What diet should a patient with hyperlipidemia follow to lower low‑density lipoprotein cholesterol and triglycerides and raise high‑density lipoprotein cholesterol?

Dietary Management of Hyperlipidemia

Patients with hyperlipidemia should follow the DASH (Dietary Approaches to Stop Hypertension) dietary pattern, which has the strongest evidence for lowering LDL cholesterol by 11 mg/dL and triglycerides, with proven cardiovascular benefits. 1

Primary Dietary Pattern Recommendation

The ACC/AHA provides a Grade A (Strong) recommendation for adults requiring LDL-C lowering to consume a dietary pattern that: 1

• Emphasizes vegetables, fruits, and whole grains
• Includes low-fat dairy products, poultry, fish, legumes, nontropical vegetable oils, and nuts
• Limits sweets, sugar-sweetened beverages, and red meats

This can be achieved through the DASH diet, USDA Food Pattern, or AHA Diet, with DASH having the highest quality evidence (High strength) for improving both blood pressure and lipid profiles. 1

Specific Lipid-Lowering Strategies

For LDL Cholesterol Reduction

Saturated Fat Restriction:

• Reduce saturated fat to <7% of total energy intake by choosing lean meats, removing poultry skin, and selecting fat-free or 1% dairy products 2
• Saturated fat is the principal dietary determinant of LDL cholesterol levels 1

Trans Fat Elimination:

• Eliminate trans fats completely (aim for <1% of calories) by avoiding partially hydrogenated oils in commercially fried foods, packaged baked goods, and stick margarine 2, 3

Dietary Cholesterol Limitation:

• Limit dietary cholesterol to <200 mg/day (approximately one egg yolk) for individuals with elevated LDL or cardiovascular disease 2, 3

Soluble Fiber Increase:

• Consume 10-25 grams/day of soluble fiber from oats, beans, lentils, barley, psyllium, Brussels sprouts, and apples, which can reduce LDL by 5-10% 2, 3

Plant Stanols/Sterols:

• Add 2 grams/day of plant stanols/sterols from fortified margarines, orange juice, or supplements to lower LDL by 10-15% 2, 3

For Triglyceride Reduction

Weight Management:

• Achieve 5-10% body weight loss if overweight, as even modest weight loss improves all lipid parameters 2, 3
• Excess body weight, reduced physical activity, and increased intake of sugar and refined carbohydrates are particularly important contributors to elevated triglycerides 1

Carbohydrate Quality:

• Avoid replacing saturated fat with refined carbohydrates and added sugars, as this worsens the lipid profile 3, 4
• Modified DASH replacing 10% of calories from carbohydrates with unsaturated fat lowered triglycerides by 10 mg/dL 1

Omega-3 Fatty Acids:

• Consume 2 servings (8 ounces) of fatty fish weekly such as salmon, mackerel, or sardines 2, 3
• High-dose omega-3 fatty acids lower triglycerides and reduce cardiovascular events 4

Alcohol Limitation:

• Limit alcohol consumption, as excessive intake aggravates hypertriglyceridemia 1

For HDL Cholesterol Optimization

Physical Activity:

• Engage in at least 150 minutes of aerobic exercise weekly to modestly raise HDL cholesterol 2

Weight Loss:

• Weight reduction improves HDL cholesterol along with other lipid parameters 2, 3

Smoking Cessation:

• Stop smoking, which can increase HDL cholesterol by up to 30% 2

Fat Quality Over Quantity:

• Replace saturated fats with unsaturated fats, particularly polyunsaturated fats from vegetable oils, nuts, and fish 3, 4

DASH Diet Modifications for Enhanced Lipid Effects

The standard DASH diet can be modified for additional lipid benefits: 1

• Replacing 10% of calories from carbohydrates with 10% protein lowered LDL-C by 3 mg/dL and triglycerides by 16 mg/dL (Moderate strength evidence)
• Replacing 10% of calories from carbohydrates with 10% unsaturated fat (8% monounsaturated, 2% polyunsaturated) lowered LDL-C similarly, increased HDL-C by 1 mg/dL, and lowered triglycerides by 10 mg/dL (Moderate strength evidence)

Mediterranean Diet Considerations

While the Mediterranean diet has strong evidence for reducing cardiovascular disease and total mortality 4, 5, the ACC/AHA guidelines note it showed no consistent effect on LDL-C, HDL-C, and triglycerides due to substantial differences and limitations in studies (Low strength evidence). 1 However, when supplemented with extra virgin olive oil, it reduced VLDL-triglycerides and improved HDL functionality. 6, 5

Implementation Timeline and Monitoring

• Check LDL cholesterol after 6 weeks of implementing dietary changes to assess response 2
• Monitor adherence every 4-6 months with follow-up lipid panels 2
• Comprehensive dietary intervention can lower LDL by approximately 20% when all strategies are combined 2
• If LDL remains above goal after 12 weeks of intensive lifestyle changes, statin medication should be added while continuing therapeutic lifestyle changes 2

Critical Pitfalls to Avoid

High Refined Carbohydrate Substitution:

• Do not simply replace saturated fat with refined carbohydrates and sugars, as low-fat, high-carbohydrate diets can reduce HDL cholesterol, particularly when carbohydrates are derived from sugars rather than unprocessed grains 1, 3

Severe Hypertriglyceridemia:

• If triglycerides are >1,000 mg/dL, restrict all dietary fats (except omega-3s) and seek immediate medical treatment to prevent pancreatitis 2

Metabolic Syndrome:

• For individuals with metabolic syndrome, emphasize weight loss, exercise, and monounsaturated fats over very low-fat diets 2