How to lower LDL cholesterol?

How to Lower LDL Cholesterol

To effectively lower LDL cholesterol, implement a combination of dietary changes, lifestyle modifications, and if necessary, medication therapy, with the primary goal of reducing saturated fat intake to 7% of total calories and adding plant stanols/sterols (2g/day) and soluble fiber (10-25g/day). 1

Lifestyle Modifications

Dietary Changes

• Reduce saturated fat intake to 7% of total calories 2, 1
• Limit dietary cholesterol to <200 mg/day 2, 1
• Increase soluble (viscous) fiber to 10-25g/day 2, 1
  • This can lower LDL cholesterol by 0.2-0.35 mmol/L (with Konjac glucomannan being most effective per gram) 3
• Add plant stanols/sterols (2g/day) 2, 1
  • These can lower LDL cholesterol by approximately 10% 3
• Replace saturated fats with:
  • Monounsaturated fats (olive oil, avocados, nuts) 2
  • Polyunsaturated fats (n-6 PUFA) 3, 4
  • When replacing with carbohydrates, choose low glycemic index options 3

Weight Management

• Achieve and maintain a healthy BMI 2, 1
• Even modest weight loss can lead to decreased plasma triglycerides and lower LDL cholesterol 2

Physical Activity

• Engage in at least 30 minutes of moderate-intensity physical activity on most days 2, 1
• Regular physical activity reduces plasma triglycerides and improves insulin sensitivity 2

Additional Lifestyle Changes

• Avoid tobacco products 1
• Limit alcohol consumption 4

Monitoring Progress

• Recheck lipid profile after 4-6 weeks of implementing dietary and lifestyle changes 1
• If LDL goal is not achieved after 6 weeks, consider intensifying dietary efforts or adding medication therapy 1

Pharmacotherapy (When Lifestyle Changes Are Insufficient)

First-Line Medication

• Statins are the first-line therapy when medication is needed 1, 5
  • High-intensity statins (atorvastatin 40-80 mg or rosuvastatin 20-40 mg) should be used to achieve at least 50% reduction in LDL-C for high-risk patients 1

Additional Medication Options

• Ezetimibe (10 mg daily) can be added if LDL goals are not achieved with statins alone 1, 5
• PCSK9 inhibitors (alirocumab, evolocumab) for persistent elevation despite combination therapy 1
• Bempedoic acid for patients with statin intolerance 1
• Fibrates for patients with elevated triglycerides (>200 mg/dL) despite statin therapy 1
• Prescription omega-3 fatty acids (2-4 g/day) if fibrates are not tolerated 1

Expected Results from Lifestyle Changes

• Step 1 diet: approximately 10% LDL reduction 6
• Dietary fibers: 5-10% LDL reduction 6
• Plant sterols/stanols: 10% LDL reduction 6
• Nut consumption: 8% LDL reduction 6
• Soy protein: 3-10% LDL reduction 6

Common Pitfalls to Avoid

• Delaying pharmacotherapy when indicated based on risk category 1
• Inadequate dosing of statins - use appropriate intensity to achieve ≥30-50% LDL-C reduction 1
• Poor follow-up - failure to reassess lipid levels after 4-6 weeks can lead to suboptimal management 1
• Ignoring adherence issues - address barriers to dietary and medication compliance 1
• Replacing saturated fat with refined carbohydrates - this can increase triglycerides and have neutral effects on cardiovascular disease risk 3

By implementing these evidence-based strategies, most individuals can achieve significant reductions in LDL cholesterol, with potential combined effects from multiple interventions reaching 20-30% reduction before medication is needed 6, 7.