One of the most significant discoveries in preventive medicine is that elevated levels of cholesterol in the blood accelerate atherosclerosis, a condition commonly known as hardening of the arteries. Along with high blood pressure, inactivity, smoking, and diabetes, high cholesterol has proven to be one of the most important promoters of heart disease, strokes, and peripheral vascular disease (blockage of circulation to the extremities, usually the legs).
Cholesterol does not directly clog arteries like grease clogs pipes. The current theory is that elevated levels of cholesterol irritate the walls of blood vessels and cause them to undergo harmful changes. Because most cholesterol is manufactured by the body itself, dietary sources of cholesterol (such as eggs) are not usually the most important problem. The relative proportion of unsaturated fats (from plants) and saturated fats (mainly from animal products) in the diet is more significant.
When the consequences of elevated cholesterol were first being researched, total cholesterol was the only measurement considered. Today, the overall lipid profile is taken into account. LDL (“bad”) cholesterol, HDL (“good”) cholesterol, and triglycerides are the most common measurements related to cholesterol. Lipoprotein A and oxidized LDL cholesterol are drawing increasing attention as well.
This change in emphasis has thrown some long-standing recommendations into confusion. For example, reducing total fat intake generally decreases total cholesterol. On this basis, medical authorities long ago adopted a policy of recommending low-fat diets. However, when you take into account other lipid measurements, it is now clear that reducing fat intake is not the clear blessing it first appeared to be. Low-fat diets improve total and LDL cholesterol levels, but worsen HDL and triglyceride levels. Conversely, low-carb, high-fat diets tend to raise levels of LDL and total cholesterol, but reduce triglycerides and raise HDL. Some researchers use these effects as “proof” that the low-fat diet is healthier,270 but, in fact, the current state of knowledge does not tell us whether the changes in lipids produced by low-fat diets are better or worse than the changes produced by low-carb diets. It is possible that a diet low in carbs and high in mono-unsaturated fats (eg, olive oil) offers the best of both worlds, but this has not been conclusively proven.271-276 What is clear is that losing weight is extremely important. If you are overweight and lose weight, your cholesterol profile is almost certain to improve.188
Increasing exercise and losing weight may produce adequate improvements in the lipid profile. If such lifestyle changes are not effective, however, there are many highly effective drugs to choose from. Medications in the statin family are most effective, and they have been shown to prevent heart attacks and reduce mortality. Other useful conventional options include ezetimibe (Zetia), fibrate drugs, and various forms of the vitamin niacin (discussed below).
There are several herbs and supplements that appear to help lower cholesterol levels. For some (such as stanols/sterols, vitamin B 3, fiber, and soy), the evidence is sufficiently strong to have produced mainstream acceptance.
Note: If your primary problem is elevated triglycerides, see the High Triglycerides article.
Stanols are substances that occur naturally in various plants. Their cholesterol-lowering effects were first observed in animals in the 1950s. Since then, a substantial amount of research suggests that plant stanols (usually modified into stanol esters) can help to lower cholesterol in individuals with normal or mildly to moderately elevated cholesterol levels. Stanols are available in margarine spreads, salad dressings, and dietary supplement tablets. Related substances called plant sterols appear to have equivalent effects,173,189 and in this subsection we will refer to sterols and stanols and their esters somewhat interchangeably.
Plant stanol esters reduce serum cholesterol levels by inhibiting cholesterol absorption.10 Because they are structurally similar to cholesterol, stanols (and sterols) can displace cholesterol from the "packages" that deliver cholesterol for absorption from the intestines to the bloodstream.1 The displaced cholesterol is then excreted from the body. This not only interferes with the absorption of cholesterol from food, it has the additional (and probably more important) effect of removing cholesterol from substances made in the liver that are recycled through the digestive tract.
Numerous double-blind, placebo-controlled studies, ranging in length from 30 days to 12 months, have found stanol esters and their chemical relatives effective for improving cholesterol profile levels.2-15,167-169,174,175,263,280 The combined results suggest that these substances can reduce total cholesterol and LDL ("bad") cholesterol by about 10%-15%.16,278,279 However, stanols/sterols do not appear to have any significant effect on HDL ("good") cholesterol or triglycerides.
Fish oil has also been shown to have a favorable effect on fats in the blood, in particular triglycerides. A study investigating the possible benefit of combining sterols with fish oil found that together they significantly lowered total cholesterol, LDL-cholesterol and triglycerides, and raised HDL-cholesterol in subjects with undesirable cholesterol profiles.286
Individuals taking statin drugs may benefit from using stanols/sterols as well.20,21,170,241,278 According to one study, if you are on statins and start taking sterol ester margarine as well, your cholesterol will improve to the same extent as if you doubled the statin dose.170 Stanols or sterols also appear to enhance the effects of cholesterol-lowering diets.17,174
Stanols or sterols also appear to be safe and effective in helping to improve cholesterol profile in people with type 2 (adult-onset) diabetes.18,19,175
For more information, including dosage and safety issues, see the full Stanols article.
The common vitamin niacin, also called vitamin B 3, is an accepted medical treatment for elevated cholesterol with solid science behind it. Several well-designed, double-blind, placebo-controlled studies have found that niacin reduced LDL cholesterol by approximately 10% and triglycerides by 25%, and raised HDL cholesterol by 20%-30%.22-27 Niacin also lowers levels of lipoprotein A—another risk factor for atherosclerosis—by about 35%. Furthermore, long-term use of niacin has been shown to significantly reduce death rates from cardiovascular disease.28
Niacin appears to be a safe and effective treatment for high cholesterol in people with diabetes as well, and (contrary to previous reports) does not seem to raise blood sugar levels.29 Unfortunately, niacin, if taken in sufficient quantities to lower cholesterol, can cause an annoying flushing reaction and occasionally liver inflammation.30 Close medical supervision is essential when using niacin to lower cholesterol.
Combining high-dose niacin with statin drugs (the most effective medications for high cholesterol) further improves lipid profile by raising HDL (“good”) cholesterol.149-151 Unfortunately, there are real concerns that this combination therapy could cause a potentially fatal condition called rhabdomyolysis.
A growing body of evidence, however, suggests that the risk is relatively slight in individuals with healthy kidneys. Furthermore, even much lower doses of niacin than the usual dose given to improve cholesterol levels (100 mg versus 1,000 mg or more) may provide a similar benefit.152 At this dose, the risk of rhabdomyolysis should be decreased.
Nonetheless, it is not safe to try this combination except under close physician supervision. Rhabdomyolysis can be fatal.
For more information, including dosage and safety issues, see the full Vitamin B3 article.
Water-soluble fiber supplements (such as psyllium, hydroxymethylcellulose and its relatives, and beta glucan from oats) are thought to lower cholesterol,253,263,291 and the FDA has permitted products containing this form of fiber to carry a "heart-healthy" label.31 It must be kept in mind, however, that the bulk of the supporting evidence for this theory comes from studies of oats conducted by manufacturers of oat products.255 A typical dose of oat bran is 5 to 10 g with each meal and at bedtime; psyllium is taken at 10 g with each meal.
Soy protein appears capable of modestly lowering total cholesterol, LDL ("bad") cholesterol, and triglycerides by approximately 5%-15%.32,238,287 The FDA has allowed foods containing soy protein to make the "heart-healthy" claim on the label. One study suggests that substituting as little as 20 g daily of soy protein for animal protein can significantly improve cholesterol levels.33 Higher doses appear to cause increased benefit.238
Although it was once thought that isoflavones are the active ingredients in soy responsible for improving cholesterol profile, evidence suggests otherwise.34-41,153,158-161,190-194,256,277,288,290 Other substances, such as certain soy proteins, may be more important. However, it has been additionally suggested that soy protein must be kept in its original state to be effective. Ordinary soy protein extracts are somewhat damaged (“denatured”). In a double-blind study of 120 people, a special “preserved” soy protein extract proved more effective for improving cholesterol profile than standard denatured soy protein extracts.260
For more information, including dosage and safety issues, see the full Soy article.
Although primarily used to stimulate gallbladder function, artichoke leaf may be helpful for high cholesterol as well.
In a double-blind, placebo-controlled study of 143 individuals with elevated cholesterol, artichoke leaf extract significantly improved cholesterol readings.81 Total cholesterol fell by 18.5% as compared to 8.6% in the placebo group; LDL cholesterol fell by 23% versus 6%; and the LDL to HDL ratio decreased by 20% versus 7%. In a subsequent study of 75 otherwise healthy people with high cholesterol, artichoke leaf extract significantly reduced total cholesterol compared to placebo, but it did not affect LDL, HDL, or triglycerides levels.283
Red yeast rice is a traditional Chinese medicinal substance. It is made by fermenting a type of yeast called Monascus purpureus over rice. It contains cholesterol-lowering chemicals in the statin family, including one identical to the drug lovastatin. Like statin drugs, red yeast rice appears to be effective for improving various aspects of the lipid profile, including total cholesterol, LDL cholesterol, and the LDL/HDL ratio.205-206,259 Presumably it also presents the same safety risks as statins, compounded by the uncertainty regarding how much active drug any particular batch of red yeast rice contains.
In a 2011 review of 22 trials, researchers concluded that an alcohol extract of red yeast rice (called xuezhikang) was no more or less effective than statins in lowering levels of cholesterol and triglycerides in people with high cholesterol and/or high triglycerides.292 They also found that the supplement may be more effective than inositol nicotinate (another cholesterol-lowering medication) in reducing cholesterol levels.
Red yeast rice significantly decreased LDL cholesterol and significantly increased HDL cholesterol compared to placebo. Results were amplified in those who took red yeast rice when compared to a nonstatin active control. The review of 20 randomized trials included 6,663 patients, some of whom were followed for up to 3.5 years. Interestingly, an evaluation of 3 trials of 191 patients found that red yeast rice was as effective as commonly prescribed statin drugs.297
For more information, including complete dosage and safety issues, see the full Red Yeast Rice article.
Numerous studies enrolling a total of many thousands of individuals purported to show that the substance policosanol, made from sugarcane, can markedly improve cholesterol profile. However, the single Cuban research group behind these studies has a financial connection to the product. It was not until 2006 that independent research groups began to report their results on the use of policosanol for hyperlipidemia. Currently, 9 such independent studies have been reported, enrolling more than 500 people, and in not one of these studies has policosanol proved to be more effective than placebo. See the full Policosanol article for detailed information.
In a 12-month study of 223 postmenopausal women, calcium supplements (calcium citrate at a dose of 1 g daily) significantly improved the ratio of HDL ("good") cholesterol to LDL ("bad") cholesterol.155 This appears to have been primarily due to a meaningful rise in HDL levels.
Krill are tiny shrimp-like crustaceans that flourish in the Antarctic Ocean and provide food for numerous aquatic animals. Krill oil, similar but not identical to fish oil, may improve cholesterol profile.204 Fish oil may enhance the effectiveness of drugs in the statin family.252,264 EPA, another constituent of fish oil, may help prevent severe heart complications in people with high cholesterol already taking statins.254
One double-blind study found evidence that cinnamon, taken at a dose of 1-6 grams daily, improved triglyceride, LDL cholesterol, and total cholesterol, without worsening HDL cholesterol in people with type 2 diabetes.198
A review of 10 randomized trials consisting of 542 patients found that cinnamon may help decrease total cholesterol, LDL cholesterol, and triglyceride levels in patients with type 2 diabetes. Doses of cinnamon ranging from 0.12 g to 6 g showed significant decreases compared to placebo or no treatment. There were also beneficial increases in HDL cholesterol as well. Unfortunately, there were several flaws in the trials, including the amount of the preferred dose and length of treatment.295 At present, it would be premature to consider cinnamon an evidence-based treatment for high cholesterol, but it has definitely shown some promise.
Inconsistent evidence hints that flaxseed might reduce LDL cholesterol and, overall, slow down atherosclerosis.95,96,98-100,157,208,284 Flaxseed oil may be helpful as well, although evidence is again inconsistent.209,242 It may be the generic fiber and not the other specific ingredients in flaxseed that benefit cholesterol levels.97,184 Studies of purified lignans (found in flaxseed) have yielded mixed results.210,269
A growing body of evidence suggests that increased consumption of nuts such as almonds, walnuts, pecans, and macadamia nuts may improve lipid profile and reduce heart disease risk, presumably because of their high monounsaturated fat content.101-109,163,211-212,281
Olive oil is known to improve cholesterol profile. Up until recently, it has been thought that the monounsaturated fats in olive oil are its primary active ingredients. However, some evidence hints that polyphenols in olive oil (particularly, virgin olive oil) may play a positive role as well.239
Some but not all studies suggest that "friendly" bacteria ( probiotics) might be able to improve cholesterol profile.123-128,213, 250 So-called " prebiotics," substances that enhance the growth of friendly bacteria, have shown inconsistent benefit in studies as well.214-221 One study found that any improvement, if it does occur, is short-lived.262
Both black tea200 and green teas enriched with either theaflavin 201 or catechins 261 have shown promise for lowering cholesterol.201,293 There is some suggestion that without such enhancement, both green tea 222 and black tea 266 may be ineffective.
Dark chocolate contains substances related to those in black and green tea, and it too has shown some promise for improving cholesterol profile.243-244, 251,262
Other preliminary double-blind trials suggest potential benefit with the Iranian herb Achillea wilhelmsii,93 the Peruvian herb caigua ( Cyclanterha pedata), carob fiber,94,223 the Chinese caterpillar/fungus cordyceps,224 Ipomoea batatus (sweet potato),162 and a drink containing broccoli and cabbage.199
Chitosan, a type of insoluble fiber derived from crustacean shells, has been proposed for reducing cholesterol levels. But, current evidence suggests that if it does offer any benefits, they are minimal at best.84-92,147,148,187,197,225-226,285
A comprehensive review combining the results of 14 studies found that glucomannan, a dietary fiber derived from the tubers of Amorphophallus konjac, significantly reduced total and LDL cholesterol levels.289
Weaker, and in some cases inconsistent, evidence suggests potential benefit with alfalfa;132-146 berberine (found in goldenseal, honey, Oregon grape, and barberry);227,282 beta-hydroxy-beta-methylbutyrate (HMB);164 blue-green algae;129-131,233 conjugated linoleic acid (CLA);165 L-carnitine;185,230-232 Ayurvedic herb Eclipta alba (also know as Bhringraja or Keshraja);257 grape polyphenols;228-229 mesoglycan;110-112 and nopal cactus.268
Studies on whether the mineral chromium can improve cholesterol levels have returned mixed results.113-121 However, this mineral may offer benefit for people taking drugs in the beta-blocker family. These medications, used for high blood pressure and other conditions, sometimes reduce HDL cholesterol levels. Chromium supplements may offset this side effect.122
Rice bran oil, like other vegetables oils, appears to favorably change lipid profile as well as reduce heart disease risk in other ways.166, 234 Weaker evidence suggests that gamma oryzanol, a substance found in rice bran oil, can also improve lipid profiles.
Substances related to vitamin E called tocotrienols are sometimes promoted as improving cholesterol levels. However, while benefit has been reported in test-tube studies, animal studies, and nonblinded human trials, properly designed studies have failed to find it effective.177, 246-249
A number of studies published in the 1980s and 1990s reported that various garlic preparations, including raw garlic, stabilized garlic powder, and aged garlic, can lower cholesterol.68,69 However, several more recent and generally better-designed studies have found that if any benefits exist, they are so small as to be of little help in real life.70-76,202,235,245
Similarly, guggul, the sticky gum resin from the mukul myrrh tree, has been widely marketed as a cholesterol-reducing herb. However, while preliminary studies found evidence of benefit,77-80 they all suffered from significant design flaws; a well-designed study did not find guggul effective.186
A small randomized trial involving 67 people with high cholesterol found evidence to support the use of sage leaf extract (500 mg every 8 hours) for modestly lowering total and LDL cholesterol levels.294 In another randomized trial of 86 people with high cholesterol and diabetes, sage leaf extract improved cholesterol (HDL and LDL) and trigycerides when compared to placebo.296
Bergamot extract is derived from a bergamot orange. When used as a supplement, the extract has properties similar to cholesterol-lowering statins. In one unblinded study, 77 patients with high cholesterol were randomly placed into 4 groups; bergamot extract, the drug rosuvastatin, bergamot and rosuvastatin, or placebo for 30 days. At the end of the study, the bergamot extract and rosuvastatin group had the biggest drop in total cholesterol compared to rosuvastatin alone. In addition, blood tests showed improvements in biomarkers associated with blood vessel damage.298 A cohort study followed 80 patients with moderately high cholesterol levels for 6 months. During this time, patients took bergamot extract. After 6 months, the bergamot extract reduced total cholesterol, LDL cholesterol, and triglycerides, while raising HDL levels. Blood vessel damage was also reduced.299 These results are promising but much more research will need to be done.
In addition, various herbs and supplements may interact adversely with drugs used to treat high cholesterol. For more information on this potential risk, see the individual drug article in the Drug Interactions section of this database.
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