Diet to lower cholesterol: what to eat and what to change

What does high cholesterol mean if you feel nothing?

It means that the blood test shows more cholesterol in your blood than is good for your arteries. And it does not hurt. Hypercholesterolaemia gives no symptoms; that is why it is measured, and why it can go unnoticed for years.

Cholesterol travels in the blood within lipoproteins, and the blood test mainly looks at two. LDL, known as “bad cholesterol”, carries it from the liver to the tissues and is what deposits on the artery wall. HDL makes the return journey. Diet mainly changes LDL.

Part of it does not depend on diet. Some people have high cholesterol because of genetics, which is called familial hypercholesterolaemia. In that case diet helps, but it is not enough on its own.

Your doctor will assess whether that applies to you, especially if there has been an early heart attack in your immediate family. The menopause, hypothyroidism and excess weight also push it up.

A lot is within your control. The European dyslipidaemia guideline places four things decided at the shop among the measures with the greatest effect on LDL [1].

These are avoiding trans fats, reducing saturated fat and increasing fibre; losing weight helps mainly if triglycerides are also high. If you want to understand what each figure measures, see the guide on LDL and HDL cholesterol.

What raises cholesterol: fat or egg?

Mainly the fat across the whole week. For years eggs were blamed because they are among the foods with the most cholesterol. But what raises blood cholesterol most is the type and amount of fat you eat, far more than the cholesterol a particular food provides.

The European dyslipidaemia guideline recommends reducing saturated fat to 10 % of daily calories [1]. And above all, it recommends replacing it with polyunsaturated fat or with monounsaturated fat of plant origin [1].

Swapping it for carbohydrates that come with their fibre also helps, such as wholegrain cereal, vegetables, fruit and pulses [1]. With cholesterol already high, the figure falls below 7 % of calories [1].

That fat is found mainly in cured meat, mature cheese, pastries and fried food, the same items that top the list of what to limit. The key word is “replace”. What leaves the plate makes room for something else, and that is how the change lasts.

There is no single egg frequency for everyone with high cholesterol. The eggs you use in omelettes and batters also count, and it is worth reviewing your overall fat pattern with your professional. The white contains no cholesterol; the yolk also contains nutrients. You can read “High cholesterol in children”.

Dietary cholesterol does not disappear from the picture, but it moves into the background. The recommendation remains not to exceed 300 mg a day, especially with high cholesterol [1].

How to shop and build the plate

There are three moves, in order of what changes the blood test most.

1. Change the fat without removing it. Use extra virgin olive oil for cooking and dressing; in a salad one tablespoon is enough. The fats that matter are in oily fish, avocado, unsalted nuts and seeds.

2. Increase fibre. The European dyslipidaemia guideline recommends a pattern with 25–40 g of total fibre a day, including 7–13 g of soluble fibre [1]. In practice, pulses, oats, barley, whole fruit, vegetables and wholegrain cereals help. Adjust the amount with your professional if you have digestive discomfort.

3. Reduce sugar and sugary drinks. Sugar raises triglycerides and weight, which belong to the same risk package. Added sugar should not exceed 10 % of daily calories [1]. To give you an idea, adding sugar to a yoghurt is about 5 g, and a can of soft drink about 30 g.

And the plate, so you do not have to weigh anything: half a plate of vegetables, a quarter protein and a quarter cereal or tuber, preferably wholegrain.

The protein can be fish, pulses, egg, chicken or turkey. If you are looking for the complete pattern, it is the Mediterranean diet with extra virgin olive oil at its centre, the one with the most trials behind it for cardiovascular prevention.

If your blood pressure is also high, choose low-salt versions of tinned foods and lean fresh meat, fish, egg or pulses instead of processed cold cuts.

What does a weekly menu to lower cholesterol look like?

It is the menu by Juana Mª González, dietitian-nutritionist and technical director at Alimmenta, with breakfast, lunch and dinner for all seven days. Who it is for: an adult with high cholesterol and no other condition that requires adjusting the plan. When this menu needs adapting: during pregnancy or breastfeeding.

Also if you have diabetes treated with insulin or medicines that can lower blood sugar too much, kidney disease or an eating disorder.

The table includes three meals with white meat and no red meat as a main dish. There is oily fish on four days, including tuna, and pulses at four meals if we count peas.

Wholegrain cereals, fresh dairy and olive oil help form the pattern; the table does not set portions or guarantee the protein each person needs.

The table does not set quantities: use the hand method as a guide and adjust them to your needs. Between meals, fruit, a plain unsweetened yoghurt or a handful of nuts. If you need ideas for the start of the day, there are nine breakfasts worked out with the same logic.

If you also have high triglycerides

This is the most common situation, and the plan is similar but the order changes. Triglycerides respond less to saturated fat and much more to three things: alcohol, sugar and excess weight.

On sugar, the European dyslipidaemia guideline is explicit. It asks to limit soft drinks strongly if you have high triglycerides or abdominal fat [1]. It also calculates that regularly taking between 15 and 20 % of calories as fructose raises triglycerides by 30 to 40 % [1].

The same applies to alcohol. It is the first thing to reduce or avoid, and there is no “good” amount to recommend.

The third is weight. Losing just 5 to 10 % of your starting weight already improves the lipids in the blood test [1]. There is no need to reach any round number. If you are overweight, that first stretch is the most effective, and you can do it with the weight-loss diet guide.

If uric acid is also high on the same blood test, three of the four changes coincide: alcohol, sugary drinks and weight. The rest is in the food guide for uric acid.

Do yoghurts with sterols and “cholesterol” supplements work?

Plant sterols in fortified foods can reduce LDL [1]. The effect depends on the amount consumed and the product; the guideline does not show that taking them reduces heart attacks [1]. If you are considering one of these products, check the indication and the label with your team, without using it as a substitute for medication.

That is why the European dyslipidaemia guideline states that their use may be considered [1]. It would apply to people with high cholesterol and low or intermediate risk who do not need medication, or as an addition when medication is not reaching target.

Your doctor or dietitian-nutritionist prescribes them. They are not a shortcut to avoid changing your shopping, and we do not recommend any brand.

Oats and barley provide fibre, including beta-glucans [1]. A breakfast with oats does not allow a fixed percentage reduction in LDL to be promised, nor does it justify taking a supplement on your own.

As for other “cholesterol” supplements, do not take them on your own. If any is considered appropriate, your doctor or dietitian-nutritionist will prescribe it.

How long does it take to fall, and can I stop the tablet if it does?

The second question first, because it is the important one. No, neither on your own nor on our advice. Adjusting or stopping a statin, or any other medicine, is a medical decision made with your blood tests in front of you.

Sometimes your doctor decides to review the plan when they see the changes. That conversation should happen with data, and without having stopped anything beforehand.

As for timing, we will not give you a percentage or a date. It depends on your starting point, how much genetics influences it, your medication and how much your diet changes.

What does make sense is agreeing with your doctor when the blood test will be repeated, so that a year does not go by without knowing whether what you are doing is working.

Nor will you find target figures here for total cholesterol, LDL or triglycerides. The number you need to reach depends on your overall cardiovascular risk, and that is calculated and set by the person treating you. Two people with the same LDL may have different targets.

What about menopause and the rest of the blood test?

Cholesterol almost never comes alone, and looking at it in isolation is the most costly mistake. The assessment considers overall vascular risk [1]. That is, cholesterol, blood pressure, blood sugar, weight and smoking together, not one value on its own.

The Mediterranean pattern prioritises olive oil, vegetables, fruit, pulses and wholegrain cereals.

At menopause, cholesterol rises even if you change nothing, because the drop in oestrogen pushes LDL upwards. It is a time to look at the blood test without dramatising it. If you have kidney disease, this plan does not suit you without adjustment. Protein, potassium, phosphorus and salt are adjusted with your nephrologist.

Exercise also counts, even if its effect is moderate. Brisk walking for about 25 to 30 km a week can raise HDL by between 3 and 6 mg/dl [1]. It is not spectacular, but it is real.

Does anything change with cholesterol after 60?

After 60 there is no different diet because of age. To estimate cardiovascular risk in apparently healthy people aged 60 to 69, the ESC/EAS update recommends SCORE2; from 70 onwards, SCORE2-OP [2].

These tools do not apply in the same way if there is already atherosclerotic cardiovascular disease, diabetes, chronic kidney disease or a genetic or rare disorder of lipids or blood pressure [2]. The assessment belongs to the professional, not to a single LDL figure.

The dietary pattern, saturated fats and fibre still matter at the table [1]. If shopping, cooking or chewing has become difficult, we can adapt the preparations without assuming that, because of your age, you need to eat less.

The drug decision depends on risk and on LDL after non-drug measures have been optimised [2]; this menu does not allow you to decide whether to start or stop a statin.

What mistakes do we see in consultation?

These are questions we can review with you when you have high cholesterol.

• Cutting out eggs and keeping the cured meat in your sandwich. It is the change that moves the blood test least, and it leaves untouched what raises it most.
• Switching to “light” products without checking the ingredients. Many biscuits and pastries in that aisle still contain palm or coconut oil.
• Removing olive oil out of fear of fat. It is the fat worth keeping, and without it the plate loses flavour and the plan lasts two weeks.
• Changing the fat and forgetting the fibre. Pulses and oats add their share, and they are the first thing dropped when people are in a hurry.