What are the recommendations to lower cholesterol?

Recommendations to Lower Cholesterol

Limit saturated fat to less than 7% of total daily calories and dietary cholesterol to under 200 mg per day, while adding 2 grams of plant stanols/sterols and 10-25 grams of soluble fiber daily to maximize LDL cholesterol reduction. 1

Primary Dietary Fat Modifications

Saturated Fat Restriction:

• Keep saturated fat intake below 10% of total energy, with further reduction to <7% for individuals with LDL cholesterol ≥100 mg/dL 2
• For every 1% reduction in saturated fat replaced with polyunsaturated fat, expect LDL cholesterol to decrease by approximately 1.8 mg/dL 1
• Moving from highest to lowest quintile of saturated fat intake (approximately 7% difference) should lower LDL cholesterol by about 0.35 mmol/L or 10% 3

Dietary Cholesterol:

• Limit cholesterol intake to <300 mg/day for general population 2
• Further restrict to <200 mg/day for those with LDL cholesterol ≥100 mg/dL 2, 1

Trans Fat Elimination:

• Minimize trans-unsaturated fatty acid intake to <1% of energy 2
• Avoid products containing partially hydrogenated oils including crackers, cookies, doughnuts, and fried foods 2

Enhanced LDL-Lowering Strategies

Plant Stanols/Sterols:

• Add 2 grams daily of plant stanols/sterols to enhance LDL cholesterol lowering by approximately 10% 2, 1
• These compounds are available in fortified foods and supplements 1

Soluble Fiber:

• Increase soluble (viscous) fiber intake to 10-25 grams per day 2, 1
• For every gram increase in soluble fiber, expect LDL cholesterol to decrease by an average of 2.2 mg/dL 1
• Large doses of soluble fiber (3.5-7.0 g/day) can lower LDL cholesterol by 0.2-0.35 mmol/L 3
• Konjac glucomannan is the most effective soluble fiber per gram 3

Fat Replacement Strategy

When reducing saturated fat, choose replacements based on your weight goals:

• If weight loss is needed: Replace saturated fat with carbohydrates, preferably whole grains and high-fiber foods 2
• If weight maintenance is the goal: Replace saturated fat with monounsaturated fats (olive oil, canola oil, nuts) or polyunsaturated fats 2
• Replacing saturated fat with monounsaturated fat lowers LDL cholesterol by approximately 1.3 mg/dL per 1% energy substitution 1

Important caveat: Replacing saturated fat with refined carbohydrates may increase triglycerides and lower HDL cholesterol, so choose high-fiber, whole-grain carbohydrates instead 2

Omega-3 Fatty Acids

• Consume fish, especially oily fish, at least 2-3 times per week to provide dietary n-3 polyunsaturated fat 2, 1
• For severe hypertriglyceridemia (>1,000 mg/dL), fish oil supplements containing n-3 fatty acids may be beneficial, though they can increase LDL cholesterol and require monitoring 2
• Large doses of fish oil (3.5 g/day) lower triglycerides by a mean of 0.45 mmol/L 3

Weight Management and Physical Activity

Weight Loss:

• Even modest weight loss of 5-7% of starting weight improves dyslipidemia 2
• Structured programs emphasizing reduced fat intake (<30% of daily energy), regular physical activity, and frequent contact are necessary for sustained weight loss 2
• Weight reduction is particularly important for those with elevated triglycerides and low HDL cholesterol 2

Physical Activity:

• Engage in at least 30 minutes of moderate-intensity aerobic exercise 5 times weekly 4
• Regular physical activity reduces triglycerides and improves insulin sensitivity 2
• Exercise shows a dose-response relationship with HDL cholesterol levels 4

Practical Dietary Pattern

Follow these specific food choices:

• Consume a diet rich in vegetables, fruits, and whole-grain, high-fiber foods 2, 5
• Choose lean meats and vegetable protein alternatives 2
• Select fat-free (skim) or low-fat (1% fat) dairy products 2
• Include nuts in your diet, which can lower LDL cholesterol by approximately 8% 5
• Minimize beverages and foods with added sugars 2
• Choose and prepare foods with little or no salt (limit sodium to 2,400 mg/day) 2

Expected Outcomes

Cumulative LDL cholesterol reduction from dietary interventions:

• Step 1 diet: -10% 5
• Dietary fibers: -5 to -10% 5
• Plant sterols/stanols: -10% 5
• Nut consumption: -8% 5
• Combined approach can achieve 23% reduction in total cholesterol and LDL cholesterol within 2-3 weeks 6

When Diet Alone Is Insufficient

Pharmacological therapy should be initiated if:

• Lifestyle modifications fail to achieve LDL cholesterol <100 mg/dL 2
• Patients have clinical cardiovascular disease and LDL >100 mg/dL (start medication simultaneously with lifestyle changes) 2
• Statin therapy is the preferred first-line pharmacological treatment 2, 7
• Ezetimibe can be added to statin therapy or used alone when statins are not tolerated to further reduce LDL cholesterol 8

Common pitfall: Many patients consume refined carbohydrates when reducing fat intake, which can worsen triglycerides. Always emphasize replacing saturated fat with either healthy unsaturated fats or high-fiber, whole-grain carbohydrates—never refined carbohydrates 2, 3.