Definition

What Is High Cholesterol?

Hypercholesterolemia is defined as total blood cholesterol above 200 mg/dL, with LDL cholesterol above 130 mg/dL considered borderline-high. LDL particle number matters most, and inflammation and oxidation of LDL in the artery wall are part of how plaque forms.

Cholesterol is a vital molecule: it forms every cell membrane in the body, is the backbone of all steroid hormones (cortisol, estrogen, testosterone, vitamin D), enables bile production for fat digestion, and is essential for brain function. Recent guidelines dropped a specific daily limit for cholesterol in food: observational studies show no consistent link with heart disease, though intakes above today's average raise LDL in most trial analyses²³.

Atherosclerosis, the progressive hardening and narrowing of arteries from plaque deposits, is the underlying mechanism behind coronary artery disease, heart attacks and ischemic strokes. The good news: LDL lowering through diet and, where needed, medication reduces cardiovascular events.

⚠️ Important: High cholesterol is a cardiovascular risk factor that requires clinical assessment. If you have been diagnosed with familial hypercholesterolemia, or have existing cardiovascular disease, please work with your physician before modifying or stopping statin therapy. The nutritional strategies here are evidence-based and many can be used alongside conventional treatment.

An artery cut open to show yellow cholesterol plaque narrowing it, a close-up of cholesterol among blood cells and a blood drop labeled high cholesterol, beside an oil bottle, avocado, garlic and leaves labeled healthy diet

Understanding Your Cholesterol Numbers

Total CholesterolDesirable: <200 mg/dL

LDL ("Bad")Optimal: <100 mg/dL (high-risk: <70)

HDL ("Good")Optimal: >60 mg/dL

TriglyceridesNormal: <150 mg/dL

ApoB (best marker)Optimal: <70 mg/dL

hs-CRP (inflammation)Optimal: <1 mg/L

Types & Classifications

🧬 Primary / Familial Hypercholesterolemia

Genetically driven: mutations in the LDL receptor gene (LDLR), ApoB gene or PCSK9 gene impair LDL clearance from the blood. Familial Hypercholesterolemia (FH) affects 1 in 250 people and causes LDL levels above 190 mg/dL despite a healthy diet. Heterozygous FH raises cardiovascular risk 3 to 10x; homozygous FH (1 in 300,000) requires aggressive intervention. Statin therapy is typically essential; diet supports it.

⚖️ Secondary Hypercholesterolemia

Cholesterol elevation caused by an underlying, addressable condition: hypothyroidism (substantially raises LDL; always test TSH in hypercholesterolemia), type 2 diabetes / insulin resistance (raises triglycerides and small dense LDL), chronic kidney disease, liver disease, obstructive sleep apnea and medications (thiazide diuretics, beta blockers, corticosteroids, anabolic steroids, retinoids). Secondary causes must be ruled out before initiating statin therapy.

🔀 Mixed Dyslipidemia

The most metabolically dangerous pattern, elevated LDL combined with high triglycerides (>150 mg/dL) and low HDL (<40 mg/dL in men, <50 mg/dL in women). This "atherogenic triad" is the lipid signature of insulin resistance, metabolic syndrome and NAFLD (nonalcoholic fatty liver disease). Even with a "normal" LDL number, high triglycerides and low HDL indicate significant cardiovascular risk. The dietary change most consistently associated with improving this pattern is reducing refined carbohydrates and sugar.

Signs & Symptoms

Symptoms of High Cholesterol

High cholesterol is almost entirely asymptomatic until vascular damage is advanced, hence the term "silent killer." By the time symptoms appear, atherosclerosis has typically been progressing for 20 to 30 years.

Symptom	What happens
Early & Subtle Signs
Xanthelasma & Corneal Arcus	Yellowish fatty deposits under the eyelid skin (xanthelasma) or a gray-white arc around the cornea (corneal arcus before age 45) are direct cholesterol deposits, visible markers of hypercholesterolemia or familial hypercholesterolemia. Tendon xanthomas (fatty bumps over the Achilles tendon or knuckles) indicate severe, long-standing cholesterol elevation and strongly suggest FH.
Peripheral Artery Disease Symptoms	Atherosclerosis affecting the leg arteries causes claudication: cramping, aching or fatigue in the calves, thighs or buttocks during walking that resolves with rest. As disease progresses: cold feet, diminished foot pulses, non-healing wounds on the toes or feet, and skin color changes. PAD is a major marker of systemic atherosclerosis; its presence correlates strongly with coronary and carotid artery disease.
Erectile Dysfunction as Early Warning	Endothelial dysfunction, the impaired ability of blood vessel walls to relax and dilate, is one of the earliest manifestations of atherosclerosis. The penile arteries are smaller than the coronary arteries, and ED often precedes cardiac symptoms by 3 to 5 years in men with underlying cardiovascular disease. ED in men under 50 is now considered a cardiovascular risk marker.
Advanced & Emergency Signs
Chest Pain (Angina)	Stable angina (chest tightness, pressure or pain triggered by exertion and relieved by rest or nitrates) indicates significant coronary artery narrowing (>70% occlusion). Unstable angina (occurring at rest or with increasing frequency/severity) is a cardiovascular emergency. Atherosclerotic plaque rupture, triggered by inflammation, causes acute myocardial infarction (heart attack).
TIA & Stroke Symptoms	Carotid artery atherosclerosis causes transient ischemic attacks (TIAs, "mini-strokes"): sudden one-sided weakness or numbness, speech difficulty, visual disturbance or severe headache lasting minutes to hours. TIA is a medical emergency: in a large US study, 10.5% of people seen in the emergency department with a TIA had a stroke within 90 days, half of them within 2 days³⁵.
Elevated Triglycerides & Fatty Liver	Severely elevated triglycerides (above 500 mg/dL) raise the risk of acute pancreatitis, a potentially life-threatening emergency with severe abdominal pain, nausea and vomiting. Moderate hypertriglyceridemia (150 to 500 mg/dL) drives NAFLD, fat accumulation in the liver that can progress to NASH (nonalcoholic steatohepatitis), cirrhosis and liver cancer. The dietary change most consistently linked to lower triglycerides is cutting sugar, fructose and refined carbohydrates, and stopping alcohol entirely.

Treatment Comparison

Conventional and Holistic Treatment for High Cholesterol

🌿 HOLISTIC

💊 CONVENTIONAL

🌿

Holistic / Functional Approach

Lipid-lowering diet, berberine, plant sterols, omega-⁠3, red yeast rice, psyllium, vitamin K2, nattokinase

Berberine Evidence

Small reductions in LDL and triglycerides in meta-analyses, from trials mostly in China³

Dietary Impact

Dietary patterns emphasizing soluble fiber, plant sterols, soy protein and nuts lowered LDL by about 17% across 7 controlled trials, and by 35% in one small 4-⁠week trial²

Timeline

Lipids are rechecked 4 to 12 weeks after starting or adjusting treatment.¹³

Advantage

Diet lowers LDL and can also improve weight, blood sugar and blood pressure

Full Holistic Approach Includes

An anti-atherogenic dietary pattern (see Diet section below), the foundation of cholesterol management.²
Plant sterols and stanols: structurally mimic cholesterol and competitively block its intestinal absorption.⁶
Omega-⁠3 fatty acids: EPA reduces VLDL synthesis and triglycerides.⁵
Psyllium husk (10 to 15 g/day in two doses with water), a soluble fiber that binds bile acids and lowered LDL by about 14 mg/dL in pooled trials¹⁰
Red yeast rice: discuss with your doctor before taking any. Its active compound, monacolin K, is chemically identical to a prescription statin, so this is a statin whether or not it is sold as a supplement. European regulators cap supplements at under 3 mg of total monacolins per day; EFSA judged intakes of 10 mg/day a significant safety concern and recorded severe reactions, including rhabdomyolysis and liver injury, at intakes as low as 3 mg/day. The FDA treats monacolin K as an unapproved drug. Product quality also varies: in one analysis of 35 red yeast rice supplements, 16 contained detectable citrinin, a toxin that can harm the kidneys, though all were within the European limit. Never combine it with a prescription statin, and do not use it as a statin substitute without medical supervision⁴
Nattokinase (2,000 to 4,000 FU/day), an enzyme from fermented soy with trial evidence for lower fibrinogen (a cardiovascular risk factor) and clotting factors; no reliable evidence of plaque reduction. Not suitable with anticoagulant or antiplatelet medications; because of its bleeding risk, do not start it without medical advice (see the supplement table)
CoQ10 (200 to 400 mg ubiquinol/day), sometimes suggested with red yeast rice or statins, which lower circulating CoQ10; trial evidence for benefit is mixed

✅ Key point: These are complements to lipid-lowering medication where it is indicated, not substitutes for it, and the choice belongs with your prescriber.

💊

Conventional / Medical Approach

Statins, cholesterol-absorption inhibitors, PCSK9 inhibitors, fibrates, bile acid sequestrants, prescription omega-⁠3

Statins (First-Line)

HMG-CoA reductase inhibitors reduce LDL 30 to 49% (moderate intensity) or 50% or more (high intensity)¹³; reduce major cardiovascular events by about 22% for each 39 mg/dL (1 mmol/L) of LDL lowering¹⁶

Absorption Inhibitors (Add-On)

In the IMPROVE-IT trial, adding an absorption inhibitor to a statin brought average LDL to 53.7 mg/dL, against 69.5 mg/dL on the statin alone, with slightly fewer cardiovascular events²⁵

PCSK9 Inhibitors

Injectable monoclonal antibodies; in the FOURIER trial, adding one to a statin lowered LDL by 59% and major cardiovascular events by 15%²⁶

Side Effects

Statins: muscle pain, mostly mild, though in blinded trials over 90% of muscle symptoms reported on a statin were not caused by it¹⁴; rhabdomyolysis (rare); elevated liver enzymes; a higher chance of a diabetes diagnosis, a relative increase of about 10% with low or moderate intensity and 36% with high intensity, mostly in people already near the threshold¹⁵; lower blood CoQ10. Fibrates: GI upset, gallstone risk, myopathy (especially with statins). PCSK9 inhibitors: injection site reactions, high cost.

Conventional Approach Includes

High-intensity statins, first-line for high-risk patients (existing CVD, diabetes, FH or 10-⁠year ASCVD risk above 7.5%); reduce LDL by 50% or more¹³
Moderate-intensity statins, for intermediate-risk patients; 30 to 49% LDL reduction¹³
PCSK9 inhibitors, given as injections every two weeks or monthly, for FH, statin-intolerant patients or very-high-risk individuals unable to achieve LDL targets
Fibrates, primarily for severe hypertriglyceridemia (>500 mg/dL) and mixed dyslipidemia; lower triglycerides by up to about 50% and raise HDL modestly²⁷; avoid certain fibrate and statin combinations (myopathy risk)
Prescription omega-⁠3 (EPA-only), FDA-approved for elevated triglycerides in patients on statins.
Bile acid sequestrants, which bind bile acids in the gut to lower LDL²⁷; GI side effects (constipation, bloating); impair absorption of fat-soluble vitamins and many medications

⚠️ Statin consideration: Despite excellent cardiovascular event reduction in high-risk populations, statins work best alongside diet and weight management, which they do not replace. For people at lower risk, guidelines start with diet and lifestyle, and your clinician will decide with you whether and when medication is needed.

Nutritional Strategy

Diet for High Cholesterol

The cholesterol-lowering foods, and what to limit

What to eat or do	Details
✅ Eat More Of:
Oatmeal (steel-cut) with berries, ground flaxseed & walnuts	3 g or more of oat beta-glucan a day lowered LDL by about 10 mg/dL in pooled trials²⁹; flaxseed adds ALA omega-⁠3, and walnuts count toward the daily nuts below.
Green tea (2 to 3 cups a day, or an EGCG extract agreed on with your clinician, since high doses can harm the liver)	It lowered LDL by only about 2 mg/dL in a meta-analysis of 14 trials; extracts giving 800 mg or more of EGCG a day raised liver enzymes in trials.³⁰
Fatty fish 4 to 5x/week (wild salmon, sardines, Atlantic mackerel, herring)	At prescription doses (far more than meals of fish supply), omega-⁠3 lowers triglycerides by roughly 20 to 30%, improves HDL particle quality and reduces LDL oxidation.⁵
Extra-virgin olive oil (3 to 4 tbsp, 45 to 60 mL, a day) as primary fat	In the PREDIMED trial, about 30% fewer major cardiovascular events than on a reduced-fat diet.³¹
Raw garlic (2 to 4 cloves/day) or aged garlic extract	Allicin inhibits cholesterol synthesis and LDL oxidation and decreases platelet aggregation.⁷
Avocado (½ to 1 daily)	Replaces saturated fat with monounsaturated fat; in people with high cholesterol it lowered LDL by about 9 mg/dL, on low-certainty evidence³².
Tomatoes/tomato paste daily	Lycopene, better absorbed from cooked tomatoes with olive oil.
Legumes (1 cup daily: lentils, chickpeas, black beans)	Soluble fiber and plant protein; about a serving a day lowered LDL by about 7 mg/dL in 26 trials.³³
Turmeric + black pepper (1 to 2 tsp daily)	Curcumin lowered LDL by about 5 mg/dL in a meta-analysis of 64 trials, though the evidence was rated low certainty¹⁷; black pepper improves curcumin absorption.
❌ Avoid or Reduce:
Trans fats (partially hydrogenated oils)	Raise LDL, lower HDL, increase Lp(a) and directly promote arterial inflammation. Manufacturers can no longer add them to US foods, a ban fully in force since 2021 ³⁷.
Refined carbohydrates & added sugar	Drive triglycerides, VLDL and small dense LDL.
Processed meats (bacon, deli meats, hot dogs)	High in sodium, nitrites and saturated fat; independently associated with cardiovascular disease.
Alcohol	Raises triglycerides, drives VLDL, increases blood pressure and promotes liver fat accumulation (NAFLD). Even moderate consumption worsens triglyceride-dominant dyslipidemia.

What to eat or do	Details
Top Cholesterol-Lowering Foods and the Evidence
Pectin-Rich Fruits	Apples, pears and citrus provide pectin, a soluble fiber that lowers LDL about as much, gram for gram, as oat fiber, a small effect³⁴.
Nuts (Walnuts, Almonds)	A daily serving lowered LDL by about 5 mg/dL in 61 trials, more at about 2 oz (60 g) a day or more²⁸.

Supplement Protocol

Evidence-Based Supplements for High Cholesterol

These supplements can support diet and, where indicated, medication.

Supplement	What it is for	Typical range	Timing	Notes & cautions
Berberine HCl	Helps the liver clear LDL from the blood. Meta-analyses of randomized trials report reductions in LDL of about 18 mg/dL (0.46 mmol/L) and triglycerides of about 30 mg/dL (0.34 mmol/L), which reviewers call small.³	Set with your prescriber	With meals	If your prescriber agrees, start at 500 mg once daily for 1 week, then increase to twice daily, then 3 times daily, to limit loose stools and nausea. Berberine inhibits CYP3A4 and P-glycoprotein, so it can raise blood levels of many prescription medicines, and it lowers blood sugar on its own. Check with your prescriber before starting it, particularly alongside glucose-lowering medication, an anticoagulant, an immunosuppressant or any drug with a narrow safe range. Not for use in pregnancy or breastfeeding.
Plant Sterols / Stanols	Similar in structure to cholesterol, they block its absorption in the gut. A meta-analysis of 124 placebo-controlled trials in 9,600 adults found a dose-response reduction in LDL of 6 to 12% across intakes of 0.6 to 3.3 g/day, around 10% at 2 g/day, without affecting HDL or triglycerides.⁶	Set with your prescriber	With meals containing some fat	Do not exceed 3 g/day (may reduce fat-soluble vitamin absorption). Carotene and vitamin E levels may decrease slightly; compensate with colorful vegetables.
Omega-⁠3 (EPA + DHA)	They lower the liver's triglyceride output. The American Heart Association reports that 4 g/day of prescription omega-⁠3 lowers triglycerides by roughly 20 to 30%, with 1 to 2 g/day achieving about 5 to 10%. REDUCE-IT found 4 g/day of prescription EPA reduced cardiovascular events by 25% in statin-treated patients with elevated triglycerides.⁵	Set with your prescriber	With the largest fat-containing meal	Prescription omega-⁠3 is a medicine, not the same as a fish oil supplement. At high doses fish oil can have an antiplatelet effect, so tell your prescriber if you take a blood thinner. In heart trials, fish oil supplements raised the risk of atrial fibrillation, an irregular heartbeat, more so above 1 g a day³⁶, so check this dose with your clinician first.
Psyllium Husk	A soluble fiber that binds bile acids in the gut, so the liver draws LDL from the blood to make more bile. Pooled trials show LDL falls by about 14 mg/dL (0.35 mmol/L).¹⁰	Set with your prescriber	30 minutes before meals with a large glass of water	Start at 5 g/day and increase over 2 weeks to prevent bloating and gas. Drink at least 8 oz (240 mL) of water per dose: psyllium without adequate water can cause GI obstruction. If on thyroid medication, take psyllium 4+ hours away (can interfere with absorption).
Aged Garlic Extract (AGE)	Meta-analyses find a modest reduction in total cholesterol, about 9%, but reviewers call its robustness debatable and its value in treating high cholesterol questionable.⁷	Set with your prescriber	With meals, can be split morning and evening	If taking blood thinners, consult your physician: garlic has modest antiplatelet effects. Do not take with antiretroviral medications; it may reduce drug levels.
Artichoke Leaf Extract	It is thought to reduce cholesterol production in the liver and increase bile acid excretion. A meta-analysis of 14 randomized trials found artichoke leaf extract lowered LDL by about 17 mg/dL¹⁸.	Set with your prescriber	As your prescriber advises	If you have gallstones, or have never been checked for them, agree on this with your clinician first: gallstones are common and usually silent, and stimulating gallbladder contraction when stones are present can trigger biliary colic or block a bile duct.
Vitamin K2 (MK-⁠7)	Menaquinone-⁠7 activates Matrix Gla Protein, an inhibitor of arterial calcification. A three-year randomized trial reported improved arterial stiffness in healthy postmenopausal women. The evidence is small, and this is not established as a treatment for high cholesterol.⁸	Set with your prescriber	With the largest fat-containing meal (fat-soluble)	If you take a vitamin K antagonist blood thinner, K2 can affect your INR; consult your physician.
Nattokinase	Bleeding risk: do not take this without medical advice. A fibrin-degrading enzyme from fermented soy. A 26-⁠week randomized trial reported reductions in fibrinogen and clotting factors. Its safety trials excluded people taking anticoagulants, and case reports describe bleeding when it was combined with a prescription anticoagulant. Not appropriate alongside anticoagulant or antiplatelet medicines, including aspirin.¹¹	Do not start without medical advice, and never with a blood thinner or antiplatelet medicine.	On an empty stomach or between meals	Never with blood thinners or antiplatelet medicines, including aspirin: significant bleeding risk. Discontinue 7 to 10 days before any surgery. Not suitable during pregnancy.
Niacin (Nicotinic Acid)	No longer recommended for routine use. High-dose niacin does raise HDL and lower triglycerides and Lp(a), but two large outcome trials found those changes brought no benefit. AIM-HIGH was halted early for futility, and HPS2-⁠THRIVE, in 25,673 patients, found no reduction in major vascular events when niacin was added to statin therapy. Both found real harm: new-onset diabetes and worsened diabetic control, plus excess infections, bleeding and gastrointestinal, musculoskeletal and skin events. The National Lipid Association advises curtailing routine use in statin-treated patients. It retains a narrow role, decided by a specialist, in familial hypercholesterolemia, severe hypertriglyceridemia and statin intolerance.¹²	Specialist decision only. Not a self-directed supplement.	Set by the specialist, who also manages flushing	If a specialist prescribes niacin, liver enzymes (ALT, AST) are checked at baseline and periodically. It needs caution with active liver disease, gout or peptic ulcer; it is tapered rather than stopped abruptly and needs extra monitoring with a statin because of myopathy risk. Niacinamide is a different compound with no lipid effect and is not interchangeable.
CoQ10 (Ubiquinol)	Essential for mitochondrial energy production and a lipid-phase antioxidant. Statins and red yeast rice both lower CoQ10 levels, which is why supplementing it is often suggested for statin-related muscle symptoms. Trial evidence for that is mixed and it is not established practice.⁹	Set with your prescriber	With a fat-containing meal, for absorption	Discuss it with your prescriber before taking it alongside red yeast rice or a statin. Choose a third-party tested product.

References & Evidence Notes

Each numbered entry below is either a source you can follow or a note setting out what the evidence does and does not support. Both are numbered together so the markers in the text line up.

Last reviewed October 20, 2026. Supplement entries are cross-checked against the NIH National Center for Complementary and Integrative Health and the Linus Pauling Institute Micronutrient Information Center.⁹ This page is nutrition education, not medical advice, and it does not replace your doctor. If you take a statin or any lipid-lowering medication, do not change or stop it, and do not add a supplement, without speaking to your prescriber.

Centers for Disease Control and Prevention. High Cholesterol Facts. cdc.gov. ↩
Chiavaroli L, Nishi SK, Khan TA, et al. Portfolio Dietary Pattern and Cardiovascular Disease: a systematic review and meta-analysis of controlled trials. Prog Cardiovasc Dis. ScienceDirect. In 7 trial comparisons in 439 adults with high cholesterol, adding the Portfolio pattern to a cholesterol-lowering diet reduced LDL by about 17%, with high certainty evidence, PubMed 29807048. The 35% figure comes from a 4-⁠week trial in which 13 adults with high cholesterol ate the Portfolio diet and LDL fell by 35.0%, against 12.1% on a low saturated fat diet, PubMed 14624410. ↩ ↩ ↩ ↩
Ju J, et al. Efficacy and safety of berberine for dyslipidaemias: a systematic review and meta-analysis of randomized clinical trials. PubMed 30466986. See also the sex-specific meta-analysis, PubMed 36941490. ↩ ↩ ↩
European Food Safety Authority. Scientific opinion on the safety of monacolins in red yeast rice. PMC7009499. On product quality and citrinin contamination see PMC11202976, and Mayo Clinic's summary of red yeast rice. ↩
Skulas-Ray AC, et al. Omega-⁠3 Fatty Acids for the Management of Hypertriglyceridemia: a Science Advisory from the American Heart Association. Circulation. 2019. ahajournals.org. ↩ ↩ ↩ ↩
Plant sterols and plant stanols in the management of dyslipidaemia and prevention of cardiovascular disease. PMC10343346. Meta-analysis of 124 placebo-controlled trials in 9,600 adults. ↩ ↩ ↩
Effect of garlic on serum lipids: an updated meta-analysis. PubMed 23590705. See also Stevinson C, Pittler MH, Ernst E. Garlic for treating hypercholesterolemia. NCBI Bookshelf. ↩ ↩ ↩
Knapen MHJ, et al. Menaquinone-⁠7 supplementation improves arterial stiffness in healthy postmenopausal women: a double-blind randomised clinical trial. Thromb Haemost. 2015. ↩ ↩
National Center for Complementary and Integrative Health (NIH), nccih.nih.gov, and the Linus Pauling Institute Micronutrient Information Center, lpi.oregonstate.edu/mic. ↩
Pooled analyses of psyllium and soluble fiber trials for LDL reduction, PubMed 38688104, a meta-analysis of randomized trials in adults reporting an LDL fall of about 0.35 mmol/L. It pooled 29 randomized trials in 2,769 adults. ↩
Memorial Sloan Kettering Cancer Center, Nattokinase, mskcc.org. Hsia CH, et al. Nattokinase decreases plasma levels of fibrinogen, factor VII and factor VIII in human subjects. Nutr Res. 2009, PubMed 19358933. The human trial evidence does not cover people taking anticoagulants, so the combination is unstudied rather than shown to be safe. ↩
HPS2-⁠THRIVE Collaborative Group. Effects of extended-release niacin with laropiprant in high-risk patients. N Engl J Med. 2014;371:203-⁠212, and the AIM-HIGH Investigators, N Engl J Med. 2011;365:2255-⁠2267. National Lipid Association summary: lipid.org. ↩
On when to recheck cholesterol: the ACC/AHA cholesterol guideline, as summarized for family physicians, advises repeating a fasting lipid measurement 4 to 12 weeks after starting a statin or changing its dose, to assess adherence and the response to medication and lifestyle changes, and every 3 to 12 months after that as needed. It sets the goal of moderate-intensity statin therapy as a 30 to 49% fall in LDL, and of high-intensity therapy as 50% or more, AAFP guideline summary, 2019. ↩
On statins and muscle symptoms: an individual participant data meta-analysis of 19 double-blind placebo-controlled trials in 123,940 people found that statins caused a small excess of mostly mild muscle pain, mainly in the first year, and that more than 90% of the muscle symptoms reported by people taking a statin were not caused by it, PubMed 36049498. ↩
On statins and diabetes: an individual participant data meta-analysis of large blinded statin trials found a 10% proportional increase in new diabetes diagnoses with low- or moderate-intensity statins and a 36% increase with high-intensity statins, with most new diagnoses in people whose blood sugar was already close to the diagnostic threshold, and noted that this is already counted within the overall reduction in cardiovascular risk, PubMed 38554713. ↩
On how much statins reduce events: an individual participant meta-analysis of 26 randomized trials in about 170,000 people found that major vascular events fell in proportion to LDL lowering, rate ratio 0.78 per 1.0 mmol/L reduction, similar in all types of patient studied, so each 1.0 mmol/L reduction lowered the annual rate by just over a fifth, PubMed 21067804. ↩
On curcumin and cholesterol: a meta-analysis of 64 randomized controlled trials found turmeric or curcumin lowered LDL by 4.89 mg/dL and total cholesterol by 3.99 mg/dL, with evidence assessed as low to very low certainty, PubMed 37230418. ↩
On artichoke and cholesterol: a meta-analysis combining 15 effect sizes from 14 randomized trials found artichoke leaf extract lowered LDL by 17.48 mg/dL and total cholesterol by 17.01 mg/dL, with no significant effect on HDL, PubMed 34569671. ↩
On how common high cholesterol is in the US: the CDC reports that about 86 million US adults have total cholesterol above 200 mg/dL, nearly 25 million above 240 mg/dL, and that slightly more than half of adults who could benefit from cholesterol medicine, 54.5%, are taking it, CDC, High Cholesterol Facts. ↩
On what raises cholesterol: the CDC lists a diet high in saturated and trans fat, too little physical activity and weight gain, smoking, type 2 diabetes, age and inherited familial hypercholesterolemia as risk factors, CDC, High Cholesterol Risk Factors. ↩
On how fast diet can work: in a 2003 randomized trial, 46 adults with high cholesterol ate a diet built on plant sterols, soy protein, viscous fiber and almonds for one month under close supervision, and LDL fell by 28.6%, not significantly different from a starting-dose statin in the same trial, against 8.0% on a low saturated fat control diet, PubMed 12876093. ↩
On when to call for help: NHS guidance advises calling emergency services for chest pain that feels tight or squeezing, chest pain spreading to the arms, neck or jaw, or severe difficulty breathing, and for the stroke signs of face drooping, arm weakness and slurred speech, adding that someone whose symptoms disappear still needs assessment in the hospital, NHS, heart attack and NHS, TIA. ↩
On cholesterol in food: an American Heart Association science advisory noted that recent guidelines dropped a specific dietary cholesterol target, found that observational studies in several countries generally show no significant link between dietary cholesterol and cardiovascular disease, and that most analyses of intervention trials link intakes above current averages with higher total or LDL cholesterol, and advised focusing on healthy eating patterns instead, PubMed 31838890. ↩
On lipoprotein(a): the European Atherosclerosis Society's 2022 consensus statement reports that Lp(a) concentration is more than 90% determined by genetics, that lifestyle measures have minimal impact on it, and that high Lp(a) affects about 1.4 billion people worldwide and is a causal risk factor for cardiovascular disease and aortic valve stenosis. It recommends measuring Lp(a) at least once in adults, treats above 50 mg/dL (125 nmol/L) as raised risk, and does not recommend niacin for lowering it because two outcome trials showed no clinical benefit, PubMed 36036785. ↩
On adding a cholesterol-absorption inhibitor to a statin: in the IMPROVE-IT trial of 18,144 people recently hospitalized with an acute coronary syndrome, average LDL was 53.7 mg/dL with the combination against 69.5 mg/dL on the statin alone, and major cardiovascular events at 7 years were 32.7% against 34.7%, PubMed 26039521. ↩
On PCSK9 inhibitors: in the FOURIER trial of 27,564 people with cardiovascular disease already taking a statin, the injected PCSK9 inhibitor lowered LDL by 59% against placebo and reduced major cardiovascular events from 11.3% to 9.8% over a median 2.2 years, a hazard ratio of 0.85, PubMed 28304224. ↩
On other lipid-lowering medicines: a clinical review reports that fibrates can lower triglycerides by as much as 50% and raise HDL by 5 to 20%, and that bile acid sequestrants bind bile acids in the gut to lower cholesterol, commonly cause gastrointestinal side effects such as bloating and cramping, can reduce the absorption of other medicines and call for monitoring of vitamin absorption in some patients, StatPearls, lipid-lowering drug therapy. ↩
On nuts: a meta-analysis of 61 controlled trials in 2,582 people found that each daily serving of tree nuts lowered LDL by 4.8 mg/dL, with stronger effects at 60 g a day or more and no difference by nut type, PubMed 26561616. ↩
On oats: a meta-analysis of randomized trials found that 3 g a day or more of oat beta-glucan lowered LDL by 0.25 mmol/L, about 10 mg/dL, without changing HDL or triglycerides, PubMed 25411276. ↩
On green tea: a meta-analysis of 14 randomized trials in 1,136 people found green tea or its extracts lowered LDL by 2.19 mg/dL, PubMed 21715508. The European Food Safety Authority found that supplements giving 800 mg or more of EGCG a day raised liver enzymes in trials, and that rare liver injury has been reported even with the tea, PubMed 32625874. ↩
On olive oil: in the PREDIMED trial of 7,447 adults at high cardiovascular risk in Spain, a Mediterranean diet supplemented with extra-virgin olive oil had a hazard ratio of 0.69 for major cardiovascular events against advice to reduce dietary fat, over a median 4.8 years, PubMed 29897866. ↩
On avocado: a meta-analysis of trials found no significant change in LDL overall, but in people with high cholesterol avocado lowered LDL by 9.4 mg/dL, with the certainty of the findings graded low to very low, PubMed 36565850. ↩
On beans, lentils and chickpeas: a meta-analysis of 26 randomized trials in 1,037 people found that about one serving a day, a median 130 g, lowered LDL by 0.17 mmol/L, about 7 mg/dL, PubMed 24710915. ↩
On pectin and other soluble fibers: a meta-analysis of 67 controlled trials found that 2 to 10 g a day of soluble fiber lowered LDL by about 0.057 mmol/L per gram, that pectin, oat and psyllium fiber did not differ in effect, and that the effect is small within the practical range of intake, PubMed 9925120. ↩
On stroke after a TIA: in a cohort of 1,707 people diagnosed with a TIA in 16 northern California emergency departments, 180 (10.5%) had a stroke within 90 days, 91 of them in the first 2 days, PubMed 11147987. ↩
Gencer B, Djousse L, Al-Ramady OT, Cook NR, Manson JE, Albert CM. Effect of long-term marine omega-⁠3 fatty acids supplementation on the risk of atrial fibrillation in randomized controlled trials of cardiovascular outcomes: a systematic review and meta-analysis. Circulation. 2021;144(25):1981-⁠1990. PubMed 34612056. Seven trials with 81,210 people followed for about 5 years: omega-⁠3 supplements were linked to a higher risk of atrial fibrillation (hazard ratio 1.25), more so in trials of more than 1 g a day (1.49), and the risk rose with each additional gram. ↩
On trans fat in US foods: the FDA determined in 2015 that partially hydrogenated oils, then the major source of artificial trans fat, are no longer generally recognized as safe; manufacturers could not add them to most foods after June 18, 2018, with a final compliance date of January 1, 2021; trans fat also occurs naturally in milk, butter, cheese and meat, which the ruling did not affect, FDA, trans fat. ↩

Cause	How It Contributes to High Cholesterol	What Helps
Saturated and trans fat	A diet high in saturated fat and trans fat may contribute to high cholesterol and heart disease²⁰	Replacing them with olive oil, nuts, avocado, fatty fish and soluble fiber, as the diet section sets out
Inherited high cholesterol (familial hypercholesterolemia)	An inherited condition causes very high LDL from a young age that, left untreated, worsens with age²⁰	Lipid-lowering medication set by a clinician, with diet as support; testing close relatives
Low activity and weight gain	Not getting enough activity can lead to weight gain, which can raise cholesterol²⁰	Regular activity and the diet section's food pattern
Type 2 diabetes	Type 2 diabetes lowers HDL and raises LDL²⁰	Good diabetes care and cutting refined carbohydrates and added sugar, as the diet section advises
Smoking	Smoking damages blood vessels so fatty deposits collect more easily, and may lower HDL²⁰	Stopping smoking, with support from a clinician
Age	The body clears cholesterol from the blood less well with age, so risk rises for everyone²⁰	Regular lipid testing, so a rise is found early