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Home > Living Well > Health Library > High Cholesterol (Holistic)
Add whole grains, legumes, fruits, and vegetables to your meals to reduce heart disease risk
30 grams (about 1 ounce) a day of powdered soy protein added to food or drinks can help lower cholesterol
Take 1.6 grams a day as a supplement or in specially fortified margarines to help reduce cholesterol
600 to 900 mg a day of a standardized garlic extract may help lower cholesterol and prevent hardening of the arteries
Start a regular exercise program to help raise HDL ("good") cholesterol
Foods that contain saturated fat, hydrogenated fat, and cholesterol (such as animal products, fried foods, and baked snacks) can raise cholesterol.
Cut the bad fats
Foods that contain saturated fat, hydrogenated fat, and cholesterol (such as animal products, fried foods, and baked snacks) can raise cholesterol
Pick a plant-based diet
Emphasize vegetarian meals whenever possible to reap the rewards of avoiding animal fats and increasing fiber and other cholesterol-stabilizing nutrients
Aim for a healthy body weight to avoid problems with blood lipids and other heart disease risk factors
Use a regular program of aerobic exercise to maintain optimal blood lipid levels and lower heart disease risk
Maintain healthy HDL ("good") cholesterol levels and low heart disease risk by avoiding cigarette smoke
Use at least 100 mg per day vitamin C and/or up to 400 IU vitamin E to protect LDL cholesterol from damage that can increase heart disease risk
Although it is by no means the only major risk factor, elevated serum (blood) cholesterol is clearly
associated with a high risk of heart disease.
Most doctors suggest cholesterol levels should stay under 200 mg/dl. As levels fall below 200, the risk of
heart disease continues to decline. Many doctors consider cholesterol levels of no more than 180 to be
optimal. A low cholesterol level, however, is not a guarantee of good heart health, as some people with low
levels do suffer heart attacks.
Medical laboratories now subdivide total cholesterol measurement into several components, including LDL
("bad") cholesterol, which is directly linked to heart disease, and HDL ("good")
cholesterol, which is protective. The relative amount of HDL to LDL is more important than total cholesterol.
For example, it is possible for someone with very high HDL to be at relatively low risk for heart disease
even with total cholesterol above 200. Evaluation of changes in cholesterol requires consultation with a
healthcare professional and should include measurement of total serum cholesterol, as well as HDL and LDL
The following discussion is limited to information about lowering serum cholesterol levels or increasing
HDL cholesterol using natural approaches. Because high cholesterol is linked to atherosclerosis and heart
disease, people concerned about heart disease should also learn more about atherosclerosis.
This condition does not produce symptoms. Therefore, it is prudent to visit a health professional on a regular basis to have cholesterol levels measured.
Exercise increases protective HDL cholesterol,1 an effect that occurs even from walking.2 Total and LDL cholesterol are typically lowered by exercise, especially when weight-loss also occurs.3 Exercisers have a relatively low risk of heart disease.4 However, people over 40 years of age, or who have heart disease, should talk with their doctor before starting an exercise program; overdoing it may actually trigger heart attacks.5
Obesity increases the risk of heart disease,6 in part because weight gain lowers HDL cholesterol.7Weight loss reduces the body's ability to make cholesterol, increases HDL levels, and reduces triglycerides (another risk factor for heart disease).8, 9 Weight loss also leads to a decrease in blood pressure.
Smoking is linked to a lowered level of HDL cholesterol10 and is also known to cause heart disease.11Quitting smoking reduces the risk of having a heart attack.12
The combination of feelings of hostility, stress, and time urgency is called type A behavior. Men,13, 14 but not women,15 with these traits are at high risk for heart disease in most, but not all, studies.16 Stress17 or type A behavior18 may elevate cholesterol in men. Reducing stress and feelings of hostility has reduced the risk of heart disease.19
Doctors and researchers are interested in alpha-linolenic acid (ALA)—the special omega-3 fatty acid found in large amounts in flaxseeds and flaxseed oil. ALA is a precursor to EPA, a fatty acid from fish oil that is believed to protect against heart disease. To a limited extent, ALA converts to EPA within the body. However, unlike EPA, ALA does not lower triglyceride levels (a risk factor for heart disease). Preliminary research on the effects of ALA from flaxseed has produced conflicting results.
In 1994, researchers conducted a study in people with a history of heart disease, using what they called the "Mediterranean" diet. The diet was significantly different from what people from Mediterranean countries actually eat, in that it contained little olive oil. Instead, the diet included a special margarine high in ALA. Those people assigned to the "Mediterranean" diet had a remarkable 70% reduced risk of dying from heart disease compared with the control group during the first 27 months. Similar results were also confirmed after almost four years. Although cholesterol levels fell only modestly in the "Mediterranean" diet group, the positive results suggest that people with elevated cholesterol attempting to reduce the risk of heart disease should consider such a diet. The diet was high in beans and peas, fish, fruit, vegetables, bread, and cereals; and low in meat, dairy fat, and eggs. Although the authors believe that the high ALA content of the diet was partially responsible for the surprising outcome, other aspects of the diet may have been partly or even totally responsible for decreased death rates. Therefore, the success of the "Mediterranean" diet does not prove that ALA protects against heart disease.
Preliminary research consistently shows that people who eat nuts frequently have a dramatically reduced risk of heart disease. This apparent beneficial effect is at least partially explained by preliminary and controlled research demonstrating that nut consumption lowers cholesterol levels. Of nuts commonly consumed, almonds and walnuts may be most effective at lowering cholesterol. Macadamia nuts have been less beneficial in most studies, although one controlled trial found a cholesterol-lowering effect from macadamia nuts.Hazelnuts, and pistachio nuts, have also been reported to help lower cholesterol.
Nuts contain many factors that could be responsible for protection against heart disease, including fiber, vitamin E, alpha-linolenic acid (found primarily in walnuts), oleic acid, magnesium, potassium, and arginine. Therefore, exactly how nuts lower cholesterol or lower the risk of heart disease remains somewhat unclear. Some doctors even believe that nuts may not be directly protective; rather, people busy eating nuts will not simultaneously be eating eggs, dairy, or trans fatty acids from margarine and processed food, the avoidance of which would reduce cholesterol levels and the risk of heart disease. Nonetheless, the remarkable consistency of research outcomes strongly suggests that nuts do help protect against heart disease. Although nuts are loaded with calories, a preliminary trial surprisingly reported that adding hundreds of calories per day from nuts for six months did not increase body weight in humans—an outcome supported by other reports. Even when increasing nut consumption has led to weight gain, the amount of added weight has been remarkably less than would be expected, given the number of calories added to the diet. Given the number of calories per ounce of nuts, scientists do not understand why moderate nut consumption apparently has so little effect on body weight.
Soluble fiber from beans,oats,psyllium seed,glucomannan, and fruit pectin has lowered cholesterol levels in most trials. Doctors often recommend that people with elevated cholesterol eat more of these high-soluble fiber foods. However, even grain fiber (which contains insoluble fiber and does not lower cholesterol) has been linked to protection against heart disease, though the reason for the protection remains unclear. It makes sense for people wishing to lower their cholesterol levels and reduce the risk of heart disease to consume more fiber of all types. Some trials have used 20 grams of additional fiber per day for several months to successfully lower cholesterol. Psyllium has also been found to enhance the effect of the cholesterol-lowering drug simvastatin.
Oat bran is rich in a soluble fiber called beta-glucan. In 1997, the U.S. Food and Drug Administration passed a unique ruling that allowed oat bran to be registered as the first cholesterol-reducing food at an amount providing 3 grams of beta-glucan per day, although some evidence suggests this level may not be high enough to make a significant difference. Several double-blind and other controlled trials have shown that oat bran and oat milk supplementation may significantly lower cholesterol levels in people with elevated cholesterol, but only weakly lowers them in people with healthy cholesterol levels.
Flaxseed, another good source of soluble fiber, has been reported to lower total and LDL cholesterol in preliminary studies. A double-blind trial found that while both flaxseed and sunflower seed lowered total cholesterol, only flaxseed significantly lowered LDL. Amounts of flaxseed used in these trials typically range from 30–50 grams per day. A controlled trial found that partially defatted flaxseed, containing 20 grams of fiber per day, significantly lowered LDL cholesterol, suggesting that at least one of the cholesterol-lowering components in flaxseed is likely to be the fiber in this product, as opposed to the oil removed from it. Controlled trials of flaxseed oil alone have shown inconsistent effects on blood cholesterol.
When people eat a number of small meals, serum cholesterol levels fall compared with the effect of eating the same food in three big meals. People with elevated cholesterol levels should probably avoid very large meals and eat more frequent, smaller meals.
Most dietary cholesterol comes from egg yolks. Eating eggs has increased serum cholesterol in most studies. However, eating eggs does not increase serum cholesterol as much as eating foods high in saturated fat, and eating eggs may not increase serum cholesterol at all if the overall diet is low in fat.
Egg consumption does not appear to be totally safe, however, even for people consuming a low-fat diet. When cholesterol from eggs is cooked or exposed to air, it oxidizes. Oxidized cholesterol is linked to increased risk of heart disease. Eating eggs also makes LDL cholesterol more susceptible to damage, a change linked to heart disease.
Whether or not egg eaters are more likely to die from heart disease is a matter of controversy. In one preliminary study, egg eaters had a higher death rate from heart disease, even when serum cholesterol levels were not elevated. However, another preliminary study found no evidence of an overall significant association between egg consumption, and risk of heart disease or stroke, except in people with diabetes. Until more is known, limiting egg consumption may be a good idea, particularly for people with existing heart disease or diabetes.
Eating animal foods containing saturated fat is linked to high cholesterol levels and heart disease. Significant amounts of animal-based saturated fat are found in beef, pork, veal, poultry (particularly in poultry skins and dark meat), cheese, butter, ice cream, and all other forms of dairy products not labeled "fat free." Avoiding consumption of these foods reduces cholesterol and has been reported to reverse even existing heart disease.
Unlike other dairy foods, skimmed milk, nonfat yogurt, and nonfat cheese are essentially fat-free. Dairy products labeled "low fat" are not particularly low in fat. A full 25% of calories in 2% milk come from fat. (The "2%" refers to the fraction of volume filled by fat, not the more important percentage of calories coming from fat.)
In addition to large amounts of saturated fat from animal-based foods, Americans eat small amounts of saturated fat from coconut and palm oils. Palm oil has been reported to elevate cholesterol. Research regarding coconut oil is mixed, with some trials finding no link to heart disease, while other research reports that coconut oil elevates cholesterol levels.
Despite the links between saturated fat intake and serum cholesterol levels, not every person responds to appropriate dietary changes with a drop in cholesterol. A subgroup of people with elevated cholesterol who have what researchers call "large LDL particles" has been reported to have no response even to dramatic reductions in dietary fat. (LDL is the "bad" cholesterol most associated with an increased risk of heart disease.) This phenomenon is not understood. People who significantly reduce intake of animal fats for several months but do not see significant a reduction in cholesterol levels should discuss other approaches to lowering cholesterol with a doctor.
Yogurt, acidophilus milk, and kefir are fermented milk products that have been reported to lower cholesterol in most, but not all, double-blind and other controlled research. Until more is known, it makes sense for people with elevated cholesterol who consume these foods, to select nonfat varieties.
While coconut oil is high in saturated fat, some evidence suggests it does not cause unhealthy changes in blood cholesterol levels compared with other saturated fats. In a controlled study of people with high cholesterol, coconut oil resulted in higher total and LDL cholesterol levels compared with safflower oil (a polyunsaturated oil), but lower levels compared with butter, while HDL levels were similar for all three diets. Another controlled study compared coconut oil with canola oil, and found that coconut oil raised total and LDL cholesterol in people with high cholesterol who were not taking cholesterol-lowering drugs, but did not affect these levels in people who were taking these drugs. HDL levels were not reported in this study.fatty acids (TFAs) are found in many processed foods containing partially hydrogenated oils. The highest levels occur in margarine. Margarine consumption is linked to increased risk of unfavorable changes in cholesterol levels and heart disease. Margarine and other processed foods containing partially hydrogenated oils should be avoided.
Trans fatty acids (TFAs) are found in many processed foods containing partially hydrogenated oils. The highest levels occur in margarine. Margarine consumption is linked to increased risk of unfavorable changes in cholesterol levels and heart disease. Margarine and other processed foods containing partially hydrogenated oils should be avoided.
However, special therapeutic margarines are now available that contain substances, called phytostanols, that block the absorption of cholesterol. The FDA has approved some of these margarines as legitimate therapeutic agents for lowering blood cholesterol levels. The best-known of these products is Benecol™. The cholesterol-lowering effect of these margarines has been demonstrated in numerous double-blind and other controlled trials.
Our proprietary "Star-Rating" system was developed to help you easily understand the amount of scientific support behind each supplement in relation to a specific health condition. While there is no way to predict whether a vitamin, mineral, or herb will successfully treat or prevent associated health conditions, our unique ratings tell you how well these supplements are understood by some in the medical community, and whether studies have found them to be effective for other people.
For over a decade, our team has combed through thousands of research articles published in reputable journals. To help you make educated decisions, and to better understand controversial or confusing supplements, our medical experts have digested the science into these three easy-to-follow ratings. We hope this provides you with a helpful resource to make informed decisions towards your health and well-being.
3 StarsReliable and relatively consistent scientific data showing a substantial health benefit.
2 StarsContradictory, insufficient, or preliminary studies suggesting a health benefit or minimal health benefit.
1 StarFor an herb, supported by traditional use but minimal or no scientific evidence. For a supplement, little scientific support.
Chromium supplementation has reduced total cholesterol, LDL cholesterol and increased HDL cholesterol in double-blind and other controlled trials, although other trials have not found these effects. One double-blind trial found that high amounts of chromium (500 mcg per day) in combination with daily exercise was highly effective, producing nearly a 20% decrease in total cholesterol levels in just 13 weeks.
Brewer's yeast, which contains readily absorbable and biologically active chromium, has also lowered serum cholesterol. People with higher blood levels of chromium appear to be at lower risk for heart disease. A reasonable and safe intake of supplemental chromium is 200 mcg per day. People wishing to use brewer's yeast as a source of chromium should look for products specifically labeled "from the brewing process" or "brewer's yeast," since most yeast found in health food stores is not brewer's yeast, and does not contain chromium. Optimally, true brewer's yeast contains up to 60 mcg of chromium per tablespoon, and a reasonable intake is 2 tablespoons per day.
Fenugreek seeds contain compounds known as steroidal saponins that inhibit both cholesterol absorption in the intestines and cholesterol production by the liver. Dietary fiber may also contribute to fenugreek's activity. Multiple human trials (some double-blind) have found that fenugreek may help lower total cholesterol in people with moderate atherosclerosis or those having insulin-dependent or non-insulin-dependent diabetes. One human double-blind trial has also shown that defatted fenugreek seeds may raise levels of beneficial HDL cholesterol. One small preliminary trial found that either 25 or 50 grams per day of defatted fenugreek seed powder significantly lowered serum cholesterol after 20 days. Germination of the fenugreek seeds may improve the soluble fiber content of the seeds, thus improving their effect on cholesterol. Fenugreek powder is generally taken in amounts of 10 to 30 grams three times per day with meals.
Use of psyllium has been extensively studied as a way to reduce cholesterol levels. An analysis of all double-blind trials in 1997 concluded that a daily amount of 10 grams psyllium lowered cholesterol levels by 5% and LDL cholesterol by 9%. Since then, a large controlled trial found that use of 5.1 grams of psyllium two times per day significantly reduced serum cholesterol as well as LDL-cholesterol. Generally, 5 to 10 grams of psyllium are added to the diet per day to lower cholesterol levels. The combination of psyllium and oat bran may also be effective at lowering LDL cholesterol.
Researchers have determined that one of the ingredients in red yeast rice, called monacolin K, inhibits the production of cholesterol by stopping the action of the key enzyme in the liver (HMG-CoA reductase) that is responsible for manufacturing cholesterol. Monacolin K is the same compound as lovastatin (Mevacor), a prescription drug used to treat high cholesterol. However, the amount of monacolin K in red yeast rice is small (5 mg per 2.4 grams of red yeast rice) when compared with the 20 to 40 mg of lovastatin typically used to lower cholesterol levels. It appears that monacolin compounds present in red yeast rice work together with monacolin K to produce a greater cholesterol-lowering effect than would be expected from the small amount of monacolin K alone.
The red yeast rice used in various studies was a proprietary product called Cholestin, which contains ten different monacolins.
Note: Cholestin has been banned in the United States, as a result of a lawsuit alleging patent infringement.
Other red yeast rice products currently on the market differ from Cholestin in their chemical makeup. None contain the full complement of ten monacolin compounds that are present in Cholestin, and some contain a potentially toxic fermentation product called citrinin. Despite these concerns, other red yeast rice products are being widely used and both anecdotal reports and clinical research suggest that they have a similar safety and efficacy profile as that of Cholestin.
A synthetic molecule related to beta-sitosterol, sitostanol, is available in a special margarine and has also been shown to lower cholesterol levels. In one controlled trial, supplementation with 1.7 grams per day of a plant-sterol product containing mostly sitostanol, combined with dietary changes, led to a dramatic 24% drop in LDL ("bad") cholesterol compared with only a 9% decrease in the diet-only part of the trial.Other controlled and double-blind trials have confirmed these results. A review of double-blind trials on sitostanol found that a reduction in the risk of heart disease of about 25% may be expected from use of sitostanol-containing spreads, a larger clinical effect than that produced by people reducing their saturated fat intake. Supplementation with sitostanol in the amount of 1.8 grams per day for six weeks has also been shown to enhance the cholesterol-lowering effect of statin drugs.
Soy supplementation has been shown to lower cholesterol in humans. Soy is available in foods such as tofu, miso, and tempeh and as a supplemental protein powder. Soy contains isoflavones, naturally occurring plant components that are believed to be soy's main cholesterol-lowering ingredients. A controlled trial showed that soy preparations containing high amounts of isoflavones effectively lowered total cholesterol and LDL ("bad") cholesterol, whereas low-isoflavone preparations (less than 27 mg per day) did not. However, supplementation with either soy or non-soy isoflavones (from red clover) in pill form failed to reduce cholesterol levels in a group of healthy volunteers, suggesting that isoflavone may not be responsible for the cholesterol-lowering effects of soy. Further trials of isoflavone supplements in people with elevated cholesterol, are needed to resolve these conflicting results. In a study of people with high cholesterol levels, a soy preparation that contained soy protein, soy fiber, and soy phospholipids lowered cholesterol levels more effectively than isolated soy protein.
High amounts (several grams per day) of niacin, a form of vitamin B3, lower cholesterol, an effect recognized in the approval of niacin as a prescription medication for high cholesterol. The other common form of vitamin B3—niacinamide—does not affect cholesterol levels. Some niacin preparations have raised HDL cholesterol better than certain prescription drugs. Some cardiologists prescribe 3 grams of niacin per day or even higher amounts for people with high cholesterol levels. At such intakes, acute symptoms (flushing, headache, stomachache) and chronic symptoms (liver damage, diabetes, gastritis, eye damage, possibly gout) of toxicity may be severe. Many people are not able to continue taking these levels of niacin due to discomfort or danger to their health. Therefore, high intakes of niacin must only be taken under the supervision of a doctor.
Symptoms caused by niacin supplements, such as flushing, have been reduced with sustained-release (also called "time-release") niacin products. However, sustained-release forms of niacin have caused significant liver toxicity and, though rarely, liver failure. One partial time-release (intermediate-release) niacin product has lowered LDL cholesterol and raised HDL cholesterol without flushing, and it also has acted without the liver function abnormalities typically associated with sustained-release niacin formulations. However, this form of niacin is available by prescription only.
Artichoke has moderately lowered cholesterol and triglycerides in some, but not all, human trials. One double-blind trial found that 900 mg of artichoke extract per day significantly lowered serum cholesterol and LDL cholesterol but did not decrease triglycerides or raise HDL cholesterol. However, in another double-blind trial, supplementation with an artichoke extract significantly increased HDL cholesterol. Cholesterol-lowering effects occurred when using 320 mg of standardized leaf extract taken two to three times per day for at least six weeks.
Berberine, a compound found in certain herbs such as goldenseal, barberry, and Oregon grape, has been found to lower serum cholesterol levels. In a study of people with high cholesterol levels, 500 mg of berberine taken twice a day for three months lowered the average cholesterol level by 29%. No significant side effects were reported, except for mild constipation.
Caution: Calcium supplements should be avoided by prostate cancer patients.
Some preliminary and double-blind trials have shown that supplemental calcium reduces cholesterol levels. Possibly the calcium is binding with and preventing the absorption of dietary fat. However, other research has found no substantial or statistically significant effects of calcium supplementation on total cholesterol or HDL ("good") cholesterol. Reasonable supplemental levels are 800 to 1,000 mg per day.
In a double-blind trial, supplementation with a cranberry extract (500 mg three times per day after meals) for 12 weeks significantly lowered serum total cholesterol and LDL cholesterol levels compared with placebo in patients with type 2 diabetes who were taking oral hypoglycemic medication.
Green tea has been shown to lower total cholesterol and LDL cholesterol levels according to several preliminary and controlled trials. However, not all trials have found that green tea intake lowers lipid levels. Much of the research documenting the health benefits of green tea is based on the amount of green tea typically drunk in Asian countries—about three cups per day, providing 240 to 320 mg of polyphenols.
Tocotrienols, a group of food-derived compounds that resemble vitamin E, may lower blood levels of cholesterol, but evidence is conflicting. Although tocotrienols inhibited cholesterol synthesis in test-tube studies, human trials have produced contradictory results. Two double-blind trials found that 200 mg per day of either gamma-tocotrienol or total tocotrienols were more effective than placebo, reducing cholesterol levels by 13–15%. However, in another double-blind trial, 200 mg of tocotrienols per day failed to lower cholesterol levels, and a fourth double-blind trial found 140 mg of tocotrienols and 80 mg of vitamin E (d-alpha-tocopherol) daily resulted in no changes in total cholesterol, LDL cholesterol, or HDL cholesterol levels.
Animal studies indicate that saponins in alfalfa seeds may block absorption of cholesterol and prevent the formation of atherosclerotic plaques. However, consuming the large amounts of alfalfa seeds (80 to 120 grams per day) needed to supply high doses of these saponins may potentially cause damage to red blood cells in the body.
The fiber-like supplement chitosan appears to reduce the absorption of bile acids or cholesterol; either of these effects may cause a lowering of blood cholesterol. This effect has been repeatedly demonstrated in animals, and a preliminary human study showed that 3 to 6 grams per day of chitosan taken for two weeks resulted in a 6% drop in cholesterol and a 10% increase in HDL ("good") cholesterol. Another preliminary trial showed a 43% lowering of total cholesterol in people being treated for kidney failure with dialysis who took 4 grams per day of chitosan for 12 weeks. These people also appeared to have improved kidney function and less severe anemia after chitosan treatment. In a double-blind trial, however, administration of 2.4 grams of chitosan per day for three months to people with high cholesterol had no effect on their cholesterol levels. Another study also found no cholesterol-lowering effect of chitosan when taken in amounts up to 6.75 grams per day for 8 weeks.
Chitosan in large amounts, given with vitamin C, has been shown to reduce dietary fat absorption in animals fed a high-fat diet. However, the absorption of minerals and fat-soluble vitamins was also reduced by feeding animals large amounts of chitosan. In studies in humans, chitosan did not reduce the absorption of dietary fat.
Preliminary Chinese research has found that high doses (12 grams per day) of the herb fo-ti may lower cholesterol levels. Double-blind or other controlled trials are needed to determine fo-ti's use in lowering cholesterol. A tea may be made from processed roots by boiling 3 to 5 grams in a cup of water for 10 to 15 minutes. Three or more cups should be drunk each day. Fo-ti tablets containing 500 mg each are also available. Doctors may suggest taking five of these tablets three times per day.
Wild yam has been reported to raise HDL cholesterol in preliminary research. Doctors sometimes recommend 2 to 3 ml of tincture taken three to four times per day, or 1 to 2 capsules or tablets of dried root taken three times per day.
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4. Pekkanen J, Marti B, Nissinen A, Tuomilehto J. Reduction of premature mortality by high physical activity: a 20-year follow-up of middle-aged Finnish men. Lancet 1987;1:1473-7.
5. Willich SN, Lewis M, Lowel H, et al. Physical exertion as a trigger of acute myocardial infarction. Triggers and Mechanisms of Myocardial Infarction Study Group. N Engl J Med 1993;329:1684-90.
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9. Wood PD, Stefanick ML, Dreon DM, et al. Changes in plasma lipids and lipoproteins in overweight men during weight loss through dieting as compared with exercise. N Engl J Med 1988;319:1173-9.
10. Dwyer JH, Rieger-Ndakorerwa GE, Semmer NK, et al. Low-level cigarette smoking and longitudinal change in serum cholesterol among adolescents. JAMA 1988;2857-62.
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Last Review: 06-08-2015
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