Lifestyle Interventions to Lower Cholesterol

If you’re diagnosed with hyperlipidemia, you may need to start medication under a doctor’s supervision. In addition to this treatment, lifestyle changes play a key role in lowering cholesterol.

Typically known as “bad” cholesterol, LDL is what most people have in mind when they talk about high cholesterol. Ideally, you want your LDL to be below 100 mg/dL (or below 70 if you have other risk factors or established heart disease).

Typically, elevated LDL will be a result of your diet and/or genetic predisposition.

“The most common factor that will increase LDL is saturated fats in the diet,” says Dr. Jaime Burkle, a top preventive cardiologist and Chair of Cardiology at Atria. “The big three categories of foods to limit are red meat, dairy, and fried foods.”

Adhering to a Mediterranean diet—high in fresh fruits and vegetables, legumes, whole grains, fish, and olive oil—is a proven method for keeping LDL numbers in check. In particular, adding high-fiber foods, such as oatmeal and legumes, is thought to be helpful for reducing the amount of cholesterol your body absorbs.

For years, scientists thought that dietary cholesterol affected circulating cholesterol. As a result, public health officials instructed us to avoid high-cholesterol foods, such as meat, dairy, shellfish, and eggs only to later learn that a low-cholesterol diet wouldn’t help lower your cholesterol levels unless it was actually a diet low in saturated fats.

Though there is a significant overlap in foods high in cholesterol and high in saturated fat, there are important exceptions. “The perfect example is eggs,” says Dr. Burkle. “Eggs have high dietary cholesterol, but people who consume eggs regularly don't have as high cholesterol as those who consume large amounts of saturated fats. Saturated fats directly correlate with LDL cholesterol, whereas dietary cholesterol doesn't.”

“The vast majority of our blood cholesterol is made in the liver from fat and this is not cholesterol that's absorbed,” says Dr. Benjamin Lewis, a leading cardiologist at Atria.

(An exception is for the people who absorb more cholesterol than others. Advanced cardiovascular labs can test this and inform your doctor about what to do next.)

For years, HDL was known as “good” cholesterol, but today that comes with an asterisk: “We're learning that, when it comes to cardiovascular risk, HDL follows a U-shaped curve,” says Dr. Burkle. “So you're at high risk if your HDL is low, but you’re also at risk if your HDL is too high.”

Ideal HDL values are between 45 to 65 mg/dL and under 100mg/dL. Eating fatty fish or taking a fish oil supplement can help boost HDL numbers when they are low. If your HDL is high and you’re otherwise healthy, Atria experts advise you not to worry and monitor it over time.

Triglycerides are the first products to circulate in your blood after you eat, carrying fatty acids that cells use as fuel; the excess is stored as fat for future use. While triglycerides themselves are not atherosclerosis-producing particles, their byproducts are, so people who have consistently elevated triglycerides will be at risk of developing cardiovascular disease over time. Additionally, extremely high levels of triglycerides (1,500 mg/dL) can pose an acute risk very quickly (whereas elevated cholesterol is a long-term risk).

“When it comes to triglycerides, diet is a cornerstone of treatment, because it's directly proportional to the amount of carbs and fat you eat,” says Dr. Burkle. “Restricting carbohydrates and fat and improving diet and exercise can result in a 75% reduction in your triglycerides, which is impressive.”

Alcohol can also increase triglyceride levels, so it’s a good idea to watch how much you drink—especially since it can lower your inhibitions and lead to unhealthy snacking and other poor dietary choices.

Try not to worry about this number, says Dr. Burkle: “You don't need to be a mathematician to understand that if I give you a number, which is the sum of LDL and HDL, you will get a new number. But is that really telling you anything? It's not. I tell my patients, ‘Forget about total cholesterol. Let's look at the LDL and the HDL separately.’”

As a marker of overall atherogenic—or plaque-producing—particles, testing for apo-B will capture all of the “bad” actors in the bloodstream. “All the particles that can cause blockage or atherosclerosis carry this little protein in the surface called apo-B,” says Dr. Burkle. Tracking LDL is like counting the total number of murderers in a city whereas tracking apo-B is like counting the total number of criminals. It gives you a more complete look at all of the threats in the system.

“Inflammation is also very, very important,” says Dr. Burkle. “You don't develop atherosclerosis based on cholesterol alone. You have to have elevated cholesterol and inflammation. So even when cholesterol levels are under control, it's important to also look at high-sensitivity C-reactive protein, homocysteine, Lp-PLA2, and other inflammatory markers to determine if a patient is truly low-risk.”

Stress is an important contributor to heart disease, including high cholesterol. When the body is in a frequent state of fight-flight-or-freeze, the elevated cortisol and adrenaline can spike blood sugar and triglycerides, leading to elevated LDL.

It helps to remember the acronym MESH:

• Meditation is hugely beneficial for decreasing stress; “It doesn’t have to be three hours a day,” says Dr. Burkle. “Just devote some time daily to meditation.”
• Exercise is another proven way to lower stress levels.
• Sleep is crucial—it’s difficult to be relaxed on low sleep.
• Hydration is another key factor in keeping the body functioning smoothly and reducing physical stress.

During periods of stress, Dr. Lewis recommends trying to keep up your usual healthy habits. “It might not make you feel less stressed, but it gives you the psychological and physical reserves to deal with the stress in your life.”

“With cardiovascular health, there’s no pill that will benefit you as much as exercise,” says Dr. Lewis. For optimal heart health, we advise exercising four days a week for 30-45 minutes.

Cardio workouts have long been associated with heart health, but don’t neglect strength training: “For years, as cardiologists, we were focusing on cardio,” says Dr. Lewis, “but we're learning more and more that building muscle mass has a very strong beneficial metabolic effect. You're able to use sugar better, and you're able to store sugars and fats better when you have more muscle mass. So I recommend my patients spend as much time doing strength training as their cardio.”

While lifestyle changes are necessary for anyone with high cholesterol, they do not replace the role of medication when it’s needed. Fortunately, physicians have more medications than ever to choose from or use in combination—including long-acting injections and others. Should you need them, your cardiologist can decide which medications are best for you.