Diet and Cholesterol Reduction

After a comprehensive assessment of recent clinical evidence, the most current National Cholesterol Education Program Adult Treatment Panel (ATP) III guidelines call for renewed emphasis on lowering levels of serum cholesterol (1). The ATP III update recommends that physicians set a low-density lipoprotein (LDL) cholesterol goal of less than 1.8 mmol/L (<70 mg/dL) for high-risk patients, based on studies such as the Heart Protection Study (2). Although the cut-points of 3.4 mmol/L (130 mg/dL) and 4.1 mmol/L (160 mg/dL) for LDL cholesterol in moderate- and low-risk individuals remain unaltered, it may not be long before they are also lowered.

Statins have been very successful in lowering cholesterol levels, but despite this, some people prefer to try diet first. Furthermore, a small number of individuals prefer to avoid the statin-related increased risk for myalgia, and a very small number of people have a contraindication to statins (3). The study by Gardner and colleagues in this issue (4) is an important reminder that diet, in addition to drugs, can play a role in achieving cholesterol targets. Gardner and colleagues, performing a 4-week study in which the investigators provided all of the food, found that a more “plant-based” diet low in saturated fat yielded an advantage of 0.18 mmol/L (7.0 mg/dL) in LDL cholesterol reduction compared with the control diet, a more traditional low-saturated-fat diet. Put in different terms, the plant-based diet achieved an additional reduction in LDL cholesterol level of 4.7 percentage points over the 4.6% reduction in the control group. The 9.3% total reduction in LDL cholesterol from baseline in participants following the plant-based diet is large enough that we would expect it to reduce all-cause mortality if sustained over time (5).

Gardner and colleagues asked whether plant-based foods have additional cholesterol-lowering benefits that are unrelated to …