|Year : 2015 | Volume
| Issue : 3 | Page : 193-198
Nonpharmacological cholesterol-lowering approach: Managing cholesterol naturally
Department of Clinical Research Studies, J. Lind Institute, Houston, USA
|Date of Web Publication||12-Jun-2015|
J. Lind Institute, Houston
Source of Support: None, Conflict of Interest: None
Cholesterol is a lipid molecule which is biosynthesized by all animal cells. Also, it is an essential structural component of cell membranes which is normally required for maintaining both fluidity and membrane structural integrity. Dyslipidemia is known as abnormal blood lipids considered as one of the major risk factors for heart disease. In an attempt to increase the effectiveness of healthy diet in reducing serum cholesterol, the American Heart Association along with the National Cholesterol Education Program Adult Treatment Panel III recently recommend the use of functional foods or foods high in components that reduce cholesterol as options in the dietary strategy. These foods include, green vegetables, fruits, avocado, fish oil, almond and nuts. Furthermore, those foods items are all permitted by the USA Food and drug administration to carry a health claim that they reduce the risk of cardiovascular disease. Individually, these foods have been shown to lower serum cholesterol by 4-7%. Dietary modification can be considered as a powerful nonpharmacological approach for improving blood lipids. Physical activity can improve lipid profiles either directly by reducing body weight or indirectly without reduced body weight; when weight loss occurs in conjunction with activities, low-density lipoprotein and total cholesterol are usually lowered.
Keywords: Cholesterol, diet, dyslipidemia, health, lipid
|How to cite this article:|
Mahmood L. Nonpharmacological cholesterol-lowering approach: Managing cholesterol naturally. CHRISMED J Health Res 2015;2:193-8
|How to cite this URL:|
Mahmood L. Nonpharmacological cholesterol-lowering approach: Managing cholesterol naturally. CHRISMED J Health Res [serial online] 2015 [cited 2020 Oct 31];2:193-8. Available from: https://www.cjhr.org/text.asp?2015/2/3/193/158669
| Introduction|| |
Reducing elevated cholesterol is a key public health challenge. There is substantial evidence from randomized controlled trials that some foods components can significantly reduce cholesterol.  Also, they may affect inflammatory markers, coagulation parameters, platelet and endothelial function. The epidemiological studies which have evaluated the association of plasma cholesterol concentration with cardiovascular disease risk do not provide a definitive answer. , Improved dietary fat quality that can be achieved by replacing SFA with unsaturated fat reduces low-density lipoprotein (LDL)-cholesterol and can increase high-density lipoprotein (HDL)-cholesterol, further improving blood lipid profile. 
In clinical studies where all foods were provided, LDL-cholesterol is reduced by 22-30%, whereas HDL-cholesterol is increased.  By careful food type's selection, suitable to the individual, the effect of including at least two components in the diet with good compliance could be a sustainable 10% reduction in LDL-cholesterol; which is enough to make a significant impact on cholesterol management naturally and reduce the need for pharmaceutical intervention. ,
| Literature Review|| |
What is "cholesterol"?
Cholesterol is a lipid molecule that is biosynthesized by all animal cells. Also, it is an essential structural component of cell membranes which is normally required for maintaining both fluidity and membrane structural integrity.  Since animal fats are complex of triglycerides (TGs), cholesterol and phospholipids; so all food containing animal fats contain cholesterol. The major dietary sources of cholesterol include beef, poultry, shrimp, cheese, egg yolk, and milk.  Cholesterol and lipoprotein have different classifications, and each one has a different role in the body; those include Total cholesterol, HDL, LDL, TG [Table 1].
It is an abnormal blood lipids level, it has become a public health concern all over the world; most of the older adults have borderline or high total cholesterol [Table 2]. Dyslipidemia is considered as one of the major risk factors for heart disease.  Excess cholesterol builds up in the arteries walls; this buildup leads to atherosclerosis, a disease in which blood flow is impaired as a result of narrowed arteries. In advanced progress, when the blood supply to the heart is completely blocked, the result is a heart attack.  There are different forms of dyslipidemia; it can be 'Hypertriglyceridemia' that implies elevated TGs. While, "Hyperlipidemia" indicates elevated cholesterol and TGs or "Hypercholesterolemia" which indicates elevated blood cholesterol levels. Whereas "Hyperlipoproteinemia" is defined as elevated lipoproteins. Furthermore, It can come in a form of "Hypoalphalipoprotein" which is a syndrome denotes low HDL-cholesterol. ,
Dyslipidemia associations and health complications
Dyslipidemia is a major cause of heart diseases especially heart attack as a result of atherosclerosis (clogging and damaging of arteries). It can lead to stroke, fatty liver, kidneys and eyes damage.  Dyslipidemia can be associated with different conditions and health problems include hypertension, genetic predisposition, diabetes and obesity, sedentary life-style, smoking and fatty food consumption can play a major role also in developing dyslipidemia. 
Recent studies suggest that some dietary strategies may be effective in reducing total cholesterol concentrations; healthy diets have been shown to be effective in reducing cardiovascular disease risk and mortality.  In an attempt to increase the effectiveness of healthy diet in reducing serum cholesterol, the American Heart Association along with the National Cholesterol Education Program Adult Treatment Panel III recently recommend the use of functional foods or foods high in components that reduce cholesterol as options in the dietary strategy.  These foods include green vegetables, fruits, avocado, fish oil, almond, and nuts. Furthermore, those foods items are all permitted by the USA Food and Drug Administration to carry a health claim that they reduce the risk of cardiovascular disease. Individually, these foods have been shown to lower serum cholesterol by 4-7%. 
Almond and nuts
Some randomized controlled studies investigated the effects of almonds on blood lipid measures that have been conducted in subjects with normal blood lipid levels; one of them was a 6-week study while the other two were 4-week studies. These researches cumulatively suggested that the daily consumption of 68 g of almonds for a period of 4 weeks actually improved the blood lipid profiles by significantly reducing TC levels, LDL levels, and the ratio of LDL to HDL.  Furthermore, one study has demonstrated that patients who were consuming an average of 78 g/day of almonds reduced LDL by 9.4% while those consuming 37 g/day reduced LDL-cholesterol by 4.4% with a significant increase in HDL levels and decrease in lipoprotein A and Apo B levels.  A total of six randomized controlled studies investigated the effects of almonds on blood lipid measures that have been conducted in subjects who had other diet-related diseases, i.e. overweight and obese patients, or others with prediabetes or type 2-diabetes. The study durations have ranged from 6 to 18 months. The lipid profiles were maintained or improved in all four studies conducted in prediabetic or diabetic subjects who consumed 28 g of almonds daily.  Another two randomized controlled studies studied the effect of almonds on blood glucose control for subjects with prediabetes; one was a postmeal study with a breakfast consumption of a 580-kcal contained 44.5 g of almonds resulted in significant reductions in blood glucose levels in the morning and throughout the day.  Whereas the other study was a 16-week study; subjects who consumed 60 g/day of almonds as part of an American Diabetes Association (ADA) diet experienced significant improvements in both fasting insulin and measures of insulin resistance relative to subjects who consumed the ADA diet without almonds. 
Researchers have identified the health benefits of Almond: It is a rich source of healthy fat that is, unsaturated fats, predominantly monounsaturated fat, with a percentage 66% of total fat and low proportion of saturated fat around 7% of total fat. Moreover, like all other plant foods, they are also cholesterol free. Furthermore, it contains natural plant sterols 172 mg of plant sterols per 100 g that are able to help to lower cholesterol levels via reducing the cholesterol reabsorption process in the intestine.  It can prevent the oxidation of LDL-cholesterol; a study found that introducing almonds in the diet for a month may lead to a reduction in oxidized LDL-cholesterol which is known as a sticky substance that can block the arteries. Almond skins are rich sources of antioxidants called polyphenols which might help in preventing the oxidation process of cholesterol, particularly in conjunction with antioxidant Vitamin E.  Another study supported the moderating effects of almond consumption on postprandial glycemia when a serum glucose concentration 60 min after breakfast and lunch meals has been observed to be lower when 43 g of almonds were ingested with the meals that may be attributable to the fiber and fat content of almonds. 
Nuts and almonds are rich in several beneficial compounds, as ω-6, ω-9, and ω-23 fatty acids that have demonstrated beneficial effects on blood cholesterol and lipoprotein profiles. The highly unsaturated ω-23 fatty acids eicosapentaenoic acid known as (EPA) and docosahexaenoic acid (DHA) are significantly responsible for this effect. Additionally, metabolic studies have shown that consumption of n-6 PUFA lowers circulating cholesterol levels.  Nuts are complex plant foods which are rich sources of unsaturated fat and contain several nonfat constituents include plant protein, fibber, Vitamins as A, C, E, micronutrients, e.g. copper and magnesium, plant sterols, and phytochemicals that provide additional protective effects which have shown favorable lipid-altering activity.  A possible explanation can be related to the presence of lipid-altering phytochemicals such as plant sterols that is found in almonds. Also, nuts contain significant amounts of phytosterols and other phytochemical compounds, polyphenols, and ellagic acid. The major phytosterol component is β-sit sterol; one of the several plant sterols implicated in cholesterol lowering. Researches have shown that 2 g of plant sterols/day can significantly reduce cholesterol absorption, which in turn can decrease both plasma TC and LDL-C concentrations.  Nuts contain a variety of phenolic compounds which are localized principally in their skin, including flavonols, anthocyanins procyanidins B2 and B3, and phenolic acids. Flavonols have been shown to be bioavailable and contribute to the antioxidant protection against LDL-C oxidation in vitro and in vivo. 
Studies have noticed that a supplemented diet given for hypercholestrolemic rats with different amount of avocado lead to a significant decrease in TG, LDL and total cholesterol by 28.29%, 14.16%, and 27.58% respectively with a significant increase in HDL-cholesterol for about 30%, therefore, the best results of lipid profile was determined by increased level of diet with added avocado.  These results may be due to avocado's antioxidants contents that can scavenge the free radical and inhibit the lipid oxidation processes. Another result can be related to the fiber contents of avocado since the soluble fibers can bind to the bile acids in the small intestine that alters micelle formation and decrease its absorption in the small intestine, so bile acid will be excreted in the faces.  Avocado has been shown to modulate postprandial inflammatory responses to a hamburger meal and postprandial vascular reactivity in healthy volunteers. Interestingly hypolipidemic effects of avocado have been also indicated in a hypercholesterolemic mouse model. Furthermore, a recent experimental study has notified that a dietary avocado oil supplementation can attenuate the alterations induced by type I diabetes mellitus along with oxidative stress in electron transfer at the complex II-complex III segment of the electron transport chain in rat kidney mitochondria. Additionally, many beneficial effects of avocado have been in vitro, in human oral cancer cell lines, where avocado extracts induced apoptosis via a reactive oxygen species-mediated mechanism. 
The beneficial effects of dietary fish oil on prevention or retardation of atherosclerosis have been addressed in different studies, thought to be related to the high quantities of omega-3 polyunsaturated fatty acids which are found in many types of fish. These fatty acids have been indicated to have immunosuppressive along with anti-inflammatory effects, increase erythrocyte deformability, reduce platelet aggregation and monocyte adhesion, stimulate endothelium-derived relaxing factor synthesis, improve fibrinolysis, alter prostaglandin synthesis, lower blood pressure, plasma triacylglycerol and very low density lipoprotein, and to protect against peroxidation.  According to researches, fish and its oil are rich in omega-3 fatty acids (n-3 FA) which are considered beneficial in the prevention of heart disease. Supplementation of the EPA along with DHA has consistently been shown to reduce the concentration of TG and LDL-cholesterol in the plasma by inhibition of hepatic TG synthesis, which can leads to reduced synthesis and secretion of very-low-density lipoprotein (VLDL)-C. The reduction of VLDL-C normally leads to decrease the formation of LDL-cholesterol, which is a major risk factor for heart diseases. It has been indicated that high doses of omega-3 fatty acids increase (HDL-C), which is inversely related to the incidence of cardiovascular diseases.  A large volume of the medical literature has indicated that fish oils containing omega-3 fatty acids can prevent and help to improve or prevent arteriosclerosis, heart failure, strokes, and peripheral vascular diseases. Omaega-3 fatty acids have been reported to lower bad cholesterol around 25% and TGs by 65%. Furthermore, omega-3 fatty acids from flax seeds oil have the ability to make platelets less sticky, and consequently it reduces the tendency of the blood to clot. 
Dietary fiber in green vegetables is widely prescribed, alone or associated with lipid-lowering therapies, in order to reduce cholesterol levels. There are evidences suggesting that soluble fibers can interfere with lipid and/or bile acid metabolism. Based on clinical trials, it is hypothesized that soluble fiber intake can reduce plant sterols absorption among subjects who was receiving highly effective lipid-lowering therapy. The role of fiber intake was tested in different lipid-lowering strategies, and chosen to attain similar changes in lipid profile through distinct mechanisms.  It has been indicated that the consumption of soluble fibers can promote a moderate effect in lowering cholesterol in hypercholesterolemic patients. Studies have shown that fibers seemed to act synergistically at the recommended dose for total 25 g and soluble fibers 6 g intake. The addition of fibers to the diet in patients receiving the highly effective therapy can bring important benefits. Fiber supplementation has shown an inverse relationship between fiber intake and weight loss; studies have demonstrated a reduction in fasting glucose, postprandial and glycated hemoglobin levels that associated with soluble fiber intake. 
Patients with diabetes are advised to increase their intake of dietary fiber, in the National Health and Nutrition Examination Survey. The Study, their average daily intake was found to be only 16 g. The mechanisms of the improved glycemic control that is associated with high fiber intake remain undefined. Whether this effect is due to an increase in soluble fiber, insoluble fiber or both is unclear. It helps in causing increased fecal excretion of bile acids and malabsorption of fat. Studies suggested that the degree of reduction in the absorption of fat was insignificant, or another possibility is that dietary fiber can improve glycemic control via reducing or delaying the absorption of carbohydrates.  The action of soluble fiber in the small intestine is playing a major role in regulating whole-body cholesterol absorption in both animal and human studies. This capacity of fibers to reduce cholesterol absorption and its possible interruption of the enter hepatic circulation of bile acids, as suggested in studies investigations which is resulted in a significant reduction 4f hepatic free and esterified cholesterol pools. 
Different fruits and especially berries are well known for their accumulation of antioxidant components, e.g. polyphenols, Vitamin C, and carotenoids. They are amongst the highest antioxidant capacity of commonly-eaten foods. There are main areas where berries may beneficially influence glycemic control for diabetic patients; they can protect the pancreatic Beta cells from glucose-induced toxicity and oxidative stress, Inhibit the starch digestion and absorption, Suppress the glucose release from the liver and improve the glucose uptake in peripheral tissues such as muscles.  Substantial evidences have been reported that berry components can influence parameters relevant to heart diseases in both in vitro studies and animal models; the raspberry juice reduced risk factors for atherosclerosis in hypercholesterolemic hamster models. 
Individuals with elevated serum cholesterol levels can improve their endothelium-dependent vasodilation after berry anthocyanin intake along with serum lipid profiles and decreased markers of inflammation. The intake of berries has been noticed to have anti-inflammatory effects that can underline many beneficial effects in a range of conditions where inflammation is part of the development of the disease. The intake of various berries was also associated with decreased heart diseases risk factors in overweight women. Nevertheless, heart diseases risk factors were decreased after blueberry intake in a group of obese subjects with metabolic syndrome, along with significant decreases in blood pressure.  One study has been reported that the consumption of fruit was inversely related to LDL-cholesterol concentration in men and women groups, subjects with highest intake of fruits their LDL concentration was about 6% lower than those with lower fruit intake after 8 weeks intervention period. 
Dietary modification can be considered as a powerful nonpharmacological approach for improving blood lipids. Diet that is high in Trans and saturated-fat or cholesterol increase TGs, LDL, as well as total blood cholesterol. Monounsaturated fats e.g. olive oil that seem to sustain HDLs and lower LDLs and TG, whereas polyunsaturated fats (e.g. corn oil) seem to have a neutral effect in managing blood cholesterol.  In general, reducing Trans and saturated-fat and cholesterol intake could improve blood lipids; although there is variability in individuals' responses to the changes in dietary habits, or reducing total calories consumed, particularly saturated fat calories, which can result in weight loss, naturally lowers total and LDL-cholesterol. 
HDL-cholesterol may be lower as well, but once dieting is coupled with exercise, HDL-cholesterol can be maintained. On the other hand, high-carbohydrate diets can increase TG levels and decrease HDL-cholesterol, but this effect is negated with physical activity.  Dietary fibers, especially soluble fiber help in lowering blood cholesterol levels, when weight loss is combined with exercises, HDL level is more likely to be sustained or increased. Furthermore, weight loss can improve glycemic control, lowers blood pressure, and reduces inflammation linked to metabolic and cardiac diseases. , Physical activity can improve lipid profiles either directly by reducing body weight or indirectly without reduced body weight; when weight loss occurs in conjunction with activities, LDL, and total cholesterol are usually lowered. 
| Conclusion|| |
As researches have indicated that the top dietary recommendations for lowering cholesterol are to eliminate or at least drastically limit the foods that contain saturated fats, trans-fats, dietary cholesterol, and refined carbohydrates. It has been shown that some foods has a significant role in lowering or managing total lipid profile such as green vegetables and some fruits, avocado, nuts and almonds along with fish oil .  Cholesterol lowering foods should be incorporated into everyone's diet for optimal health. The percentages by which these foods lower cholesterol reflect people who have high levels of cholesterol >200 mg/dL and have been diagnosed with hypercholesterolemia. Changing the unhealthy eating habits along with physical activity can improve lipid profiles either directly by reducing body weight or indirectly without reduced body weight; when weight loss occurs in conjunction with activities, LDL, and total cholesterol are usually lowered. 
| References|| |
Altena TS, Michaelson JL, Ball SD, Thomas TR. Single sessions of intermittent and continuous exercise and postprandial lipemia. Med Sci Sports Exerc 2004;36:1364-71.
Herd SL, Kiens B, Boobis LH, Hardman AE. Moderate exercise, postprandial lipemia, and skeletal muscle lipoprotein lipase activity. Metabolism 2001;50:756-62.
Hyson D, Rutledge JC, Berglund L. Postprandial lipemia and cardiovascular disease. Curr Atheroscler Rep 2003;5:437-44.
Whaley M, Brubaker P, Otto R. ACSM's Guidelines for Exercise Testing and Prescription. 7 th
ed. Baltimore: Lippincott Williams and Wilkins; 2005. p. 212-7.
Gill JM, Hardman AE. Exercise and postprandial lipid metabolism: An update on potential mechanisms and interactions with high-carbohydrate diets (review). J Nutr Biochem 2003;14:122-32.
Zhang JQ, Ji LL, Nunez G, Feathers S, Hart CL, Yao WX. Effect of exercise timing on postprandial lipemia in hypertriglyceridemic men. Can J Appl Physiol 2004;29:590-603.
Tseng LN, Tseng YH, Jiang YD, Chang CH, Chung CH, Lin BJ, et al.
Prevalence of hypertension and dyslipidemia and their associations with micro- and macrovascular diseases in patients with diabetes in Taiwan: An analysis of nationwide data for 2000-2009. J Formos Med Assoc 2012;111:625-36.
Ashish S, Anita S, Apurva A. Association of dyslipidemia with diabetic retinopathic complications in type 2 diabetes. J Adv Res Biol Sci 2011;3:10-3.
Jenkins DJ, Kendall CW, Faulkner D, Vidgen E, Trautwein EA, Parker TL, et al.
A dietary portfolio approach to cholesterol reduction: Combined effects of plant sterols, vegetable proteins, and viscous fibers in hypercholesterolemia. Metabolism 2002;51:1596-604.
Jenkins DJ, Kendall CW, Marchie A, Faulkner DA, Wong JM, de Souza R, et al.
Effects of a dietary portfolio of cholesterol-lowering foods vs lovastatin on serum lipids and C-reactive protein. JAMA 2003 23;290:502-10.
US Food and Drug Administration. FDA authorizes new coronary heart disease health claim for plant sterol and plant stanol esters. Washington, DC: US FDA; 2000. (Docket No. 001-1275, OOP-1276).
Sabaté J, Haddad E, Tanzman JS, Jambazian P, Rajaram S. Serum lipid response to the graduated enrichment of a Step I diet with almonds: A randomized feeding trial. Am J Clin Nutr 2003;77:1379-84.
Jenkins J, Kendall W, Marchie A, Parker L, Connelly W, Qian W, et al
. Dose response of almonds on coronary heart disease risk factors: Blood lipids, oxidized lowdensity lipoproteins, lipoprotein (a), homocysteine, and pulmonary nitric oxide: A randomized, controlled, crossover trial. Circulation 2002;106:1327-32.
Lovejoy JC, Most MM, Lefevre M, Greenway FL, Rood JC. Effect of diets enriched in almonds on insulin action and serum lipids in adults with normal glucose tolerance or type 2 diabetes. Am J Clin Nutr 2002;76:1000-6.
Mori AM, Considine RV, Mattes RD. Acute and second-meal effects of almond form in impaired glucose tolerant adults: A randomized crossover trial. Nutr Metab (Lond) 2011;8:6.
Wien M, Bleich D, Raghuwanshi M, Gould-Forgerite S, Gomes J, Monahan-Couch L, et al.
Almond consumption and cardiovascular risk factors in adults with prediabetes. J Am Coll Nutr 2010;29:189-97.
Blanco Mejia S, Kendall CW, Viguiliouk E, Augustin LS, Ha V, Cozma AI, et al.
Effect of tree nuts on metabolic syndrome criteria: A systematic review and meta-analysis of randomised controlled trials. BMJ Open 2014;4:e004660.
Jenkins DJ, Kendall CW, Marchie A, Faulkner DA, Wong JM, de Souza R, et al.
Direct comparison of a dietary portfolio of cholesterol-lowering foods with a statin in hypercholesterolemic participants. Am J Clin Nutr 2005;81:380-7.
Jenkins DJ, Kendall CW, Josse AR, Salvatore S, Brighenti F, Augustin LS, et al.
Almonds decrease postprandial glycemia, insulinemia, and oxidative damage in healthy individuals. J Nutr 2006;136:2987-92.
Ramachandran H, Narasimhamurthy K, Raina PL. Modulation of cholesterol induced hyper-cholesterolemia through dietary factors in Indian desert gerbils (Meriones hurricinae). Nutr Res 2003;23:245-56.
Vorster HH, Raal FJ, Ubbink JB, Marais AD, Rajput MC. Phytosterols - A new dietary aid for the treatment of hypercholesterolaemia. S Afr Med J 2003;93:581-2.
Jones PJ, MacDougall DE, Ntanios F, Vanstone CA. Dietary phytosterols as cholesterol-lowering agents in humans. Can J Physiol Pharmacol 1997;75:217-27.
Chen CY, Milbury PE, Lapsley K, Blumberg JB. Flavonoids from almond skins are bioavailable and act synergistically with vitamins C and E to enhance hamster and human LDL resistance to oxidation. J Nutr 2005;135:1366-73.
Kumar D, Parcha V, Dhulia F, Maithani A. Evaluation of anti-hyperlipidemic activity of method extract Salvador olcoides (Linn) leaves in Triton WR-1339 (Tyloxaol) induced hyperlipidemic rats. J Pharm Res 2011;4:512-3.
Mohammed S. Hypolipdemic and antioxidant activities of avocado fruit pulp on high cholesterol fed diet in rats. Afr J Pharm Pharmacol 2011;5:1475-83.
Pahua R, Ortiz M, Chamorro C, Hernandez N, Garduno S, Necoechea M, et al
. Hypolipidemic effect of avocado Persea Americana Mil; seed in a hypercholesterolemic mouse model. Plant Foods Hum Nutr 2012;67:10-6.
Bittolo B, Cazzolato G, Alessandrini P, Soldan S, Casalino G, Avogarom P. Effects of concentrated DHA and EPA supplementation on LDL peroxidation and vitamin E status in type IIb hyperlipidemic patients. In: Drevon CA. Baksaas I, Krokan HE, editors. Omega-3 Fatty Acids: Metabolism and Biological Effects. Base1. Switzerland: Verlag Birkhbuser; 1993. p. 51-8.
Koro CE, Bowlin SJ, Stump TE, Sprecher DL, Tierney WM. The independent correlation between high-density lipoprotein cholesterol and subsequent major adverse coronary events. Am Heart J 2006;151:755.e1-55.e6.
Reddy NK, Kumar DN, Rayudu NV, Sastry BK, Raju BS. Prevalence of risk factors for coronary atherosclerosis in a cross-sectional population of Andhra Pradesh. Indian Heart J 2002;54:697-701.
Miettinen T, Gylling H. The effects of statins and sitosterols: Benefit or not? Curr Atheroscler Rep 2009;11:23-7.
Davis HR Jr, Altmann SW. Niemann-Pick C1 Like 1 (NPC1L1) an intestinal sterol transporter. Biochim Biophys Acta 2009;1791:679-83.
Karlström B, Vessby B, Asp NG, Boberg M, Gustafsson IB, Lithell H, et al.
Effects of an increased content of cereal fibre in the diet of Type 2 (non-insulin-dependent) diabetic patients. Diabetologia 1984;26:272-7.
Turley SD, Daggy BP, Dietschy JM. Psyllium augments the cholesterol-lowering action of cholestyramine in hamsters by enhancing sterol loss from the liver. Gastroenterology 1994;107:444-52.
Halvorsen BL, Carlsen MH, Phillips KM, Bøhn SK, Holte K, Jacobs DR Jr, et al.
Content of redox-active compounds (ie, antioxidants) in foods consumed in the United States. Am J Clin Nutr 2006;84:95-135.
Tulio AZ Jr, Chang C, Edirisinghe I, White KD, Jablonski JE, Banaszewski K, et al.
Berry fruits modulated endothelial cell migration and angiogenesis via phosphoinositide-3 kinase/protein kinase B pathway in vitro
in endothelial cells. J Agric Food Chem 2012;60:5803-12.
Basu A, Du M, Leyva MJ, Sanchez K, Betts NM, Wu M, et al.
Blueberries decrease cardiovascular risk factors in obese men and women with metabolic syndrome. J Nutr 2010;140:1582-7.
Obarzanek E, Sacks FM, Vollmer WM, Bray GA, Miller ER 3 rd
, Lin PH, et al.
Effects on blood lipids of a blood pressure-lowering diet: The Dietary Approaches to Stop Hypertension (DASH) Trial. Am J Clin Nutr 2001;74:80-9.
Durstine J, Moore G. ACSM's Exercise Management for Persons with Chronic Diseases and Disabilities. 2 nd
ed. Champaign, IL, Human Kinetics; 2003. p. 142-8.
Roitman J. ACSM's Resource Manual for the Guidelines for Exercise Testing and Prescription. 4 th
ed. Baltimore: Lippincott Williams and Wilkins; 2001. p. 263-76.
Koutsari C, Karpe F, Humphreys SM, Frayn KN, Hardman AE. Exercise prevents the accumulation of triglyceride-rich lipoproteins and their remnants seen when changing to a high-carbohydrate diet. Arterioscler Thromb Vasc Biol 2001;21:1520-5.
Koutsari C, Hardman AE. Exercise prevents the augmentation of postprandial lipaemia attributable to a low-fat high-carbohydrate diet. Br J Nutr 2001;86:197-205.
Petitt DS, Arngrímsson SA, Cureton KJ. Effect of resistance exercise on postprandial lipemia. J Appl Physiol 2003;94:694-700.
Sorace P, Lafontaine T, Thomas R. Know the risks: Lifestyle management of dyslipidemia. ACSM's Health Fit J 2006;10:18-25.
[Table 1], [Table 2]