What is recommended to reduce cholesterol and Low-Density Lipoprotein (LDL)?

From the Guidelines

To reduce cholesterol and LDL, a combination of lifestyle modifications and medications is recommended, with statins as the first-line treatment, aiming for an LDL-C goal of <100 mg/dL, and considering therapeutic lifestyle changes, such as a heart-healthy diet and regular physical activity, as essential modalities in clinical management. The recommended approach includes:

• Adopting a heart-healthy diet low in saturated fats and trans fats, while increasing fiber intake through fruits, vegetables, whole grains, and legumes 1
• Regular physical activity of at least 150 minutes of moderate exercise per week to help lower LDL levels 1
• Weight management, as losing even 5-10% of body weight can improve cholesterol profiles 1
• For medications, statins are the first-line treatment, including atorvastatin (10-80mg daily), rosuvastatin (5-40mg daily), or simvastatin (10-40mg daily) 1
• Other options include ezetimibe (10mg daily), which blocks cholesterol absorption, PCSK9 inhibitors for severe cases, and bile acid sequestrants 1
• Limiting alcohol consumption, quitting smoking, and managing stress can further support cholesterol reduction 1
• Regular monitoring through lipid panels every 3-6 months is essential to track progress and adjust treatment as needed 1 It is also important to consider the patient's risk factors, such as diabetes, and adjust the treatment plan accordingly, with a goal of achieving at least a 30% to 40% reduction in LDL-C levels 1.

From the FDA Drug Label

As an adjunct to diet, alone or in combination with other low density lipoprotein cholesterol (LDL-C)-lowering therapies, in adults with primary hyperlipidemia, including heterozygous familial hypercholesterolemia (HeFH), to reduce LDL-C. Cholestyramine for Oral Suspension, USP powder is indicated as adjunctive therapy to diet for the reduction of elevated serum cholesterol in patients with primary hypercholesterolemia (elevated low density lipoprotein [LDL] cholesterol) who do not respond adequately to diet

To reduce cholesterol and Low-Density Lipoprotein (LDL), the following are recommended:

• Diet: as an adjunct to diet, alone or in combination with other LDL-C-lowering therapies
• Alirocumab (SQ): as an adjunct to diet, alone or in combination with other LDL-C-lowering therapies, in adults with primary hyperlipidemia, including HeFH, to reduce LDL-C 2
• Cholestyramine (PO): as adjunctive therapy to diet for the reduction of elevated serum cholesterol in patients with primary hypercholesterolemia (elevated LDL cholesterol) who do not respond adequately to diet 3 Key points:
• Diet is the primary recommendation for reducing cholesterol and LDL
• Alirocumab (SQ) and cholestyramine (PO) can be used as adjunctive therapies to diet in patients with primary hyperlipidemia or HeFH.

From the Research

Dietary Recommendations

To reduce cholesterol and Low-Density Lipoprotein (LDL), the following dietary recommendations are suggested:

• A healthy diet rich in vegetables, fruits, whole-grain, high-fiber foods, and fish, with a small amount of saturated and trans fats 4
• Increased dietary fiber intake, which is associated with significantly lower prevalence of cardiovascular disease and lower LDL-cholesterol concentration of about 5-10% 4
• Replacement of saturated fat with monounsaturated fatty acids (MUFA) or n-6 polyunsaturated fatty acids (PUFA) to lower plasma LDL cholesterol and ameliorate the LDL/HDL ratio 5
• Consumption of fiber-rich, low glycemic index (GI) foods to lower LDL cholesterol with no detrimental effects on triglycerides 5
• Inclusion of polyphenol-rich foods, which may have a lowering effect on postprandial triglycerides 5
• Use of functional foods such as psyllium, beta-glucans, and phytosterols, which have accepted health claims for cholesterol-lowering effects 5

Lifestyle Modifications

In addition to dietary changes, the following lifestyle modifications are recommended:

• Weight reduction, which can lower cardiovascular risk predominantly by lowering fasting triglyceride 6
• Physical activity, which can reduce cardiovascular risk and lower fasting triglyceride 6, 7
• Restricting intakes of alcohol, added sugars, and refined starches to reduce triglyceride levels 7
• Participating in daily physical activity to reduce triglyceride levels 7

Specific Nutrients and Foods

Specific nutrients and foods that may help reduce cholesterol and LDL include:

• Plant sterols/stanols, which can lower LDL cholesterol by about 10% for a 2 g/day dose 4, 6, 8
• Soluble fiber, such as Konjac glucomannan, which can lower LDL cholesterol by 0.2-0.35 mmol/L for a 3.5-7.0 g/day dose 6
• Fish oil, which can lower triglyceride with a mean lowering of 0.45 mmol/L for a 3.5 g/day amount 6
• Nuts, which can lower LDL cholesterol by about 8% 4