Rethinking Cholesterol Counseling

For so many patients, cholesterol counseling can feel like a very long list of restrictions. They leave the visit knowing exactly what foods they're supposed to cut back on, but still wondering, okay, what can I eat? And that's really understandable. As clinicians, we spend a lot of time talking about what to limit, but much less time talking about what our patients should add to the plate. I know I used to be guilty of this. Welcome back to the Exam Room Nutrition Podcast. I'm your host, Colleen Sloan. I'm a physician assistant and registered dietitian, and we're continuing our special four-part avocados in practice mini-series brought to you by Avocados Love One Today. In today's episode, we're talking about heart health, cholesterol counseling, and the power of food swaps. Joining me again is Patricia Bannon, a registered dietitian and nutrition expert, as we discuss why saturated fat and added sugars get so much attention, what foods we should be encouraging patients to eat more of, and what the research says about making substitutions that support cardiovascular health. Patricia, welcome back. Hey Colleen, it's great to be back. All right, let's talk all about heart health today. And most of my listeners know the current health guidelines emphasize limiting saturated fat and added sugars. But I would love for you to back it up and tell us why those two nutrients are such a focus when we are talking about cholesterol and cardiovascular disease.

Yes, those are the two nutrients we go to, and for good reason. Although, as you said, you know, we also want to know what we can eat. But when it comes to saturated fat and added sugar, saturated fat, it gets a lot of attention because it's been shown to raise LDL cholesterol, which can contribute to that plaque buildup in the arteries and increase our risk of cardiovascular disease. The added sugar, excess added sugar, can raise triglycerides and contribute to insulin resistance, weight gain, and poor overall cardiometabolic health. So because heart disease is the leading cause of death in the United States, both of these nutrients are targets, right, for prevention and for counseling. But the goal shouldn't be to just get rid of the fat and carbohydrates. It's really improving the quality of the diet. So replacing saturated fats with unsaturated fats and choosing fiber-containing carbohydrates as sources more often. So focusing only on what we limit, like you said, you know, that is not a great plan because it's not sustainable. What patients can add into their diet or substitute is just as important to be talking to them about. So avocados fit really well here because most of the fat is unsaturated. One serving or one third of a medium avocado has six grams of unsaturated fat and only one gram of saturated fat. Plus, it's naturally sugar-free.

So it's a really common thing when we educate our patients that they may have high cholesterol. We commonly lead with telling them a whole list of foods that they should avoid. You can't have this, stop eating this, cut this out. But I would love to hear and dig in a little bit deeper into what exactly are some of the limitations of that approach.

Yes, the do not eat list, right? You leave the hospital with the do not eat list. This happened to my father recently, and my mom looked at and was like, I don't know what I can give him. And she's scared too, right? She doesn't want to feed him something that is off limits or could harm him. But really, it's what should I eat instead? You know, that's the list that's going to be most supportive to our patients. A more effective approach is shifting from that restriction to replacement, realistic swaps that preserve the flavor, the texture, and the enjoyment. We talked in our earlier episode about foods that were enjoyable and gave us that feeling of fullness, right? So that is so important. Um, for example, simply saying eat fewer foods with saturated fat. Okay, that's important. But then what do they do? So you can shift it to using avocado, olive oil, nuts, seeds, hummus in place of those foods with saturated fat. You know, mashed avocado works great here as a spread on sandwiches or wraps, and it also gives you that creamy, satisfying mouthfeel.

Yeah, you know, we for a long time have traditionally just told our patients, don't eat this, have a good day, and we'll recheck your labs in, you know, three months. But now we actually have literature to back up that that was not an effective approach because what ended up happening is our patients didn't know what they were supposed to replace those foods with, and they just replaced them with, you know, what they thought was better, but it was kind of like an equally evil quote unquote food and wasn't really beneficial or helpful. So we really do need to focus our education from restriction to replacement. And so I would love to hear a little bit more advice on what foods should we be encouraging our patients to add to their plate more often. And then kind of you can loop in some of the evidence about the impact of those swaps on cholesterol and triglyceride levels.

Yeah, great, Colleen. So I think encouraging foods that provide healthy unsaturated fats and fiber is really key here, you know, including avocados, nuts, seeds, beans, lentils, a lot of the foods I just mentioned. And there's a really cool study I want to share here that brings this to life. This was a study that was supported by the Avocado Nutrition Center. It was a randomized crossover feeding study of 42 adults with elevated triglycerides and overweight or obesity who completed two three-week diets. One diet included one avocado a day as part of a substitute for butter and added sugar. The avocado was incorporated into six sweet and savory recipes. So these recipes that the avocados were incorporated in were muffins, granola protein bites, salad dressing, pesto, salsa, and a marinade, right? Foods where most of us are eating throughout the day. So in the study, those foods provided either the avocado or the control, the control being the butter or the added sugar. So comparing to the control, the avocado diet reduced non-HDL cholesterol by about 5%, which investigators considered clinically meaningful. It reduced VLDL cholesterol by about 9%, and it reduced triglycerides by about 17%, which is substantial for a single food swap, particularly because triglycerides can be difficult to address with many frontline medications. And the other cool thing here, Colleen, is that dietary compliance was at least 93%. So this is suggesting that these are practical and enjoyable swaps.

Okay, talk to us about this characteristics of foods like avocados when we're thinking about replacement for foods that are higher in saturated fats and added sugars. Why is avocados such a great swap here?

Well, avocados are a great swap because they have that monounsaturated fat, they have the fiber, but they also have phytosterols in nearly 20 vitamins and minerals. So the unsaturated fats and fiber, they help reduce the LDL or bad cholesterol, which can lower the risk of heart disease. As I mentioned earlier, you know, one-third of a medium avocado, it has six grams of unsaturated fat, only one gram of saturated fat, and three grams of fiber. You know, so that composition is really supporting here. Avocados are also the richest known fruit source of phytosterols. They have 38 milligrams of beta testosterone per serving. So phytosterols, they can help lower cholesterol when they're consumed in sufficient amounts twice daily as part of a diet that's low in saturated fat and cholesterol. And the other thing about avocados is that they're naturally cholesterol-free, sodium-free, and sugar-free. So all these things are gonna help make them a useful replacement.

Okay, I love talking all about these replacements. I think it's so important in heart health, and especially when we're educating our patients, to make our advice practical and like something that they can use in their real life. So I want to hear more about other ways a patient can use avocado beyond a usual avocado toast.

Yes, we love avocado toast, but there's so many more ways to enjoy avocado. And that's one of the things I love is the versatility because it fits into so many familiar meals that people are already enjoying. And that's really key in terms of making them enjoy their diet that they're shifting. So the study that I mentioned is a great example of that versatility, right? One avocado per day was incorporated across meals and snacks that had six sweet and savory recipes. And that 93% compliance rate showed that people really enjoyed those recipes. So muffins and baked goods, I've mentioned this in an earlier episode. It's a great substitution. You can substitute it one for one, mashed avocado for saturated fat and a lot of baked recipes. You can blend it in. Avocados work great, blended in, as we saw in the study, into dressings, into peso, into marinades, into creamy pasta sauces. Mashed avocados are great swap on sandwiches, wraps, protein salads like tuna or chicken salad. And you know what? Dice it up, chop it up, whatever size you like. It's great as a topping. It can be a topping on grain bowls, tacos, soups, baked potatoes.

Yeah, and again, those suggestions just bring this science back to real life. And I think that's really important when we're educating our patients. Patricia, thank you so much for joining me again. This is such a fun conversation talking all about how avocados can fit within our patients to prevent cardiovascular disease. And thank you to Avocados Loved One today for sponsoring this series. I'll link the research and resources we talked about today in the show notes. And be sure to come back tomorrow when we're talking about what may be getting overlooked in our blood sugar conversation. We'll see you tomorrow.