What can I do to lower my cholesterol without medicine?

Hyperlipidemia or dyslipidemia, colloquially known as high cholesterol, is characterized by high blood serum levels of low-density lipoprotein (LDL) and triglycerides (TG) and low levels of high-density lipoprotein (HDL).¹ Clinical practice guidelines recommend maintaining a heart-healthy lifestyle, including a healthy diet, weight control, and adequate levels of physical activity.^1-3

Diet

The 2018 American College of Cardiology and American Heart Association (ACC/AHA) guidelines for the management of cholesterol recommend emphasizing intake of fruits, vegetables, whole grains, legumes, low-fat dairy products, low-fat poultry without the skin, fish, seafood, nuts, and nontropical vegetable oils.¹ They further recommend limiting intake of sweets, sugar-sweetened beverages, and red meats. Guidelines advise that dietary patterns should be adjusted for personal and cultural preferences. Consideration should be made for comorbidities and any potential dietary or nutritional recommendations surrounding those comorbidities, such as diabetes or hypertension. 

European Society of Cardiology and the European Atherosclerosis Society (ESC/EAS) guidelines similarly recommend a diet rich in varying fruits and vegetables, whole grains, legumes including soy and soy protein, lean meats, and low-fat dairy.² The guidelines further recommend eating at least 2-3 servings of fish per week along with other sources of omega-3 polyunsaturated fatty acids (n-3 PUFAs) such as nuts and soy. They also emphasize preparing food by grilling, boiling, or steaming and avoiding frying foods.

ESC/EAS include more specific guidance on dietary recommendations to reduce total cholesterol and LDL levels, including reducing dietary saturated fat (recommended levels are <10% of total caloric intake), reducing trans fat, and increasing soluble fiber (recommended daily intake of 5-15 g).² Similarly, the National Lipid Association guidelines recommend that saturated fat intake be no more than 7% of total energy consumption.³ Dietary saturated fatty acids have the strongest impact on LDL with an increase of 0.8-1.6 mg/dL (0.02-0.04 mmol) for every additional 1% of energy coming from saturated fat.⁴

Soy protein can also modestly reduce LDL in those with hyperlipidemia, with greater benefits for those with higher levels of plasma cholesterol, with a reduction of about 10 mg/dL (0.3 mmol/L) for total cholesterol (TC) levels of 200-260 mg/dL (5.2-6.7 mmol/L), about 20 mg/dL (0.5 mmol/L) for TC 269-335 mg/dL (6.7-8.7 mmol/L), and about 68 mg/dL (1.8 mmol/L) for TC >335 mg/dL (>8.7 mmol/L).⁵

ESC/EAS guidelines also note that phytosterols, naturally occurring plant compounds found in vegetables, fruit, some nuts, grains, and legumes, can help reduce TC levels while not affecting TG levels.² However, there is currently no literature supporting that increased consumption of phytosterols reduces the risk of ASCVD.

There is observational evidence that fish oil and omega-3 fatty acids may reduce TG levels, but doses >3 g per day may increase LDL.⁶ Guidelines advise that there isn’t enough evidence available to recommend a certain level of fish oil or omega-3 fatty acid consumption.²

Weight Management

Guidelines also recommend that those with hyperlipidemia maintain a healthy body mass index.^1-3 Dietary recommendations include adjusting caloric intake to avoid weight gain. For patients who are overweight or who have obesity, guidelines recommend weight loss of 5-10% of overall body weight. For these patients, dietary recommendations include appropriate caloric intake to promote weight loss. Physical activity recommendations further promote weight loss for patients who are overweight or who have obesity.

While weight management is effective for increasing HDL levels, the effect of weight reduction on TC and LDL is relatively modest. A 2002 study finding that HDL increased by about 0.4 mg/dL (0.01 mmol/L) for every 2.2 lbs (1 kg) lost.⁷ However, a 1992 meta-analysis  found that in morbidly obese patients, LDL decreased by about 8 mg/dL (0.2 mmol/L) for every 22 pounds (10 kg) of weight loss.⁸

Physical Activity

ESC/EAS guidelines advise that increasing physical activity can reduce total cholesterol and LDL while increasing HDL.² ACC/AHA guidelines recommend that otherwise healthy adults with hyperlipidemia engage in 3-4 sessions of moderate to vigorous intensity aerobic physical activity per week lasting on average 40 minutes per session.¹ Similarly, National Lipid Association guidelines recommend ≥150 minutes per week of moderate or high intensity physical activity.³

While physical activity is broadly recommended to reduce the risk of heart disease, it is not as effective as diet for the management of cholesterol. A 2006 Cochrane review examined the effect of exercise on a variety of cardiovascular health markers, finding that exercise decreased TG (0.18 mmol/L, p=0.01) and increased HDL (0.06 mmol/L, p<0.0001). In a head-to-head analysis with diet, there was no significant difference between exercise and diet for TG and HDL. However, diet alone was significantly more effective for reducing TC (0.22 mmol/L, p=0). Comparing diet and exercise to diet alone, there was no significant difference for any of the measured cholesterol markers, indicating that the addition of exercise did not make a measurable impact on cholesterol levels.

References

1. Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. Jun 25 2019;73(24):e285-e350. doi:10.1016/j.jacc.2018.11.003
2. Reiner Z, Catapano AL, De Backer G, et al. ESC/EAS Guidelines for the management of dyslipidaemias: the Task Force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS). Eur Heart J. Jul 2011;32(14):1769-818. doi:10.1093/eurheartj/ehr158
3. Jacobson TA, Ito MK, Maki KC, et al. National lipid association recommendations for patient-centered management of dyslipidemia: part 1--full report. J Clin Lipidol. Mar-Apr 2015;9(2):129-69. doi:10.1016/j.jacl.2015.02.003
4. Mensink RP, Zock PL, Kester AD, Katan MB. Effects of dietary fatty acids and carbohydrates on the ratio of serum total to HDL cholesterol and on serum lipids and apolipoproteins: a meta-analysis of 60 controlled trials. Am J Clin Nutr. May 2003;77(5):1146-55. doi:10.1093/ajcn/77.5.1146
5. Dewell A, Hollenbeck PL, Hollenbeck CB. Clinical review: a critical evaluation of the role of soy protein and isoflavone supplementation in the control of plasma cholesterol concentrations. J Clin Endocrinol Metab. Mar 2006;91(3):772-80. doi:10.1210/jc.2004-2350
6. Harris WS, Mozaffarian D, Rimm E, et al. Omega-6 fatty acids and risk for cardiovascular disease: a science advisory from the American Heart Association Nutrition Subcommittee of the Council on Nutrition, Physical Activity, and Metabolism; Council on Cardiovascular Nursing; and Council on Epidemiology and Prevention. Circulation. Feb 17 2009;119(6):902-7. doi:10.1161/circulationaha.108.191627
7. Kraus WE, Houmard JA, Duscha BD, et al. Effects of the amount and intensity of exercise on plasma lipoproteins. N Engl J Med. Nov 7 2002;347(19):1483-92. doi:10.1056/NEJMoa020194
8. Dattilo AM, Kris-Etherton PM. Effects of weight reduction on blood lipids and lipoproteins: a meta-analysis. Am J Clin Nutr. Aug 1992;56(2):320-8. doi:10.1093/ajcn/56.2.320