Supplements for Hypercholesterolemia
For adults with hypercholesterolemia, plant stanols/sterols at 2 g/day are the only supplements with strong evidence for LDL-C reduction, while prescription omega-3 fatty acids (not over-the-counter supplements) may be considered for specific patients with elevated triglycerides and cardiovascular risk.
Plant Stanols/Sterols: The Evidence-Based Choice
Plant stanols/sterols at 2 g/day lower LDL-C by up to 15% and represent a therapeutic option for individuals with elevated LDL cholesterol levels. 1 Maximum effects are observed at intakes of 2 g per day, with no additional benefit beyond this dose 1. These compounds are currently available in various foods, drinks, and soft gel capsules 1.
- To sustain LDL-C reductions, you must consume plant stanols/sterols daily, similar to taking lipid-lowering medication 1
- Plant sterols compete with cholesterol for absorption in the intestine, decreasing absorption efficiency 1
- Intakes of 2-3 g per day decrease total and LDL cholesterol by 9-20%, with considerable individual variability 1
- Little effect on HDL cholesterol or triglyceride levels has been reported 1
Omega-3 Fatty Acids: Prescription vs. Over-the-Counter
Nonprescription fish oil supplements are NOT recommended for cardiovascular risk reduction or cholesterol management. 1 The critical distinction is between dietary supplements and FDA-approved prescription products:
Why Over-the-Counter Fish Oil Fails
- Over-the-counter fish oil products are classified as dietary supplements, not FDA-approved medications 1
- Manufacturing processes are not regulated to the same degree as prescription medications 1
- Content and quality vary significantly, and some may contain impurities including saturated fat, oxidized lipids, and contaminants 1
- Large quantities of capsules may be required to match prescription-strength dosing, contributing to increased caloric intake 1
- Common gastrointestinal side effects include burping, fishy taste, and dyspepsia 1
- Nonprescription fish oil products have not been demonstrated to have cardiovascular outcomes benefits 1
When Prescription Omega-3s Are Appropriate
- For patients with documented CHD, consume 1 g of EPA+DHA per day, preferably from oily fish, though EPA+DHA supplements could be considered in consultation with a physician 1
- For hypertriglyceridemia (≥500 mg/dL), 2-4 g of EPA+DHA per day as prescription capsules under physician care are recommended 1
- Prescription omega-3 products (icosapent ethyl) are FDA-approved and have verified efficacy, consistent content, and consistent purity 1
Dietary Approaches Over Supplements
The American Heart Association recommends consuming oily fish at least twice weekly rather than relying on supplements. 1 Eat a variety of fish, preferably oily fish (salmon, trout, sardines), at least twice per week for cardiovascular benefits 1.
Dietary Fiber
- Increase viscous (soluble) fiber to >10 g/day from whole foods 2
- Fiber supplements are not recommended for heart disease risk reduction, as there are no long-term trials showing relationships between these supplements and cardiovascular disease 1
- The recommendation is to increase fiber intake through food consumption—vegetables, cereals, grains, and fruits 1
Soy Protein Considerations
Soy protein (20-50 g daily) may lower LDL cholesterol when it replaces dairy or animal proteins, particularly in hypercholesterolemic individuals 1. The evidence favors soy protein rather than soy isoflavones as the responsible nutrient 1. However, some commercial soy foods prepared by ethanol washing remove most isoflavones and other potentially active components 1.
What Does NOT Work
Folate and B Vitamins
- Available evidence is inadequate to recommend folate and other B vitamin supplements as a means to reduce cardiovascular disease risk 1
- Trials of homocysteine-reducing vitamin therapy have been disappointing despite observational associations 1
General Phytochemicals
- Until more information is gathered about specific flavonoids and sulfur-containing compounds, a diet consistent with AHA recommendations is the most prudent approach 1
Critical Implementation Points
Plant stanols/sterols require daily consumption to maintain LDL-C reductions—they function like medication, not occasional supplements. 1 Choose vehicles (foods, drinks, capsules) based on availability and caloric content considerations 1.
Never substitute over-the-counter fish oil for prescription omega-3 products when prescription products are indicated. 1 The manufacturing standards, purity, and clinical evidence differ fundamentally between these categories.
Prioritize dietary sources of omega-3 fatty acids (≥2 servings of oily fish weekly) over any supplementation. 1 This approach provides omega-3s within the context of a heart-healthy dietary pattern without the risks of supplement contamination or inconsistency.