Herbal Cholesterol Supplements for Managing High Cholesterol
Plant sterols/stanols (2-3g per day) are the only herbal supplements with strong evidence for lowering LDL cholesterol by 9-20%, though they have not been proven to reduce cardiovascular mortality. 1
Efficacy of Plant Sterols/Stanols
- Plant sterols can reduce LDL cholesterol by 9-20% at doses of 2-3g per day, making them significantly more effective than other herbal supplements for lowering LDL cholesterol 1
- The maximum effective dose is approximately 2-3g per day, with little to no effect on HDL cholesterol or triglyceride levels 1
- Intakes exceeding 3g/day do not provide additional cholesterol-lowering benefits 1
- The American Heart Association recommends the addition of plant stanol/sterols (2g per day) as a reasonable approach to further lower LDL-C 2
Place in Therapy
- Plant sterols/stanols should be considered as adjunctive therapy rather than primary therapy for hypercholesterolemia 1
- Treatment algorithm for managing high cholesterol:
- First-line: Maximally tolerated statins with or without ezetimibe and/or bempedoic acid, combined with a heart-healthy diet 1
- Second-line adjunctive therapy: Add plant sterols (stanols) at 2-3g per day if LDL-cholesterol goals are not achieved 1
- Third-line: Consider PCSK9-targeted therapy if goals still not achieved 1
Other Herbal Supplements
- Other nutraceuticals such as red yeast rice, bergamot, berberine, and artichoke have been studied for cholesterol-lowering effects 2
- Unfortunately, there are still limited data to draw firm conclusions about their long-term safety and efficacy compared to plant sterols/stanols 2
Safety Considerations
- Some concerns exist regarding plant sterols potentially decreasing plasma levels of fat-soluble vitamins and antioxidants 1
- The American Heart Association recommends that plant sterol-containing foods be reserved for adults requiring lowering of total and LDL cholesterol due to hypercholesterolemia or for secondary prevention after an atherosclerotic event 1
Important Caveats
- While plant sterols effectively lower cholesterol, there is currently no direct evidence that they reduce the risk of coronary heart disease mortality, despite their cholesterol-lowering effects 1
- For patients with established cardiovascular disease, statins remain the only group of drugs that have shown consistent reductions in hard outcomes 3
- Therapeutic lifestyle changes remain essential and include:
- Diet with restricted calories from saturated fat (<7% of total caloric intake)
- Cholesterol intake less than 200 mg/day
- Increased soluble fiber (10-25g per day)
- Reduction in trans fat (to less than 1% of caloric intake) 2