Cholesterol might not be the villain we've been told it is

For decades, cholesterol has been considered one of the great evils of the dietary world. It's a major factor in heart disease, we were told, and the higher your levels, the higher your risk. So eat the egg whites but throw out that cholesterol-laden yolk, and don't you dare go near that lobster or shrimp unless you want to turn your arteries into little cement-filled tubes.

But with the Dietary Guidelines Advisory Committee's declaration that cholesterol is "not considered a nutrient of concern for over-consumption," that advice might be thrown in the garbage itself.

The statement worked its way into a December draft report issued by the committee, which provides recommendations for the federal Dietary Guidelines for Americans that are issued jointly by the secretaries of the U.S. Department of Health and Human Services and the U.S. Department of Agriculture and updated every five years.

The final 2015 report hasn't been issued yet — it's expected to be released in a few weeks — but even the advisory committee's preliminary statement might be enough to make even the most health-conscientious Americans throw their hands up in frustration. The last time the guidelines were updated in 2010, they considered consuming less dietary cholesterol a "major goal" for Americans, and advised less than 300 mg per day (an egg has about 186 mg).

So why the turnaround?

Recent (and not-so-recent) medical research. Studies are showing that cholesterol might not be the culprit we've been told it was for the past 40 years. For instance, a national study issued in 2009 by UCLA found that nearly 75 percent of patients hospitalized by a heart attack had cholesterol levels "that would indicate they were not at high risk for a cardiovascular event," and close to half had LDL ("bad" cholesterol) levels classified as "optimal."

One article, published in 2010 in Current Atherosclerosis Reports, noted that recent studies documented the "lack of effect of dietary cholesterol on [cardiovascular heart disease] risk, suggesting that guidelines for dietary cholesterol should be revisited." Another study, published in 2013, "suggests that egg consumption is not associated with the risk of CVD and cardiac mortality in the general population."

Jennifer Haythe, M.D., assistant professor of medicine in the Division of Cardiology, Center for Advanced Cardiac Care at Columbia University Medical Center, said that this research is showing that "maybe cholesterol isn't the bad guy."

Nate E. Lebowitz, M.D., a cardiologist with the Advanced Cardiology Institute at Hackensack University Medical Center Cardiovascular Partners Plus, said cholesterol itself doesn't cause disease — after all, our livers produce about 75 percent of the cholesterol in our bodies, and we need that waxy, fat-like substance because it helps our bodies make vitamin D, hormones and the substances that help digest foods.

What actually creates problems for the heart are the lipoproteins, which are the particles that shuttle cholesterol through the bloodstream, Lebowitz said. For many years, though, there wasn't a good way to break down lipoprotein counts in the doctor's office, and so the cholesterol test was used as a sort of general indicator. This led to the concept of "good" cholesterol (high-density lipoproteins, or HDL) and "bad" cholesterol (low-density lipoproteins, or LDL), and the utterly simplified story that went something like this: LDL particles collect in the arteries, and HDL particles "scrub" them off. So you want more HDL cholesterol because it keeps your arteries clear, and the better your ratio of HDL-to-LDL is, the safer you are.

But, Lebowitz said, the standard cholesterol blood test was "a very poor attempt" to represent what was going on, because there's actually different types of LDL particles — the small, dense kind that worm their way into artery walls and cause plaque buildup, and the larger, less dangerous types that are less likely to do that.

So even though higher LDL numbers aren't particularly good — the more total LDL floating around, the higher the likelihood that some will be the more threatening type — treatment should depend on what type of particle is present, he said.

For instance, two brothers could have the exact same LDL count, Lebowitz said, but depending on the type of LDL particle, one could be at "incredibly high-risk" while the other, not so much — but on the old test, you'd never know which brother had which type. Newer tests are now readily available, however, and they'll break down what types of lipoprotein particles are present, leading to more individualized treatment, he said.

Jeffrey Matican, M.D., chief of cardiology and medical staff president at Englewood Hospital and Medical Center, added that overall cholesterol counts are the "least important" of the numbers given to patients, and traditional factors like age, weight, or an individual's history of smoking or diabetes, as well as the type of LDLs present, are better for assessing risk.

"There's a disconnect quite often — someone can have very good LDL cholesterol, but their particle numbers are very high, and they have a lot of small, dense particles ... And I've had people with reasonably high LDL cholesterol, but their lipoprotein particles are very low. And those people you don't really have to treat, because the things that are invading the [artery] walls are the lipoprotein particles — not the cholesterol."

So is it time to change your diet once more?

First, understand that your genes play a much greater role in your cholesterol level than your diet.

"Whether what you're eating actually changes the blood concentration [of cholesterol] seems to be what's called into question here," Haythe said. "It may be more genetically geared."

"I don't think that dietary cholesterol is much of an issue at all," said Lebowitz with the Advanced Cardiology Institute at Hackensack University Medical Center. Genetics, he said, are a better predictor of cholesterol levels than how many eggs one has for breakfast.

So, if you've been avoiding eggs and shrimp like the plague for heart health, then yes, you can relax on that (unless you're diabetic, in which case experts advise to keep avoiding cholesterol). But, like every dietary dictum, this one comes with the caveat that moderation is best, because overindulging in high-cholesterol foods carries its own risks. You may be hypersensitive to dietary cholesterol (which means that what you eat actually does affect the cholesterol levels in your blood), and many high-cholesterol foods like steak, cheese, onion rings, and ice cream, are also loaded with saturated fat — still (as of now) a dietary no-no.

And the real villains — experts say — are simple carbohydrates like sugar, white bread, pasta and corn syrup, which, they note, while low in cholesterol and fat, have led to increases in obesity, diabetes, and blood pressure, and cause inflammation in the arteries.

Matican said that those who eat a low-carbohydrate diet will likely have less to worry about than those who eat a higher-carbohydrate diet.

Dr. Roger Blumenthal, director of the Johns Hopkins Ciccarone Center for the Prevention of Heart Disease and co-chairman of the American College of Cardiology/American Heart Association Prevention Guidelines Committee, said that the best advice is the same advice that doctors and nutritionists have been repeating for generations: Eat a well-balanced diet heavy on fruits, vegetables, whole grains, and the monounsaturated and polyunsaturated fats found in things like fish, nuts and olive oil, while limiting red meat, fried foods and sugary desserts.

"A vegetarian diet is best, but probably not practical for most Americans," Blumenthal said. "But doing things in moderation — that's more practical."

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Are superfoods actually super?

First it was blueberries, spinach and salmon. Then it was wheatgrass, green tea and any kind of nut. Now it's kale, quinoa and pumpkin seeds. Next week — who knows?

If you're confounded by the number of foods that have been named "superfoods" over the years, you're not alone. It seems that every six months, some obscure vegetable or oddly colored drink is pushed as the cure-all for everything that ails us, all the while promising to prevent Alzheimer's, ward off cancer and keep us living well into our eighth or ninth decade.

And it's worked — for the vendors, at least. According to the market research firm Global Industry Analysts, the worldwide market for superfoods, which is fueled primarily by baby boomers with disposable income and a desire to stay healthy and live long, is expected to reach $130 billion in 2015.

But are the foods all they're cracked up to be? Or is it just a ploy to keep us searching the shelves at our supermarkets for the next big thing?

The European Union took a definitive stance in 2007 when it banned use of the term "superfood" on packaging unless the claim could be supported by scientific evidence. The United States has no such ban, however, and while there's general consensus as to what the word refers to — a food that's rich in vitamins, antioxidants or other nutrients — it's still "purely a marketing term," said Dr. Ilya Raskin, a professor at Rutgers School of Environmental and Biological Sciences.

"In some cases, what is touted as a superfood may have some advantages over conventional foods — you will not hear that term associated with what we know is bad for you, like fat-loaded junk food," Raskin said. "But I do think it has a misleading ring to it."

Superfoods have been bestowed with "mythological" powers, he said, and although some of these are science-based and quantifiable (blueberries, often placed in the superfood category, have demonstrated benefits for those with such health conditions as metabolic syndrome, but apparently so do strawberries and cranberries), they don't take into account a person's individual needs.

For instance, grapes and watermelon may be packed with nutrients and antioxidants, but they're also high in sugar. That might not be a problem for the average person, but for those with diabetes, it can present a "clear danger," he said.

Green tea is a similar case. Numerous Internet articles claim that the drink can prevent cancer, lower blood pressure and fight off everything from diabetes to tooth decay. But while there is some evidence to support certain claims (such as a 2014 study that found that green tea may benefit cognitive function), other studies have had mixed results, and the Food and Drug Administration won't allow labels to say the drink can reduce risk of heart disease or cancer.

Furthermore, there is evidence that the concentrated doses of green tea extract found in some supplements could actually do harm to the liver.

But still, no one will say that drinking a normal amount of green tea is bad for you, and that might be the biggest benefit of the superfood craze: Instead of being bombarded with marketing from companies that are trying to make unhealthy things sound healthy, superfoods actually are healthy — even if it's not in the overblown way advertisers want us to believe.

Janet Brancato, a registered dietitian and community educator at The Valley Hospital in Ridgewood, pointed out that a little good publicity for things like broccoli or cauliflower isn't necessarily a bad thing. "[It's] a marketing term for healthy food, and I think it's helped to make it more popular and trendy," she said.

But potential problems can arise when consumers either eat too much of one thing (for some, blueberries can cause serious gastrointestinal distress, and too much kale may cause or exacerbate hypothyroidism), or ignore fruits and vegetables that haven't received that label; blueberries are marketed as superfood, even though there's no evidence that they're any more "super" than strawberries, apples or blood oranges.

Susan Kraus, a clinical dietitian with the Hackensack University Medical Center, said that diversity in food selection is more important than focusing on any individual item.

"People will label anything as a superfood … but we need a good 50-plus nutrients a day, so it's not just one food that we want to hone in on," she said.

And Dr. Patricia Murphy, a cardiologist at Westwood Cardiology, said no one food holds a monopoly over heart health, which comes more from eating a wide variety of colorful fruits and vegetables.

"The benefit [of superfoods] are exaggerated, but it's good for people to think about what they're eating and make healthy choices," she said. "I still think that the advice from [author] Michael Pollan is the best: 'Eat food. Not too much. Mostly plants.' "

So will washing down a steady diet of kale and quinoa with gallons of green tea keep us disease-free? No, probably not. Raskin said that for the best results, the old advice is still the best: Talk to a physician or nutritionist about what diet best suits you. And ignore the next round of articles on "must-eat" foods.

"I try to eat healthy according to the recommendations of dietitians and physicians, and maintain a healthy diet emphasizing sufficient servings of fruits and vegetables," he said. "And that kind of basic nutritional advice will trump any specific superfood at any time."

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Cow milk vs. nut milk - who wins?

Humans have been drinking cow's milk for thousands of years, but lately, more and more Americans are edging towards a new competitor: nut milks.

Made by soaking and sometimes blending almonds, cashews, hazelnuts, or pistachios in water, they're not dairy products, but are similar enough that they've already put a dent in the cow's milk market — especially almond milk, which, according to the market research firm IRI, has become the nation's most popular non-dairy alternative with 2014 sales grossing nearly $700 million to date.

Meanwhile, according to the U.S. Department of Agriculture, per capita consumption of cow's milk has dropped by about 25 percent since 1975. This is partly because of the prevalence of other bottled drinks like soda or iced tea, but some is also due to the nut-milk juggernaut.

Initially, the move appears to make sense for consumers, especially the waistline-conscious. One cup of unsweetened almond milk has about 30 calories and 2.5 grams of fat, none of which is saturated. A cup of 2 percent dairy milk, by comparison, has about 120 calories and 5 grams of fat, 3 of which is saturated.

It's also an attractive alternative for the lactose intolerant, who may be searching for a way to continue imbibing their recommended daily intake of calcium (to maintain bone health) and vitamin D (to support the immune system). Although nut milks have neither naturally, they're fortified during processing to about the same levels as dairy.

"It's the same benefits that we get from drinking skim milk," said Peggy Policastro, nutrition specialist at Rutgers University. "But you really have to make sure that the nut milk is fortified. Natural milk is very high in calcium and vitamin D, and if you exclude that, your diet will be deficient."

Seems like a wonder drink, doesn't it? Not to everyone.

Andrea Anfuso-Sisto, a registered dietitian at Valley Hospital in Ridgewood, said that although nut milk is a good alternative source for calcium and vitamin D, it is much lower in protein: traditional milk has about 8 grams per cup, but most nut milks, including almond and cashew, have 1 gram or less.

That could be a necessary tradeoff for the lactose intolerant, she said, but for those without some sort of milk allergy, dairy is probably better, especially for young kids who need the protein during growth spurts. They often have milk at breakfast alongside a cereal that has plenty of carbohydrates, but little else.

"Most cereals aren't a good source of protein, so it's good to balance that out," she said. "So you're missing the calories [with nut milk], but it's at the cost of the protein."

Furthermore, she said, many types of nut milk are sweetened to soften the drink's inherently raw taste, so blindly grabbing for Almond Breeze in a grocer's refrigerated case could mean buying "vanilla" instead of "unsweetened vanilla" (and the half-gallon containers do look similar). The taste difference is marked, but so is the nutritional: no sugar in the unsweetened, 13 grams in the sweetened.

Other nut milks are similar — sweetened cashew milk has 5 grams of sugar, and Pacific's brand of hazelnut milk has 14 — and all of it is added sugar that's not found naturally in the drink. This type of sugar has been linked to obesity, diabetes and cardiovascular disease.

Cow's milk, Anfuso-Sisto said, may have 11 grams itself, but that's natural sugar, similar to the fructose in an apple.

"If you're talking about the recommendations for added sugar each day, females get about 100 calories (6 teaspoons) and males get about 150 (9 teaspoons). Things like pieces of fruit or glasses of milk don't count — but the sweetened almond milk would," she said.

Policastro agreed, and said that consumers must be aware of what they're buying.

"It's similar to chocolate milk; you're still getting the vitamin D, but you're getting a lot of sugar," she said.

But she didn't share Anfuso-Sisto's concern about the lack of protein, and said that Americans regularly get "more than enough" in their regular diet. In her opinion, the best kind of milk is the kind that people will actually drink.

"Drink whichever you like better. Just don't leave a milk out of your diet, because that's where you're getting your calcium," she said.

Email: janoski@northjersey.com

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So, should you avoid eating carbs?

Yes, a new study has found that a low-carbohydrate diet helped participants drop weight faster over 12 months than a low-fat one, but let's not toss the rye bread and start frying up the eggs just yet.

Look past the headlines that the study, led by Tulane University's Dr. Lydia Bazzano and published this week in the Annals of Internal Medicine, has generated, and you will find that the message is not, in fact, about the importance of really cutting back on carbohydrates — it's yet another heads up to be more careful about what we're eating.

The study found that a group following a low-carb diet lost more weight — an average of 7.7 pounds worth — and their levels of HDL ("good") cholesterol had increased "significantly more" than a group following a low-fat diet over a year's time. Their triglycerides also fell sharply, and their Framingham scores, which predict how likely a patient is to have a heart attack within 10 years, also dropped.

Many see the results as an endorsement of an Atkins-like high-protein, high-fat diet, but Sharon R. Akabas, Ph.D., director of the M.S. in nutrition program at the Institute of Human Nutrition for Columbia University, said that we may be missing the point.

"The message that may be lost in translation is that eating unprocessed foods is very important," she said.

America has made a "big mistake" in making fat out to be villainous, she said, and the foods we developed in the wake of the "low-fat" craze may be low in fat but high in sugar and really low in nutrients. So while there's nothing inherently wrong with using a low-fat diet to keep your weight down, it's difficult to do without eventually eating processed foods. The reason? We've got to get our calories somehow. Low-carb diets, on the other hand, may not be as difficult to maintain; dieters may eat more fat, but if it's healthy fat – from nuts and olive oil, for example – that's OK.

"The higher-fat diet seems to allow us to select less processed foods, and that allows people to manage their weight better," Akabas said. "That ultimately affects their health in a positive way." In other words, she noted, this study reinforces what scores of previous studies have found: "People should reduce their simple sugars and processed foods while moving to a more plant-based diet."

The study took a group of 148 obese people and divided them into two groups: one that followed a traditional low-fat diet that restricted them to getting no more than 30 percent of their daily energy intake from fat, and another that followed a low-carbohydrate approach and limited participants to no more than 40 grams a day (an average diet allows for around 300 grams). The subjects ranged from 22 to 75 years old, had a body mass index of between 30 and 45 (doctors prefer it to be between 18 and 25), and had no reported history of cardiovascular problems. The diets included no specific calorie goal, and both groups were asked not to change their physical activity levels.

Cardiologist Benita Burke, M.D., medical director of Valley Medical Group's Heart Care for Women, said that the study had flaws, such as a limited scope, short timeline and a reliance on participants reporting what they ate. And while triglycerides and other inflammation markers fell among the low-carb eaters, blood pressure readings didn't, and levels of LDL cholesterol — (the "bad" cholesterol) — didn't change with either group. Larger studies with final tallies of how many patients later suffered heart attacks or strokes are necessary before a final judgment is made, she said.

The one benefit, Burke said, was the insinuation that sugar is a no-no. "It's a good thing to say, 'Keep people away from the bagels and the muffins,' because we have to stay away from them. We know it turns into sugar, and we're already on sugar overload," she said.

"It all comes back to these processed foods and these sugars … everything we eat that's 'white' should be out."

Email: janoski@northjersey.com

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