Cholesterol is a fatty substance that circulates in the blood. Most of the cholesterol in the body is produced by the liver with levels influenced by various factors, including genetics, diet, age, physical activity, and other elements. Managing cholesterol levels may involve dietary changes, lifestyle adjustments, medication, or a combination of these approaches. Despite its negative reputation, cholesterol isn’t entirely bad for you. It is essential for producing vitamin D and hormones such as oestrogen, progesterone and cortisol as well as substances that help in digestion. However, excessive cholesterol can accumulate in your arteries, increasing the risk of heart attack or stroke. Whether it benefits or harms your health depends on the type and amount in your body. This article aims to explain the role of cholesterol and how certain dietary and lifestyle changes can impact cholesterol levels.

Here is what is covered:

• Clinical Measurements
• Adopt a heart-healthy diet/supplement consideration
• Maintain a healthy weight
• Regular Exercise
• Avoid Smoking and Limit Alcohol
• Consider medications if necessary
• Key Points

Clinical Measurements

Markers routinely used to measure cholesterol levels with a blood test in general practice include the following:

Total Cholesterol (TC): Total cholesterol content within the three major lipoproteins; HDL, LDL and Very Low-Density Lipoprotein (VLDL – carries triglycerides).

Low-density lipoprotein cholesterol (LDL-C): High levels can lead to blocked arteries and is often referred to as ‘’bad’’ cholesterol.

High-density lipoprotein cholesterol (HDL-C): Considered ‘’good’’ cholesterol as it removes excess cholesterol from arteries.

Triglycerides (TG): The main form of fat ingested through the diet.

Non-HDL Cholesterol: TC minus HDL-C

Elevated total cholesterol (TC) and high levels of LDL-C in the blood are considered primary factors contributing to atherosclerosis (plaque build-up) and coronary artery disease. Consequently, statins are prescribed to lower TC and LDL-C, aiming to reduce the risk of cardiovascular disease (CVD).

Further tests to support the assessment of cardio-metabolic health status and/or the risk of developing CVD, beyond the standard LDL cholesterol measurement include advanced lipid profile testing focused on cholesterol particle concentrations and size. Growing evidence suggests that the size and quantity of LDL particles is important to test. Small dense LDL particles are considered more atherogenic (plaque forming) as they can more easily penetrate the arterial wall while large buoyant LDL particles are generally considered less harmful because they are less likely to penetrate the arterial walls (1).

One of the hidden risk factors for CVD are elevated levels of Lipoprotein(a), often abbreviated as Lp(a). Lp(a) is a type of lipoprotein that carries cholesterol and are considered a genetic risk factor for CVD as it can contribute to plaque build-up in the arteries. Unlike LDL, Lp(a) levels are largely determined by genetics and are less responsive to lifestyle changes or medications commonly used to lower LDL cholesterol, such as statins (2).

Advanced testing for LDL particle size and/or Lp(a) amongst others can help in better assessing cardiovascular risk and tailoring more effective treatment strategies. This can be particularly useful for individuals who have normal LDL cholesterol levels but still have other risk factors for heart disease or individuals with familial hypercholesterolaemia.

Emerging evidence focuses on Apolipoprotein B (ApoB) – a protein found in LDL and other atherogenic lipoproteins that contribute to cardiovascular disease. Unlike LDL-C, which estimates cholesterol concentration, ApoB provides a direct count of all potentially harmful particles, making it a valuable marker for assessing cardiovascular risk. Since each LDL particle contains one ApoB molecule, its measurement can offer a clearer picture of plaque build-up risk. While not yet a standard test, ApoB may complement traditional lipid panels and help guide more personalised treatment strategies (3) (4).

Dietary and Lifestyle Adjustments for Lowering Cholesterol.

Scientific evidence indicates that dietary changes have potential to improve LDL cholesterol levels. However, the effectiveness of these dietary interventions can vary among individuals. While some people may see significant improvements through diet and lifestyle adjustments alone, others might need a combination of dietary changes and medication to achieve optimal results.

Some of the evidenced dietary measures include:

A. Increase Soluble Fibre Intake

Fibre can be soluble or insoluble. Soluble fibre is a form of fibre that absorbs water to form a gel-like substance. While it is important to include both forms in the diet, soluble fibre can help lower cholesterol by reducing the absorption of LDL in the bloodstream (5) (6) (7) (8).

• Foods rich in soluble fibre include oats, legumes (beans, peas, lentils), fruits (berries, apples, pears, oranges), vegetables (carrots, broccoli, brussels sprouts, onions) and flaxseed.

• Consuming 5-10 grams of soluble fibre daily can lower LDL cholesterol by about 5% e.g. one serving of oats provides 3-4 grams of fibre and adding fruit such as berries will add even more fibre (9).

B. Incorporate Healthy Fats

• Replace saturated fats (primarily found in meat, cheese, butter, cakes, biscuits) with unsaturated fats.
• Sources of unsaturated/healthy fats: Olive oil, avocados, nuts (monounsaturated fats), and fatty fish – salmon, mackerel, anchovies, sardines, herring (polyunsaturated fats) are linked to lower cardiovascular risk (10).
• Omega-3 fatty acids from fish oil have been shown to lower triglycerides and slightly increase HDL cholesterol (11) (12) (13).

C. Reduce Dietary Cholesterol

Reducing dietary cholesterol can help lower blood cholesterol levels for some people, but the relationship between dietary cholesterol and blood cholesterol is complex and varies among individuals.

• Some individuals experience significant increases in blood cholesterol levels when they consume more dietary cholesterol (e.g. eggs, animal products) while others show minimal or no change in blood cholesterol levels. For many years, dietary guidelines recommended limiting dietary cholesterol intake to reduce the risk of heart disease.
• More recent guidelines emphasise the importance of overall dietary patterns rather than isolating specific nutrients like cholesterol as well as overall lifestyle factors like physical activity and weight management.
• Regular monitoring of blood cholesterol levels can help determine the impact of dietary changes and guide adjustments as needed.
• Foods high in cholesterol include red meat, shrimp, full-fat dairy, baked goods, and egg yolks. However, it is thought that saturated fat in these foods, rather than dietary cholesterol, has a greater impact on cholesterol levels except in the case of eggs and shrimp where their consumption on blood cholesterol is minimal (14) (15).

D. Eat Plant Sterols and Stanols

Plant sterols and plant stanols are naturally occurring compounds found in small amounts in various plant-based foods such as fruits, vegetables, nuts, seeds, cereals, legumes, and vegetable oils.

• They are structurally like cholesterol and are known for their cholesterol-lowering properties.
• They are often added to foods such as margarine, orange juice, and yoghurt.
• Both plant sterols and stanols have been shown to lower LDL cholesterol by blocking the absorption of cholesterol in the intestines.
• Several studies have demonstrated that consuming about 2 grams of plant sterols or stanols per day can lower LDL cholesterol by about 10%. This amount is difficult to achieve through diet alone, which is why fortified foods and supplements are often recommended (16) (17) (18) (19).

Supplement Considerations

• Omega 3: Lower triglycerides and may slightly increase HDL cholesterol.
• Plant sterols: Block cholesterol absorption in the intestines, reducing LDL levels.
• Psyllium soluble fibre: Binds cholesterol in the gut, lowering LDL cholesterol (20).
• Coenzyme Q10: May improve lipid profiles and support heart health, particularly for those on statins (21).
• Phosphatidylcholine (Lecithin): Helps emulsify fats, potentially reducing cholesterol absorption (22).

Weight loss can have a significant positive impact on cholesterol levels, particularly on lowering LDL cholesterol and triglycerides, while potentially increasing HDL cholesterol.

• Weight loss helps decrease the amount of fat, particularly visceral fat, which is closely linked to higher LDL cholesterol levels.
• Weight loss improves insulin sensitivity and reduces inflammation in the body both of which are linked to improved lipid profiles.
• Studies have shown that losing even a small percentage of body weight (5-10%) can help lower LDL cholesterol levels (23).

Aerobic exercises (e.g., walking, running, cycling, swimming) are particularly effective in raising HDL cholesterol and lowering LDL cholesterol and triglycerides (24).

• Recommendations: at least 150 minutes of moderate aerobic exercise or 75 minutes of vigorous exercise per week.

   A. Quitting smoking initiates a series of positive changes in the body that collectively improve cholesterol levels:

• Improves HDL cholesterol levels (25).
• Reduces oxidative stress, thereby decreasing the likelihood of LDL oxidation (26).
• Help lower triglyceride levels (27).
• May allow the endothelium (inner lining of blood vessels) to heal, improving its function and reducing the risk of cholesterol build up (28).
• Quitting smoking reduces inflammation, contributing to better cholesterol management (26).

      b. Alcohol Consumption

• Moderate alcohol consumption has been linked to increased HDL (“good”) cholesterol and potential heart benefits. However, excessive drinking raises the risk of high blood pressure, heart disease, and elevated triglycerides. In many cases, the risks outweigh the benefits, making moderation and a balanced lifestyle the best choices for heart health (29) (30).
• Recent research also challenges the idea of a “safe” alcohol dose, suggesting that any alcohol consumption may be associated with increased cardiovascular risks (31) (32).

When dietary and lifestyle changes are not enough, medications including statins or other cholesterol-lowering medications can be effective.

• Consult with a healthcare provider for personalised advice.

Key Points

1. Understanding Cholesterol

• Cholesterol is essential for hormone production, digestion, and vitamin D synthesis, but excessive levels can increase cardiovascular risks.
• Different cholesterol types: LDL (“bad”), HDL (“good”), total cholesterol, and triglycerides, with advanced testing for LDL particle size, Lipoprotein(a), and ApoB can provide a deeper risk assessment.

2. Adopt a Heart-Healthy Diet

• Increase Soluble Fibre: Foods like oats, legumes, fruits, and vegetables reduce LDL absorption.
• Incorporate Healthy Fats: Replace saturated fats with unsaturated sources like olive oil, avocados, nuts, and fatty fish.
• Dietary Cholesterol: Focus on overall dietary patterns rather than isolating cholesterol-rich foods.
• Plant Sterols and Stanols: Found in fortified foods or supplements, these can lower LDL by blocking cholesterol absorption.

3. Maintain a Healthy Weight

• Weight loss lowers LDL and triglycerides while boosting HDL.
• Even a 5-10% reduction in body weight improves lipid profiles and reduces inflammation.

3. Exercise Regularly

• Aerobic activities like walking or swimming enhance HDL and reduce LDL and triglycerides.
• Aim for 150 minutes of moderate or 75 minutes of vigorous exercise weekly.

4. Avoid Smoking and Limit Alcohol

• Quitting smoking boosts HDL, reduces LDL oxidation, and heals blood vessels.
• Moderate alcohol (1 drink/day for women, 2 for men) may raise HDL but should be approached cautiously.

5. Consider Medications if Necessary

• Statins and other medications may be needed for individuals who don’t respond sufficiently to diet and lifestyle changes.
• Consult a healthcare provider for personalised guidance.

By incorporating these strategies, you may effectively manage cholesterol levels and reduce cardiovascular risks. It is important to consult with a healthcare provider before starting any new supplement, especially for those with existing health conditions or are taking medications as well as regular check-ups to monitor cholesterol levels.

References

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