High Cholesterol
The right diet is the key to managing many diseases and to improving general quality of life. For this condition, scientific research has found benefit in the following healthy eating tips.
High-Fiber Diet
Eating fiber-rich foods like whole grains, legumes, fruits, and vegetables can help reduce cholesterol levels.High-Fiber DietDietary fiber is categorized as soluble or insoluble. Soluble fiber interacts with water, often (but not always) forming a gel-like substance, and is fermentable by intestinal bacteria, while insoluble fiber does not interact with water and is usually not fermentable. Gel-forming soluble fiber (also called viscous fiber) sequesters dietary cholesterol (reducing its absorption) and alters the gut microbiome, leading to better cholesterol metabolism and lower cholesterol levels.214,215,216 Good sources of gel-forming soluble fiber include vegetables like sweet potatoes, carrots, artichokes, Brussels sprouts, broccoli, and other greens; fruits like apples, pears, berries, and bananas; legumes including lentils, peas, and beans; and whole grains like oats, rye, and barley.214Psyllium husks and flaxseeds are functional foods with high gel-forming soluble fiber content and have been shown in multiple clinical trials and meta-analyses to lower high LDL- and non-HDL-cholesterol levels. Typical amounts used in clinical trials were equivalent to two to three tablespoons for flaxseeds and about two to three teaspoons for psyllium husk.218,219 Insoluble fiber, found in high amounts in vegetables, whole wheat and other grain brans, and nuts and seeds, has important impacts on digestive function but is not likely to contribute as much to cholesterol lowering as soluble fiber.214,221
Diets high in legume and whole-grain fiber (especially barley and oat) have been found in multiple studies to be associated with lower LDL-cholesterol levels.222,223 A meta-analysis of findings from 58 randomized controlled trials found beta-glucan from oats can reduce LDL- and non-HDL-cholesterol levels.224 One literature review determined that regular daily intake of 4–10 grams of soluble fiber can result in a 5–10% reduction in LDL-cholesterol.215 Furthermore, a growing body of evidence shows increasing dietary fiber intake, by increasing whole grains or adding psyllium husk for example, can enhance the effectiveness of widely used cholesterol-lowering drugs called statins.226,227
The recommended daily allowance (RDA) for total dietary fiber is 38 grams in healthy adult men up to age 50 and 25 grams in healthy adult women up to age 50, but most Americans do not consume this amount.214 In fact, the average daily fiber intake in 2015–16 among US adults was found to be 17.33 grams.229 Randomized controlled trials show getting a minimum of 25–40 grams of total fiber, including a minimum of 7–13 grams of soluble fiber, per day can lower LDL-cholesterol by at least 5–10%.215 Dietary fiber has benefits beyond lowering cholesterol: A meta-analysis of data from 17 studies found the risk of death from any cause was 16% lower in those with the highest, versus lowest, daily fiber intake.231
Mediterranean Diet
A Mediterranean-style diet has been associated with lower cholesterol levels and better cardiovascular, metabolic, and overall health.Mediterranean DietThe foundation of the Mediterranean diet is a healthy, plant-based diet, high in whole grains, vegetables and fruits, legumes, and nuts and seeds. It also includes modest amounts of fish, low-fat dairy products, lean poultry, and red wine, and highlights olive oil as its main fat source.227 It is the most studied dietary pattern to date, and has been associated with a wide range of health benefits, including lower risks of heart disease, obesity, type 2 diabetes, and Alzheimer disease.228 Adherence to a Mediterranean diet has been shown to be associated with healthy lipid levels and reduced cardiovascular risk. In a large meta-analysis that included data from 57 controlled trials, participants assigned to a Mediterranean eating pattern experienced a reduction in LDL-cholesterol and increase in HDL-cholesterol levels compared with those assigned to other dietary changes or no dietary intervention.229 Another meta-analysis of 121 randomized controlled trials found a reduction in LDL-cholesterol levels was maintained after 12 months in subjects receiving a Mediterranean diet intervention, but not those receiving a low-fat, low-carbohydrate, or DASH diet interventions.230
Portfolio Diet
The portfolio diet emphasizes four dietary components that lower cholesterol levels: phytosterols, viscous soluble fiber, soy protein, and nuts. Some research suggests this diet can be as effective as a widely used cholesterol-lowering drug.Portfolio DietA diet emphasizing a portfolio of foods with evidence supporting their cholesterol-lowering effects has been developed and compared with other diets and cholesterol-lowering drugs. The goals of the portfolio diet are to consume, per 1,000 calories of daily energy intake:
- ~1 gram of plant sterols from a sterol-enriched food
- ~10 grams of viscous fiber from oats, barley, and psyllium
- ~22 grams of soy protein from soymilk, tofu, or soy-based meat replacements
- ~14–22 grams of almonds, other tree nuts, or peanuts
In a randomized controlled trial with 46 participants who had high cholesterol levels, a portfolio diet was as effective as lovastatin (Mevacor®) and more effective than a low saturated fat diet, lowering LDL-cholesterol levels by 28.6% after one month.231 In a six-month controlled trial, 345 participants with high cholesterol levels ate either a low saturated fat or portfolio diet. The portfolio diet group had a reduction in LDL-cholesterol of more than 13%, while the low saturated fat group had a 3% reduction; levels of fat-soluble nutrients did not change with either diet.232,233 A meta-analysis of findings from seven trials found the portfolio diet, added to the Step II dietary recommendations of the National Cholesterol Education Program, lowered LDL-cholesterol levels by 17%, as well as total and non-HDL-cholesterol levels and other markers of cardiovascular risk.234 Furthermore, a large observational study that used data collected from more than 123,000 participants in the Women’s Health Initiative from 1993 through 2017 found higher scores reflecting adherence to the portfolio diet were correlated with lower risks of cardiovascular disease, coronary artery disease, and heart failure.235
Dietary Approaches to Stop Hypertension (DASH)
The DASH eating pattern has been shown to lower LDL-cholesterol levels and improve cardiovascular and metabolic health.Dietary Approaches to Stop Hypertension (DASH)The Dietary Approaches to Stop Hypertension (DASH) diet is predominantly plant based, is low in saturated fats and cholesterol, and emphasizes fruits, vegetables, whole grains, legumes, nuts, and low-fat dairy products.236 Although DASH was developed to lower high blood pressure, research has shown adherence to this dietary pattern also lowers non-HDL-cholesterol levels.237,238 One large review of 15 observational studies and 31 controlled trials found the DASH diet lowered LDL-cholesterol levels and improved other cardiovascular and metabolic health parameters.239
Coffee
Including specific foods and beverages, such as soy foods, nuts and seeds, fish, garlic, coffee, and alcohol, in your regular diet may improve cholesterol and other lipid levels.CoffeeAlthough certain specific foods have been studied for their effects on blood cholesterol levels, current research and recommendations mainly focus on overall dietary patterns. Nevertheless, some individual foods deserve mention.
While coffee consumption has been associated with decreased risks of cardiovascular disease, obesity, and diabetes, drinking coffee prepared without the use of a paper filter has been strongly linked to negative impacts on lipid profiles, including elevation of total and LDL-cholesterol levels.240,241
Fish
Including specific foods and beverages, such as soy foods, nuts and seeds, fish, garlic, coffee, and alcohol, in your regular diet may improve cholesterol and other lipid levels.FishAlthough certain specific foods have been studied for their effects on blood cholesterol levels, current research and recommendations mainly focus on overall dietary patterns. Nevertheless, some individual foods deserve mention.
A meta-analysis of 14 controlled trials found oily fish consumption raised HDL-cholesterol levels but did not impact levels of other forms of cholesterol. In addition, fish consumption lowered triglyceride levels.242
Garlic
Including specific foods and beverages, such as soy foods, nuts and seeds, fish, garlic, coffee, and alcohol, in your regular diet may improve cholesterol and other lipid levels.GarlicAlthough certain specific foods have been studied for their effects on blood cholesterol levels, current research and recommendations mainly focus on overall dietary patterns. Nevertheless, some individual foods deserve mention.
According to a large analysis of findings from numerous controlled trials, adding garlic to the diet can lower cholesterol levels in as little as eight weeks.243 In one placebo-controlled trial with 80 participants with cardiovascular disease, 2 grams of garlic powder per day for 60 days lowered total and LDL-cholesterol and raised HDL-cholesterol levels.244
Olive Oil
Replacing foods high in trans and saturated fats with foods rich in high-quality polyunsaturated and monounsaturated fats, like those in fish, nuts and seeds, and olive oil, can help lower cholesterol levels and reduce cardiovascular risk.Olive OilIt is increasingly evident that quality matters more than quantity when it comes to dietary fat. Low-fat diets have consistently been shown to have little impact on cardiovascular risk, but changes in dietary fatty acid composition may have meaningful effects.
The most studied dietary monounsaturated fatty acid is the omega-9 fatty acid oleic acid. Oleic acid is found mainly in olive oil but is also present in avocado and nut and seed oils. Multiple clinical trials have shown replacing saturated and trans fats with high-oleic acid oils can lower total and LDL-cholesterol levels without affecting HDL-cholesterol levels,245 and a growing body of evidence shows high intake of olive oil is associated with lower risk of cardiovascular events and death.246
Soy Foods
Including specific foods and beverages, such as soy foods, nuts and seeds, fish, garlic, coffee, and alcohol, in your regular diet may improve cholesterol and other lipid levels.Soy FoodsAlthough certain specific foods have been studied for their effects on blood cholesterol levels, current research and recommendations mainly focus on overall dietary patterns. Nevertheless, some individual foods deserve mention.
Soybeans are high in phytosterols and viscous soluble fiber, and have a relatively low ratio of omega-6 to omega-3 fatty acids, all of which may contribute to their cholesterol-lowering effects. Furthermore, soy protein fractions have been found to reduce dietary cholesterol absorption and cholesterol production by the liver. Soy proteins also decrease bile acid resorption, increasing the utilization of cholesterol to manufacture new bile acids.247 Preclinical and clinical trials show replacing animal protein with soy protein, and other plant-sourced proteins, substantially lowers total cholesterol, LDL-cholesterol, and non-HDL-cholesterol levels.248,249
Trans Fats
Replacing foods high in trans and saturated fats with foods rich in high-quality polyunsaturated and monounsaturated fats, like those in fish, nuts and seeds, and olive oil, can help lower cholesterol levels and reduce cardiovascular risk.Trans FatsIt is increasingly evident that quality matters more than quantity when it comes to dietary fat. Low-fat diets have consistently been shown to have little impact on cardiovascular risk, but changes in dietary fatty acid composition may have meaningful effects.
Trans fats are polyunsaturated fats that have been subjected to partial hydrogenation to increase their solid phase temperature range. Partially hydrogenated oils are used to make highly processed fat products such as shortening and margarine. Trans fats are also generated naturally as polyunsaturated fatty acids age but are found only in small amounts in unprocessed fats and oils. Trans fats are closely associated with cardiovascular disease and have been found to increase cholesterol synthesis in the liver.250
Saturated Fats
Replacing foods high in trans and saturated fats with foods rich in high-quality polyunsaturated and monounsaturated fats, like those in fish, nuts and seeds, and olive oil, can help lower cholesterol levels and reduce cardiovascular risk.Saturated FatsIt is increasingly evident that quality matters more than quantity when it comes to dietary fat. Low-fat diets have consistently been shown to have little impact on cardiovascular risk, but changes in dietary fatty acid composition may have meaningful effects.
Saturated fats are mainly found in animal foods, but coconut and palm oils are also rich sources. Higher intakes of saturated fatty acids appear to be associated with higher combined risk of heart disease and stroke.251 According to one analysis, replacing 10% of dietary saturated fat with polyunsaturated fatty acids could reduce cardiovascular events by 27%.252 The saturated fatty acids in coconut and palm oil differ from those in animal fat such as butter, and some clinical trials have found coconut oil has less negative impact on cholesterol metabolism than butter.253,254
Polyunsaturated Fats (PUFAs)
Replacing foods high in trans and saturated fats with foods rich in high-quality polyunsaturated and monounsaturated fats, like those in fish, nuts and seeds, and olive oil, can help lower cholesterol levels and reduce cardiovascular risk.Polyunsaturated Fats (PUFAs)It is increasingly evident that quality matters more than quantity when it comes to dietary fat. Low-fat diets have consistently been shown to have little impact on cardiovascular risk, but changes in dietary fatty acid composition may have meaningful effects.
The most important dietary PUFAs are categorized, based on their structure, as either omega-6 or omega-3 fatty acids. Major dietary omega-6 fats include arachidonic acid (mainly from animal fats) and linoleic acid (mainly from plant fats); major dietary omega-3 fats include eicosapentaenoic acid and docosahexaenoic acid (EPA and DHA, mainly from fish fats) and alpha-linolenic acid (mainly from plant fats, especially flaxseed, hemp seed, and canola oils). Increasing omega-6 PUFA intake, particularly in the form of linoleic acid, can reduce total and LDL-cholesterol levels.255,256 However, one meta-analysis of data from eleven randomized controlled trials found replacing saturated fats with mostly omega-6 PUFAs does not lower risk of cardiovascular events or death.257 Omega-3 fatty acids appear to have varied effects on cholesterol metabolism: both alpha-linolenic acid and EPA have been found to reduce LDL-cholesterol and have no impact on HDL-cholesterol levels, but DHA appears to cause an increase in both LDL- and HDL-cholesterol levels.256 Although the average US adult diet provides 20–50 times more omega-6 than omega-3 fatty acids, some research suggests a lower ratio of omega-6 to omega-3 fat intake, such as 4–5:1, may be associated with lower risks of cardiovascular and other chronic inflammatory conditions.259
Monounsaturated Fats
Replacing foods high in trans and saturated fats with foods rich in high-quality polyunsaturated and monounsaturated fats, like those in fish, nuts and seeds, and olive oil, can help lower cholesterol levels and reduce cardiovascular risk.Monounsaturated FatsIt is increasingly evident that quality matters more than quantity when it comes to dietary fat. Low-fat diets have consistently been shown to have little impact on cardiovascular risk, but changes in dietary fatty acid composition may have meaningful effects.
The most studied dietary monounsaturated fatty acid is the omega-9 fatty acid oleic acid. Oleic acid is found mainly in olive oil but is also present in avocado and nut and seed oils. Multiple clinical trials have shown replacing saturated and trans fats with high-oleic acid oils can lower total and LDL-cholesterol levels without affecting HDL-cholesterol levels,259 and a growing body of evidence shows high intake of olive oil is associated with lower risk of cardiovascular events and death.260
Nuts
Including specific foods and beverages, such as soy foods, nuts and seeds, fish, garlic, coffee, and alcohol, in your regular diet may improve cholesterol and other lipid levels.NutsAlthough certain specific foods have been studied for their effects on blood cholesterol levels, current research and recommendations mainly focus on overall dietary patterns. Nevertheless, some individual foods deserve mention.
People who eat nuts and seeds regularly have been found to have better lipid profiles and overall cardiovascular and metabolic health (including less overweight and obesity) than those who don’t eat nuts.261,262,263,264 In addition, a number of clinical trials have shown adding nuts and seeds to the diet is an effective strategy for lowering total, LDL-, and non-HDL cholesterol, as well as triglycerides.265 In particular, pecans,266 almonds,267 Brazil nuts,268 pistachios,269 hazelnuts,270 walnuts,270 and sunflower seeds272 have been found to improve cholesterol levels, while cashews have not shown these beneficial effects.273,274 Peanuts (which are technically in the legume family) have also failed to demonstrate beneficial effects on cholesterol levels.275
Seeds
Including specific foods and beverages, such as soy foods, nuts and seeds, fish, garlic, coffee, and alcohol, in your regular diet may improve cholesterol and other lipid levels.SeedsAlthough certain specific foods have been studied for their effects on blood cholesterol levels, current research and recommendations mainly focus on overall dietary patterns. Nevertheless, some individual foods deserve mention.
People who eat nuts and seeds regularly have been found to have better lipid profiles and overall cardiovascular and metabolic health (including less overweight and obesity) than those who don’t eat nuts.275,276,277,278 In addition, a number of clinical trials have shown adding nuts and seeds to the diet is an effective strategy for lowering total, LDL-, and non-HDL cholesterol, as well as triglycerides.279 In particular, pecans,280 almonds,281 Brazil nuts,282 pistachios,283 hazelnuts,284 walnuts,284 and sunflower seeds286 have been found to improve cholesterol levels, while cashews have not shown these beneficial effects.287,288 Peanuts (which are technically in the legume family) have also failed to demonstrate beneficial effects on cholesterol levels.289
Cholesterol
Replacing foods high in trans and saturated fats with those rich in high-quality fats, like omega-3 and omega-6 polyunsaturated and omega-9 monounsaturated fatty acids, can help lower cholesterol levels and reduce cardiovascular risk.CholesterolIt is increasingly evident that quality matters more than quantity when it comes to dietary fat. Low-fat diets have consistently been shown to have little impact on cardiovascular risk, but changes in dietary fatty acid composition may have meaningful effects.
While diets associated with lower cholesterol levels and cardiovascular risk are often inherently low in cholesterol, dietary cholesterol intake has not been correlated with cholesterol levels, and reducing cholesterol intake has not been shown to be an effective way to reduce high cholesterol levels.289
Low-Sugar
Including specific foods and beverages, such as soy foods, nuts and seeds, fish, garlic, coffee, and alcohol, in your regular diet may improve cholesterol and other lipid levels.Low-SugarAlthough certain specific foods have been studied for their effects on blood cholesterol levels, current research and recommendations mainly focus on overall dietary patterns. Nevertheless, some individual foods deserve mention.
High consumption of sugar-sweetened foods and beverages, as well as refined carbohydrates (which are rapidly converted into glucose in the body), is strongly correlated with heart disease, although evidence linking sugars to high cholesterol levels is limited.290,291 Observational data from studies with almost 30,000 US adult participants found high intake of sugar-sweetened beverages in particular were associated with higher LDL-cholesterol and triglyceride levels and lower HDL-cholesterol levels.292 A meta-analysis of findings from 13 observational studies in children and youth also show links between increased sugar-sweetened beverage intake and worsening lipid profiles in this age group.293 However, a randomized controlled trial in 203 high consumers of sugar-sweetened beverages found switching to artificially-sweetened beverages did not improve lipid levels.294
Low-Carbohydrate
Low-carbohydrate diets appear to slightly increase LDL-cholesterol levels but have positive impacts on HDL-cholesterol and triglyceride levels. It is unclear how these effects influence cardiovascular outcomes.Low-CarbohydrateVarious degrees of carbohydrate restriction are sometimes used to manage metabolic disorders like type 2 diabetes and obesity. These diets can also affect lipid levels, having in particular a positive effect on triglyceride levels.295 One meta-analysis of findings from eight randomized controlled trials comparing low-carbohydrate to low-fat diets found these diets had similar effects on LDL-cholesterol levels, but adherence to low-carbohydrate diets resulted in lower triglyceride and higher HDL-cholesterol levels.296 Another meta-analysis that included 12 randomized controlled trials found that adhering to a low-carbohydrate diet raised LDL-cholesterol levels slightly, but all of the effects of the diet on lipid levels and other markers of cardiovascular risk disappeared within two years of monitoring.297 Furthermore, an analysis of 121 clinical trials with a combined total of almost 22,000 participants found neither low-carbohydrate nor low-fat diets led to lasting changes in cardiovascular risk factors, including cholesterol levels.298
One analysis examined data from 37 clinical trials to compare the effects of diets with three different degrees of carbohydrate restriction: a very low-carbohydrate diet, in which less than 30% of daily calorie intake was from carbohydrates (a ketogenic diet); a low-carbohydrate diet, in which calories from carbohydrates ranged from 30% to less than 40% of total calories; and a moderately low-carbohydrate diet, in which carbohydrate calories ranged from 40% to less than 45% of daily calories. The analysis showed LDL-cholesterol and HDL-cholesterol levels increased more in those eating a very low-carbohydrate diet compared with those eating a moderately low-carbohydrate diet. The analysis also found substituting carbohydrate calories with saturated fat calories resulted in higher total and LDL-cholesterol levels.299 The effect of these differences on cardiovascular outcomes is still unknown, but some evidence has indicated a very low-carbohydrate diet, particularly one that includes high intake of animal (saturated) fat, may be associated with increased mortality.300
Vegetarian
Vegetarian diets are generally rich in soluble fiber, phytosterols, and soy protein, all of which have been shown to lower LDL-cholesterol levels.VegetarianA vegetarian diet excludes meat, poultry, and fish, while a vegan diet also excludes eggs and dairy products. These diets are generally low in saturated fat and excess calories and high in heart-protective foods like legumes, soy foods, nuts, seeds, vegetables, fruits, and whole grains.301,302 In addition to soluble fiber, vegetarian and vegan diets are high in phytosterols, plant lipids similar in structure and function to cholesterol. Phytosterols are found in all plant foods but are especially abundant in unrefined vegetable, nut and seed, and olive oils. When consumed in amounts of 600–3,300 mg per day, phytosterols have been found to improve lipid profiles by inhibiting dietary cholesterol absorption and stimulating cholesterol excretion.301 In addition, consuming about 25 grams of soy protein per day has been shown to lower LDL-cholesterol levels by 3–4%.304 A large review that included findings from 20 meta-analyses of observational studies and clinical trials determined vegetarian diets were associated with lower total and LDL-cholesterol levels, but had negative impacts on HDL-cholesterol levels and vitamin B12 status.305
Vegan
Vegan diets are generally rich in soluble fiber, phytosterols, and soy protein, all of which have been shown to lower LDL-cholesterol levels.VeganA vegetarian diet excludes meat, poultry, and fish, while a vegan diet also excludes eggs and dairy products. These diets are generally low in saturated fat and excess calories and high in heart-protective foods like legumes, soy foods, nuts, seeds, vegetables, fruits, and whole grains.305,306 In addition to soluble fiber, vegetarian and vegan diets are high in phytosterols, plant lipids similar in structure and function to cholesterol. Phytosterols are found in all plant foods but are especially abundant in unrefined vegetable, nut and seed, and olive oils. When consumed in amounts of 600–3,300 mg per day, phytosterols have been found to improve lipid profiles by inhibiting dietary cholesterol absorption and stimulating cholesterol excretion.305 In addition, consuming about 25 grams of soy protein per day has been shown to lower LDL-cholesterol levels by 3–4%.308 A large review that included findings from 20 meta-analyses of observational studies and clinical trials determined vegetarian diets were associated with lower total and LDL-cholesterol levels, but had negative impacts on HDL-cholesterol levels and vitamin B12 status.309
Alcohol Consumption
Including specific foods and beverages, such as soy foods, nuts and seeds, fish, garlic, coffee, and alcohol, in your regular diet may improve cholesterol and other lipid levels.Alcohol ConsumptionAlthough certain specific foods have been studied for their effects on blood cholesterol levels, current research and recommendations mainly focus on overall dietary patterns. Nevertheless, some individual foods deserve mention.
Regular light to moderate alcohol consumption is associated with increased HDL-cholesterol levels and decreased risk of atherosclerosis.309 Light to moderate alcohol intake is defined as a maximum of two drinks per day for men and one drink per day for women, with a drink being 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of spirits.310 In fact, two alcoholic drinks per day has been found to raise HDL-cholesterol by 12%.309