Also indexed as: Dyslipidemia, Dyslipidemic Diet,
Hypercholesterolemia, Hypercholesterolemic Diet, Hyperlipoproteinemia
See also:
Atherosclerosis
Take control of your cholesterol to lower your heart disease
risk. According to research or other evidence, the following self-care steps may be
helpful:
Cut the bad fats
Foods that contain saturated fat, hydrogenated fat, and
cholesterol (such as animal products, fried foods, and baked snacks) can raise
cholesterol
Reduce risk with fiber
Add whole grains, legumes, fruits, and vegetables to your meals to
reduce heart disease risk
Get some supplemental garlic
600 to 900 mg a day of a standardized garlic extract may help
lower cholesterol and prevent hardening of the arteries
Add soy protein to your diet
30 grams (about 1 ounce) a day of powdered soy protein added to
food or drinks can help lower cholesterol
Talk to your doctor
Atorvastatin (Lipitor), rosuvastatin (Crestor), and lovastatin
(Mevacor) are often prescribed to lower blood cholesterol levels
Raise “good” cholesterol with exercise
Start a regular exercise program to help raise HDL
cholesterol
These recommendations are not comprehensive and are not intended to replace
the advice of your doctor or pharmacist. Continue reading the full high cholesterol article
for more in-depth, fully-referenced information on medicines, vitamins, herbs, and dietary and
lifestyle changes that may be helpful.
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About
Product ratings
Symptoms
Dietary changes
Lifestyle changes
Other therapies
Vitamins
Herbs
References
About high cholesterol
Although it is by no means the only major risk factor, elevated serum (blood) cholesterol
is clearly associated with a high risk of heart
disease.
Most doctors suggest cholesterol levels should stay under 200 mg/dl. As levels fall below
200, the risk of heart disease continues to decline. Many doctors consider cholesterol levels
of no more than 180 to be optimal. A low cholesterol level, however, is not a guarantee of
good heart health, as some people with low levels do suffer heart attacks.
Medical laboratories now subdivide total cholesterol measurement into several components,
including LDL (“bad”) cholesterol, which is directly linked to heart disease, and
HDL (“good”) cholesterol, which is protective. The relative amount of HDL to LDL
is more important than total cholesterol. For example, it is possible for someone with very
high HDL to be at relatively low risk for heart disease even with total cholesterol above 200.
Evaluation of changes in cholesterol requires consultation with a healthcare professional and
should include measurement of total serum cholesterol, as well as HDL and LDL cholesterol.
The following discussion is limited to information about lowering serum cholesterol levels
or increasing HDL cholesterol using natural approaches. Because high cholesterol is linked to
atherosclerosis and heart disease, people concerned about heart disease should also learn more
about atherosclerosis.
Product ratings for high
cholesterol
Science Ratings
Nutritional Supplements
Herbs
Beta-glucan
Beta-hydroxy-beta-methylbutyrate (HMB)
Chromium/brewer’s yeast
Fiber
Glucomannan
Sitostanol
Soy
Vitamin B3 (niacin
only) (see toxicity warnings)
Vitamin B5
(pantethine only)
Vitamin C (protection
of LDL cholesterol)
Fenugreek
Psyllium
Red yeast rice
Beta-sitosterol
Calcium
Charcoal
Copper
Fish oil (krill
oil)
Flaxseed (raw)
Inositol
hexaniacinate
Royal jelly
Tocotrienols
Achillea wilhelmsii
Artichoke
Berberine
Garlic
Green tea
Green tea (enriched
with theaflavins)
Guggul
Chitosan
Chondroitin
sulfate
Creatine
monohydrate
L-carnitine
Lecithin
Magnesium
Policosanol
Vitamin E
Alfalfa
Fo-ti
Maitake
Wild yam
Reliable
and relatively consistent scientific data showing a substantial health benefit. Contradictory, insufficient, or preliminary studies
suggesting a health benefit or minimal health benefit. For an herb, supported by traditional use but minimal
or no scientific evidence. For a supplement, little scientific support and/or minimal health
benefit.
What are the symptoms?
This condition does not produce symptoms. Therefore, it is prudent to visit a health
professional on a regular basis to have cholesterol levels measured.
Dietary changes that may be helpful
Eating animal foods containing saturated fat is linked to high cholesterol
levels1 and heart
disease.2 Significant amounts of animal-based saturated fat are found in beef,
pork, veal, poultry (particularly in poultry skins and dark meat), cheese, butter, ice cream,
and all other forms of dairy products not labeled “fat free.” Avoiding consumption
of these foods reduces cholesterol and has been reported to reverse even existing heart
disease.3
Unlike other dairy foods, skimmed milk, nonfat yogurt, and nonfat cheese are essentially
fat-free. Dairy products labeled “low fat” are not particularly low in fat. A full
25% of calories in 2% milk come from fat. (The “2%” refers to the fraction of
volume filled by fat, not the more important percentage of calories coming from fat.)
In addition to large amounts of saturated fat from animal-based foods, Americans eat small
amounts of saturated fat from coconut and palm oils. Palm oil has been reported to elevate
cholesterol.45 Research regarding coconut oil is mixed, with some trials finding no link
to heart disease,6 while other
research reports that coconut oil elevates cholesterol levels.78
Despite the links between saturated fat intake and serum cholesterol levels, not every
person responds to appropriate dietary changes with a drop in cholesterol. A subgroup of
people with elevated cholesterol who have what researchers call “large LDL
particles” has been reported to have no response even to dramatic reductions in dietary
fat.9 (LDL is the “bad” cholesterol most associated with an increased
risk of heart disease.) This phenomenon is not understood. People who significantly reduce
intake of animal fats for several months but do not see significant a reduction in cholesterol
levels should discuss other approaches to lowering cholesterol with a doctor.
Yogurt, acidophilus milk, and kefir are fermented milk products that have been reported to
lower cholesterol in most,10111213
141516 but not all, double-blind and other controlled
research.171819 Until more is known, it makes sense for
people with elevated cholesterol who consume these foods, to select nonfat varieties.
Eating fish has been reported to increase HDL cholesterol20 and is linked to a
reduced risk of heart disease in most,21 but not all, studies.22 Fish
contains very little saturated fat, and fish
oil contains EPA and DHA, omega-3 fatty
acids that appear to protect against heart disease.23
Vegetarians have lower
cholesterol24 and less heart disease25 than meat eaters, in part because
they avoid animal fat. Vegans (people who eat no meat, dairy, or eggs) have the lowest
cholesterol levels,26 and switching from a standard diet to a vegan diet, along
with other lifestyle changes, has been reported to reverse heart disease in controlled
research.2728
Dietary cholesterol
Most dietary cholesterol comes from egg yolks. Eating eggs has increased serum cholesterol in
most studies.29 However, eating eggs does not increase serum cholesterol as much as
eating foods high in saturated fat, and eating eggs may not increase serum cholesterol at all
if the overall diet is low in fat.30
Egg consumption does not appear to be totally safe, however, even for people consuming a low-fat diet. When cholesterol from eggs is
cooked or exposed to air, it oxidizes. Oxidized cholesterol is linked to increased risk of heart disease.31 Eating eggs also
makes LDL cholesterol more susceptible to damage, a change linked to heart
disease.32
Whether or not egg eaters are more likely to die from heart disease is a matter of
controversy. In one preliminary study, egg eaters had a higher death rate from heart disease,
even when serum cholesterol levels were not elevated.33 However, another
preliminary study found no evidence of an overall significant association between egg
consumption, and risk of heart disease or
stroke, except in people with
diabetes.34 Until more is known, limiting egg consumption may be a good idea,
particularly for people with existing heart disease or diabetes.
While coconut oil is high in saturated fat, some evidence suggests it does not cause
unhealthy changes in blood cholesterol levels compared with other saturated fats. In a
controlled study of people with high cholesterol, coconut oil resulted in higher total and LDL
cholesterol levels compared with safflower oil (a polyunsaturated oil), but lower levels
compared with butter, while HDL levels were similar for all three diets.35 Another
controlled study compared coconut oil with canola oil,36 and found that coconut oil
raised total and LDL cholesterol in people with high cholesterol who were not taking
cholesterol-lowering drugs, but did not affect these levels in people who were taking these
drugs. HDL levels were not reported in this study.
Fiber
Soluble fiber from beans,37
oats,38 psyllium
seed,39 glucomannan, and fruit
pectin40 has lowered cholesterol levels in most trials.4142
Doctors often recommend that people with elevated cholesterol eat more of these high-soluble
fiber foods. However, even grain fiber (which contains insoluble fiber and does not
lower cholesterol) has been linked to protection against heart disease, though the reason for
the protection remains unclear.43 It makes sense for people wishing to lower their
cholesterol levels and reduce the risk of heart disease to consume more fiber of all types.
Some trials have used 20 grams of additional fiber per day for several months to successfully
lower cholesterol.44 Psyllium has also been found to enhance the effect of the
cholesterol-lowering drug
simvastatin.45
Oat bran is rich in a soluble fiber called
beta-glucan. In 1997, the U.S. Food and Drug Administration passed a unique ruling that
allowed oat bran to be registered as the first cholesterol-reducing food at an amount
providing 3 grams of beta-glucan per day, although some evidence suggests this level may not
be high enough to make a significant difference.46 Several double-blind and other
controlled trials have shown that oat bran474849 and oat
milk50 supplementation may significantly lower cholesterol levels in people with
elevated cholesterol, but only weakly lowers them in people with healthy cholesterol
levels.51
Flaxseed, another good source of soluble
fiber, has been reported to lower total and LDL cholesterol in preliminary
studies.5253 A double-blind trial found that while both flaxseed and
sunflower seed lowered total cholesterol, only flaxseed significantly lowered
LDL.54 Amounts of flaxseed used in these trials typically range from 30–50
grams per day. A controlled trial found that partially defatted flaxseed, containing 20 grams
of fiber per day, significantly lowered LDL cholesterol, suggesting that at least one of the
cholesterol-lowering components in flaxseed is likely to be the fiber in this product, as
opposed to the oil removed from it.55 Controlled trials of flaxseed oil alone have
shown inconsistent effects on blood cholesterol.565758
Alpha-linolenic acid
Doctors and researchers are interested in alpha-linolenic acid (ALA)—the special omega-3
fatty acid found in large amounts in flaxseeds and flaxseed oil. ALA is a precursor to EPA, a
fatty acid from fish oil that is believed to
protect against heart disease. To a limited extent, ALA converts to EPA within the
body.59 However, unlike EPA, ALA does not lower triglyceride levels (a risk factor for heart
disease).60 Preliminary research on the effects of ALA from flaxseed has produced
conflicting results.
In 1994, researchers conducted a study in people with a history of heart disease, using
what they called the “Mediterranean” diet.61 The diet was significantly
different from what people from Mediterranean countries actually eat, in that it contained
little olive oil. Instead, the diet included a special margarine high in ALA. Those people
assigned to the “Mediterranean” diet had a remarkable 70% reduced risk of dying
from heart disease compared with the control group during the first 27 months. Similar results
were also confirmed after almost four years.62 Although cholesterol levels fell
only modestly in the “Mediterranean” diet group, the positive results suggest that
people with elevated cholesterol attempting to reduce the risk of heart disease should
consider such a diet. The diet was high in beans and peas, fish, fruit, vegetables, bread, and
cereals; and low in meat, dairy fat, and eggs. Although the authors believe that the high ALA
content of the diet was partially responsible for the surprising outcome, other aspects of the
diet may have been partly or even totally responsible for decreased death rates. Therefore,
the success of the “Mediterranean” diet does not prove that ALA protects against
heart disease.63
Soy
Tofu, tempeh, miso, and some protein powders in health food stores, are derived from soybeans.
In 1995, an analysis of many trials proved that soy reduces both total and LDL
cholesterol.64 Since then, other double-blind and other controlled trials have
confirmed these findings.65666768 Trials
showing statistically significant reductions in cholesterol have generally used more than 30
grams per day of soy protein. However, if soy replaces animal protein in the diet, as little
as 20 grams per day has been shown to significantly reduce both total and LDL
cholesterol.69 Isoflavones found in soy beans appear to be key cholesterol-lowering
ingredients of the bean,7071 but animal research suggests other
components of soy are also important.7273
Sugar
Eating sugar has been reported to reduce protective HDL cholesterol74 and increases
other risk factors linked to heart disease.75 However, higher sugar intake has been
associated with only slightly higher risks of heart disease in most reports.76
Although the exact relationship between sugar and heart disease remains somewhat unclear, many
doctors recommend that people with high cholesterol reduce their sugar intake.
Coffee
Drinking boiled or French press coffee increases cholesterol levels.77 Modern paper
coffee filters trap the offending chemicals and keep them from entering the cup. Therefore,
drinking paper-filtered coffee does not increase cholesterol levels.78
79 Espresso coffee has amounts of the offending chemicals midway between those of other
unfiltered coffees and paper-filtered coffee,80 but there is little research
investigating the effect of espresso on cholesterol levels, and studies to date have produced
conflicting results.8182 The effects of decaffeinated coffee on
cholesterol levels remain in debate.83
Alcohol
Moderate drinking (one to two drinks per day) increases protective HDL
cholesterol.84 This effect happens equally with different kinds of
alcohol-containing beverages.8586 Alcohol also acts as a blood
thinner,87 an effect that should lower heart disease. However, alcohol consumption
may cause liver disease (e.g., cirrhosis), cancer, high blood pressure, alcoholism, and, at high intake, an increased
risk of heart disease. As a result, some
doctors never recommend alcohol, even for people with high cholesterol. Nevertheless, those
who have one to two drinks per day appear to live longer88 and are clearly less
likely to have heart disease.89 Therefore, some people at very high risk of heart
disease—those who are not alcoholics, who have healthy livers and normal blood pressure,
and who are not at high risk for cancer, particularly breast cancer—are likely to receive more benefit
than harm, from light drinking.
Olive oil
Olive oil lowers LDL cholesterol,9091 especially when the olive oil
replaces saturated fat in the diet.92 People from countries that use significant
amounts of olive oil appear to be at low risk for heart disease.93 A double-blind
trial showed that a diet high in monounsaturated fatty acids from olive oil, lowers
cardiovascular disease risk by 25%, as compared with a 12% decrease from a low-fat (25% fat)
diet.94 The trial also found that
low-fat diets decrease HDL cholesterol by 4%, which is undesirable, since HDL cholesterol
is protective against heart disease. Diets high in monounsaturated fatty acids from olive oil
do not adversely affect HDL levels. Although olive oil is clearly safe for people with
elevated cholesterol, it is, like any fat or oil, high in calories, so people who are overweight should limit its use.
Trans fatty acids and margarine
Trans fatty acids (TFAs) are found in many processed foods containing partially hydrogenated
oils. The highest levels occur in margarine. Margarine consumption is linked to increased risk
of unfavorable changes in cholesterol levels95 and heart disease.96 Margarine and other
processed foods containing partially hydrogenated oils should be avoided.
However, special therapeutic margarines are now available that contain substances, called
phytostanols, that block the absorption of cholesterol.97 The FDA has approved some
of these margarines as legitimate therapeutic agents for lowering blood cholesterol levels.
The best-known of these products is Benecol™. The cholesterol-lowering effect of these
margarines has been demonstrated in numerous double-blind and other controlled
trials.9899100101102103104
Garlic
Garlic is available as a food, as a spice in powder form, and as a supplement. Eating garlic
has helped to lower cholesterol in some research,105 though several double-blind
trials have not found garlic supplements to be thusly effective.106107108 Although some of the negative reports have been criticized,109 the
relationship between garlic and cholesterol lowering remains unproven.110 However,
garlic is known to act as a blood thinner111 and may reduce other risk factors for
heart disease.112 For these reasons, some doctors recommend eating garlic as food,
taking 900 mg of garlic powder from capsules, or using a tincture of 2 to 4 ml, taken three
times daily.
Nuts
Preliminary research consistently shows that people who eat nuts frequently have a
dramatically reduced risk of heart
disease.113114 This apparent beneficial effect is at least
partially explained by preliminary and controlled research demonstrating that nut consumption
lowers cholesterol levels.115116 Of nuts commonly consumed,
almonds117118 and walnuts119120121
may be most effective at lowering cholesterol. Macadamia nuts have been less beneficial in
most studies,122123124 although one controlled trial found
a cholesterol-lowering effect from macadamia nuts.125 Hazelnuts126 and
pistachio nuts127 have also been reported to help lower cholesterol.
Nuts contain many factors that could be responsible for protection against heart disease,
including fiber, vitamin E, alpha-linolenic acid (found primarily in
walnuts), oleic acid, magnesium, potassium, and arginine. Therefore, exactly how nuts lower
cholesterol or lower the risk of heart disease remains somewhat unclear. Some doctors even
believe that nuts may not be directly protective; rather, people busy eating nuts
will not simultaneously be eating eggs, dairy, or trans fatty acids from margarine and
processed food, the avoidance of which would reduce cholesterol levels and the risk of heart
disease.128129 Nonetheless, the remarkable consistency of research
outcomes strongly suggests that nuts do help protect against heart disease. Although nuts are
loaded with calories, a preliminary trial surprisingly reported that adding hundreds of
calories per day from nuts for six months did not increase body weight in humans130 —an outcome
supported by other reports.131 Even when increasing nut consumption has led to
weight gain, the amount of added weight has been remarkably less than would be expected, given
the number of calories added to the diet.132 Given the number of calories per ounce
of nuts, scientists do not understand why moderate nut consumption apparently has so little
effect on body weight.
Number and size of meals
When people eat a number of small meals, serum cholesterol levels fall compared with the
effect of eating the same food in three big meals.133134 People with
elevated cholesterol levels should probably avoid very large meals and eat more frequent,
smaller meals.
Lifestyle changes that may be helpful
Exercise increases protective HDL cholesterol,135 an effect that occurs even
from walking.136 Total and LDL cholesterol are typically lowered by exercise,
especially when weight-loss also occurs.137 Exercisers have a relatively low risk
of heart disease.138 However,
people over 40 years of age, or who have heart disease, should talk with their doctor before
starting an exercise program; overdoing it may actually trigger heart attacks.139
Obesity increases the risk of heart
disease,140 in part because weight gain lowers HDL cholesterol.141 Weight loss reduces the body’s ability to
make cholesterol, increases HDL levels, and reduces triglycerides (another risk factor for heart
disease).142143 Weight loss also leads to a decrease in blood
pressure.
Smoking is linked to a lowered level of HDL cholesterol144 and is also known to
cause heart disease.145 Quitting
smoking reduces the risk of having a heart attack.146
The combination of feelings of hostility, stress, and time urgency is called type A
behavior. Men,147148 but not women,149 with these traits are
at high risk for heart disease in most, but not all, studies.150
Stress151 or type A behavior152 may elevate cholesterol in men. Reducing
stress and feelings of hostility has reduced the risk of heart disease.153
Other therapies
People with high cholesterol are commonly advised to reduce their consumption of dietary
cholesterol and saturated fats.
Vitamins that may be helpful
Glucomannan is a water-soluble dietary fiber that is derived from konjac root.
Controlled154155 and double-blind156157 trials
have shown that supplementation with glucomannan significantly reduced total blood
cholesterol, LDL cholesterol, and
triglycerides, and in some cases raised HDL cholesterol. Effective amounts of glucomannan
for lowering blood cholesterol have been 4 to 13 grams per day.
Test tube and animal studies indicate that
policosanol is capable of inhibiting cholesterol production by the liver.158159 Extensive preliminary and double-blind research in Cuba and other countries in
Latin America has demonstrated that taking 10 to 20 mg per day of policosanol extracted from
sugar cane results in significant changes in blood cholesterol levels, including total
cholesterol (17 to 21% lower on average), LDL cholesterol (21 to 29% lower), and HDL
cholesterol (7 to 29% higher).160161162163164165166167168169170 However, virtually all of this research was conducted by a single research
group from Cuba. Follow-up double-blind studies performed in the United States,171172 Canada,173 and Germany174 found that sugar cane-derived
policosanol in amounts of 10 to 80 mg per day taken for 12 weeks had no effect on serum
cholesterol levels in people with initially high cholesterol levels. Until additional
independent studies are performed, the effect of policosanol on serum cholesterol levels must
be considered uncertain.
The combined results of nine double-blind trials indicate that supplementation with HMB (beta-hydroxy-beta-methylbutyrate effectively
lowers total and LDL cholesterol.175 All trials used 3 grams per day, taken for
three to eight weeks.
Vitamin C appears to protect LDL
cholesterol from damage.176 In some clinical trials, cholesterol levels have fallen
when people with elevated cholesterol supplement with vitamin C.177 Some studies
report that decreases in total cholesterol occur specifically in LDL
cholesterol.178 Doctors sometimes recommend 1 gram per day of vitamin C. A review
of the disparate research concerning vitamin C and heart disease, however, has suggested that most
protection against heart disease from vitamin C, is likely to occur with as little as 100 mg
per day.179
Pantethine, a byproduct of vitamin B5 (pantothenic acid), may help reduce the
amount of cholesterol made by the body. Several preliminary180181
182183184 and two controlled185186 trials
have found that pantethine (300 mg taken two to four times per day) significantly lowers serum
cholesterol levels and may also increase HDL. However, one double-blind trial in people whose
high blood cholesterol did not change with diet and drug therapy, found that pantethine was
also not effective.187 Common pantothenic acid has not been reported to have any
effect on high blood cholesterol.
Chromium supplementation has reduced total
cholesterol,188189 LDL cholesterol190191 and
increased HDL cholesterol192193 in double-blind and other controlled
trials, although other trials have not found these effects.194195 One
double-blind trial found that high amounts of chromium (500 mcg per day) in combination with
daily exercise was highly effective, producing nearly a 20% decrease in total cholesterol
levels in just 13 weeks.196
Brewer’s yeast, which contains
readily absorbable and biologically active
chromium, has also lowered serum cholesterol.197 People with higher blood
levels of chromium appear to be at lower risk for heart disease.198 A reasonable
and safe intake of supplemental chromium is 200 mcg per day. People wishing to use
brewer’s yeast as a source of chromium should look for products specifically labeled
“from the brewing process” or “brewer’s yeast,” since most yeast
found in health food stores is not brewer’s yeast, and does not contain chromium.
Optimally, true brewer’s yeast contains up to 60 mcg of chromium per tablespoon, and a
reasonable intake is 2 tablespoons per day.
High amounts (several grams per day) of niacin, a form of vitamin B3, lower cholesterol, an effect recognized in
the approval of niacin as a prescription medication for high cholesterol.199 The
other common form of vitamin B3—niacinamide—does not affect cholesterol levels.
Some niacin preparations have raised HDL cholesterol better than certain prescription
drugs.200 Some cardiologists prescribe 3 grams of niacin per day or even higher
amounts for people with high cholesterol levels. At such intakes, acute symptoms (flushing,
headache, stomachache) and chronic symptoms (liver damage, diabetes,
gastritis, eye damage, possibly gout) of
toxicity may be severe. Many people are not able to continue taking these levels of niacin due
to discomfort or danger to their health. Therefore, high intakes of niacin must only be taken
under the supervision of a doctor.
Symptoms caused by niacin supplements, such as flushing, have been reduced with
sustained-release (also called “time-release”) niacin products. However,
sustained-release forms of niacin have caused significant liver toxicity and, though rarely,
liver failure.201202203204205 One
partial time-release (intermediate-release) niacin product has lowered LDL cholesterol and
raised HDL cholesterol without flushing, and it also has acted without the liver function
abnormalities typically associated with sustained-release niacin formulations.206
However, this form of niacin is available by prescription only.
In an attempt to avoid the side effects of niacin, alternative health practitioners
increasingly use inositol hexaniacinate,
recommending 500 to 1,000 mg, taken three times per day, instead of niacin.207208 This special form of niacin has been reported to lower serum cholesterol but so
far has not been found to cause significant toxicity.209 Unfortunately, compared
with niacin, far fewer investigations have studied the possible positive or negative effects
of inositol hexaniacinate. As a result, people using inositol hexaniacinate should not take it
without the supervision of a doctor, who will evaluate whether it is helpful (by measuring
cholesterol levels) and will make sure that toxicity is not occurring (by measuring liver enzymes, uric acid and glucose levels, and by
taking medical history and doing physical examinations).
Soy supplementation has been shown to lower
cholesterol in humans.210 Soy is available in foods such as tofu, miso, and tempeh
and as a supplemental protein powder. Soy contains isoflavones, naturally occurring plant
components that are believed to be soy’s main cholesterol-lowering ingredients. A
controlled trial showed that soy preparations containing high amounts of isoflavones
effectively lowered total cholesterol and LDL (“bad”) cholesterol, whereas
low-isoflavone preparations (less than 27 mg per day) did not.211 However,
supplementation with either soy212 or non-soy isoflavones (from red
clover)213 in pill form failed to reduce cholesterol levels in a group of healthy
volunteers, suggesting that isoflavone may not be responsible for the
cholesterol-lowering effects of soy. Further trials of isoflavone supplements in people with
elevated cholesterol, are needed to resolve these conflicting results. In a study of people
with high cholesterol levels, a soy preparation that contained soy protein, soy fiber, and soy
phospholipids lowered cholesterol levels more effectively than isolated soy
protein.214
Soy contains phytosterols. One such molecule,
beta-sitosterol, is available as a supplement. Beta-sitosterol alone, and in combination
with similar plant sterols, has been shown to reduce blood levels of cholesterol in
preliminary215 and controlled216217 trials. This effect may
occur because beta-sitosterol blocks absorption of cholesterol.218 In studying the
effects of 0.8, 1.6, and 3.2 grams of plant sterols per day, one double-blind trial found that
higher intake of sterols tended to result in greater reduction in cholesterol, though the
differences between the effects of these three amounts were not statistically
significant.219
A synthetic molecule related to
beta-sitosterol, sitostanol, is available in a special margarine and has also been shown
to lower cholesterol levels. In one controlled trial, supplementation with 1.7 grams per day
of a plant-sterol product containing mostly sitostanol, combined with dietary changes, led to
a dramatic 24% drop in LDL (“bad”) cholesterol compared with only a 9% decrease in
the diet-only part of the trial.220 Other controlled and double-blind trials have
confirmed these results.221222223224
225226 A review of double-blind trials on sitostanol found that a reduction
in the risk of heart disease of about 25% may
be expected from use of sitostanol-containing spreads, a larger clinical effect than that
produced by people reducing their saturated fat intake.227 Supplementation with
sitostanol in the amount of 1.8 grams per day for six weeks has also been shown to enhance the
cholesterol-lowering effect of statin drugs.228
Tocotrienols, a group of food-derived
compounds that resemble vitamin E, may lower
blood levels of cholesterol, but evidence is conflicting. Although tocotrienols inhibited
cholesterol synthesis in test-tube studies,229230 human trials have
produced contradictory results. Two double-blind trials found that 200 mg per day of either
gamma-tocotrienol231 or total tocotrienols232 were more effective than
placebo, reducing cholesterol levels by 13–15%. However, in another double-blind trial,
200 mg of tocotrienols per day failed to lower cholesterol levels,233 and a fourth
double-blind trial found 140 mg of tocotrienols and 80 mg of vitamin E (d-alpha-tocopherol)
daily resulted in no changes in total cholesterol, LDL cholesterol, or HDL cholesterol
levels.234
In a double-blind study of people with elevated blood levels of cholesterol or
triglycerides, supplementation with krill oil from Antarctic krill (a zooplankton crustacean)
for three months decreased levels of total cholesterol, LDL cholesterol, and triglycerides,
and increased HDL-cholesterol levels. Krill oil was significantly more effective than both
regular fish oil and a
placebo.235
Activated charcoal has the ability to
adsorb (attach to) cholesterol and bile acids present in the intestine, preventing their
absorption.236237 Reducing the absorption of bile acids results in
increased cholesterol breakdown by the liver. In controlled studies of people with high
cholesterol, activated charcoal reduced total- and LDL-cholesterol levels, when given in
amounts from 4 to 32 grams per day. Larger amounts were more effective: reductions in total
and LDL cholesterol were 23% and 29%, respectively, with 16 grams daily, and 29% and 41% with
32 grams daily.238 Similar results were reported in other controlled239
and preliminary240 studies using 16 to 24 grams per day, but one small double-blind
trial found no effect of either 15 or 30 grams per day in patients with high
cholesterol.241
Deficiency of the trace mineral, copper, has been linked to high blood
cholesterol.242243 In a controlled trial, daily supplementation with 3
to 4 mg of copper for eight weeks decreased
blood levels of total cholesterol and LDL cholesterol, in a group of people over 50 years of
age.244
Beta-glucan is a type of soluble fiber molecule derived from the cell wall of
baker’s yeast, oats and barley, and many
medicinal mushrooms, such as maitake.
Beta-glucan is the key factor for the cholesterol-lowering effect of oat bran.245246247248 As with other soluble-fiber components, the
binding of cholesterol (and bile acids) by beta-glucan and the resulting elimination of these
substances in the feces is very helpful for reducing blood cholesterol.249
250251 Results from a number of double-blind trials with either oat- or
yeast-derived beta-glucan indicate typical reductions, after at least four weeks of use, of
approximately 10% for total cholesterol and 8% for LDL (“bad”) cholesterol, with
elevations in HDL (“good”) cholesterol ranging from zero to 16%.252253254255256 For lowering cholesterol levels,
the amount of beta-glucan used has ranged from 2,900 to 15,000 mg per day.
Some preliminary257 and double-blind258259 trials have
shown that supplemental calcium reduces
cholesterol levels. Possibly the calcium is binding with and preventing the absorption of
dietary fat.260 However, other research has found no substantial or statistically
significant effects of calcium supplementation on total cholesterol or HDL
(“good”) cholesterol.261 Reasonable supplemental levels are 800 to
1,000 mg per day.
In one double-blind trial,262
vitamin E increased protective HDL cholesterol, but several other trials,263264265 found no effect of vitamin E. However, vitamin E is known to
protect LDL cholesterol from damage.266 Most cardiologists believe that only
damaged LDL increases the risk of heart disease. Studies of the ability of vitamin E
supplements to prevent heart disease have
produced conflicting results,267 but many doctors continue to recommend that
everyone supplement 400 IU of vitamin E per day to lessen the risk of having a heart attack.
L-carnitine is needed by heart muscle to
utilize fat for energy. Some,268269 but not all, preliminary trials
report that carnitine reduces serum cholesterol.270 HDL cholesterol has also
increased in response to carnitine supplementation.271272 People have
been reported in controlled research to stand a greater chance of surviving a heart attack if
they are given L-carnitine supplements.273 Most trials have used 1 to 4 grams of
carnitine per day.
Magnesium is needed by the heart to
function properly. Although the mechanism is unclear, magnesium supplements (430 mg per day)
lowered cholesterol in a preliminary trial.274 Another preliminary study reported
that magnesium deficiency is associated with a low HDL cholesterol level.275
Intravenous magnesium has reduced death following heart attacks in some, but not all, clinical
trials.276 Though these outcomes would suggest that people with high cholesterol
levels should take magnesium supplements, an isolated double-blind trial reported that people
with a history of heart disease assigned to magnesium supplementation experienced an
increased number of heart attacks.277 More information is necessary before the
scientific community can clearly evaluate the role magnesium should play for people with
elevated cholesterol.
Chondroitin sulfate has lowered serum
cholesterol levels in preliminary trials.278279 Years ago, this
supplement dramatically reduced the risk of heart attacks in a controlled, six-year follow-up
of people with heart disease.280
The few doctors aware of these older clinical trials sometimes tell people with a history of
heart disease or elevated cholesterol levels, to take approximately 500 mg of chondroitin
sulfate three times per day.
Although lecithin has been reported to
increase HDL cholesterol and lower LDL cholesterol,281 a review of the research
found that the positive effect of lecithin was likely due to the polyunsaturated fat content
of the lecithin.282 If this is so, it would make more sense to use inexpensive
vegetable oil, rather than take lecithin supplements. However, an animal study found a
cholesterol-lowering effect of lecithin independent of its polyunsaturate
content.283 A double-blind trial found that 20 grams of soy lecithin per day for
four weeks had no significant effect on total cholesterol, LDL cholesterol, HDL cholesterol,
or triglycerides.284 Whether taking
lecithin supplements is a useful way to lower cholesterol in people with elevated cholesterol
levels remains unclear.
The fiber-like supplement chitosan appears to reduce the absorption of bile
acids or cholesterol; either of these effects may cause a lowering of blood cholesterol.
285 This effect has been repeatedly demonstrated in animals, and a preliminary human
study showed that 3 to 6 grams per day of chitosan taken for two weeks resulted in a 6% drop
in cholesterol and a 10% increase in HDL ("good") cholesterol. 286 Another
preliminary trial showed a 43% lowering of total cholesterol in people being treated for
kidney failure with dialysis who took 4 grams per day of chitosan for 12 weeks. These people
also appeared to have improved kidney function and less severe anemia after chitosan
treatment. 287 In a double-blind trial, however, administration of 2.4 grams of
chitosan per day for three months to people with high cholesterol had no effect on their
cholesterol levels. 288
Chitosan in large amounts, given with vitamin
C, has been shown to reduce dietary fat absorption in animals fed a high-fat diet.
289290291 However, the absorption of minerals and fat-soluble vitamins was also reduced by feeding animals
large amounts of chitosan. 292 In studies in humans, chitosan did not reduce the
absorption of dietary fat.293294
Royal jelly has prevented the
cholesterol-elevating effect of nicotine295 and has lowered serum cholesterol in
animal studies.296 Preliminary human trials have also found that royal jelly may
lower cholesterol levels.297298 An analysis of cholesterol-lowering
trials shows that 50 to 100 mg per day is the typical amount used in such
research.299
A double-blind trial found that 20 grams per day of creatine taken for five days, followed by ten grams
per day for 51 days, significantly lowered serum total cholesterol and triglycerides, but did
not change either LDL or HDL cholesterol, in both men and women.300 However,
another double-blind trial found no change in any of these blood levels in trained athletes
using creatine during a 12-week strength training program.301 Creatine
supplementation in this negative trial was lower—only 5 grams per day were taken for the
last 11 weeks of the study.
Octacosanol, a substance found in wheat
germ oil, is sometimes available as a supplement. Small amounts (5 to 20 mg per day) of
policosanol, an experimental supplement from Cuba consisting primarily of octacosanol, has led
to large reductions in LDL cholesterol and/or increases in HDL.302303304305 Octacosanol may lower cholesterol by inhibiting the
liver’s production of cholesterol.306
Homocysteine, a substance linked to heart disease risk, may increase the rate at
which LDL cholesterol is damaged.307 While vitamin B6, vitamin B12, and folic acid lower homocysteine,308 a recent
trial found no effect of supplements of these vitamins on protecting LDL cholesterol, even
though homocysteine was lowered.309
Are there any side effects or interactions?
Refer to the individual supplement for information about any side effects or interactions.
Herbs that may be helpful
Researchers have determined that one of the ingredients in red yeast rice, called monacolin K, inhibits the
production of cholesterol by stopping the action of the key enzyme in the liver (i.e., HMG-CoA reductase) that is
responsible for manufacturing cholesterol.310 The drug lovastatin (Mevacor®) acts in a fashion similar
to this red-yeast-rice ingredient. However, the amount per volume of monacolin K in red yeast
rice is small (0.2% per 5 mg) when compared to the 20 to 40 mg of lovastatin available as a
prescription drug.311
The red yeast rice used in various studies was a proprietary product called
Cholestin®, which contains ten different monacolins.
Note: Cholestin has been banned in the United States, as a result of a lawsuit
alleging patent infringement.
Other red yeast rice products currently on the market differ from Cholestin in their
chemical makeup. None contain the full complement of ten monacolin compounds that are present
in Cholestin, and some contain a potentially toxic fermentation product called
citrinin.312 Despite these concerns, other red yeast rice products are being widely
used and anecdotal reports suggest that they have a similar safety and efficacy profile as
that of Cholestin.
Use of psyllium has been extensively
studied as a way to reduce cholesterol levels. An analysis of all double-blind trials in 1997
concluded that a daily amount of 10 grams psyllium lowered cholesterol levels by 5% and LDL
cholesterol by 9%.313 Since then, a large controlled trial found that use of 5.1
grams of psyllium two times per day significantly reduced serum cholesterol as well as
LDL-cholesterol.314 Generally, 5 to 10 grams of psyllium are added to the diet per
day to lower cholesterol levels. The combination of psyllium and oat bran may also be effective at lowering LDL
cholesterol.315
Guggul, a mixture of substances taken from
a plant, is an approved treatment for elevated cholesterol in India and has been a mainstay of
the Ayurvedic approach to preventing atherosclerosis. One double-blind trial studying the
effects of guggul reported that serum cholesterol dropped by 17.5%.316 In another
double-blind trial comparing guggul to the drug
clofibrate, the average fall in serum cholesterol was slightly greater in the guggul
group; moreover, HDL cholesterol rose in 60% of people responding to guggul, while clofibrate
did not elevate HDL.317 A third double-blind trial found significant changes in
total and LDL cholesterol levels, but not in HDL.318 However, in another
double-blind trial, supplementation with guggul for eight weeks had no effect on total serum
cholesterol, but significantly increased LDL-cholesterol levels, compared with a
placebo.319 Daily intakes of guggul are based on the amount of guggulsterones in
the extract. The recommended amount of guggulsterones is 25 mg taken three times per day. Most
extracts contain 5 to 10% guggulsterones, and doctors familiar with their use usually
recommend taking guggul for at least 12 weeks before evaluating its effect.
In a double-blind trial, people with moderately high cholesterol took a tincture of
Achillea wilhelmsii, an herb used in traditional Persian medicine.320
Participants in the trial used 15 to 20 drops of the tincture twice daily for six months. At
the end of the trial, participants experienced significant reductions in total cholesterol,
LDL cholesterol and triglycerides, as well as
an increase in HDL cholesterol compared to those who took placebo. No adverse effects were
reported.
Reports on many double-blind garlic trials
performed through 1998 suggested that cholesterol was lowered by an average of 9 to 12% and
triglycerides by 8 to 27% over a one-to-four month period.321322
323 Most of these trials used 600 to 900 mg per day of garlic supplements. More
recently, however, several double-blind trials have found garlic to have minimal success in
lowering cholesterol and triglycerides.324325326
327328 One negative trial has been criticized for using a steam-distilled
garlic “oil” that has no track record for this purpose,329 while the
others used the same standardized garlic products as the previous positive trials. Based on
these findings, the use of garlic should not be considered a primary approach to lowering high
cholesterol and triglycerides.330
Part of the confusion may result from differing effects from dissimilar garlic products. In
most but not all trials, aged garlic extracts and garlic oil (both containing no allicin) have
not lowered cholesterol levels in humans.331332 Therefore, neither of
these supplements can be recommended at this time for cholesterol lowering. Odor-controlled,
enteric-coated tablets standardized for allicin content are available and, in some trials,
appear more promising.333 Doctors typically recommend 900 mg per day (providing
5,000 to 6,000 mcg of allicin), divided into two or three admininstrations.
Green tea has been shown to lower total
cholesterol levels and improve people’s cholesterol profile, decreasing LDL cholesterol
and increasing HDL cholesterol according to preliminary studies.334335336337 However, not all trials have found that green tea intake lowers
lipid levels.338 Much of the research documenting the health benefits of green tea
is based on the amount of green tea typically drunk in Asian countries—about three cups
per day, providing 240 to 320 mg of polyphenols.
An extract of green tea, enriched with a compound present in black tea (theaflavins), has
been found to lower serum cholesterol in a double-blind study of people with moderately high
cholesterol levels.339 The average reduction in total serum cholesterol during the
12-week study was 11.3%, and the average reduction in LDL cholesterol was 16.4%. The extract
used in this study provided daily 75 mg of theaflavins, 150 mg of green tea catechins, and 150
mg of other tea polyphenols.
Artichoke has moderately lowered
cholesterol and triglycerides in some,340 but not all,341 human trials.
One double-blind trial found that 900 mg of artichoke extract per day significantly lowered
serum cholesterol and LDL cholesterol but did not decrease triglycerides or raise HDL
cholesterol.342 Cholesterol-lowering effects occurred when using 320 mg of
standardized leaf extract taken two to three times per day for at least six weeks.
Berberine, a compound found in certain herbs such as goldenseal, barberry, and Oregon
grape, has been found to lower serum cholesterol levels. In a study of people with high
cholesterol levels, 500 mg of berberine taken twice a day for three months lowered the average
cholesterol level by 29%. No significant side effects were reported, except for mild
constipation.343
Fenugreek seeds contain compounds known as
steroidal saponins that inhibit both cholesterol absorption in the intestines and cholesterol
production by the liver.344 Dietary fiber may also contribute to fenugreek’s
activity. Multiple human trials (some double-blind) have found that fenugreek may help lower
total cholesterol in people with moderate
atherosclerosis or those having insulin-dependent or non-insulin-dependent diabetes.345346347
One human double-blind trial has also shown that defatted fenugreek seeds may raise levels of
beneficial HDL cholesterol.348 One small preliminary trial found that either 25 or
50 grams per day of defatted fenugreek seed powder significantly lowered serum cholesterol
after 20 days.349 Germination of the fenugreek seeds may improve the soluble fiber
content of the seeds, thus improving their effect on cholesterol.350 Fenugreek
powder is generally taken in amounts of 10 to 30 grams three times per day with meals.
Preliminary Chinese research has found that high doses (12 grams per day) of the herb fo-ti may lower cholesterol levels. Double-blind
or other controlled trials are needed to determine fo-ti’s use in lowering cholesterol.
A tea may be made from processed roots by boiling 3 to 5 grams in a cup of water for 10 to 15
minutes. Three or more cups should be drunk each day. Fo-ti tablets containing 500 mg each are
also available. Doctors may suggest taking five of these tablets three times per day.
Wild yam has been reported to raise HDL
cholesterol in preliminary research. Doctors sometimes recommend 2 to 3 ml of tincture taken
three to four times per day, or 1 to 2 capsules or tablets of dried root taken three times per
day. 351
Animal studies suggest that the mushroom
maitake may lower fat levels in the blood.352 This research is still
preliminary and requires confirmation with controlled human trials.
Animal studies indicate that saponins in
alfalfa seeds may block absorption of cholesterol and prevent the formation of
atherosclerotic plaques.353 However, consuming the large amounts of alfalfa seeds
(80 to 120 grams per day) needed to supply high doses of these saponins may potentially cause
damage to red blood cells in the body.354
Are there any side effects or interactions?
Refer to the individual herb for information about any side effects or interactions.
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