By Jack Challem

Jonathan Tuttle, 45, a magazine art director in the San Francisco Bay Area, knows how difficult it can be to reduce an elevated risk of heart disease. He’s a little overweight, he has diabetes, he faces the stress of regular deadlines, and he doesn’t exercise nearly enough. But last year, when medical tests found that his blood level of triglycerides, a fat related to cholesterol, was more than twice the norm, he realized he had to do something.

Tuttle might well have gone to the health food store and shelled out for guggulipid or pantethine, two of the most promising cholesterol-lowering supplements. But if he had, he probably wouldn’t have done himself any good. In fact, his total cholesterol was already an enviably low 134. Luckily, he had an alternative-minded physician (he lives in Northern California, after all) who recommended something that would take aim directly at his high triglycerides: Fish oil supplements, the doctor told him, would bring these bad guys down, without any of the side effects that typically come with drugs.

Tuttle took this advice and also decided to eat more nuts (known to protect the heart) and cut back a bit on carbs, which tend to raise triglycerides. After one month on his new regimen, without making any other lifestyle change, he cut his triglyceride level nearly in half.

Tuttle’s experience reflects some of the big changes taking place in the world of heart disease. For decades, physicians viewed total cholesterol as the Rosetta stone for determining a person’s chance of developing heart trouble. That emphasis continues, but many new players have emerged on the scene, some of which may be even more important. These days you’re just as likely to hear about low-density lipoprotein (LDL), or bad cholesterol, as you are about total cholesterol. In fact, last summer the National Cholesterol Education Program (NCEP) came out with a report advising that acceptable levels of LDL for people at high risk of heart disease be lowered—and that more people in this category consider taking cholesterol-lowering statin medications.

But there’s more. In addition to triglycerides, high levels of homocysteine—a byproduct of protein metabolism that can damage blood vessel walls and set the stage for cholesterol deposits—are now considered a red flag for heart disease. And C-reactive protein, virtually unheard of several years ago, is moving its way closer to center stage. It’s a marker for inflammation, which is now considered a major contributor to many of the problems that can cause a heart attack.

Of course, following a heart-healthy diet can do a lot to reduce your risk, but for many people, it’s not enough. And heart-protecting drugs can come with troublesome side effects, such as fatigue and the possibility of liver disease. For some risk factors, like homocysteine and low-density lipoprotein, there aren’t even any drugs to consider.

That’s where supplements come in. “In many cases, they can improve your numbers as well as drugs can,” says Ron Hunninghake, a physician at The Bright Spot for Health, a nutritional medicine center in Wichita, Kansas. “Plus, they’re less expensive, and side effects are rare.”

But how do you know which one is best for you? That’s where things get tricky. In general, the NCEP recommends that all adults get a cholesterol check in their twenties, and every five years after that if they come out okay (and more often, if not). A complete blood panel will tell you not only your total cholesterol number but also your levels of good and bad cholesterol as well as triglycerides.

But there are also blood tests for the other factors we talk about below, and frankly, you’d be wise to request them, too, especially if you have health problems or if a parent or sibling has had heart disease. (Remember, roughly 50 percent of heart attacks occur in people with normal cholesterol levels.) Then, with a more complete picture of your personal heart disease risk, you can zero in on any supplements that are most likely to help. If you’re like Tuttle, making the right choices will mean that you won’t have to work too hard to reap big rewards.

Total Cholesterol
Some experts, compelled by that 50 percent statistic, now feel that total cholesterol is no longer a key concern. But others disagree. You can rise above the contradictions by not betting your life on cholesterol alone—but it’s still a good idea to pay attention to that basic number.

Meaningful numbers
Desirable cholesterol is below 200; borderline high is between 200 and 239; high is 240 and above.

Beneficial supplements
• Plant sterols. Beta-sitosterol and other plant sterols have a chemical structure similar to that of cholesterol, which enables them to reduce the absorption of cholesterol from the intestine. Dozens of studies have found that plant sterols can lower cholesterol levels by an average of 6 to 8 percent. Although they’re added to some popular brands of cholesterol-lowering margarine, supplements enable you to avoid the extra calories in those spreads. Take at least 1.3 grams of sterol supplements twice a day. Look for products labeled plant sterols, phytosterols, or beta-sitosterol.

• Pantethine. This form of the B vitamin pantothenic acid is the precursor to coenzyme A, which helps the body burn sugars and fats. Pantethine is especially effective in reducing cholesterol levels. Hunninghake recommends 300 milligrams twice daily as a starting dose; in some studies patients took a total of 900 mg daily.

• Guggulipid. Although the scientific evidence hasn’t been consistent, guggul (as it is also known) does seem to lower cholesterol levels in many people. It’s an Ayurvedic herb (Commiphora mukul) that contains plant sterols. Take 50 mg twice daily.

• Niacin. This particular form of vitamin B-3 has been known since the 1950s to reduce cholesterol levels. Approved by the Food and Drug Administration for lowering cholesterol, it is sold both by prescription and over the counter, but there’s no real difference between the two versions; it’s just that once the FDA approves something, it must be sold and regulated as a drug. As effective as niacin is, it does have a drawback: It triggers the release of histamine, which often will turn the skin beet red and tingly for about an hour. If you keep taking niacin, the intense flushing episodes should eventually ease. Start at 100 mg once or twice a day and work up to 500 to 1,000 mg three times a day.

• Policosanol. Derived from sugarcane and beeswax, this supplement has been shown in several studies to be a potent cholesterol-buster. But much of the research is on Cuban products, so you can’t be sure that American ones are equally good. If you want to give it a try, take 10 mg a day.

• Coenzyme Q10. People who must take statins should also take 100 to 200 mg of coQ10 a day because statins can deplete your body’s natural supply.

Low-Density Lipoprotein (LDL) Cholesterol
Even within this crucial category, there are subtypes to worry about. Small, dense LDL globules are far more likely to cause blood clots than are larger, less dense ones. And when a person’s antioxidant intake is low, LDL oxidation increases, which appears to be a key step in the development of heart disease, says Michael Janson, a nutritionally oriented physician in New Smyrna, Florida, and author of Dr. Janson’s Healthy Living Newsletter. If your total LDL is high, it may be wise to have an additional blood test to find out which type predominates.

Meaningful numbers
The optimal LDL level is less than 100 milligrams per deciliter. You should be concerned if your level is borderline high, from 130 to 159, and especially if it’s above 160. But even if your LDL is under 100, your overall disease risk is three to five times higher if your blood has more of the small, dense particles.

Beneficial supplements
• Plant sterols (discussed above) can lower LDL levels by an impressive 8 to 14 percent. Pantethine and niacin also reduce LDL, but there are currently no research findings on how any of these supplements might influence LDL particle size. Follow the dosage recommendations under “Total Cholesterol,” above.

• Vitamin E won’t lower LDL, but will curb its tendency to promote heart disease. Contrary to common thinking, LDL is not entirely bad—it’s needed to transport fat-soluble nutrients, such as vitamin E and coenzyme Q10, throughout the bloodstream. Vitamin E and other fat-soluble antioxidants prevent LDL oxidation. Take 400 to 800 IU of natural-source (not synthetic) vitamin E.

• Dietary options. To lower LDL, reduce your intake of saturated fat (in fatty meats and full- and low-fat dairy products) and avoid processed foods containing trans fats such as most shortenings, partially hydrogenated oils, and many cookies and crackers. A recent study by Canadian researchers found that trans fats boost the number of hazardous small, dense LDL particles in the bloodstream.

High-Density Lipoprotein (HDL) Cholesterol
HDL is widely considered the “good” form of cholesterol, mainly because it helps transport the LDL or bad cholesterol to the liver, where the LDL is then processed for excretion. The higher your HDL levels, the lower your risk of heart disease.

Meaningful numbers
Ideal HDL levels are 55 mg/dL or higher for women and 45 mg/dL or higher for men. However, the ratio of HDL to other types of blood fats may be an even better gauge of risk. (See “What’s a Healthy Blood-Fat Ratio?” page 90.)

Beneficial supplements
• L-carnitine, a component of protein, is highly recommended by Patrick Fratellone, an integrative cardiologist in New York City. Take 3,000 mg 15 to 30 minutes before breakfast.

• Fish oil supplements contain eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)—both essential dietary fats that boost HDL. They’re also potent blood thinners so they prevent clotting, and they help to regulate heart rhythm. The standard daily dose for good health is 2 grams, but Fratellone recommends at least 3 g if you’re looking to boost HDL. Since fish oil is a blood thinner, be sure to consult with your physician if you’re also taking any anticoagulant medications, such as Coumadin.

• Niacin, a form of vitamin B-3, will raise HDL levels. But again, remember that you may experience an intense one-hour flushing sensation after you take it. Aim for 500 to 1,000 mg three times daily.

• Dietary options. If you’re trying to boost HDL, don’t skimp too much on fats, particularly heart-healthy fish oils and olive oil. Low-fat diets, long recommended to reduce the risk of heart disease, actually lower HDL levels. But cut back on refined carbs, which can decrease your HDL.

Triglycerides
Although cholesterol gets most of the attention, triglycerides actually account for the lion’s share of fat found in the blood and in body fat. No one’s exactly sure what kind of damage they cause, but a higher ratio of triglycerides to HDL has been associated with a 16-fold increase in heart attack risk.

Meaningful numbers
Anything under 150 mg/dL is considered normal, but given how quickly you can land in dangerous territory, Fratellone thinks it’s wise to aim for 100 mg or less. Levels of 150 to 199 mg are borderline high, and 200 mg and above are considered high.

Beneficial supplements
• Fish oil supplements, as Tuttle found, can lead to impressive reductions in triglyceride levels. Take at least 3 grams a day. In some studies, plant sterols have also been shown to reduce triglycerides.

• Dietary options. Triglyceride levels are directly related to the quantity of refined carbohydrates you eat, so reduce your intake of table sugar, white bread, cookies and other sweets, refined pasta, and bagels, and focus instead on whole grains.

C-Reactive Protein
The current theory about heart disease is that it begins as an inflammatory disorder of the blood vessels, and C-reactive protein (CRP) is both a marker and a promoter of that process. Paul M. Ridker, the cardiologist at Harvard Medical School who helped put C-reactive protein on the map, has found that high CRP levels can indicate up to a fourfold increase in heart attack risk. The C-reactive protein test is particularly good for identifying people whose cholesterol levels are normal but who are nonetheless at risk, which may
include those who are obese or have diabetes.

Meaningful numbers
Low risk is less than 1 mg/L; average risk is 1 to 3; and anything above 3 warrants a CRP-lowering strategy and additional testing to look for bacterial, viral, or parasitic infections that may require specific drug treatment. For the baseline test, make sure your doctor orders the “high-sensitivity” or “cardiac” CRP test, not the older and less precise version.

Beneficial supplements
• Natural-source vitamin E (or d-alpha tocopherol) can quickly reduce CRP levels, according to several clinical studies. In one conducted with diabetic patients, 800 IU taken daily lowered CRP by 50 percent after just four weeks. Take 400 to 800 IU a day.

• Studies have found that fish oil supplements reduce blood vessel inflammation and the tendency of plaque to rupture and cause atherosclerotic blockage. Take at least 3 grams every day.

• Vitamin C quenches free radicals, which in turn helps dampen inflammation. Vitamin C’s activity is enhanced if you take it with bioflavonoids, another family of anti-inflammatory antioxidants in fruits and vegetables. Take at least 1 gram three times daily—and more if you can tolerate it (some people experience digestive trouble from vitamin C) as well as 250 mg of flavonoids (e.g., quercetin, Pycnogenol, or grape-seed extract) two to four times daily, suggests Fratellone.

• Some herbs also have anti-inflammatory properties and may reduce CRP levels. You might try ginger capsules, 2 to 4 grams daily, and turmeric, 600 mg three times daily.

• Dietary options. Refined carbs boost CRP levels, so it’s best to lean toward fish and brightly colored vegetables and fruit.

Homocysteine
An amino acid, homocysteine is normally a short-lived byproduct of protein metabolism—it’s only when levels become elevated that they cause trouble. If you don’t eat lots of veggies, particularly those that contain folic acid such as spinach, romaine lettuce, and other greens, there’s a good chance your homocysteine is too high.

Meaningful numbers
The American Heart Association considers normal levels to be from 5 to 15 micromoles per liter of blood, but many experts consider that too wide a range. Fratellone says ideal levels are under 7.

Beneficial supplements
• Three B vitamins are particularly helpful in breaking down homocysteine: folic acid (1,000 to 5,000 mcg daily), vitamin B-6 (25 to 50 mg daily), and vitamin B-12 (2,000 mcg daily).

• Dietary options. Load up on leafy greens.

Glucose Tolerance
Diabetes can quadruple the risk of heart disease, and prediabetic conditions such as insulin resistance also set the stage (high blood sugar levels elevate insulin, a hormone that can increase CRP). Even modest increases in blood sugar levels—those well within the medical norm—can boost risk.

Meaningful numbers
Virtually every standard blood test measures your fasting glucose. The standard range for normal is 60 to 99 mg/dL, though some experts, like Fratellone, think it should be more like 60 to 80. If your fasting glucose is above that, you might also want to request a glycated hemoglobin test, which looks at glucose-caused protein damage in red blood cells and hence provides a picture of glucose levels over the previous three months. The normal range is 4.5 to 5.7 percent, but Fratellone believes it’s best to keep it under 5.5 percent.

Beneficial supplements
Many supplements can help lower and stabilize glucose and insulin levels, but if you already take glucose-regulating drugs, be sure to work with your physician to adjust their dosage.

• Alpha-lipoic acid, an antioxidant, is widely used in Germany to treat peripheral neuropathy, a nerve disease caused by diabetes. Studies have found that it can lower both glucose and insulin levels. Take 100 to 300 mg daily.

• Chromium picolinate, a popular form of an essential mineral, has been shown to lower glucose and cholesterol levels. Take 400 to 1,000 mcg daily.

• Cinnamon can lower fasting glucose, total cholesterol, and triglyceride levels by about one-fourth, according to a small recent study of diabetics at the Human Nutrition Research Center, in Beltsville, Maryland. The study used 1 to 6 grams in capsule form, equal to one-quarter to a little more than one teaspoon of the ground spice. (Hello, cinnamon toast!)

• Ginseng supplements can blunt excessive post-meal increases in glucose, according to studies at the University of Toronto. Taken 40 minutes before a glucose-tolerance test, 1 to 3 grams of American ginseng (Panax quinquefolius L.) significantly reduced the rise in blood sugar.

• Silymarin, the antioxidant-rich extract of milk thistle, is well known for increasing liver activity. That’s important because your liver works in tandem with your pancreas to regulate blood sugar levels. In a study of 60 diabetics, Italian researchers found that 600 mg of silymarin daily reduced several key measures of glucose tolerance, including fasting glucose and insulin, over the course of a year.

• Dietary options. Your own body’s response to food can often tell you plenty. Feeling tired and having difficulty concentrating about an hour after lunch or dinner points to poor glucose tolerance—and probably meals with too many refined carbs and sugars. So go for whole, minimally processed foods. “Supplements can provide quick results,” says Hunninghake, “but it makes no sense to take them and continue eating junk food.”