February 2008

Cholesterol Ed: A Crash Course for Clients
By Valerie Yeager
Today’s Dietitian
Vol. 10 No. 2 P. 58

In light of poor awareness statistics, you may need to schedule a heart-to-heart with your clients about cholesterol—sorting out the facts, encouraging testing, and recommending the best foods for cardiovascular health.

Good cholesterol, bad cholesterol, high density, low density. Although this may sound like the beginning of a Dr. Seuss book, cholesterol is not something to take lightly. It’s an issue that should concern everyone, regardless of age, weight, or sex. High cholesterol is a killer. And a large majority of the population isn’t even aware what their cholesterol levels are. Educating clients—and helping them shop for and prepare foods that will promote healthy cholesterol—is critical.

Combinations of high total cholesterol, high levels of low-density lipoprotein (LDL) cholesterol, and low levels of high-density lipoprotein (HDL) cholesterol contribute to heart disease and stroke. And a recent study by the Department of Veterans Affairs has proven that high cholesterol may also increase the risk of cognitive impairment, which may lead to Alzheimer’s disease.1

So what can your clients do to reduce their risk of experiencing such health issues? Exercise, a healthy diet, and medication (for those with very high cholesterol) will have a positive impact. But your clients may not even know at what point in life to begin worrying about cholesterol or know how to fix any problems. So what can you do to help them? Educate, educate, educate.

Prior to doing research for this article, I admit that I believed a cholesterol myth: Only overweight, older people are in danger. Having a cholesterol test was something that never occurred to me. I’m 24, of average weight, a moderate exerciser, and a generally healthy eater. Yet, according to nearly every major medical association, I should be preparing for the second cholesterol test of my life, not the first. It’s recommended that anyone older than the age of 20 have his or her cholesterol checked at least every five years.

Recent studies have shown that I’m not alone in my ignorance. A Society for Women’s Health Research (SWHR) study shows that adult women were more likely to know how much they weighed in high school than their current cholesterol number. While 79% knew their high school weight, less than one third knew their current cholesterol level. Of the women who had a recent cholesterol test, only 57% could recall their cholesterol number.2

These data suggest a major disconnect between women—and presumably all adults—understanding the risks associated with high cholesterol and taking action to monitor and control it. Even though most women in the study knew that high cholesterol is linked to hardening of the arteries, heart disease, and stroke, very few were taking steps to protect themselves.

The following statistics from the survey—conducted by phone with 524 women in summer 2007—prove that cholesterol education should become more prevalent:

• One in three participants did not know that women can exercise regularly and maintain a healthy diet but still have dangerously high cholesterol levels.

• More than one third of the women were surprised to learn that high cholesterol has no symptoms.

• Approximately one half of the women were not familiar with the terms LDL and HDL, both crucial to managing cholesterol and heart health.

• Forty-three percent of the women were surprised to learn that heart disease kills six times as many women as breast cancer.

Educating Clients About Cholesterol
As the SWHR study shows, while many Americans are aware that high cholesterol is dangerous, they often know very little about cholesterol or lowering/maintaining their own cholesterol levels.

Explaining the difference between HDL and LDL is essential. For men and women, an LDL level below 100 milligrams per deciliter and an HDL level of at least 50 milligrams per deciliter  are recommended. An HDL that falls below 50 milligrams per deciliter puts a person at an increased risk of heart disease and heart attack. Thus, when a client requests a blood test, he or she should be provided with numbers for their HDL, LDL, and total cholesterol.3

Even if a client’s test reveals healthy cholesterol levels, maintaining these levels should be of concern. For those with high cholesterol, the goal is to raise HDL levels and lower LDL levels. Simple as that may sound, making the lifestyle changes required to increase the likelihood of having healthy cholesterol can be a daunting task, so start with the basics.

The Basics
The American Heart Association Nutrition Committee recommends the following for cardiovascular disease reduction:

• Balance calorie intake and physical activity to achieve or maintain a healthy body weight.
• Consume a diet rich in fruits and vegetables.

• Consume whole grain, high-fiber foods.

• Consume fish, especially oily fish, at least twice per week.

• Limit intake of saturated fat to less than 7% of total calories, trans fat to less than 1% of energy, and cholesterol to less than 300 milligrams per day by:

- choosing lean meat and vegetable alternatives;
- choosing nonfat, 1%, and low-fat dairy products; and
- minimizing intake of partially hydrogenated fats.

• Minimize intake of beverages and foods with added sugar.

• Choose and prepare foods with little or no salt.

• Consume alcohol in moderation.4

Similarly, the National Cholesterol Education Program Therapeutic Lifestyle Changes diet suggests the following:

• total fat equals 10% to 25%;

• less than 7% of total calories from saturated fat and trans fat;

• less than 200 milligrams cholesterol;

• 20 to 30 grams fiber per day;

• adjust total calories for weight goals;

• expend at least 200 calories in exercise per day; and

• preferably consume plant sterols/stanols (2 to 3 grams per day) and soluble fiber (10 to 25 grams per day).

Choosing foods that actively lower LDL cholesterol, such as soy protein, nuts, dietary fibers (eg, oats and barley), and phytosterols (ie, plant sterols and stanols), is important. Soy protein, oats, and barley provide a modest LDL-lowering benefit of approximately 5% to 7.5% with a consumption of 3 to 10 grams per day, which is helpful for those with slightly elevated cholesterol. Consumption of 25 grams of soy protein per day results in a significant reduction in LDL cholesterol. Three 250-milliliter glasses of soy milk is equal to approximately 25 grams of soy protein.5

Foods containing phytosterols—such as regular and low-fat vegetable oil spreads, dairy, fruit juices, and grains—also actively lower LDL levels. On average, consumption of 2 to 3 grams of phytosterols per day may reduce LDL cholesterol by 10%.

Smart Shopping
Your clients need to choose foods that actively lower LDL cholesterol, are low in saturated fat, are high in fiber ... the list seems to go on and on. Even after counseling your clients on the good and bad sources of cholesterol, shopping for and preparing some of these items may be daunting.

Ruth Carey, RD, LD, an Oregon-based nutrition consultant in private practice, often counsels patients on cholesterol-healthy diets. As she suggests, “[H]elp the client construct a shopping list while in the office for a consult. Remind clients to shop the perimeter of the store mostly and avoid a lot of processed or packaged foods.” Find out where your clients shop, the time they have to shop for and prepare foods, their family size, and their budget. Keeping this information in mind, suggest specific food items and brands that will fit clients’ lifestyle and budget. Generate a list, organized by product brands and location within the store.

Among the foods Carey suggests that everyone purchase to maintain or lower bad cholesterol are the following:

• nonfat dairy products;

• fresh and frozen fruits and vegetables;

• whole grain foods, especially oatmeal or oat products and barley;

• olive and canola oil;

• nuts such as almonds and walnuts;

• foods with plant sterols or stanols (eg, Promise activ Spread, Promise activ SuperShots, and BENECOL Spread); and

• beans/legumes.

On Carey’s personal grocery list are beans, lentils, blueberries, oatmeal, barley, nonfat milk, and yogurt. (See the “Sample Shopping List” sidebar for a detailed list.)
Also, advise your clients on hidden sources of saturated fat, which are often found in foods that no longer contain trans fat such as palm and palm kernel oils and coconut oil, which is found in movie theater popcorn. Advise your clients to avoid these foods and instead focus on healthier sources of fat, such as olive oil.

Another concern your clients may have is maintaining healthy cholesterol while consuming low-carbohydrate diets, which are often rich in animal-based products. As Carey points out, “Cholesterol is only in foods of animal origin: eggs, meats, and high-fat dairy products.” These foods also contain saturated fats that can raise cholesterol. So how can a client on a low-carb diet keep his or her heart healthy? Carey suggests that these clients “eat primarily fish, skinless chicken breast meat, and nonfat dairy products as their protein sources. Eating lots of vegetables and fruits gives soluble fiber that helps lower cholesterol.”

Genes Play a Factor, Too
I was shocked to learn that my 57-year-old mother—who has a slim 110 pounds on her 5’3” frame; exercises at least 30 minutes per day, four to five days per week; and consumes an exceptional diet of greens, fruits, and seafood—has significantly high cholesterol. How could this seemingly healthy, thin, active woman be at risk for cholesterol-related heart disease or stroke?

A study conducted by the American Academy of Neurology shows that healthy women with no history of heart disease or stroke are more than twice as likely to suffer a heart attack or stroke if they have high cholesterol than are healthy women with lower cholesterol levels. Being of average weight, eating relatively healthy foods, and exercising moderately does not protect against high cholesterol. Genetics may also play a role. In fact, if there is a strong family history, pediatricians recommend that children as young as 8 be screened for cholesterol.

So how can people with an already healthy lifestyle lower their cholesterol? Carey emphasizes adding plant sterols, oatmeal, and almonds to their diet in addition to limiting saturated fats, trans fats, and cholesterol—especially as clients age. As she says, “Cholesterol always raises some with age, but high levels certainly can be prevented.” Statins are also an option, but diet should still be of primary concern. 

Heart of the Matter
Heart attacks kill six times as many women as breast cancer. Yet, one in six Americans aged 20 or older—nearly 36 million people—have never had their cholesterol checked. The first step is to have your clients get a cholesterol test. From there, you are more likely to effectively approach your clients’ behavior and lifestyle than their physician may be. Diet is of the utmost importance when it comes to having healthy cholesterol levels, and your guidance will help clients become more comfortable purchasing foods that will help lower their cholesterol. Although it’s something you may be accustomed to as a nutrition professional, you can take pride in knowing that you may be saving lives.

— Valerie Yeager is an editor and a freelance writer based in Philadelphia.

Sample Shopping List

Brussels sprouts
Salad greens
Nonfat milk
Soy yogurt
Nonfat cottage cheese
Fat-free cream cheese
Vegetable oil spreads
Skinless chicken
Ground turkey
Loin cuts of beef and pork
Oatmeal/oat bran
100% whole grain bread
Whole wheat tortillas
Brown rice
Whole grain crackers
Almond butter spread
Dried beans
Canned light tuna or salmon
Soy, canola, grapeseed, and olive oils
Dried herbs and seasonings
Orange juice with plant sterols

— Ruth Carey, RD, LD

Sample Menu


11/2 cups oatmeal
1 cup nonfat milk
1 cup blueberries
Coffee or black or green tea


23 almonds
1 pear


1 sandwich on 100% whole wheat light bread, with 2 ounces each of turkey, tomato, lettuce, and mustard
2 cups mixed greens with olive oil and lemon
Promise activ SuperShots
1 fresh apple

Afternoon Snack

1/2 cup edamame
Nonfat yogurt


4 ounces salmon
8 ounces quinoa/bean salad
1 cup steamed broccoli with Promise activ Spread
1 cup nonfat milk
4 ounces sorbet

Evening Snack

Fresh berries or fruit in season

Nutrient Analysis:

2,000 calories
Less than 7% saturated fat, minimal trans fat
Less than 200 grams cholesterol
11 grams soluble fiber
2 grams plant sterols

For weight reduction, omit the almonds, limit the sorbet or dessert, and encourage 200 to 250 calories expenditure of exercise per day.

— RC
1. Veterans Affairs Research & Development. National cholesterol education month. Newswise. September 6, 2005. Available at: http://www.newswise.com/articles/view/514249

2. Society for Women’s Health Research. Knowledge of cholesterol numbers lagging among women. August 21, 2007. Available at: http://www.womenshealthresearch.org/site/News2?

3. Mayo Clinic. Boosting the “good” cholesterol. August 1, 2006. Available at: http://www.mayoclinic.org/news2006~mchi/3557.html

4. Lichtenstein AH, Appel LJ, Brands M, et al. Diet and lifestyle recommendations revision 2006: A scientific statement from the American Heart Association Nutrition Committee. Circulation. 2006;114(1):82-96.

5. Food and Drug Administration. FDA approves new health claim for soy protein and coronary heart disease. October 20, 1999. Available at: http://www.fda.gov/bbs/topics/ANSWERS/ANS00980.html.
Accessed December
17, 2007.