Tips to naturally lower cholesterol
Introduction: Over one billion pounds a year are spent on statins in the UK. In some people these are needed to avoid an increased risk of heart disease, stroke and peripheral vascular disease, especially those with heart problems, diabetes, high blood pressure or smokers. In many other people the side effects of statins can be avoided by adopting evidence based lifestyle strategies.
This page provides information on what prompts our body to make more cholesterol than we need. We describe how to naturally lower cholesterol with diet, exercise and anti-nflammatory strategies, which don’t just harp on about reducing fat intake, but address the complete picture to both naturally lower cholesterol and improve your total feeling of well-being.
Background – What is cholesterol?
Cholesterol is a sterol (modified steroid) that is essential structural component of their cell membranes. They are not needed by plants to maintain membrane structural integrity and fluidity. Cholesterol also serves as a building block for the biosynthesis of steroid hormones such as testosterone, bile acids and vitamin D.
Although cholesterol has important functions, epidemiological studies strongly link increased levels high levels of cholesterol in the blood with increased risk of heart disease, stroke, dementia, other neurodegenerative disorders, cancer development and its progression after diagnosis [Chomistek, Platz].
How cholesterol absorbed and secreted:
Cholesterol can be absorbed directly from the gut from animal sources or can be made by many cells in our body but mainly those in the liver with the help of the enzyme HMG-CoA reductase (the target for statins). To a certain extent, the body compensates for any absorption of additional cholesterol by reducing cholesterol synthesis. Cholesterol is recycled in the body. Every day, up to 1g of cholesterol enters the colon. This cholesterol originates from the diet, bile, and desquamated intestinal cells, and can be metabolized into a non-absorbable sterol that is excreted in the faeces by a cholesterol-reducing bacterium origin has been isolated from human feces. The liver excretes it in a non-esterified form (via bile) into the digestive tract. Typically, about 50% of the excreted cholesterol is reabsorbed by the small intestine back into the bloodstream.
How is cholesterol transported around the body:
Cholesterol is transported around the body in lipoproteins. The total level, measured in the blood stream should ideally be less than 5mmol/L or less for healthy adults or less than 4mmol/L or people with a high cardiac risk such as angina, know heart disease, peripheral vascular disease, diabetes or even a strong family history. A lipoprotein with a low protein: cholesterol ratio is called a low density lipoprotein (LDL), one with a high protein: cholesterol ratio is a high density lipoprotein (HDL):
- high-density lipoprotein (HDL)– carries cholesterol away from the cells and back to the liver, where it’s either broken down or passed out of the body as bile; for this reason, HDL is referred to as “good cholesterol”, and higher levels are better (1mmol/L or more).
- low-density lipoprotein (LDL)– carries cholesterol to the cells that need it, but if there’s too much cholesterol for the cells to use, it can build up in the artery walls, leading to disease of the arteries; for this reason, LDL is known as “bad cholesterol” and it is better to have lower levels (3mmol/L or less).
What influences cholesterol levels
How can we reduce levels
The absorption / excretion circulation pathways, highlighted above, indicates that the cause of raised serum levels are complex and influence by a host of genetic, environmental, dietary and biological factors. In other words its not just about the amount of cholesterol we eat but why the body chooses to increase cholesterol levels. The ones we can control, through our daily lifestyle choices, can be split into the following categories:
- Lack of physical activity
- High dietary cholesterol unsaturated fat intake
- High transfat intake
- Low omega 3 fatty acid intake
- Processed sugar intake
- Chronic inflammation
- Healthy gut microflora
- Polyphenol rich foods
- Dietary intake of plant sterols
Lack of physical activity.
Cholesterol is an excellent energy source especially, useful to individuals participating in regular exercise. Exercise has been shown not only to help weight control but lower serum triglycerides, total cholesterol and improve the ratio of high-density lipoprotein to low-density lipoprotein [Rock]. Furthermore, there is evidence, that even before weight reduction occurs, exercise directly lowers excess serum testosterone, oestrogen and leptin levels and raises adiponectin levels independent of weight loss all of which have an effect cholesterol pathways [Friedenreich, Foster-Schubert]. Try to be physically active throughout the day (using the stairs instead of the lift, getting off the bus or tube one stop earlier, choosing to walk or cycle rather than using the car etc). It’s important to avoid long periods of sedentary behaviour and prioritise time to introduce a formal workout 2-4 times a week – Tips to increase exercise levels
Excess dietary cholesterol and saturated fat intake.
Cholesterol is a good source of energy so if you need it eating cholesterol rich foods is absolutely fine – You don’t have to miss out on a tasty shrimp and lobster super after a good run or gym class but think again if you have been sitting on the couch all day. Eating large quantities of cholesterol rich animal products when you don’t need the calories can increase serum levels as, in this situation, the adaptive mechanism is simply overloaded and the body has to find locations to store this extra cholesterol such as the liver and arteries. Since all animal cells manufacture cholesterol, all animal-based foods contain cholesterol in varying amounts. They are not found in plants or plant products so it is best to eat more plants and less animals. (Tips for tasty non-meat recipes). Likewise, saturated fats contain a lot of energy so if they are not required for energy they add to the burden of triglyceride and cholesterol storage. Plant oils can contain saturated fats but they are not harmful and certainly don’t have the problems of meat fats which via the cooking process carcinogens can be converted to carcinogens use as heterocyclic amines and polycyclic aromatic hydrocarbons. Clinical studies have shown that higher intake of meat saturated fats have a much greater impact on triglyceride and cholesterol levels and heart disease than plant saturated fats which are a useful source of energy, provided you need it, otherwise they will also contribute to weight gain.
Foods high in saturated fats and cholesterol include:
- Butter, lard,
- Pies, cakes,
- Fatty cuts of meat, sausages, bacon,
- Cheese, cream and products made with them.
- Shrimp and lobster
Higher intake of transfats
These are man made in a process were unsaturated vegetable oils are partially hydrogenated to produce saturated fats. This alters the melting point and freezing points, which make them useful for margarine, snack foods, packaged baked goods and frying fast food where they are widely used. Apart from energy, trans-fats have little nutritional value and have been shown to consistently be associated with increased risk of heart in part by raising levels of LDL and lowering HDL. Fortunately, awareness on their health risks and pressure on the food industry is reducing their use.
Low intake of polyunsaturated fats:
Several studies, including a meta-analysis by Cambridge University, have found a significantly reduced risk of heart disease and lower cholesterol (LDL) with higher levels of both omega-3 and 6 fats . A scientific report from the American Heart Association has also found a favourably link between lower cholesterol (LDL) and higher dietary omega 3&6 polyunsaturated fat intake. Consequently they advise eating plenty of omega 3 and not to limit omega 6 intake but for optimal health aim for at least 10% of calories coming from omega-6 fats.
Short chain omega 3 consisting of alpha-linolenic acid (ALA) and eicosatetraenoic acid (ETA) are found in plant oils such as walnuts, edible seeds, clary sage, algal oil, flaxseeds and flaxseed oils, sacha inchi, echium and hemp oils. Long chain omega 3 consisting of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are found in algae, edible seaweed, phytoplankton, oily fish such as herring, mackerel, salmon, menhaden and sardine as well as cod liver, squid, krill oils and other marine foods. DHA is the primary structural component of the human brain, skin and retina.
Most omega-6 fatty acids in the diet originate from vegetable oils, nuts, grape seed oil, soya, flaxseed and oily vegetables such as avocado. Linoleic acid, the shortest-chained omega-6 fatty acid, is an essential fatty because the human body cannot synthesize it. The other omega 6’s can occur in smaller amounts in foods including evening primrose oil, borage oil, and black currant seed oil and include gamma-linolenic acid (GLA), Di Homo gamma linoleic acid (DGLA) and Arachidonic acid (AA). These later three omega 6’s are generally synthesised by the body.
The trouble with a typical western diet it that is becoming low in omega 3. Meat rawly roam free and eat grass an chickens don’t forage for grain and bugs. As consequence the ration of omega 3 to 6 is changing to 10-20:1 when ideally they should be 3-4:1. The best way to improve this ratio is to eat oily fish 2-3 times a week as part of a regular balanced diet.
Sources of polyunsaturated fatty acids include:
Fish: The most widely available source of unsaturated fats and the essential long chain n-3 fatty acids EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid is cold water oily fish. Interestingly, however, fish do not synthesize them; they obtain them from the algae and plankton they eat. Fish with the highest levels include mackerel, salmon, herring, anchovies, pollock, shark, swordfish and sardines. Tuna also contain n−3 in somewhat lesser amounts as does the oils from these fish have a profile of around seven times as much n−3 as n−6. Consumers of oily fish should be aware of the potential presence of heavy metals such as mercury, cadmium (from discarded batteries) PCB’s, dioxin. As these accumulate in the food chain larger fish such as shark and sword fish have the highest levels. It is suggested that their intake should be limited to twice a week (which is still more than the majority of people currently consume in a western diet). However, after extensive review of the evidence the Harvard’s school of Public Health, reported in the Journal of the American Medical Association that the benefits of fish intake generally far outweigh the potential risks. Contamination is even lower in white, sea fish such as bass and bream, and no limits have been set on their consumption, although these have lower omega-3 levels. Freshwater fish such as trout and lake varieties are almost completely free of the potential heavy metal contamination and have good levels of omega3. Some protection from mercury contamination can be gained from eating foods rich in selenium (brazil nuts, crab meat) and this metal can bind to the mercury and stop it being absorbed into the body.
Linseeds (flax seeds) and the healthy oil it produces have a very high percentage of unsaturated to saturated fats. It also contains a high percentage of omega-3 content, six times richer than most fish oils albeit in the short chain form (alpha-linoleic acid) with a 3:6 ratio of approximately three to one.
Avocado have the highest oil content of all fruits and most of this is unsaturated, mainly monounsaturated and omega-9. Other natural sources of healthy fats include rapeseed oil which is cheap and convenient, as it can be grown in northern European countries.
Nuts and seeds almost all contain a good percentage of unsaturated fats but walnuts are one of few nuts that contain appreciable omega-3, with approximately a 1:4 ratio. Pumpkin seeds have a high percentage of unsaturated fats (90%) and a good ratio of omega 3:6 (3:1).
Kiwi fruit has an even better ratio of omega 3:6 but there are only small quantities of oil in kiwi’s as opposed to linseeds.
Microalgae are rich sources of the longer chain omega-3 fatty acid (EPA and DHA) and can be produced commercially in bioreactors. This process may be the answer to supplying the future populations of the world with enough omega-3 and is the only source of DHA acceptable to vegans. Brown algae (kelp) is also an excellent source of EPA.
Other plant based foods with a good ratio of omega 3:6 include acai, butternuts, chai sage, shiso and lingonberry. The leafy green vegetable Portulaca oleracea (Purslane) has the highest omega 3 levels of the green vegetables but this is very rarely used in western cooking. Some vegetables contain a small amount of omega 3, particularly strawberries and broccoli.
Extracted plant oils. Most oils used for cooking or salads contain a mixture of saturated and unsaturated fats. Linseeds (flax seeds) oil is healthy as it has a very high percentage of unsaturated to saturated fats. Olive and rapeseed (canola) oils have a particularly a good percentage of unsaturated fats. Sunflower, soya bean and corn oil all contain mostly polyunsaturated fat so are also reasonable choices but tend to be heavily processed during manufacturing. Palm and coconuts have the worst percentage of unsaturated fats but cold pressed varieties can still be healthy. In terms of omega 3:6 ratio the best oils are linseeds, rapeseed (canola), soybean and olive oils (which also has omega-9). Oils from microalgae and kelp contain the highest DHA and EPA levels and are usually taken as a supplement rather than used for cooking.
Some meat: If you have a high cholesterol try to eat less meat but if you do want to, try to buy grass-fed animals, particularly game or highland. Studies suggest that the evolutionary human diet, rich in game animals, seafood and other sources of n−3, may have provided such a ratio. Chickens which roam around eating grass, worms and insects as well as grain generally have much higher omega-3.
Some eggs produced by chickens fed a diet of greens and insects produce higher levels of n−3 fatty acids (mostly ALA) than chickens fed corn or soybeans. Like the meat, in addition to feeding chickens insects and greens, fish oils may be added to their diet to increase the amount of fatty acid concentrations in eggs. The addition of flax, chia and canola seeds to the diet of chickens, both good sources of alpha-linolenic acid, increases the omega-3 content of the eggs but this is very rarely done for mass produced chicken eggs.
Some milk and cheese from grass-fed cows may also be good sources of omega-3. One UK study showed that half a pint of milk from grass feed cows provides 10% of the recommended daily intake (RDI) of ALA, while a piece of organic cheese the size of a matchbox may provide up to 88%. One UK company is now producing premier cheese which is made only from milk from cows which have grasses on the first spring grass – packed with Natural fats and nutrients.
Higher processed sugar intake:
A number of cohort studies have linked higher processed sugar intake with higher serum cholesterol and heart disease. Not withstanding the influence of sugars on obesity, the two explanations of why sugar increases cholesterol are firstly that the peaks and troughs of insulin levels signal the metabolism into believing it needs to store more energy so decreases excretion of cholesterol and increases reabsorption. The second explanation, expanded below, is that sugar leads to increased expression of inflammatory markers including 12-lipoxygenase (12-LOX) and its arachidonate metabolites [Yang]. Chronic inflammation is linked to high cholesterol levels … The most convincing study, published in the Journal of the American Medical Association, analyzed the dietary habits of a cohort 6110 Americans and showed that, after several years, those who eat more than 10% of their daily calories as sugar had significantly raised triglyceride levels, lower HDL and higher LDL cholesterol levels [Welsh]. – tips to reduce process sugar intake
Not having a healthy gut bacterial flora:
Research presented at the American Heart Association’s Scientific Sessions in 2012 reported that a formulation of Lactobacillus may be able to reduce blood levels of LDL (bad cholesterol). A total of 60 people, between the ages of 18-65, took part in the randomised, double-blind placebo controlled study trial study, 30 in the probiotic group and 30 forming the placebo group for 12 weeks [Fuentes]. The group taking the probiotic strains observed a significant reduction in total cholesterol levels, of 13.6%. The reason why probiotic bacteria reduce cholesterol is that they produce significant levels of bile salt hydrolase, which is effective at metabolising bile salts which contain cholesterol. In addition these strains have a high ability to incorporate dietary fat into their bacterial cellular surface therefore reducing the absorption of saturated fat from the diet. The bacteria were also shown to create large quantities of both butyric acid and propionic acid, both of which are produced by the anaerobic bacterial fermentation process [Boosch]. Finally probiotic bacteria help reduce inflammation in the body along with other factors regular exercise, polyphenol rich diet, macrobiotic diet as opposed to pro-inflammatory factors such as obesity, exposure to environmental of ingested toxins. It’s important to note that not all probiotic formulations have these properties so invest in a good one – More about good quality probiotics. Apart from a good probiotic supplement healthy bacteria can be founds in:
- Miso Soup
- Other fermented cabbage foods
Dietary phytochemicals and polyphenols;
Numerous cohort studies have linked higher intake of polyphenol rich foods with lower total cholesterol, LDL and heart disease. The beneficial affect on cholesterol appeared to be synergistic appeared to be synergistic flavonoids rich foods are combined with isoflavones and plant sterols (see below). As well as heart disease, these natural chemicals have numerous health benefits particularly in the reduction of chronic diseases which affect humans including diabetes (read more), dementia, arthritis (read more) and Parkinson’s disease. Foods with high polyphenol content include:
- Leafy green vegetables
- Cruciferus vegetables
- Chocolate (unsweetend of course)
- Herbs and spices
Phytosterols are structurally related to cholesterol. Plants manufacture phytosterols, which can compete with cholesterol for reabsorption in the intestinal tract, thus potentially reducing cholesterol reabsorption. When intestinal lining cells absorb phytosterols, in place of cholesterol, they usually excrete the phytosterol molecules back into the gut, an important protective mechanism. Sitosterol and campesterol are the most frequent plant sterols and constitute about 60% and 35%, respectively, of plant sterols in food. Plant stanols, are the saturated form of plant sterols, meaning they have no double bond in the sterol ring. Saturated sitosterol is known as sitostanol and saturated campesterol is campestanol. Plant foods that are particularly rich in phytosterols (stanol or sterol esters) include:
- Flax seed,
- Soy beans,
- Pumpkin seeds,
- Beans and buckwheat but are also found in
- Grains, vegetables, fruits, nuts and seeds.
Regular intake of these foods are linked to lower serum cholesterol levels as highlighted in a recent meta-analysis of 41 trials. From these data it appeared that 2-3 g/day seemed to be the optimal amount to reduced low-density lipoprotein (LDL) by about 10% and higher intake of sterol esters did not seems to reduce cholesterol further. The beneficial effects, however, were found to be additive with other lifestyle interventions. For example, eating foods low in saturated fat and cholesterol and high in phytosterols reduced LDL by up to 20% and eating them with statin medication almost doubled their cholesterol lowering capacity. In addition, a growing body of scientific evidence also suggests other positive health outcomes that include the reduced risk of certain types of cancer [Katan]. Although further research is needed to determine whether this reduction in LDL will lead to a reducing in heart attack, numerous organisations are promote their intake as a therapeutic option including the American Heart Association (AHA) Spanish Cardiology Society, the Association of Clinical and Public Health Nutritionists in Finland, and the National Heart Foundation in Australia.
Plant sterol and stanol supplements: A dietary supplement is regarded by many as a convenient way to boost daily intake, especially those who do not like eating plant sterol rich foods. They would also be useful for those getting side effects of statins as studies show how they enhance the LDL lowering effect of statins so one option would be to lower the statin dose and take a concomitant plant sterols supplement. There are some safety issues related to very high intake (>3g / day) of plant esters sterols as this is known to increase serum plant sterol levels.20,50 which some argue may potential increase artherosclerosis. This risk is believed to be largely hypothetical, and any increase due to the small increase in plasma plant sterols may be more than offset by the decrease in plasma LDL. High doses can potentially affect the absorption of cartenoids and fat-soluble vitamin.21 . This can, in theory, constitute a hazard to children, pregnant and breastfeeding women. Because of this theoretical risk, labelling, therefore, advises these individuals to avoid consuming these products. 10,1122. Despite this theoretic risk, meta-anlaysies have not demonstrated lower vitamin A, D, E and K levels after have plant sterol intake [Rosin]. The reality that in a western diet the consumption of plant sterols is usually very much less than 0.5g / day so individually can safely be advised to eat considerable more of these foods. As an added precaution, nutritional supplements and functional foods can be enriched with saturated, less absorbable plant stanol esters which not only serum cholesterol, but also plant sterol levels 20,50 Hallikainen]. The safety and efficacy of plant stanol ester have been confirmed in more than 70 published clinical studies and the ingredient is a well-established and widely recommended dietary measure to reduce serum cholesterol. Daily intake of 2 g plant stanols as plant stanol ester lowers LDL-cholesterol by 10%, on average. In Europe, foods with added plant stanol ester have been on the market for 20 years, and today such products are also available in many Asian and American countries. For optimal cholesterol lowering aiming at a lower risk of cardiovascular disease, plant stanol ester should be used daily, in sufficient amounts, with a meal and in combination with other recommended dietary changes [Hallikainen].
- Exercise most days and avoid periods of inactivity through eat day.
- If you are not underweight consider taking some exercise first thing in the morning before breakfast
- Reduce overall energy intake aim for overnight fasting (no food for 13 hours)
- Reduce cholesterol and saturated fat rich food intake
- Eat less meat and more plants
- Increase polyunsaturated fatty acid intake
- Stop eating processed sugar
- Increase intake of polyphenol rich foods
- Increase plant sterols (esters and stanols)
- Increase probiotic bacteria intake to help maintain gut health
In conclusion, foods which contain lower levels of saturated fats and higher levels of unsaturated facts are beneficial to the health because they reduce the risk of cancer, reduce the cholesterol, and low density lipoprotein (LDL-bad fats), reduce blood pressure and the risk of cardiovascular disease including strokes and heart attacks. Foods which contain higher levels of omega3 (particularly the longer chain varieties EPA and DHA) are thought to also protect individuals from degenerative disorders such as dementia, poor eyesight and Parkinson’s disease. It would be very wise to ask your doctor to measure your lipid profile with a fasting blood test. If your cholesterol or LDL is high it is time to change the type of fat you eat, to reduce the risk of cancer relapse and improve your chances of survival, not only from cancer but heart disease and stroke.
If these dietary measures don’t reduce your total cholesterol or improve the ration of LDL (Bad) to HLDL (good) cholesterols then it may be wise to consider supplementation with polyphenols, plant sterols and stanols and a good quality probiotic. If these still fail then you have to discuss a statin with the GP but even if you are on a statin you could adopt these measures to make the statin more effective so you could even take a lower dose.
Rosin S et al. Optimal Use of Plant Stanol Ester in the Management of Hypercholesterolemia. Cholesterol 2015 doi: 10.1155/2015/706970
Hallikainen MA, et al Comparison of the effects of plant sterol ester and plant stanol ester-enriched margarines in lowering serum cholesterol concentrations in hypercholesterolaemic subjects on a low-fat diet. Eur J Clin Nutr. 2000 54(9):715-25.
Katan MB, Grundy SM, Jones P, Law M, Miettinen T, Paoletti R. Efficacy and safety of plant stanols and sterols in the management of blood cholesterol levels. Mayo Clin Proc. 2003;78:965–978. [PubMed]
Welsh J, Sharma A, Abramson J et al Caloric sweetener consumption and dyslipidemia among US adults.2010 JAMA 21; 303(15),1490-7.
Kitahara C, de González B, Jee S et al Total Cholesterol and Cancer Risk in a Large Prospective Study. 2011 J Clin Oncol 29:1592-98.
Te Morenga L, Mallard S, Jim Mann J et al Dietary sugars and body weight: systematic review and meta-analyses of randomised controlled trials and cohort studies BMJ 2013;346:e7492
Kitahara C, de González B, Jee S et al Total Cholesterol and Cancer Risk in a Large Prospective Study. 2011 J Clin Oncol 29:1592-98.
Yang J Chan D, Felix E et al A Sucrose-Enriched Diet Promotes Tumorigenesis in Mammary Gland in Part through the 12-Lipoxygenase (inflammatory) pathway. 2015 Cancer Res; 76(1); 24–29.
Platz EA, Clinton SK and Giovannucci E. Association between plasma cholesterol and prostate cancer in the PSA era. Int J Cancer 2008;123(7):1693-1698.
Chomistek AK, et al. Vigorous Physical Activity, Mediating Biomarkers, and Risk of Myocardial Infarction. Med Sci Sports Exerc 2011;43(10):1884-1890.
Rock CL, et al. Results of the Exercise and Nutrition to Enhance Recovery and Good Health for You (ENERGY) Trial: A Behavioral Weight Loss Intervention in Overweight or Obese Breast Cancer Survivors. J Clin Oncol 2015;33(28):3169-3176.
Friedenreich CM, et al. Alberta physical activity and postmenopausal breast cancer prevention trial: sex hormone changes. J Clin Oncol 2010;28(9):1458-1466.
Foster-Schubert K, et al. Effect of diet and exercise, alone or combined, on weight and body composition in overweight-to-obese post-menopausal women. Obesity 2012;20(8):1628–1638.
Fuentes M, et al 2013. Cholesterol-lowering efficacy of Lactobacillus plantarum CECT 7257, 7528 and 7529 in hypercholesterolaemic adults. British Journal of Nutrition, Volume 109, Issue 10, May 2013 pp 1866-1872.
Bosch M, et al 2013. Lactobacillus plantarum CECT 7527, 7528 and 7529: probiotic candidates to reduce cholesterol levels. Journal of the science of food and agriculture: 2013, Nov pg.