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Your Guide on How to Lower Cholesterol

Medically reviewed by Leigh Ann Anderson, PharmD. Last updated on May 21, 2021.

Reducing High Cholesterol Levels

Cholesterol is a waxy substance made by your liver. It is important for cell growth and making certain hormones. Lipoproteins are proteins that attach to cholesterol to carry it throughout your body.

But when blood lipid levels get too high (called hyperlipidemia), it can block and narrow your arteries (causing atherosclerosis) and lead to heart disease with an increased risk for heart attack and stroke. That's why it's important to keep your cholesterol levels in check.

Main Types of Cholesterol

  • Low-density lipoprotein (LDL), often called "bad" cholesterol, helps to move cholesterol throughout your body. LDL can stick to the walls of your arteries and block them. 
  • High-density lipoprotein (HDL), or "good" cholesterol, helps to move extra cholesterol to your liver so it can be removed from your body.
  • Triglycerides are a common type of fat that stores energy for the body and can elevate the risk for heart disease if your HDL is low and LDL is high. High triglycerides may also increase your risk for pancreatitis, a serious inflammation of the pancreas.
  • Total cholesterol, a total of your LDL, HDL, and VLDL cholesterol values.

Total cholesterol levels over 200 milligrams per deciliter (mg/dL) may mean you have a greater chance for heart disease. Your doctor may treat you based on factors such as your cholesterol levels, your overall risk for heart disease in the next 10 years, and the risk factors you currently have for heart disease, such as:

  • Being overweight or obese
  • Having diabetes
  • Current smoker
  • High blood pressure
  • Gender
  • Family history

Doctors often prescribe an initial program directed towards healthy lifestyle changes when a patient without heart disease is first diagnosed with high cholesterol levels.

By closely following your diet and being more physically active, you can lower your blood lipid levels. However, factors beyond your control such as your family history may also contribute to high levels. Many patients need the help of medications plus diet and exercise to help keep their lipid levels in check.

Related: What should my cholesterol level be?

What is a Heart-Healthy Diet?

In general, choose these options for a heart-healthy diet:

  • Limit the saturated fat and trans fats you eat is an important step in your diet to lower cholesterol. Use vegetable oils high in monounsaturated fat (such as canola, olive, and safflower oil).
  • Avoid hydrogenated or partially hydrogenated fats (trans fats). FDA regulators have banned the use of artificial trans fats in processed foods. Read labels to choose sources of oils low in bad fats.
  • Poultry, fish, and lean cuts of meat. Remove the skin from chicken and trim the fat from meat. Eat less organ meat (such as liver, brain, and kidney).
  • The AHA recommends at least two servings of fish a week, and fatty fish (mackerel, herring, tuna, salmon, trout) with omega-3 fatty acids can help lower triglyceride levels and be healthy for the heart overall, although omega-3 fatty acids won't lower cholesterol
  • Fresh fruits and vegetables without added fats, salt or sugar.
  • Foods high in fiber, such as whole grain breads and cereals, oats, bran, whole wheat pasta, rice, peas and beans. Avoid white bread or pasta which is loaded with sugar but lacking in fiber. Adults should aim in consuming at least 25 to 30 grams of fiber each day.
  • Eat fewer egg yolks as whole eggs or in prepared foods (try substituting two egg whites for each whole egg in recipes, or using an egg substitute).
  • Skim milk instead of low fat or whole milk.
  • Low-fat or no-fat cheeses (like low-fat or fat-free cottage cheese). Cut down on full-fat processed, natural, and hard cheeses.
  • Fewer commercially prepared and processed foods made with saturated or hydrogenated fats or "partially hydrogenated vegetable oil" (like cakes, cookies, chips and crackers).

Where is saturated fat found? Foods made with saturated, hydrogenated or partially hydrogenated fats are usually solid at room temperature. For example, you will find saturate fats in red meat, poultry skin (like turkey or chicken skin), egg yolks (not whites), lard or butter, whole milk, full fat dairy products, palm and coconut oil, desserts, snacks and sweets (especially processed snacks), and fried or fast foods. Fast food can be especially high in salt, too, worsening blood pressure.

Healthy Diets to Lower Cholesterol, Blood Pressure

Mediterranean Diet: Studies have shown that the Mediterranean diet can lower your LDL and reduce the risk of cardiovascular disease. It may also lower your risk for cancer, Parkinson's disease and Alzheimer's disease. The American Heart Association recommends the Mediterranean Diet.

This diet also encourages daily exercise and social activity, especially when sharing meals with others.

The traditional cooking style of the countries around the Mediterranean sea is a focus of this diet. It is recognized by the 

Products used include:

  • Extra virgin olive oil instead of butter or other fats
  • Herbs to season foods and avoiding excess salt
  • Legumes
  • Small handful of nuts daily (avoid sweetened or salted nuts)
  • Fresh fruits and vegetables
  • Whole grains
  • Low fat dairy, low-fat Greek or plain yogurt
  • Fish and poultry as "heart-healthy" options at least twice a week, and limiting red meat to only a few times per month or less. Choose fatty fish such as mackerel, herring, sardines, albacore tuna, salmon and lake trout which are rich in omega-3 fatty acids. Grill or bake rather than fry.
  • Daily exercise
  • A small glass of red wine (5 ounces for women, 10 ounces for men). This is optional. If you don't drink, do not start for health benefits, as drinking is not without risks. 

DASH Diet: Research shows that the DASH diet lowers high blood pressure and improves levels of cholesterol. Limiting your salt intake is important for blood pressure control and overall heart health. Exercising daily and not smoking are other important tools. The American Heart Association also recommends the the DASH diet.

  • DASH diet centers around eating vegetables, fruits and whole grains.
  • Include fish, lean poultry, beans, and a small handful of tree nuts such as walnuts, almonds, pistachios, cashews, or pecans. All nuts are high in calories, so eat small amounts.
  • Select unsaturated vegetable oils, like canola or olive oil. Use olive oil as a substitute for butter when possible.
  • Low-fat or fat-free dairy products are preferred. Avoid saturated fat, such as what you might find in fatty meats, dairy products like cheese and milk, and tropical oils like palm and coconut oils.
  • Limit baked goods that are high is sugar and saturated fats.
  • Drink plenty of fresh water instead of sugar-sweetened beverages or colas.

Therapeutic Lifestyle Changes (TLC) Diet: Another eating plan is the Therapeutic Lifestyle Changes diet to lower your risk for heart disease. This diet is also combined with lifestyle changes like weight loss and exercise. 

The TLC Diet was created by the National Institute of Health’s (NIH) National Cholesterol Education Program (NCEP). TLC diet is low in saturated fat, trans fat, and dietary cholesterol, and promotes increased physical activity and ways to manage weight for people whose cholesterol level is above their goal. The TLC guide includes helpful lists and charts, sample menus, a 10-year coronary heart disease risk calculator.

In this diet you have to meet certain numbers:

  • Less than 7% of your daily calories should come from saturated fat. Daily fat consumption (saturated fat + other fats like polyunsaturated and monounsaturated) should not exceed 35%. Work with your doctor to meet these goals.
  • Limit dietary cholesterol intake to 200 mg per day. It is suggested to eat no more than 2 egg yolks per week.

Plant sterols, stanols and soluble fiber are also recommended for further LDL lowering. In addition, 30 minutes of moderately intense exercise, such as brisk walking, is recommended on most (preferably all) days of the week.

Other recommended diets for heart health include vegetarian and vegan diets, which focus on fruits, vegetables, beans and lentils, nuts and seeds, whole grains, and elimination of all meat (red meat, poultry and seafood).

Vegetarians may still incorporate some dairy and eggs to their diets, but vegans do not. Vegan diets exclude meat, poultry, fish, eggs and dairy products and any foods that contain these products. A flexitarian diet is primarily a plant-based diet but includes meat, dairy, eggs, poultry and fish on occasion or in small quantities. 

Learn More: Types of vegetarian diets

Exercise and Weight Loss

Regular physical activity may help reduce deaths from heart disease by lowering LDL levels, raising HDL levels, and lowering high blood pressure. Other advantages are lowering triglyceride levels, weight loss and improving the fitness of your heart and lungs.

Start with easier activity like walking or a stationary bike if you have not exercised in a while. If you have heart disease or have had a heart attack talk with your doctor before starting an activity.

Begin by doing the activity for a few minutes most days, then work up to a longer program at least 30 minutes per day, most days of the week. This can include regular aerobic activities such as:

  • Brisk walking
  • Jogging
  • Swimming
  • Bicycling
  • Playing tennis
  • Consider non-weight bearing exercises like swimming, riding a bike or a stationary bike if you have arthritis or other pain when exercising

Drugs Used to Help Lower Cholesterol

Medicine is usually prescribed when LDL levels remain high after following a healthy diet for at least 6 to 12 months. However, some people may start drug therapy sooner or right away because of very high cholesterol levels or heart disease. Keep following your diet and exercise plan.

Drugs that lower blood cholesterol work in different ways. Some drugs are more potent than others, and they have different side effects. The choice of medication or combination of medications will depend upon your risk factors, family history, age, other medical conditions and your preferences for treatments. Common choices include:

HMG-CoA reductase inhibitors (statins)

Generic Name Brand Name
atorvastatin Lipitor
fluvastatin Lescol XL
lovastatin Altorcor, Altoprev
pitavastatin LivaloZypitamag
pravastatin Pravachol
rosuvastatin Crestor, Ezallor Sprinkle 
simvastatin ZocorFloLipid

HMG-CoA reductase inhibitors (statins) work by blocking the cholesterol-producing mechanisms of the liver and helping the liver to remove cholesterol from your blood. Statins can lower your bad LDL cholesterol by as much as 60% depending on the drug and dosage.

Statins are some of the most potent medications available to lower your lipids. Certain statin drugs lower LDL levels more than others, so your doctor will choose a potency based on your needs. Most statins are now available as a generic option and are very affordable.

Muscle pain is a side effect some patients notice with statin use. In many patients, muscle pain may be mild and may lessen over time. However, if you experience unexplained muscle pain, tenderness, or weakness while taking a statin, contact your doctor immediately. On rare occasions, these muscle problems can be serious, with muscle breakdown resulting in kidney damage (rhabdomyolysis).

Some statin drugs are also known to interact adversely with other drugs, and this may influence prescribing choice.

Combination statins

  • Caduet (amlodipine and atorvastatin)
  • Roszet (ezetimibe and rosuvastatin)
  • Vytorin (ezetimibe and simvastatin)

PCSK9 inhibitors

Generic Name Brand Name
alirocumab Praluent
evolocumab Repatha, Repatha Sureclick, Repatha Pushtronex

PCSK9 inhibitors (proprotein convertase subtilisin/kexin type 9 inhibitors) can help to drastically lower cholesterol. These drugs limit the action of the PCSK9 enzyme to help remove LDL from the blood. PCSK9 inhibitors can lower LDL levels by up to 70 percent.

They can help lower high cholesterol in patients with heart disease or high cholesterol due to a genetic risk. They are options if you need additional LDL-lowering after using maximum tolerated doses of statins or other lipid-lowering therapies. These drugs can be combined with statins.

Repatha has been shown to reduce the risk of heart attack, stroke, and the need for certain heart procedures.

Cholesterol absorption inhibitors

Generic Name Brand Name
ezetimibe Zetia

Ezetimibe (Zetia) reduces total cholesterol and LDL bad cholesterol by blocking the absorption of dietary and naturally-made cholesterol. It is classified as a cholesterol absorption inhibitor.

Ezetimibe tablets used alone have not been shown to prevent heart disease or heart attacks. Ezetimibe is usually used in combination with a statin drug.

Side effects are mild and may include diarrhea, joint pains, and feeling tired. Muscle aches may occur, especially when used with a statin. Contact your doctor if you experience unexplained muscle weakness or pain.

Bile-acid sequestrants

Generic Name Brand Name
colestipol Colestid
cholestyramine Prevalite
colesevelam Welchol

Bile is needed for digestion. Bile-acid sequestrants work inside the intestine where they bind to bile acids from the liver and prevent them from being taken back into the blood. Bile is made largely from cholesterol, so these drugs help to lower the body's supply of cholesterol. These drugs are no longer frequently prescribed.

Gastrointestinal side effects can be a limiting factor in treatment. The most common side effects from bile-acid sequestrants are constipation, bloating, cramping, upset stomach, and possible liver damage.

Fibric acid derivatives

Generic Name Brand Name
gemfibrozil Lopid
fenofibrate Fenoglide, Lipofen, Tricor, Trilipix (discontinued), others
clofibrate (discontinued) Atromid-S (discontinued)

Fibric acid derivatives are used to lower triglycerides and reduce cholesterol, and can also increase HDL levels. Fibrates are especially helpful for people with high triglyceride levels.

These agents decrease triglycerides by lowering the liver's production of VLDL cholesterol to increase the removal of triglycerides from your blood.

Side effects may include gastrointestinal discomfort, aching muscles, sensitivity to sunlight, and skin rashes.

Nicotinic acid (niacin)

Generic Name Brand Name
niacin immediate-release Niacor
niacin extended-release Niaspan

Nicotinic Acid (niacin or vitamin B3) lowers triglycerides, total and LDL cholesterol, and raises HDL. Nicotinic acid is found in food, but is available in high doses by prescription. These agents are rarely prescribed.

Niacin decreases triglycerides by limiting your liver's ability to produce LDL and VLDL cholesterol. Niacin doesn't provide any added benefit over using statins alone. Niacin has also been linked to liver toxicity and a risk for stroke, so most doctors now recommend it only for people who can't take statins or PCSK9 inhibitors.

The main side effects are flushing, itching, tingling and headache; taking with food may lessen side effects. The extended-release products may cause less flushing but also are linked with a higher risk of liver toxicity. It can also increase blood sugar levels, uric acid production, and lower blood pressure.

Adenosine triphosphate-citrate lyase (ACL) inhibitors

Generic name Brand name
bempedoic acid Nexletol
bempedoic acid and ezetimibe Nexlizet

Nexletol (bempedoic acid) is an oral once-daily, non-statin (LDL-C) lowering medicine. Bempedoic acid is classified as an adenosine triphosphate-citrate lyase Citrate Lyase (ACL) inhibitor that lowers LDL-C by inhibition of cholesterol synthesis in the liver.

Nexlizet (bempedoic acid and ezetimibe), a combination ACL inhibitor and cholesterol absorption inhibitor was cleared in March 2020. 

Both agents are used once daily in addition to diet and maximally tolerated statin therapy for the treatment of adults with heterozygous familial hypercholesterolemia (HeFH) or established atherosclerotic cardiovascular disease (ASCVD) who require additional lowering of LDL (“bad”) cholesterol.

Common side effects these agents included upper respiratory tract infections, muscle spasms, and hyperuricemia, among others. An increased risk of tendon rupture or injury is listed as a serious warning for bempedoic acid.

Angiopoietin-like 3 (ANGPTL3) inhibitors

Generic Brand
evinacumab-dgnb Evkeeza

Evkeeza binds and blocks ANGPTL3, a protein that plays a key role in lipid metabolism. It is given as a 60 minute intravenous (IV) infusion once every 4 weeks.

Evkeeza (evinacumab-dgnb) is used in addition to other LDL-C lowering therapies to treat adults and children, aged 12 years and older, with Homozygous familial hypercholesterolemia (HoFH). HoFH is a rare, inherited and often fatal condition in which patients cannot remove unwanted LDL from their body.

In studies, common side effects (≥5%) were nasopharyngitis (common cold), influenza-like illness, dizziness, rhinorrhea (runny nose), and nausea.

Dietary Supplements for Cholesterol

Certain nutritional supplements may have added benefit. However, using these agents alone may not provide enough benefit for your heart. Ask your doctor for recommendations about use of supplements.

  • Fish oil: An oily fish added to your diet 2 times per week may help to lower triglycerides. If you prefer a one gram fish oil supplement can be used each day.
  • Soy may have an added effect to slightly lower your lipids such as LDL, triglycerides, and improve HDL. Soy protein foods include tofu, soy butter, edamame, other soy products used to replace meat.
  • Plant sterols: May lower cholesterol. Found in certain margarines, orange juice, and dietary supplements.
  • While garlic is available as a dietary supplement, it has not been shown to be effective in reducing lipid levels.

Also see: Cholesterol Medications and Alcohol Interactions

See Also

Sources

Further information

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.