How to manage Hyperlipidemia (HLD) without medication?

Non-Pharmacological Management of Hyperlipidemia

All patients with hyperlipidemia should initiate therapeutic lifestyle changes (TLC) consisting of dietary modification, regular physical activity, and weight management, which can reduce LDL cholesterol by 15-25 mg/dL and should be implemented for 12 weeks before considering medication. 1

Dietary Modifications

The cornerstone of non-pharmacological treatment is reducing saturated fat to <7% of total calories and dietary cholesterol to <200 mg/day. 1

Specific Dietary Interventions:

• Replace saturated fats (cheese, whole milk, red meat) with monounsaturated fats (olive oil, canola oil) and polyunsaturated fats (corn oil, peanuts) to lower LDL without adversely affecting HDL 1

• Eliminate trans-fatty acids from the diet by avoiding partially hydrogenated oils 1

• Limit salt intake to 6 g/day to address concurrent cardiovascular risk factors 1

• Add plant stanols/sterols (2 g/day) when initial dietary changes fail to achieve LDL goals, as these interfere with intestinal cholesterol absorption and can lower LDL by an additional 8-10% 1

• Increase viscous (soluble) fiber to 10-25 g/day from sources like oats, beans, and vegetables for additional LDL reduction 1

• Increase omega-3 fatty acids from fish, which helps lower triglycerides 1

Combining a low saturated fat diet with exercise lowers total cholesterol by 7-18%, LDL cholesterol by 7-15%, and triglycerides by 4-18%, while increasing HDL cholesterol by 5-14%. 2

Physical Activity

Engage in at least 30-60 minutes of moderate-intensity physical activity on most days (preferably daily), which is equivalent to a brisk walk at 15-20 minutes per mile. 1

Exercise Prescription:

• Moderate-intensity aerobic activity (40-60% of maximum capacity) should be performed for 30-60 minutes on most days 1

• Vigorous-intensity activity (≥60% of maximum capacity) for 20-40 minutes on 3-5 days per week provides additional cardiovascular benefits 1

• Resistance training with 8-10 different exercises, 1-2 sets per exercise, 10-15 repetitions at moderate intensity, performed 2 days per week 1

• Increase daily lifestyle activities such as taking walking breaks at work, gardening, and household work 1

Exercise primarily increases HDL cholesterol (by 2-14%) and decreases triglycerides, making it complementary to dietary interventions that primarily lower LDL. 2, 3

Weight Management

For overweight/obese individuals (BMI ≥25 kg/m²), reduce body weight by 10% in the first year through caloric restriction and increased caloric expenditure. 1

Weight Goals:

• Target BMI: 18.5-24.9 kg/m² 1

• Waist circumference goals: <40 inches in men, <35 inches in women when BMI ≥25 kg/m² 1

Weight loss combined with healthy diet and physical activity can increase HDL cholesterol by 10-13%. 3

Smoking Cessation

Complete smoking cessation is mandatory, as stopping smoking can increase HDL cholesterol levels by up to 30%. 1

• Provide counseling, pharmacotherapy (nicotine replacement, bupropion), and referral to formal cessation programs 1

Alcohol Moderation

Limit alcohol intake to 2 drinks/day in men and 1 drink/day in women among those who drink. 1

• Moderate alcohol consumption can beneficially affect HDL cholesterol 3

Expected Outcomes and Timeline

Therapeutic lifestyle changes should be evaluated at 12 weeks, with consideration of pharmacological therapy if LDL goals are not achieved. 1

Lipid Monitoring:

• Measure fasting lipid profile annually in all adults with hyperlipidemia 1

• For low-risk individuals (LDL <100 mg/dL, triglycerides <150 mg/dL, HDL >50 mg/dL), reassess every 2 years 1

Common Pitfalls to Avoid

Do not replace saturated fats with high-carbohydrate diets, as this raises triglycerides and lowers HDL despite lowering LDL 1

Avoid trans-unsaturated fatty acids completely, as they worsen lipid profiles 1

For middle-aged or older sedentary patients, or those with suspected cardiovascular, respiratory, metabolic, orthopedic, or neurological disorders, consult a physician before initiating vigorous exercise programs 1

Combined Lifestyle Interventions

Combining multiple lifestyle interventions produces synergistic effects: nutritional supplements (fish oil, oat bran, plant sterols) combined with exercise decrease total cholesterol by 8-26%, LDL cholesterol by 8-30%, and triglycerides by 12-39%, while increasing HDL cholesterol by 2-8%. 2

All lifestyle modifications should be implemented simultaneously rather than sequentially to maximize cardiovascular risk reduction. 1, 4