--- topic: "High Cholesterol" title: "High Cholesterol: What to Try First" order: 1 description: "Which foods lower LDL cholesterol, how much each helps, and when a statin is worth taking, with the trials behind each step." question: "What lowers cholesterol naturally, and when are statins worth it?" answer: "A full food-first plan probably lowers LDL cholesterol by 15 to 30 percent; statins are worth adding when heart-attack risk is high." actions: - "Add soluble fiber: 3+ g a day of oat beta-glucan lowered LDL by about 10 mg/dL across 28 trials; nuts, soy protein and plant sterols add to it [1][7]." - "Replace some saturated fat (butter, fatty meat, tropical oils) with polyunsaturated fat from nuts, seeds and fish; trials cutting it for two years or more saw fewer cardiovascular events [2]." - "Ask for a 10-year risk estimate: at 10 percent or more, or after a heart attack or stroke, a statin is worth discussing alongside food changes [3][4]." cautions: - "Cholesterol of 310 mg/dL (8 mmol/L) or more, early heart disease in the family, or fatty tendon lumps can signal familial hypercholesterolemia, which usually needs medication plus diet [5]." - "Red yeast rice contains lovastatin, a statin, in unpredictable amounts and sometimes the kidney toxin citrinin, so ask your clinician first, especially with a statin or in pregnancy [9]." - "Do not stop a prescribed statin on your own: in large trials, over 90 percent of muscle complaints among statin users were not caused by the statin [11]." confidence: 4 confidenceNote: "Food effects on LDL are consistent across many trials and statin benefit is firmly established, but the food trials measured cholesterol, not heart attacks." evidenceSummary: rctCount: 1 observationalCount: 1 metaAnalysisCount: 7 totalParticipants: "170,000+ in statin trials; 56,000+ in saturated-fat trials" replicated: true newestStudyYear: 2022 references: - id: "1" pmid: "29807048" title: "Portfolio Dietary Pattern and Cardiovascular Disease: A Systematic Review and Meta-analysis of Controlled Trials" authors: "Chiavaroli L, Nishi SK, Khan TA, et al." year: 2018 journal: "Prog Cardiovasc Dis" - id: "2" pmid: "32827219" title: "Reduction in saturated fat intake for cardiovascular disease" authors: "Hooper L, Martin N, Jimoh OF, et al." year: 2020 journal: "Cochrane Database Syst Rev" - id: "3" pmid: "21067804" title: "Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of data from 170,000 participants in 26 randomised trials" authors: "Baigent C, Blackwell L, Emberson J, et al. (Cholesterol Treatment Trialists' (CTT) Collaboration)" year: 2010 journal: "Lancet" - id: "4" pmid: "35997723" title: "Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: US Preventive Services Task Force Recommendation Statement" authors: "Mangione CM, Barry MJ, Nicholson WK, et al. (US Preventive Services Task Force)" year: 2022 journal: "JAMA" - id: "5" pmid: "23956253" title: "Familial hypercholesterolaemia is underdiagnosed and undertreated in the general population: guidance for clinicians to prevent coronary heart disease: consensus statement of the European Atherosclerosis Society" authors: "Nordestgaard BG, Chapman MJ, Humphries SE, et al." year: 2013 journal: "Eur Heart J" - id: "6" pmid: "28444290" title: "Low-density lipoproteins cause atherosclerotic cardiovascular disease. 1. Evidence from genetic, epidemiologic, and clinical studies. A consensus statement from the European Atherosclerosis Society Consensus Panel" authors: "Ference BA, Ginsberg HN, Graham I, et al." year: 2017 journal: "Eur Heart J" - id: "7" pmid: "25411276" title: "Cholesterol-lowering effects of oat β-glucan: a meta-analysis of randomized controlled trials" authors: "Whitehead A, Beck EJ, Tosh S, et al." year: 2014 journal: "Am J Clin Nutr" - id: "8" pmid: "12876093" title: "Effects of a dietary portfolio of cholesterol-lowering foods vs lovastatin on serum lipids and C-reactive protein" authors: "Jenkins DJ, Kendall CW, Marchie A, et al." year: 2003 journal: "JAMA" - id: "9" pmid: "20975018" title: "Marked variability of monacolin levels in commercial red yeast rice products: buyer beware!" authors: "Gordon RY, Cooperman T, Obermeyer W, et al." year: 2010 journal: "Arch Intern Med" - id: "10" pmid: "30409567" title: "Impact of Statins on Cardiovascular Outcomes Following Coronary Artery Calcium Scoring" authors: "Mitchell JD, Fergestrom N, Gage BF, et al." year: 2018 journal: "J Am Coll Cardiol" - id: "11" pmid: "36049498" title: "Effect of statin therapy on muscle symptoms: an individual participant data meta-analysis of large-scale, randomised, double-blind trials" authors: "Cholesterol Treatment Trialists' Collaboration" year: 2022 journal: "Lancet" - id: "12" pmid: "20167359" title: "Statins and risk of incident diabetes: a collaborative meta-analysis of randomised statin trials" authors: "Sattar N, Preiss D, Murray HM, et al." year: 2010 journal: "Lancet" --- Food can cut LDL cholesterol by a sixth or more: a "portfolio" of oats, nuts, soy and plant sterols lowered it about 17 percent in pooled trials [1], and less saturated fat meant fewer cardiovascular events [2]. Statins add proven protection, since heart attacks and strokes fall in proportion to the drop in LDL [3]. The gain is greatest after a heart attack or stroke, with very high cholesterol, or at a 10-year risk of 10 percent or more [3][4][5]. ## How it works ### Why LDL is the target LDL particles carry cholesterol into artery walls. Genetic studies, cohort studies and trials together show that LDL causes atherosclerotic heart disease, and that risk falls in proportion to how far, and for how long, LDL is lowered [6]. ### Food steps, with the amounts trials used - **Soluble fiber.** At least 3 g a day of oat beta-glucan lowered LDL by 0.25 mmol/L (about 10 mg/dL) across 28 trials [7]. - **The "portfolio" pattern.** The trial diet contained, per 1,000 kcal, about 1 g of plant sterols, 21 g of soy protein, 10 g of viscous fiber and 14 g of almonds. For a 2,000 kcal day that is roughly 2 g, 43 g, 20 g and 28 g [8]. See [plant sterols](/phytosterols/cholesterol-control-and-heart-health) for sources. - **Less saturated fat.** Trials of two years or more that cut saturated fat, replacing it with polyunsaturated fat or carbohydrate, found fewer cardiovascular events [2]. ### Red yeast rice is a drug in food's clothing It contains monacolin K, which is lovastatin. Across 12 commercial products it ranged from 0.10 to 10.09 mg per capsule, and four contained citrinin, a toxin that harmed kidneys in animals [9]. See [red yeast rice](/red-yeast-rice/cholesterol-and-cardiovascular-support). ### When a statin is worth it Statins pay off most when your absolute risk is high: - **You have had a heart attack, stroke or stent.** Your absolute risk is high, and across 26 trials each 1 mmol/L fall in LDL cut major vascular events by about a fifth in every type of patient studied [3]. - **No heart disease, but age 40 to 75 with a risk factor** (high cholesterol, diabetes, high blood pressure or smoking). A 10-year risk of 10 percent or more earns a recommendation; at 7.5 to under 10 percent a statin is offered selectively [4]. - **Very high cholesterol or early heart disease in the family.** Familial hypercholesterolemia usually needs a statin plus diet [5]. - **Unsure?** A coronary calcium scan can break a tie. In one cohort of 13,644 people, statin users had fewer events if calcium was present, but not if the score was zero [10]. Side effects are real but smaller than feared. In large trials most muscle complaints among statin users were not caused by the statin, and diabetes risk rose slightly [11][12]. Pair medication with food, not instead of it, and never stop a prescribed statin without your prescriber. For the wider picture, see [what really lowers heart disease risk](/heart-disease-prevention/what-really-lowers-heart-disease-risk). ## The evidence in detail ### Does LDL cause heart disease? A European Atherosclerosis Society consensus statement pooled over 200 prospective cohorts, Mendelian randomization studies (natural experiments based on gene variants) and randomized trials, with more than 2 million participants and over 150,000 cardiovascular events. All showed a dose-dependent, log-linear link between LDL exposure and atherosclerotic disease. Any way of lowering LDL particles should lower risk in proportion to the size and duration of the fall, provided there are no harmful off-target effects [6]. ### What statins achieve The Cholesterol Treatment Trialists pooled individual data from 26 randomized trials (170,000 participants, median follow-up about 5 years). Per 1 mmol/L (about 39 mg/dL) fall in LDL, major vascular events fell by 22 percent (rate ratio 0.78, 95% CI 0.76 to 0.80) and all-cause mortality by 10 percent (0.90, 0.87 to 0.93), with no effect on cancer incidence (1.00, 0.96 to 1.04) [3]. For people without heart disease, the US Preventive Services Task Force judged the net benefit at least moderate at a 10-year risk of 10 percent or more, at least small at 7.5 to under 10 percent, and the evidence insufficient from age 76 [4]. ### What food trials achieve In Jenkins' randomized trial, 46 adults with high cholesterol spent one month on a very-low-saturated-fat control diet (n=16), the same diet plus lovastatin 20 mg (n=14), or the portfolio diet (n=16). LDL fell 8.0, 30.9 and 28.6 percent, and C-reactive protein fell 10.0, 33.3 and 28.2 percent; the portfolio and statin groups did not differ significantly [8]. That trial was small and short. A pooled analysis of 7 trial comparisons in 439 people found a smaller LDL fall of about 17 percent (0.73 mmol/L, 95% CI 0.56 to 0.89) on top of a low-saturated-fat diet, with no change in HDL or weight; certainty was graded high for LDL [1]. A meta-analysis of 28 trials found that 3 g or more of oat beta-glucan lowered LDL by 0.25 mmol/L (0.20 to 0.30), with no effect on HDL or triglycerides and a bigger effect at higher starting LDL [7]. A Cochrane review of 15 trials (about 56,700 participants, each at least two years) found that cutting saturated fat reduced combined cardiovascular events by 17 percent (risk ratio 0.83, 95% CI 0.70 to 0.98; moderate-quality evidence). About 56 people had to cut saturated fat for roughly four years to prevent one event in primary prevention [2]. ### Null and conflicting results The same Cochrane review found little or no effect of cutting saturated fat on all-cause mortality (risk ratio 0.96, 0.90 to 1.03) or cardiovascular deaths (0.95, 0.80 to 1.12) [2]. None of the fiber, sterol or portfolio trials above measured heart attacks or strokes; they measured LDL, a marker. On statins, a pooled analysis of 19 placebo-controlled trials (123,940 participants) found muscle pain or weakness reported by 27.1 percent on a statin and 26.6 percent on placebo. The excess appeared in year 1 only (rate ratio 1.07, 1.04 to 1.10; 11 extra events per 1,000 person-years), so about one in 15 muscle reports by statin users was due to the drug [11]. Statins did raise diabetes risk slightly across 13 trials (91,140 participants; odds ratio 1.09, 1.02 to 1.17), about one extra case per 255 people treated for four years [12]. ### Tools for borderline decisions In 13,644 people without heart disease followed for a median 9.4 years, statin use was linked to fewer major events when coronary calcium was present (adjusted subhazard ratio 0.76, 0.60 to 0.95) but not when the score was zero (1.00, 0.79 to 1.27). The number needed to treat over 10 years ranged from 100 (score 1 to 100) to 12 (score above 100). It was an observational, single-center study, so confounding is possible [10]. For familial hypercholesterolemia, a European consensus advises screening when adult total cholesterol is 310 mg/dL (8 mmol/L) or more, or with premature heart disease or tendon xanthomas, and treating with the maximal potent statin dose, adding ezetimibe or bile acid resins as needed [5]. ### Bottom line Confidence is fairly high (4 of 5). Statin benefit is established by pooled randomized trials [3], and food steps reliably lower LDL [1][7][8], with fewer cardiovascular events when saturated fat is cut [2]. The food trials measured cholesterol rather than heart attacks, so the best plan combines both approaches, guided by your absolute risk [4].