt in the diet rather than too much cholesterol in the diet.

A woman whose heart had been damaged by rheumatic fever was referred to Dr. Sodi for ongoing heart treatment. Her labs showed that she had at least three prominent metabolic problems. Her levels of T4, the thyroid hormone, were very low, 0.9 mcg. Her cholesterol and triglycerides were astronomically high. Total cholesterol was reported as 800 mg/dl. A healthy level is generally accepted to be 190 or lower. Her triglycerides were 4500 mg/dl. A healthy level is generally accepted to be 125 or lower.

At first, Dr. Sodi simply didn’t believe the lab. He sent the woman’s blood samples to two other laboratories for confirmation, and the numbers did not come back the same. One laboratory reported that triglycerides were 4339 and the other reported 4442. Although, as you will read later in this book, cholesterol and triglycerides do not in and of themselves clog arteries in most people, here was a person whose arteries were literally clogged with fat. Dr. Sodi decided that the need to lower lipids was urgent, and that correcting the thyroid problem could wait. No drugs then (or now) were designed to correct lipid levels that high and the only treatment seemed to be diet.

Over the decades of his practice—Dr. Sodi practiced medicine twelve hours a day every day for 67 years—the noted doctor had often successfully treated heart attack with diets that lowered the intake of sodium. Here was an opportunity to see if low-sodium diets might correct other conditions. Other doctors had been stumped. Since complete elimination of fat from the diet is practically impossible, Dr. Sodi decided also to take fat completely out of dietary consideration, not out of the diet itself, just from his thinking.

Dr. Sodi gave his patient novel instructions. Eliminate added salt from your diet. No canned soups, no pickles, no food made from mixes, only a half a teaspoon in a whole day added to food for taste. He showed her a sewing thimble. “This much salt and no more in any one day,” he said. Eliminate foods that are naturally high in sodium, a long list that in our era includes usually unsuspected sources of salt such as carrots, celery, and egg substitutes. And to see what was really causing high cholesterol and high triglycerides, Dr. Sodi also told his patient to consume two scrambled egg yolks (not the whites or an egg substitute, containing unacceptably high levels of sodium) every morning and to season her steamed vegetables every day with four ounces of unsalted butter! Dr. Sodi wrote no prescriptions. If this patient improved, it was not going to be because she had eliminated fat from her diet and it was not going to be because he had prescribed the latest and greatest medication. Dr. Sodi wished to spare his patient expense.

Two weeks later the woman came back to Dr. Sodi’s office for her labs. After adding fat (which, I emphasize, is not essential to Dr. Sodi’s method, it was only part of this test) and eliminating over 95 percent of the sodium in her diet, the patient had lowered her triglycerides from 4400 to 600 and her total cholesterol from 800 to 240. Dr. Sodi decided to continue the test. At this visit he instructed his patient, “Now go back to your original low-fat, low-cholesterol diet, but eat salty foods as you desire them.” At the follow-up visit triglycerides were back up to 2224, and the patient requested thyroid medication to relieve her fatigue. Dr. Sodi asked her to go back on the sodium-restricted diet for one month before he wrote the prescription. A month later the woman had renewed vitality and did not need thyroid medication. Her triglycerides were back up to 600, still too high, but drastically improved. Her cholesterol was once again 240.

In our age of almost universal fear of cholesterol, a level of 240 is considered too high—but compared to 800, it is an enormous improvement in the absence of medication. We now have drugs that can lower cholesterol from 240 to more acceptable levels, although we do not have drugs that reliably lower cholesterol from 800. More importantly to medicine, Dr. Sodi discovered that the diet he prescribed for recovery from heart attack had many unexpected applications. It was over 40 years later, before any other scientists published research on this method.

The July 2001 issue of the American Journal of Clinical Nutrition reported that people on the DASH (low-sodium, high-potassium) diet reduced their levels of total cholesterol by 13.7 mg/dL or 7.3 percent, and their levels of LDL cholesterol by 10.7 mg/dL or 9 percent. One of the authors of the study, Dr. Claude Lenfant [Note to Carol: Not L’enfant, it is Lenfant.], stated:

“Studies have proven the DASH diet to be beneficial for individuals with high blood pressure or those wishing to prevent high blood pressure. These latest findings provide strong evidence that individuals with high blood cholesterol can also benefit significantly from this eating plan. Physicians and their patients with heart disease can add the DASH diet to the armament of tools known to help lower a person's risk of coronary heart disease.”

Unlike Dr. Sodi’s experiment, the DASH studied involved lowering consumption of dietary fats. In the DASH study, 459 participants were randomly assigned to either the control diet, a diet enriched with fruits and vegetables, or the DASH eating plan. The DASH diet was also rich in vegetables and fruit, but was low in saturated and total fat and cholesterol and used low-fat dairy products. Both the fruits and vegetables diet and the DASH eating plan were higher in fiber and lower in white sugar than the control diet.

Indicators of heart health other than total cholesterol and LDL cholesterol did not improve. Levels of triglycerides, which may increase heart disease risk, were not significantly changed in participants on the DASH diet. DASH was associated, however, with an average decrease of 3.7 mg/dL, or 7.5 percent, of levels of high-density lipoprotein (HDL), the "good" cholesterol.

HDL at low levels (less than 40 mg/dL) is a CHD risk factor; at high levels (60 mg/dL or above), HDL is considered protective of heart disease. The drop was directly related to the individual's starting level of HDL. That is, HDL concentrations decreased more in people with higher HDL levels compared to individuals with lower levels. The researchers concluded that although this undesirable response to the DASH diet needs further study, overall, "the DASH diet affects coronary heart disease (CHD) risk favorably."

In a later study, however, the findings were not repeated. A study published in the journal Hypertension in February 2004 found that the DASH diet did not affect any of the measurements of cholesterol or triglycerides except one—reducing sodium lowered HDL or “good:” cholesterol.

However, this study only measured sodium consumption in a range from 2,000 to 6,000 mg per day, much more than Dr. Sodi recommended. It is possible that extreme sodium restriction might raise HDL cholesterol—or it might not. I simply do not know. The most recent research on diet and LDL cholesterol, the National Heart, Lung, and Blood Institute Family Heart Study, published in the American Journal of Clinical Nutrition in February 2004, links lower LDL cholesterol to higher consumption of fruits and vegetables, but not necessarily to lower sodium and higher potassium.

The bottom line for people with high blood pressure is, eating more fruits and vegetables definitely helps. The jury is still out on sodium restriction. You can, however, benefit from including greater amounts of fresh produce in your diet. Five servings a day (5-a-day), or, even better, nine servings of fruits and vegetables every day are your best dietary change for lowering cholesterol.