Cardiovascular disease is one of the leading causes of mortality in the UK and Ireland (1). Cardiovascular disease is an umbrella term for diseases that affect the heart or blood vessels. Ischemic heart disease (also known as coronary heart disease) is by far the most prevalent, which is characterised by the heart not receiving enough blood or oxygen, caused by narrowed arteries.
This article will explore the importance of maintaining healthy cholesterol levels, with a specific focus on the Ultimate Cholesterol Lowering Plan (UCLP) © from HEART UK.
Risk Factors For Heart Disease
Cardiovascular disease can be related to many risk factors, though 93% of the risks can be impacted by dietary habits and lifestyle choices (2). Modifiable risk factors for cardiovascular disease include high blood pressure — hypertension, high cholesterol, type 2 diabetes, obesity, physical inactivity, along with other lifestyle factors.
In the UK and Ireland, from 2008 – 2018, coronary heart disease rates plummeted (3). The success can be attributed to public health messaging, the use of lipid-lowering medications, and the implementation of nationwide strategies to decrease smoking. While these are all excellent changes, and has helped drive coronary heart disease deaths down, what hasn’t changed much is our dietary patterns.
One of the main dietary issues individuals face when it comes to heart health, is excess saturated fat intake.
74.5% of UK adults and 64.5% of Irish adults consume above the recommended intake of saturated fat.
Other issues include high sugar intake (which can lead to an excess in calories), excess consumption of red and processed meat intake (which is a large source of salt and saturated fat), low consumption of oil-rich fish (which has shown cardiovascular benefits), and low intakes of plant-based foods like wholegrains, fruits, vegetables, legumes, nuts, and seeds.
It’s important to note, that poor dietary patterns can increase the likelihood of cardiovascular disease by increasing some of the risk factors. An example would be a diet consisting of large quantities of saturated fat. High consumption of saturated fat can increase LDL cholesterol, which increases one’s risk for cardiovascular disease.
Why are individuals failing to adhere to the dietary recommendations? It can be quite difficult to make sustained dietary changes, especially when certain habits have been ingrained in our heads for over a lifetime. We would ideally need a plan that is easy to understand, easy to adhere to, and easy to access. This is what shaped the development of the UCLP©.
Step 1 of the UCLP©
This step focuses on motivational and behavioural strategies, and getting the patient ready to make their dietary adjustment.
Through the use of motivational interviewing (MI), the patient can explore and overcome barriers to change. MI is a collaborative and empathetic approach which involves the use of open questions, affirmations, reflective listening and certain strategies and exercises for exploring motivation to change. You can read more about MI in this blog post.
Step 1 also involves cognitive behavioural therapy (CBT). CBT is a type of therapy that encourages an understanding of how thoughts and actions can affect emotions; including motivation for change.
Step 2 of the UCLP©
This step focuses on making healthy changes to the diet, by creating a personalised “heart healthy foundation diet”. These healthy changes include minimising saturated fat, increasing consumption of oil-rich fish, prioritising plant proteins, incorporating wholegrains, and achieving the recommendation of at least five servings of fruits and vegetables per day. There has been rigorous evidence to backup each of these recommendations.
Saturated fat has been shown to have one of the largest dietary impacts on increasing LDL cholesterol levels.
The exposure to LDL particles over long periods of time, and the potential harmful oxidation/modification to these particles, can lead to a buildup of cholesterol in the arteries. This can lead to narrowing of the arteries and an increased risk of heart disease (4).
The heart healthy foundation diet recommends that individuals consume no more than 10% of total calories from saturated fat. The European Society of Cardiology and the European Atherosclerosis Society found that LDL cholesterol increases by 0.02-0.04 mmol/L for every additional 1% of energy coming from saturated fat (5).
The heart healthy foundation diet recommends oil-rich fish, particularly for their omega-3 fatty acids EPA and DHA, though also for their vitamin D content. Examples of oil-rich fish include: salmon, mackerel, herring, trout, sardines and kippers. National recommendations are set at a minimum of one serving per week.
We have lots of data demonstrating that fish consumers that stay within dietary recommendations, receive cardiovascular benefits (6-8).
National intakes of plant protein consumption is extremely poor, which include nuts, seeds and legumes. The heart healthy foundation diet recommends more plant proteins within the diet, which may lower saturated fat intake, increase unsaturated fat intake, and increase fibre intake. These factors have been shown time and time again, primarily in prospective studies, to lower cardiovascular disease risk (9-10).
The diet also recommends five servings of fruits and vegetables per day, which has been a struggle for most individuals.
In the UK and Ireland, only one third of the population consume 5 portions of fruit and vegetables.
Fruit and vegetable intake is always recommended for not only reducing the risk of cardiovascular disease, but also premature death (11).
Lastly, the heart healthy foundation recommends consuming an adequate amount of wholegrains and fibre. There are many well designed trials looking at wholegrain and fibre intake on serum cholesterol levels. More notably, Jenkins and colleagues published a randomised controlled trial, putting healthy volunteers on a very-high fibre diet (55g/1000 kcalories). In 2 weeks, individuals on the very-high fibre diet, had an average reduction in LDL cholesterol of 0.98 mmol/L or 17.65 mg/dL (12).
The Zutphen Study also demonstrated that every additional 10g of dietary fibre reduced coronary heart disease mortality by 17% (13).
After listening to all of the suggestions in Step 2, the patient then decides which, and how many dietary changes they’d like to make. They would also have to specify how they would achieve their specific dietary adjustment. It is often recommended that the patient makes realistic goals, making one change every 2-3 weeks.
Step 3 of the UCLP©
This final step applies to the patients that are willing to make further changes to their diet. The UCLP© added four additional foods that can significantly lower LDL cholesterol beyond the heart healthy foundation diet.
The four additional foods are:
- Soya – 3 servings (25g) of soya protein is linked with a 3-4% reduction in LDL cholesterol (14).
- Nuts – 1 handful (28-30g) of nuts is linked with a 4-5 mg/dL reduction in LDL cholesterol (15).
- Plant sterols/stanols – 1.5-3g of plant sterols/stanols is linked with a 7-12.5% reduction in LDL cholesterol (16).
- Foods rich in beta-glucan like oats and barley – 3 servings (3g) of beta-glucan is linked with a 5-7% reductions in LDL cholesterol (17).
When the patient is ready, they can decide which of the four foods they would like to include in their current diet. As time goes on, the patient is then encouraged to review their progress, and to consider adding more cholesterol lowering foods to their diet (if they aren’t already consuming all four).
Adopting dietary habits long-term is often a challenge. The UCLP© provides a realistic and practical solution for lowering LDL cholesterol and the risk of cardiovascular disease. If a diet is too difficult to follow or too restrictive, adherence will be an issue which inevitably will hinder long-term success and personalized goals.
The UCLP© is tailored towards individual needs, which is vital for long-term success on a diet. Each individual step the plan provides, will independently help reduce cardiovascular disease risk, the more steps chosen the better. The plan is personalised and accessible for those trying to make dietary changes, to lower their risk of developing one of our leading killer — cardiovascular disease.
Click here to access the UCLP© booklet which is aimed at the non-health professionals.
Click here to access the UCLP© factsheet for health professionals.
- British Heart Foundation (2019) Heart Statistics. https://www.bhf.org.uk/what-we-do/our-research/heart-statistics
- British Heart Foundation (2019) Heart & Circulatory Disease Statistics 2019. https://www.bhf.org.uk/what-we-do/our-research/heart-statistics/heart-statistics-publications/cardiovascular-disease-statistics-2019
- GBD Compare (2019) https://vizhub.healthdata.org/gbd-compare/
- Linton MRF et al. The Role of Lipids and Lipoproteins in Atherosclerosis. (2019) Jan 3. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK343489/
- François Mach, ESC Scientific Document Group, (2019) ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk: The Task Force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and European Atherosclerosis Society (EAS), European Heart Journal, ehz455, https://doi.org/10.1093/eurheartj/ehz455
- Orlich, M. J., Singh, P. N., Sabaté, J., Jaceldo-Siegl, K., Fan, J., Knutsen, S., … Fraser, G. E. (2013). Vegetarian dietary patterns and mortality in Adventist Health Study 2. JAMA internal medicine, 173(13), 1230–1238. doi:10.1001/jamainternmed.2013.6473, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4191896/
- Hu FB, Bronner L, Willett WC, et al (2002). Fish and Omega-3 Fatty Acid Intake and Risk of Coronary Heart Disease in Women. JAMA. 2002;287(14):1815–1821. Doi: https://doi.org/10.1001/jama.287.14.1815
- Seamus Paul, He Jiang (2004). Meta-Analysis of Observational Studies on Fish Intake and Coronary Heart Disease. https://www.ajconline.org/article/S0002-9149(04)00128-6/fulltext
- Marventano S, Izquierdo Pulido M, (2017). Legume consumption and CVD risk: a systematic review and meta-analysis. Public Health Nutr. 2017;20(2):245–254. doi: 10.1017/S1368980016002299 https://www.ncbi.nlm.nih.gov/pubmed/28077199
- Aune, D., Keum, N. (2016). Nut consumption and risk of cardiovascular disease, total cancer, all-cause and cause-specific mortality: a systematic review and dose-response meta-analysis of prospective studies. BMC medicine, 14(1), 207. doi:10.1186/s12916-016-0730-3 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5137221/
- Aune, D., Giovannucci, E., Boffetta, (2017). Fruit and vegetable intake and the risk of cardiovascular disease, total cancer and all-cause mortality-a systematic review and dose-response meta-analysis of prospective studies. International journal of epidemiology, 46(3), 1029–1056. doi:10.1093/ije/dyw319 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5837313/
- Jenkins, D.J., Popovich, D.G., Kendall, C.W., Vidgen, E., Tariq, N., Ransom, T.P., Wolever, T.M., Vuksan, V., Mehling, C.C., Boctor, D.L., Bolognesi, C., Huang, J., & Patten, R.D. (1997). Effect of a diet high in vegetables, fruit, and nuts on serum lipids. Metabolism: clinical and experimental, 46 5, 530-7. https://www.ncbi.nlm.nih.gov/pubmed/11288049
- Streppel, M.T., Ocke, M.C., Boshuizen, (2008). Dietary fiber intake in relation to coronary heart disease and all-cause mortality over 40 y: the Zutphen Study. Am J Clin Nutr. 2008; 88: 1119–1125. https://www.ncbi.nlm.nih.gov/pubmed/18842802
- Blanco Mejia, Sonia & Messina. (2019). The Journal of Nutrition Nutrition and Disease A Meta-Analysis of 46 Studies Identified by the FDA Demonstrates that Soy Protein Decreases Circulating LDL and Total Cholesterol Concentrations in Adults. Journal of Nutrition. 149. 10.1093/jn/nxz020. https://www.ncbi.nlm.nih.gov/pubmed/31006811
- Gobbo, Liana & Falk (2015). Effects of tree nuts on blood lipids, apolipoproteins, and blood pressure: Systematic review, meta-analysis, and dose-response of 61 controlled intervention trials. The American journal of clinical nutrition. 102. 10.3945/ajcn.115.110965. https://www.ncbi.nlm.nih.gov/pubmed/26561616
- Trautwein, E. A., Vermeer, M. A., Hiemstra, H., & Ras, R. T. (2018). LDL-Cholesterol Lowering of Plant Sterols and Stanols-Which Factors Influence Their Efficacy?. Nutrients, 10(9), 1262. doi:10.3390/nu10091262. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6163911/
- Rgia A Othman, Mohammed H Moghadasian, Peter Jh Jones (2011). Cholesterol-lowering effects of oat β-glucan, Nutrition Reviews, Volume 69, Issue 6, 1 June 2011, Pages 299–309, https://doi.org/10.1111/j.1753-4887.2011.00401.x