Cholesterol treatment guideline

The new Cholesterol guideline was published in November and is the result of a joint task force of the American College of Cardiology and the American Heart Association. The report was published in the journal Circulation.

Cholesterol moleculeFirst, a couple of caveats: Dietary supplements by law cannot claim to treat or prevent any illness. So to some degree, it makes sense that clinicians would not turn to them first to help patients who already have high cholesterol. Also, it should be noted that the guideline would be aimed first and foremost at specialists, who likely would be consulted only after a patient has been referred with a treatable condition.

Paucity of information on Cholesterol prevention

Nevertheless, it is telling that so little effort is spent in the guideline on discussing how to help patients to keep from crossing over the line into the treatment category, rather than spending page after page on how to fix the boat after it has sprung a leak. In the 120-page document, which includes 69 pages of actual text, only two short sections were devoted to lifestyle factors in the prevention of development of hyperlipidemia.

“Patients should consume a dietary pattern that emphasizes intake of vegetables, fruits, whole grains, legumes, healthy protein sources (low-fat dairy products, low-fat poultry (without the skin), fish/seafood, and nuts), and nontropical vegetable oils; and limits intake of sweets, sugar-sweetened beverages, and red meats,” the guideline states.

One other section of the guideline addresses prevention specifically.

“Primary prevention of ASCVD over the life span requires attention to prevention or management of ASCVD risk factors beginning early in life,” the guideline states. It then refers the reader to a table that includes one statement about encouraging a healthy lifestyle and then devotes the rest of the information on statin therapy, starting as early as age 8.

Lipid ingredients, polyphenols shown to have effects

A number of dietary ingredients have been researched for their positive effects on blood lipid profiles including lipid ingredients and many plants and fruit extracts rich in phytochemicals.

Omega-3s, for example, have been shown to have positive effects on high triglyceride levels, but the effects on LDL cholesterol specifically are less clear-cut. Levels can actually increase slightly, but the size of the LDL particles changes as well, which is a good thing. And HDL (the “good” cholesterol) goes up, too, indicating a generally positive overall trend.

Extra virgin olive oil, which is rich is some polyphenolic compounds such as hydroxytyrosol, has been suggested to benefit blood lipid profiles via a multifaceted action that includes both anti-inflammatory aspects and the promotion of cholesterol efflux. Olive is, of course, one of the main components of the Mediterranean diet, which is frequently recommended for heart health.

Drug hits one target –  supplements hit many

But this multifactorial approach doesn’t fit neatly into the mostly drug-focused paradigm of the new guideline, said James Kennedy, Ph.D. president of ingredient supplier Polyphenolics, which has a line of grape seed extracts which are among the more comprehensively researched polyphenol-based ingredients on the market.

“There is no question that statins can dramatically reduce your blood cholesterol levels,” Kennedy told NutraIngredients-USA. “They absolutely can reduce cholesterol much further than any polyphenol from a fruit or vegetable.”

“But for me it’s about lifestyle first. It just struck me as odd that here is a group concerned about our heart health and they were pretty much exclusively recommending drugs,” he said.

Kennedy said that cardiovascular disease is a multifaceted condition. Statins target one aspect of this situation and hits that nail squarely on the head. But natural ingredients, perhaps especially when offered in combination, take a more comprehensive approach to the problem.

Polyphenolics offers a line of grape seed extracts that includes MegaNatural BP, which has been researched for its effect on supporting blood pressure in the healthy range. That effect takes into account the healthy flow dynamics of the circulatory system, something that a myopic focus on cholesterol numbers glosses over.

Evidence backing many polyphenols

Grape seed extracts are just one of many polyphenol-based ingredients on the market that have been researched for their benefits in ameliorating the risk factors of CVD.

grapes are recommended in low cholesterol diets

“If you look at cardiovascular disease as a whole, a lot of polyphenols – and grape seed extract in particular – address the various areas including blood pressure and blood glucose as well as hypercholesteremia. Our industry offers a food-first approach which makes sense to consumers. They look at supplementation as a complement to everything else they are doing to address all aspects of heart disease, not just one piece of it” Kennedy said.

The entourage effect implied by the research backing polyphenols (they all appear to do slightly different things) is now starting to be borne out by research. A recent study in the journal Nutrients showed that just two weeks on a polyphenol-poor diet could alter vascular biomarkers in a group of healthy men.

And a recent review article in the journal Molecules had this to say: “Consumption of polyphenols from plant extracts and fruits increases antioxidant levels in plasma which protect vasculature and improve anti-inflammatory and lipid profiles, blood pressure, HDL-C, and vascular function.”  The review focuses on a number of polyphenols and other naturally occurring compounds, including gallic acid and punicalagin from pomegranate.

Combo products increasing in popularity

Kennedy said there is increasing interest among supplement product formulators in taking advantage of the evidence supporting the multifactorial effects of polyphenols.

“We do come into contact with customers who say they want to put together a heart health formula and want to know what they can combine our grape seed extract with,” he said.

“Recently we had a customer who wanted to combine our grape seed extract with a blueberry extract and a bergamot extract. When you go into the store you frequently see our extract in formulation with other ingredients,” Kennedy said.

The beauty of the natural approach to heart health is these ingredients can be combined with virtually no concern about antagonistic interactions, Kennedy said. Polyphenolics has continually worked on its GRAS dossier, with higher and higher dosages proven to be safe, he said.

“For the most part these are natural products and they are not known to have any cross indications. With statins, you have to dial the dose in and the patient has to be monitored very carefully.”


Pushups anybody?

The pushup is a simple exercise that can strengthen and tone many of the muscles of the upper body and core. There are many variations of the pushup that suit a range of abilities and focus on different sets of muscles.

In this article, we look at which muscles pushups work and some of the benefits of doing pushups. We also provide a guide to eight different types of pushup.

Which muscles do pushups work?

The muscles in the upper body do most of the work when a person does pushups. These muscles are:

  • chest muscle group, including the pectoralis major and pectoralis minor
  • shoulder muscle group, including the deltoid major and deltoid minor
  • upper and middle back muscles, including the latissimus dorsi, rhomboids, and trapeze muscles
  • biceps, at the front of the upper arm
  • triceps, at the back of the upper arm
  • serratus anterior, which sits on the side of the chest beneath the upper arm

However, pushups require many other muscles in the body to work to keep the body in a rigid plank position. These muscles may include:

Benefits of doing pushups

There are many benefits to regularly doing pushups, including:

Burning calories

Doing pushups can be a powerful full-body workout. They use up a large amount of energy in a short period because the movements require large muscle groups to lift and hold much of the body’s weight.

The more pushups a person does, the more calories they burn.

Improving cardiovascular health

Doing pushups uses large muscle groups to alternately lift and lower much of the body’s weight, which increases the heart rate. Raising the heart rate during exercise helps strengthen the heart muscle, enabling it to pump more oxygenated blood to the lungs and throughout the body.

Tiny blood vessels called capillaries, which supply blood from arteries to tissues and organs, also widen to allow for better blood flow.

Doing exercise that raises the heart rate can help:

  • lower blood pressure
  • regulate blood sugar and insulin levels
  • reduce the risk of heart disease and cancer
  • lower body weight or maintain a healthy weight, alongside a calorie-controlled diet

Protecting the shoulder joint

When people use the correct technique, pushups can help build up strength in the muscles around the shoulder joint. The muscles and tendons in the shoulder hold the upper arm bone in the socket.

When the muscles are weak, stress or injury to the shoulder can result in damage to the muscles and tendons.

Easy to do

Pushups are a simple exercise that requires very little or even no equipment, so a person can easily do them as part of an at-home workout. There are also many pushups variations to suit people of different strengths and abilities.

8 types of pushup

Below is a guide to eight different types of pushup. The exercises are in order of difficulty from the easiest to the most challenging.

1. Wall pushup

Wall pushups gif
Image credit: CDC, 2012.

Wall pushups are suitable for beginners or anyone with a shoulder injury. This type of pushup helps build shoulder and chest strength but places a reduced load on the muscles.

Muscles worked: arms, shoulders, and chest.

  1. Stand in front of a wall, just over an arm’s length away. Feet should be shoulder-width apart.
  2. Bring the hands to shoulder height. Lean forward, extend the arms, and place the hands flat on the wall. Hands should also be shoulder-width apart.
  3. Inhale and bend the elbows, lowering the body toward the wall. During this movement, squeeze the core and buttocks to maintain a strong, straight position.
  4. Pause for 1 second and then push off the wall with the arms, keeping the hands on the wall. The feet should remain flat on the floor. If the heels come up, move slightly closer to the wall.

Try to do 3 sets of 12 repetitions, reaching a total of 36 pushups. Take a short break between sets.

2. Modified pushup

Senior woman doing modified pushup outdoors using knees

The modified pushup is for people who want a more challenging exercise than the wall pushup but are not quite ready for a standard pushup. When doing this pushup, focus on tightening all the muscles to maintain a stiff, straight body.

Muscles worked: arms, shoulders, chest, and serratus anterior.

  1. Start on all fours, with the knees and toes touching the floor. Hold the legs and feet together.
  2. Look down at the floor to maintain a neutral head position. Place the hands below the shoulders, keeping the arms straight.
  3. Breathe in. While engaging the core and buttocks muscles, bend the elbows to lower the chest as close to the floor as possible. Pause here for 1 second.
  4. Breathe out. Push the arms straight to lift the body off the floor and back into the original kneeling position. Make sure that the back does not sag, the core remains tight, and the buttocks do not lift into the air.

Repeat the exercise 12 times and then do an additional 2 sets, with short breaks between them. This will make a total of 36 pushups.

3. Standard pushup

Gif of man doing pushups
Image credit: Frank C. Müller, 2006.

The standard pushup requires more work than the modified pushup because it does not involve using the knees to help support the body weight.

Muscles worked: arms, shoulders, chest, and serratus anterior.

  1. Start on all fours, but extend the legs so that the knees do not touch the floor. Tuck in the pelvis and keep the head in a neutral position by looking down at the floor. Place the hands under the shoulders and keep the arms straight. This is known as the plank position.
  2. Breathe in. While engaging the core and buttocks muscles, bend the elbows to lower the chest as close to the floor as possible. Pause here for 1 second.
  3. Breathe out while pushing the arms straight to lift the body off the floor and back into the plank position. Make sure that the back does not sag, the core remains tight, and the hips do not lift into the air.

Try to do 3 sets of 12 pushups.

4. Wide pushup

Woman doing wide pushups

The wide pushup is only slightly different to the standard pushup. It involves widening the distance between the hands, which places more focus on the chest muscles.

Muscles worked: chest, shoulders, and back muscles.

  1. Get into the plank position, as in the standard pushup, but place the hands further out to the side.
  2. Follow the same technique as the standard pushup for lowering and raising the body while tightening the core and buttocks. The elbows will point further out to the side as the arms bend.

Try to do a total of 36 pushups, dividing them into 3 sets with short breaks between.

5. Narrow pushup

Man doing narrow pushups

The narrow pushup is another variation of the standard pushup, but it is usually more difficult. It reduces the distance between the hands, which means that the arm muscles have to work harder.

Muscles worked: triceps and chest muscles.

  1. Get into the plank position but, this time, place the hands closer together and directly below the chest.
  2. Follow the same technique as the standard pushup for lowering and raising the body while tightening the core and buttocks. The elbows should tuck back into the body as the arms bend and straighten.

Do 3 sets of 12 repetitions to reach a total of 36 pushups.

6. Elevated pushup

Man doing elevated pushups outdoors

The elevated pushup position raises the feet above the body, meaning that a person needs more strength to get back into a plank position. A person can increase the elevation over time as their strength improves.

Muscles worked: shoulders, upper back, and triceps.

  1. Start in the plank position and then raise the lower half of the body by placing the toes on a sturdy object, such as a box, chair, or bench.
  2. Place the hands underneath the shoulders, keeping the arms straight.
  3. Breathe in. Engage the core and buttocks muscles and bend the elbows to lower the chest as close to the floor as possible. Pause here for 1 second.
  4. Breathe out. Push the arms straight to lift the body off the floor and back into the plank position. Make sure that the back does not sag, the core remains tight, and the hips do not lift into the air.

Again, aim for a total of 36 pushups, dividing them into 3 sets of 12 repetitions with a short rest before each new set.

7. Clap pushup

Man doing clap pushups.

The clap pushup, which is a type of plyometric pushup, is one of the most demanding types of pushup. A person can try this once they are very confident in their upper body strength.

The clap pushup can help increase muscle strength, power, and body awareness.

Muscles worked: shoulder, chest, and arms.

  1. Begin in the plank position with the hands slightly wider apart than the shoulders.
  2. Breathe in. While engaging the core and buttocks muscles, bend the elbows to lower the chest as close to the floor as possible.
  3. Breathe out. In one smooth movement, forcefully push the body upward by straightening the arms and lift the hands off the floor, bringing them together to clap once.
  4. Land with the hands back on the floor and a soft bend in the elbows.

This type of pushup requires a lot of strength, but a person will find that they build up endurance over time.

For this exercise, it is best to start with 5 to 10 repetitions over 3 to 5 sets. Rest sufficiently between sets to allow the body to recover.

8. Pike pushup

The pike pushup is another demanding pushup variation that loads more weight onto the shoulders and triceps when pushing back up.

Muscles worked: shoulder, serratus anterior, upper back, and triceps.

  1. Start on all fours with the hands placed shoulder-width apart, the heels off the ground, and the head looking down. Lift the buttocks into the air, keep the arms straight, and bend at the hips to form an upside down V shape. This is a similar position to the Downward Dog in yoga.
  2. Breathe in. While engaging the core and buttocks muscles, bend the elbows to lower the head and let it gently touch the floor, if possible.
  3. Breathe out. Push the arms straight to raise the head and shoulders back to the starting position.

A person can try using a yoga block or something similar if they are unable to touch the floor with their head. For this pushup, it is best to begin with short sets of 1 to 5 repetitions and then work up to larger sets of 8 to 12 repetitions.


Pushups are a type of exercise that uses the weight of the body to work the large muscle groups and raise the heart rate. As these simple exercises do not require any special equipment, a person can easily incorporate them into their home exercise routine.

There are also many pushup variations to suit different strengths, fitness levels, and needs. As a person becomes stronger and increases their endurance, they can progress to more advanced types of pushup.