Do you have high cholesterol? Or have you been told to watch your cholesterol level? You might wonder what steps to take. Eat healthier, maybe more veggies? Exercise more? Limit calories? So many questions!

I hope to help provide a little direction to help you.

What Is Cholesterol?

Let’s start with a little bit about cholesterol first. Cholesterol is a molecule made by the liver. It is a part of the lining of each of our cells and helps with hormone and vitamin D metabolism.

Our liver makes all the cholesterol we need so we don’t need to get cholesterol from our diet or the environment. We refer to it as a non-essential dietary nutrient. For this reason, our intake amount is a recommended daily allowance.

What Are Cholesterol Intake Recommendations?

The American Heart Association recommends less than 100 mg of cholesterol per day if your cholesterol levels are normal. If your cholesterol levels are abnormal, the American Heart Association refers you to your doctor. In that situation, our quickest answer is usually to try a medication or to tell you to eat healthier. While there are certain conditions where cholesterol medications are necessary, there are just as many times where modifying your diet is the first recommendation.

Often addressing dietary intake can be a long-term solution to lowering cholesterol. It can also help avoid medications. Even if you and your doctor decide that a medication would be helpful, diet changes to lower your cholesterol intake will also help your condition.

What Are Safe or Normal Cholesterol Levels?

When we talk about cholesterol levels, we measure several different components. The low-density lipoproteins (LDL) are usually what are directly related to cardiovascular risk. For this reason, LDL is sometimes called the ‘bad’ cholesterol. Sometimes we will look at other components of the lipid panel, but overall, getting LDL to the goal level is the focus. This also helps determine dietary recommendations and medication management.

The American Heart Association and the American College of Cardiology help set lipid panel guidelines. A lipid panel is a blood test that measures your cholesterol and triglyceride levels.

Here are the recommended levels for optimal health:

• Total cholesterol: Less than 200 mg/dL
• LDL: Less than 70 mg/dL
• HDL: Greater than 45 mg/dL in women and greater than 50 mg/dL in men
• Triglycerides: Less than 150 mg/dL

There are a lot of factors that go into your cholesterol levels, but one of the biggest is diet. Cholesterol levels are directly related to how much cholesterol you eat, even if high cholesterol runs in your family genetics.

How Can You Use Your Diet to Lower Cholesterol?

My first recommendation is to pay attention to how much cholesterol you are actually eating. Thankfully, a food’s cholesterol content is listed on the nutrition panel. Simply flip the package over, find the nutrition panel and the cholesterol content is listed there. We care about the milligrams of cholesterol as opposed to the percentage. Please also pay attention to the portion size as this will be how much cholesterol is in a specific portion size of that food. Your cholesterol intake throughout the day should be less than 100 mg.

Which Foods Contain Cholesterol?

Anything that has a liver to produce cholesterol will have cholesterol in it or its products. So, any kind of meat or animal product will have cholesterol in it; how much is entirely dependent on the product. That’s why it is important for you to look at the nutrition panel. Some foods are very high in cholesterol, such as eggs. One egg has anywhere from 220 to 250 mg of cholesterol. That’s over two days’ worth of cholesterol intake! However, other animal products such as skim milk won’t have as much cholesterol.

So, to reduce your cholesterol intake, it is going to mean eating a more plant-based diet. Foods that come from plants do not contain cholesterol because there’s no liver to create the cholesterol. However, it is important to note that we don’t want a highly processed plant-based diet. (Oreos are technically vegan.)

What About Protein in a Plant-Based Diet?

The next question my patients normally ask is, “What am I going to eat for protein?” A well planned, well balanced plant-based diet will get you enough protein. I will talk about protein requirements in a future blog, but just know that you can get plenty of protein through a plant-based diet.

There are a lot of plant-based protein alternatives. The key is to try to make it as unprocessed as possible. That is where your whole grains, legumes, beans, nuts and seeds come in. Meat alternatives (veggie meats) are a good option for those special occasions where we typically eat meat.

Some of the most common and highest protein containing plant products are:

• Edamame
• Tofu
• Lentils (Did you know there are 5 different colors of them?!)
• Beans
• Peas
• Tempeh
• Seitan
• Quinoa
• Millet
• Hemp

With a little bit of research, these are easy foods to learn how to cook and make tasty. There are tons of recipes online that can help with this.

7 Tips to Lower Your Cholesterol

1. Pay attention to how much cholesterol you eat each day.
2. Work on limiting cholesterol intake to less than 100 mg per day; if your cholesterol level is already high, make your intake even lower or eliminate cholesterol.
3. Follow a more whole food (unprocessed), plant-based diet.
   • Try a meatless Monday. Or a meatless Monday, Wednesday and Friday! Or a meatless week!
4. Remember, it is not just meat that contains cholesterol, but also animal products like eggs.
5. Work with your doctor to monitor your cholesterol levels as you make some of these changes so you know how much cholesterol your body can actually handle.
6. Remember that cholesterol is made by our body and therefore it is not something we are required to eat.
7. Remember that sometimes cholesterol medications are still recommended for certain conditions even if your cholesterol levels are normal. If your doctor is recommending this, make sure you understand why they want you on a cholesterol medication.

As a neurologist and subspecialist in multiple sclerosis, I am dedicated to helping patients with MS live their best lives. Many patients have questions about how dietary changes can impact their life. You will find that a well-balanced diet fuels your body and becomes a trusted companion in navigating the challenges posed by MS. It’s a flavorful quest where each meal becomes a small victory, a step towards a healthier, more vibrant life.

Dietary considerations are very important in most chronic medical conditions. From a nutritional perspective, what we expose our system to can have an important impact on our symptoms and sometimes in the course of the chronic medical condition. Multiple sclerosis is no different.

Here are answers to common questions about diet and MS.

Should I Be Supplementing My Diet with Vitamins and Other Supplements?

As a rule of thumb, I do not recommend multivitamins to all my patients with multiple sclerosis. I tend to screen for specific vitamin deficiencies. If a patient has one or more vitamin deficiencies, I recommend direct supplementation of that vitamin. I recheck the vitamin level in the future to adjust the dose.

What about Vitamin D? Which Vitamin D and How Much Should I Take?

Most patients with multiple sclerosis will be deficient or relatively deficient in vitamin D. I tend to recommend vitamin supplements with vitamin D3, which can be obtained over the counter. The goal is to have a vitamin D3 level from 60-80 ng/mL. To reach this goal, patients may need to take 2000-5000 international units of vitamin D3, particularly if they live in Nebraska or the Midwest.

Can I Take Too Much Vitamin D3?

Yes, and many of the symptoms of vitamin D3 toxicity may mimic chronic symptoms of multiple sclerosis, such as muscle aches, fatigue and even weakness.

Can Diet Decrease Inflammatory Activity and Relapses?

So far, there is no good evidence that dietary changes alone can directly modify the course of the disease and prevent inflammation and relapses (flares). However, maintaining a healthy body weight has been shown to decrease the risk of MS-related disability. A good diet and healthy body weight decreases the risk of other serious conditions such as cardiovascular and cerebrovascular conditions. This leads to improved overall health and decreased disability.

What Else Can Diet Do for Me and My Multiple Sclerosis?

Dietary changes have been shown to improve the overall quality of life and fatigue and, in some instances, hand dexterity. More than 50% of patients with multiple sclerosis suffer from MS-related fatigue. Unfortunately, the medications we use to treat fatigue in multiple sclerosis do not have great evidence backing their efficacy. Therefore, dietary changes have an important place in treating MS-related fatigue.

What Is the Best Diet for Multiple Sclerosis?

I always say that there is no one-size-fits-all when it comes to MS drugs/treatment, and I also apply this to diet. I recommend that my patients select one diet they can adhere to and follow long-term. Very restrictive diets and strict products may not be easy to obtain or even affordable.

Diets like the Mediterranean diet are easier to follow because they do not require complex planning and are more intuitive to follow. Other diets may also benefit multiple sclerosis, such as paleolithic, low-fat and intermittent fasting.

Where Can I Learn More About Diet and Multiple Sclerosis?

A good place to start is the National Multiple Sclerosis Society. The diet and nutrition section on this website has plenty of written information and pre-recorded webinars about diet and multiple sclerosis.

What is emotional eating? Emotional eating is generally when we eat as a way to suppress or soothe negative emotions such as stress, anger, fear, boredom, sadness and loneliness. When we work to reduce emotional eating, it is important to be aware of behaviors we can change to allow our food to be more useful to our bodies and to gain emotional control over food.

Here are six pointers that I have found effective in my practice as a clinical psychologist at Bryan Counseling Center.

1. Slow Down so Your Body and Brain can Communicate

Eating more slowly is one of the best ways you can get your mind and body to communicate what is really needed for nutrition. The amount of time it takes your brain to register that your stomach is full is about 20 minutes. This is why we often unconsciously overeat. Eating more slowly allows enough time to receive the signal from your brain that you are full. This in turn helps us eat the right amount of food. Simple ways to slow down might include many of your grandmother’s manners like sitting down to eat, chewing each bite 25 times (or more) and setting down your fork between bites.

2. Know Your Body’s Personal Hunger Signals

Are you responding to an emotional want or responding to your body’s needs? Often we listen first to our minds, but like many mindfulness practices, we might discover more wisdom by tuning into our bodies first. Rather than just eating when we get emotional signals, which may be different for each of us – stress, sadness, frustration, loneliness, boredom – try to listen to your body. Is your stomach growling, your energy low or are you feeling lightheaded? Too often, we eat when our mind tells us to, rather than our bodies. True mindful eating is listening deeply to our body’s signals for hunger. Ask yourself: What are your body’s hunger signals, and what are your emotional hunger triggers?

3. Cultivate a Mindful Kitchen

Do you eat alone and randomly or do you eat with others or at set times? Another way that we eat mindlessly is by wandering around looking through cabinets and eating at random times and places rather than thinking proactively about our meals and snacks. This prevents us from developing healthy environmental cues about what and how much to eat, and wires our brains with new cues for eating that are not always ideal. (For example, do you really want to create a habit of eating every time you get in the car?)

Sure, we all snack from time to time, but eating at consistent times and places can boost both your mind and body’s health, not to mention greatly helping your mood and sleep schedule. Yes, that means sitting down (at a table!), putting food on a plate or bowl, not eating it out of the container and using actual utensils. It also helps to eat with others if that is possible – not only are you sharing and getting some healthy connection, but you will also slow down and enjoy the food and conversation more.

Having a mindful kitchen means organizing and caring for your kitchen space so it encourages healthy eating and nourishing gatherings. Consider what you bring into your kitchen and where you put things away. Are healthy foods handy? What kinds of foods are in sight? When food is around, we eat it.

You don’t have to plan your food down to each bite, and it’s important to be flexible, especially on special occasions, but just be aware of the fact that you might be changing your eating habits at different times of the year or for different occasions. And when you do plan ahead, you are more likely to eat the amount your body needs at that moment rather than undereating and indulging later, or overeating and regretting it later.

4. Understand Your Motivations

Eating foods that are emotionally comforting vs. eating foods that are nutritionally healthy is a tricky balance. Ideally, we can find nourishing foods that are also satisfying and comforting. When we slow down and think about the healthy foods in our mouths we often enjoy them more than the story we want to tell ourselves about healthy food.

As we practice eating healthier and a greater variety of foods, we are less inclined to binge on our comfort foods, and more inclined to actually enjoy healthy foods. Ultimately we can find many foods mentally and physically satisfying as opposed to just a few.

5. Connect More Deeply with Your Food

Outside of hunter-gatherers or sustenance farmers, most of us have become disconnected from our food in recent years. Many of us don’t even consider where a meal comes from beyond the supermarket packaging. This is a loss because eating offers an incredible opportunity to connect us more deeply to the natural world, the elements and to each other.

When you pause to consider all of the people involved in the meal on your plate: from the loved ones (and yourself) who prepared it, to those who stocked the shelves, to those who planted and harvested the raw ingredients, to those who supported them, it is hard to not feel both grateful and interconnected. Be mindful of the water, soil and other elements that were part of its creation as you sit down to eat whatever you are eating. You can reflect on the cultural traditions that brought you this food and the recipes generously shared by friends or brought from a distant place and time to be handed down in the family.

As you consider everything that went into the meal, it becomes effortless to experience and express gratitude to all of the people who gave their time and effort, the elements of the universe that contributed their share, our friends or ancestors who shared recipes, and even the beings who may have given their lives to a part of creating this meal. With just a little more mindfulness like this, we may begin to make wiser choices about sustainability and health in our food, not just for us but for the whole planet.

6. Attend to your Plate

Multitasking and eating is a recipe for not being able to listen deeply to our body’s needs and wants. We’ve all had the experience of going to the movies with our bag full of popcorn, and before the coming attractions are over, we are asking who ate all of our popcorn. When we are distracted, it becomes harder to listen to our body’s signals about food and other needs. With your next meal, try single-tasking and just eating, with no screens or distractions besides enjoying the company you are sharing a meal and conversation with, even if it’s just your own.

While formal mindful eating practices may be what we think of when we look back on a mindfulness course or retreat we attended, the reality is that we do live – and eat – in the real world, which is a busy place. But we can take the insights gained from our formal practice – slowing down, listening to our bodies, doing one thing at a time, making even small rituals, and considering all that went into our meal on a more regular basis – and bring more informal mindfulness to our daily meals.

Finally, remind yourself each day that food is fuel for your body, not for comfort. By using mindful eating practices, you just may find the food you eat more enjoyable and nutritious.

In today’s society, we eat ‘dessert’ several times a day and don’t even bat an eye. What’s now considered normal, shouldn’t be. Think about it – sugary cereal for breakfast, donuts at the office, chocolate from the candy dish and ice cream after dinner. Has your day ever looked like that?

Treats can have their place in a healthy diet; that’s called balance. But treats need to be truly considered treats, meaning you only have them on rare occasions. It’s no secret that sugar is detrimental to our health in many ways, but it’s hard to say no!

Why is it so Hard to Avoid Sugar?

Humans are hardwired to enjoy sugar. It tastes good, sometimes makes us feel good, and it’s addictive. When we eat sugar, the pleasure centers in our brains release feel-good chemicals. This is the same effect that drugs, like cocaine, have on our brains. The brain likes that feeling, and wants more – which is why we crave more sugar.

How Can You Stop that Vicious Cycle?

• Try totally eliminating all forms of sugar for two weeks. It will be difficult for the first few days, but once you’ve broken the cycle, the cravings should decrease.
• Change your environment. If you’re constantly surrounded by sugary treats, how long can you really avoid them? If they’re not easily accessible, you’re less likely to eat them. That may mean throwing away the leftover Halloween candy. But honestly, do you really need it?
• Limit the artificial sweeteners. Even though a sugar-free cookie might be a lighter alternative, it’s still a treat. Artificial sweeteners, such as Splenda, are many times sweeter than sugar; so sometimes they only perpetuate the craving for sweets.
• Find other ways to cope with stress. Many times on a stressful day, nothing sounds better than getting lost in a pint of ice cream. Finding other ways to manage stress will serve your emotional health and your waistline. Jot down some ideas of activities you could do instead such as going for a walk, playing with your pet, calling a friend or listening to music.

You CAN do it, and You’ll Feel Better

I encourage you to look for ways to reduce the amount of sugar you eat to improve your health and how you feel. As someone who loves sweets, I know it can seem daunting. If this is the case, have a friend or family member join you for support and encouragement.

Many of us have heard of fish oil and how it can benefit heart health, and as a cardiologist, I get asked a lot of questions about it. The truth is, studies vary on this supplement. Here is information from recent studies that provide insights into the benefits of fish oil.

It All Starts with Omega-3 Fatty Acids

Omega-3 fatty acids are most abundant in marine animals. A lot of the interest in omega-3 fatty acids and fish oils have come from observations that populations who eat a lot of fish are less likely to develop heart disease. Studies have shown that eating fish once or twice a week is associated with a reduced risk of heart disease. Other animal meats also contain omega-3, but fish, in particular, is a rich source of omega-3 fatty acids.

Research Trials & a Stunning Result

In nutrition and medicine, a lot of findings start with an observation and that’s exactly the way it was with omega-3 fatty acids. The observation being that people who eat more fish tend to live longer and have a lower risk of heart disease.

Out of this came a series of trials to study omega-3 fatty acid supplements because we think these polyunsaturated fatty acids are one of the main reasons fish is such a healthy food to include in our diets. So, the question became, “can we extract that out of the fish and use it as a supplement to try and protect us from heart disease?”

Many of the trials produced some conflicting results about whether these supplements are helpful.

But one trial had stunning results. This trial studied a prescription form of omega-3 fatty acids, called icosapent ethyl; the brand name is Vascepa. This product is highly regulated and highly purified, and the study showed it provided impressive heart protecting benefits.

Breaking Down the Research

The information about fish being a part of a healthy diet that protects us from heart disease has become so much a part of our understanding that omega-3 fatty acid supplementation is still a part of the American Heart Association guidelines to help prevent heart disease. And of course, we always recommend eating fish to protect against heart disease.

But, how effective are fish oil supplements? Three specific trials tested the fish oil supplement hypothesis. These were well-conducted studies published in the New England Journal of Medicine. Let’s break them down.

The VITAL Trial

This study was done using the types of omega-3 fatty acids you’ll find as over-the-counter supplements at the same dose recommended by the American Heart Association, which is one gram per day. These trials looked primarily at prevention for men over 50 or women over 55. Over 25,000 enrollees were followed for five years. Some received omega-3 supplements, and some received a placebo. This study showed no difference in major cardiovascular events (which included heart attacks, strokes and heart disease).

So, there was no benefit that they could document in this huge trial for five years.

The ASCEND Trial

This trial also used over-the-counter supplements but studied people with diabetes who did not have a history of heart disease. Over 15,000 people participated in the trial. They took the same dose of a fish oil supplement, one gram per day, and were followed for seven years. Again, the study did not show a significant reduction in cardiovascular events.

The topline data from these two studies is that over-the-counter fish oil supplements did not seem to protect people from cardiovascular events.

The REDUCE-IT Trial

The results of this study were positive and impressive. This was a highly credible study published in the New England Journal of Medicine. It included over 8,000 patients with established heart disease, or who had diabetes plus additional risk factors. They were followed for five years. These participants were already taking a statin, a cholesterol lowering drug, so they were already getting the standard protective, preventive therapy that we recommend for all patients who’ve had a cardiovascular event.

So, these patients were receiving good care, but they still had high triglycerides, which are associated with heart event risks. Omega-3 fatty acids are particularly good at lowering triglycerides, so the thinking was perhaps those who still had high triglyceride levels despite taking a statin would benefit from this specific form of polyunsaturated fatty acid. A key difference in this study is that patients took a highly purified form of omega-3 fatty acid. It’s called icosapent ethyl; the brand name is Vascepa. This prescription drug had already been approved by the FDA for treatment of patients with severe elevations of triglycerides, one form of circulating fats in the bloodstream. To test the effects of icosapent ethyl (Vascepa) on heart disease, subjects were given four grams a day versus a placebo, and were followed for five years.

The results were something we had never seen before related to benefits. They showed a:

• 25% reduction in the combined end-point of heart attack, stroke, cardiovascular death and some coronary revascularization (i.e., getting a stent)
• 26% reduction in just heart attack, stroke and death
• 20% lower risk of death in people getting this highly purified form of omega-3 fatty acids versus a placebo

Impressive Outcomes for Highly Purified Prescription Supplement

We’ve never seen anything like these results in this area of study. It’s important to emphasize that the positive results of the REDUCE-IT trial came from a very specific form of omega-3 fatty acids in a highly purified prescription drug. This was a powerful study, and I think it will influence behavior and opinions about fish oil supplementation and omega-3 fatty acids. Over-the-counter supplements, which aren’t as highly purified or regulated, did not have the same result.

Ways to Improve Your Heart Health

If you have a history of heart disease of any kind, such as stents, angioplasties, bypass or a coronary event, you might want to discuss this purified form of omega-3 fatty acid, called Vascepa, with your doctor to see if it would be helpful for you.

As far as over-the-counter fish oil supplements, as a physician it’s difficult for me to make a strong argument for it. But if I have patients that feel it is beneficial for them in how they feel, I tell them that as long as it’s not causing you harm, ‘go for it.’ Especially if it’s not unreasonably expensive.

In cardiology and in our culture, we have a long history of trying to find that essential element out of the food and making it into a supplement, thinking that’s going to help our health. And for the most part, when put to a rigorous test, these generally fail to protect us from heart disease.

I would much rather see you eat a healthy, plant-based-leaning diet, with healthy fish and meat incorporated on a regular basis.

We tend to see more men with kidney stones than women; about 1 in 7 men will have a stone in their lifetime. Females experience about half of that. Although interestingly, in the last 10 to 20 years or so, kidney stones in females has been on the rise.

How Do Kidney Stones Form?

Calcium or Uric Acid Build Up

The most common reason is a build up of too much calcium in the urine. About 8 out of 10 types of stones that are formed are calcium stones, and a smaller percentage are what we call uric acid or gout stones.

Chronic Infection

Some kidneys stones are caused by chronic infections, but these are much less common

Other Contributors to Kidney Stones

• Age: As we get older, we’re more prone to get kidney stones. Caucasians have the highest incidence of kidney stone disease of any ethnicity.
• Family history: If someone in your family has or had kidney disease or stones, you’re more likely to develop them.
• Obesity: People who are obese and people who lose weight after bariatric or weight reduction surgery, have a higher incidence of kidney stone disease.
• High-salt diet: When you have too much calcium in your urine it is usually a result of too much sodium in your diet.

Kidney Stone Symptoms

Pain

The most common symptom of kidney stones is abrupt, severe pain. It’s usually felt in your back, or what we call the flanks, although the pain can be felt in a number of different areas, starting from your back, rotating around to the side, going into your groin, and in some cases it actually goes into your genital area. Note again that this pain would be abrupt, severe and may or may not include some blood in the urine.

What to Do if You Think You Have Kidney Stones

If you’re having severe pain, go to either an urgent care or an emergency room to be checked. Providers will likely need to do an X-ray (there are several types of X-rays or scans to diagnose kidney stones) or ultrasound, as well as a urine analysis. A physical exam also provides clues, because you may have a pelvic or bladder infection; or even appendicitis or gallbladder attack that can mimic kidney stones. It’s important to have a good handle on your medical history.

Treating Kidney Stones

Treatment depends on the size of the stone.

Water and Pain Meds for Smaller Stones

Drinking a lot of water and easing the pain are the best ways to deal with smaller stones. If the stone is less than about 5 mm, which is small, it most likely will pass through with urination, along with pain meds and hydration. Hydration will be either orally or through an IV, depending on the severity of dehydration. Finally, on rare occasions we might need to use other meds, like alpha blockers, to help pass those stones.

Surgery May be Needed for Larger Stones

If the stone is greater than about 10 mm, it likely won’t pass on its own, so surgery is the best option. Surgeries include:

• Lithotripsy, where sound waves are used to break up the stones
• Cystoscopy, which goes through the bladder with a small ‘basket’ to break up stones
• Major surgery, where the kidney stone has to be cut out or directly visualized by the surgeon

Home or Hospitalization?

Whether you are treated at home or in the hospital really depends on your degree of pain. If you can drink water and take your pain meds without nausea or vomiting, you can wait it out at home – again, taking your meds and drinking a lot of water.

But if you are vomiting or having severe nausea, which can be very common with stone disease, then you’ll likely be hospitalized.

Preventing Kidney Stones

Hydrate

I tell my patients to think about it like this: Say you’re putting sugar into iced tea. If you use too much sugar, it all falls to the bottom and the only way to get it back is to put in more tea. Well that’s what happens with urine. You get too much unwanted stuff in the urine and it falls to the bottom, and forms crystals and stones.

How much water? We want people to hydrate to the point where their urine is pale yellow. The exact amount of water is individual; we can’t tell someone how much water to drink, exactly. But seeing pale yellow urine is a good goal. If you are someone with a lot of kidney stones, you may even have to get up in the middle of the night to drink water, because during the night is the longest time you go without liquid, and that’s when your urine becomes most concentrated and can potentially form a stone.

Eat Less Salt

As I mentioned earlier, excessive salt intake is the most common reason why people get stones. Salt affects other components of urine, like uric acid and other minerals, causing crystals and stones to form. I’m a very strong proponent of the D-A-S-H (Dietary Approaches to Stop Hypertension) diet, which has been shown to decrease the incidence of stone disease as well as reduce blood pressure. The National Institutes of Health did studies on this diet dating back to the 1990s; it’s been very good for lowering blood pressure as well as preventing kidney stones.