Heart disease remains the number one cause of death in the United States. Having high cholesterol, specifically, high LDL cholesterol or “bad” cholesterol, has been linked to an increased risk of having a heart attack. According to the CDC, almost 37% of Americans have high LDL cholesterol, putting all of these people at a higher risk for a heart attack or stroke (1). Due to this risk, it is important to know your cholesterol levels and what to do when LDL is too high.
Cholesterol is strongly controlled by your genetics; some people are predisposed to high levels. However, diet and lifestyle choices play huge roles. Before diving into a diet for managing high cholesterol, start by understanding cholesterol and its role in the body.
High Cholesterol Explained
Cholesterol (a waxy-substance produced by the body used to make hormones) helps transport and digest fat. The liver produces all the cholesterol the body needs because the body needs it to survive. We do not need to eat any cholesterol from our diets to have the cholesterol our bodies need. Despite what you hear, it is not a necessary nutrient to eat, but it’s necessary to the body, and cell walls. Since the liver makes cholesterol, the only foods that contain it are those with livers. So, mostly just animal foods.
Noticing High Cholesterol
Those with high cholesterol don’t feel different. Unless you get a blood test, you won’t know if your cholesterol is high (it’s symptom-free). Because of the connection between heart disease and cholesterol, doctors always want to check it. The American Heart Association recommends that everyone over the age of 20 get their cholesterol checked every four to six years, and more often over the age of 45 or at risk for heart disease (2).
These are the conventional stats on cholesterol (3):
Total Cholesterol: Less than 200 mg/dL.
This number alone tells us very little. Interestingly, the lipid panel test doesn’t measure cholesterol directly. It measures cholesterol lipoproteins, little pockets of fat and protein that carry cholesterol inside. The total cholesterol value includes all the types of lipoproteins in the body (LDL, HDL, and VLDL). On its own, this doesn’t mean much. The quantity of each lipoprotein matters more to determine your risk for heart disease. So, don’t freak out about high numbers until you know the types and sizes of those lipoproteins.
Low-density lipoprotein (LDL or “bad” cholesterol): Less than 100 mg/dL.
This is the type of cholesterol that forms plaques in the artery walls, blocking the flow of blood, and increases your risk for heart disease or stroke. Again, this value alone is not very helpful. You need to know if the LDL particles are small and sticky (increased cardiac risk) or large and fluffy (protective). Additionally, you need to know how many of these small or large particles float around. This information is NOT available in a standard LDL test. You need to ask for more (see a recommended list below).
LDL Particle size: The size of the LDL particle seems to impact the risk of heart attack. People with small, dense LDL are at higher risk than those with large, fluffy LDL. The denser LDL particles tend to be stickier, lining the artery walls and possibly causing blockages (4). This test is not usually included in a standard cholesterol check, so you may want to ask your doctor for it specifically. We’ve provided a list to help you.
High-density lipoprotein (HDL or “good” cholesterol): Greater than 60 mg/dL. This is the type of cholesterol that helps clean up the LDL particles stuck to the artery walls, lowering your risk for heart disease. As with LDL, getting information on HDL size and number proves valuable. Large, fluffy HDL protects against the small, dense LDL. You want a good balance
Triglycerides: Less than 150 mg/dL.
Triglycerides are the type of fat most commonly found in the blood. The triglyceride molecule is made up of three fats (tri-) attached to a glycerol (sugar). Triglycerides are not the same as cholesterol, but are included in the lipid panel and indicate a greater risk of heart disease.
If you do have high cholesterol, this does not mean you will definitely have a heart attack. It is just a warning sign of higher risk. Discuss your results with your doctor! Usually, first-line treatment for high cholesterol is a class of medications called statins. Doctors recommend these because they do work quickly. However, many people experience side effects with statin medications, so discuss risks with your doctor.
If you want to try a natural approach to lowering your cholesterol first, start with diet and exercise. (More on that below!).
Lipoprotein (a) Lipoprotein (a) is a type of lipoprotein that carries cholesterol. It’s somewhat similar to LDL but is not routinely checked in a cholesterol panel. This marker has a large genetic component but can be reduced with a specific B vitamin, niacin.
Lipoprotein-associated phospholipase A2 (Lp-PLA2) Lp-PLA2: an enzyme that plays a role in inflammation to the blood vessels. It’s an independent marker for cardiovascular disease and strokes. Again, not added to most blood panels with cholesterol!
Recommended Cardiac and Cholesterol Labs
- Total Cholesterol
- HDL Cholesterol
- LDL Cholesterol
- Lipoprotein Particle Numbers
- Lipoprotein (a)
- Apolipoprotein A-1
- Apolipoprotein B
- Insulin, fasting
- (combined test: NMR Lipo-Profile)
- Genetics: APOE, PPAR-gamma
- Other recommended labs
A Diet to Lower Cholesterol
INFLAMMATION: Decrease inflammation through diet! High cholesterol is strongly correlated to chronic inflammation in the body (5). Inflammation is like getting injured over and over again, all the time. The result is the formation of free radicals which damage the cells of the body, and increase the risk of heart attacks and other diseases. Therefore, adopt an anti-inflammatory diet to reduce overall inflammation and lower cholesterol levels.
HIGH FIBER FOODS: Fiber works in two ways to help lower cholesterol. First, it traps fat and cholesterol in the digestive tract, preventing it from being absorbed into the blood stream. This keeps cholesterol levels stable. It also traps bile, a substance made from cholesterol used to digest fats. This forces your body use up any excess cholesterol made by the liver. Soluble fiber in particular has been shown to lower LDL cholesterol (6). Foods high in soluble fiber include: oats, beans, lentils, fruits and vegetables.
- Fruits and Vegetables
Almost all fruits and vegetables are both anti-inflammatory and high in fiber. Those that contain flavonoids, powerful antioxidants, protect against heart disease (7). Fruits and veggies high in flavonoids include: berries, apples, herbs, and citrus fruits. Of course, there is no need to limit yourself to only these fruits and vegetables. Be sure to eat vegetables, not just fruit. Yes, fruit contains antioxidants, but it also has more calories and sugar than vegetables, so just watch your portions.
- Fish and other foods high in polyunsaturated omega-3 fats
Omega-3 fats are highly anti-inflammatory and help lower triglyceride levels, but the effect the have on cholesterol levels remains unclear (8,9). Foods high in omega-3s include: fatty fish, flaxseeds, chia, and walnuts. There are also fish oil supplements available but quality is essential here.
- Monounsaturated fats
These include types of plant-based fats like olive oil, avocados, and nuts. Monounsaturated fats help maintain HDL or “good” cholesterol keeping it at a protective level. They simultaneously lower LDL cholesterol, reducing overall risk of disease (10, 11).
Foods to Avoid
Many people start out a low cholesterol diet by eliminating foods that contain cholesterol or animal foods. Ironically, strict avoidance of dietary cholesterol in order to lower your cholesterol isn’t necessary. The liver makes all the cholesterol found in your blood, so, eating additional cholesterol from your diet doesn’t change your blood cholesterol levels that much. The US Dietary Guidelines actually eliminated the cholesterol restriction in their 2015 recommendations because research deemed it unnecessary to maintain that restriction (12).
In addition to including certain foods in your diet, avoid other foods that raise inflammation and cholesterol levels. Some of those foods include:
Trans fats, also referred to as hydrogenated fats, are a man-made fat designed to prevent food from becoming rancid. These fats were developed to help food remain shelf-stable for longer. These fats don’t occur in nature, so once they enter the body, they wreak havoc. They increase inflammation, raise LDL, lower HDL, and increase the risk of heart disease. Trans fats have also been repeatedly connected to several diseases, including diabetes (13).
How to eliminate them
In order to get rid of trans fats, become a careful label reader. Trans fats are found in many packaged, processed foods and in some margarines. Worth noting, the current nutrition facts panel allows companies to say a food has “0 grams trans fat” if the food contains anything less than 0.5 grams per serving. So, even if the food says zero grams, you have to take your label sleuthing one step further and look at the ingredient list. If you see the words “partially hydrogenated,” this means the food contains some trans fats.
Refined carbohydrates and sugar
A diet high in refined carbohydrates and sugar increases inflammation, raises LDL cholesterol and triglycerides, and decreases good, HDL cholesterol (14, 15).
Foods that contain refined carbohydrates include: white bread, pasta, rice, pastries, etc. Foods with sugar to limit include: ice cream, baked goods, and sweetened beverages. Although you don’t need to eliminate these foods completely, the more you cut back, the faster your numbers improve.
The research on alcohol, cholesterol, and risk for heart disease is also mixed. Some studies find that moderate alcohol consumption lowers the risk of heart disease and raises good, HDL cholesterol (16). But, alcohol is an inflammatory substance and raises triglycerides when consumed in high amounts (17).
So, what should you do if you have high cholesterol? Can you drink alcohol? Based on current evidence, we recommend drinking in moderation. No more than one drink per day for women and two for men. Choose drinks that are high in antioxidants, like dark beers and red wine. If you must do a cocktail, select a low or no-calorie mixer, such as seltzer water. Also, remember alcohol is high in calories that add up really quickly, which leads to weight gain.
Saturated fat is a type of fat found mostly in animal foods, and a few plant foods, like coconut oil. Over the last 30-40 years, almost all dietary recommendations to help lower cholesterol have included information on the necessity of decreasing saturated fat intake. The problem is that the research on saturated fat and heart disease over the same time period has not fully supported this recommendation.
Research doesn’t find a strong connection between increased saturated fat intake and heart disease (16). Lowering saturated fat in the diet appears to lower cholesterol, but ONLY if the saturated fat is replaced by mono- or polyunsaturated fats. If the saturated fat comes from carbohydrates, then cholesterol levels actually go up (17). One study found that adding coconut oil, a plant-based saturated fat, did not increase cholesterol levels at all. Plus, it helped decrease abdominal obesity in women (18).
So, what do you do about saturated fat? Eat it or not?
Understand your individuality. Varies genetic factors, like having the APOE 4 gene and/or PPAR- gamma, affect your numbers. Individuals with those genes (or SNPs in those genes) may do best with a lower saturated fat diet because they are higher absorbers. Now, research is still unclear on whether or not that’s a bad thing. It’s possible they may be increasing those large fluffy cholesterol and actually creating a protective mechanism.
Those with genetic SNPs, based on current research, do best focusing on eating more heart-healthy omega-3s and monounsaturated fats. Due to mixed data, consume in moderation instead of eliminating saturated fat completely.
Do initial labs and monitor every 4-6 months while tweaking your diet and saturated fat intake.
What exactly do you eat to lower your cholesterol?
- Eat real, whole food. These foods do not contain trans fats or added sugar, making it easy to eliminate those cholesterol-raising components right off the bat. To learn more about how to implement a real food lifestyle for you, check out the 131 Method.
- Avoid processed and packaged foods. If a food lists “high fructose corn syrup” or “partially hydrogenated,” it contains trans fats or sugars. We want to minimize these highly inflammatory foods. If the ingredient list is long and full of unpronounceable words, stay away!
- Limit sugar and sweetened beverages.
- Drink alcohol in moderation.
Seems pretty simple right? This type of diet requires some mindset shifts and lifestyle changes for most people.
So, let’s talk about how to make it work…
Low Cholesterol Diet
- The first step to any diet change is to take a long, hard look at your diet and get real with yourself. Long-term diet changes require some degree of lifestyle change. To make it stick, you must evaluate your patterns, habits, people around you, and other situations contrary to your health goals.
- Take the above recommendations and figure out what to eat based on foods you actually like. A diet filled with foods you hate isn’t sustainable. So, make a list of fruits, veggies and other healthy foods you like and base your diet around those foods. Also, get rid of any “tempting” foods not on your plan. If the foods are in the pantry, you are more likely to eat them.
- Lastly, grocery shop and plan meals ahead. In order to stick to any meal plan you need the right foods available when hunger strikes (or you might end up at the drive thru). Set aside a few hours on the weekend to plan and get the foods you need to set yourself up for success during the week. These changes might be hard at first, but if you stick with them for 14-21 days, the changes become easier.
Lifestyle Changes to Naturally Lower Cholesterol
Although diet impacts cholesterol levels, other lifestyle changes also help lower cholesterol naturally.
- Exercise raises HDL cholesterol and strengthens the heart. Exercise reduces levels of inflammation, stress, helps you sleep better, and aids in weight control. Find some type of exercise you enjoy and do it every day. Go for a walk, roller skate, lift weights, dance around your living room. Whatever you do make it fun so you keep doing it!
- Manage stress. High stress and high cholesterol go together like PB&J. Cholesterol in the adrenal glands makes stress hormones. Additionally, free radicals form in the blood during periods of stress. When the liver sees free radicals, it starts to make cholesterol to neutralize them. Therefore, the more stress we endure, the higher our cholesterol (21). When doctors check the cholesterol of a stressful person, their levels are usually higher than normal.
If you want to manage your cholesterol, manage your stress. Implement stress management strategies into your life. These include regular exercise, meditation, reading, yoga and taking time out for yourself.
Before you make any diet changes, we recommend you have your cholesterol checked by a medical professional to discuss risk factors. This also gives you a starting point to see how diet and lifestyle changes impact/improve your lipids. After three to six months, have your cholesterol checked again to see your progress. The key here is communication with your doctor.