AGE STRONG: Cholesterol Management

What is cholesterol ? 

Cholesterol is a substance that is in the body and carried in the blood. It forms the building blocks of other compounds needed for your body to function. Cholesterol in the body is from two sources; food that we ingest and production in the liver. Foods from animal sources such as meat, poultry, and full fat dairy products contain cholesterol. More cholesterol is made in the liver when our diets are high in saturated and trans fats.

There are two types of cholesterol in the body: LDL – low density lipoprotein (“bad” cholesterol) and HDL – high density lipoprotein (“good” cholesterol). LDL carries cholesterol to all parts of the body, but too much LDL can lead to deposition in the walls of arteries. The LDL cholesterol binds with fats and other substances to form plaque in the walls of arteries. This plaque leads to narrowed arteries and blood flow is reduced. This plaque can result in heart disease (reduced blood flow to the arteries of the heart – the coronary arteries) and strokes (reduced blood flow to the brain). Plaque can also break off and cause a heart attack or stroke. In contrast, HDL cholesterol carries harmful cholesterol out of the arteries and helps to prevent plaques formation. 

Why is it measured ? 

Cholesterol levels are checked in order to intervene when cholesterol  levels are high, and thus lower ones risk of cardiac disease and stroke. While we focus on cholesterol reduction in cardiac disease prevention, other factors such as exercise, stress management, nutrition, hormone status and other factors should also be addressed.

Target levels for cholesterol ?

There is no one target total cholesterol or LDL level. Interventions are generally recommended based on: age, blood pressure, total cholesterol, LDL cholesterol, family history of cardiac disease. Other extremely important groups which require an individualized approach include those with cardiovascular disease and diabetes.

Who needs to be treated for elevated cholesterol ? 

There is no longer a one size fits all “target” LDL goal. Recently there have been identified four major primary- and secondary-prevention patient groups who should be treated.

The four treatment groups include:

  • Individuals without evidence of cardiovascular disease or diabetes but who have LDL-cholesterol levels between 70 and 189 mg/dL and a 10-year risk of atherosclerotic cardiovascular disease >7.5%. The Framingham Risk Calculator  is generally recommended to be used to calculate this risk. For Individuals with a 10-year risk of cardiovascular disease of less than 7.5%, a lifetime risk calculator can be used Q-RISK This calculator is also useful to assess how altering variables such as cholesterol, will impact on risk of cardiovascular disease.

  • Individuals with LDL-cholesterol levels >190 mg/dL, such as those with familial hypercholesterolemia.

  • Individuals with clinical atherosclerotic cardiovascular disease.

  • Individuals with diabetes aged 40 to 75 years old with LDL-cholesterol levels between 70 and 189 mg/dL and without evidence of atherosclerotic cardiovascular disease.

Pharmaceutical approaches to lower cholesterol

Generally, the decision to start pharmaceutical methods to lower cholesterol is made on an individualized basis. The main approach to lower cholesterol through pharmaceutical methods is through the use of a drug class called statins. These drugs disrupt production of cholesterol by blocking an enzyme inside the liver cells, resulting in less cholesterol being released into the bloodstream. These drugs may also reduce the inflammatory process that is set up in plaque. Other drug types may also be employed. Strategies to prevent the absorption of cholesterol from the gut may also be employed. Therapies may also increase the breakdown of fatty acids in the liver in order to prevent cholesterol production.

Statins may lead to side effects such as muscle pain and weakness, elevation of liver enzymes,  and may reduce the antioxidant CoQ10.

General guidelines are detailed below

Women with cardiovascular disease: several large trials have demonstrated that aggressive lipid lowering is beneficial in people with coronary heart disease. Many healthcare providers recommend treating all patients with CVD with high-dose statin therapy. Lifestyle interventions will also be reviewed. A target LDL cholesterol level below 70 to 80 mg/dL is recommended for people who have CVD and have multiple major risk factors (such as diabetes or smoking). A target LDL cholesterol level less than 100 mg/dL is recommended for people who have CVD but do not have many additional risk factors. Lifestyle changes as well as non-statin medications may be recommended when LDL cholesterol levels are higher than 100 mg/dL.

High triglycerides: elevated triglycerides have not generally been thought to pose the same risk of disease as elevated LDL cholesterol. However, healthcare providers often recommend treatment for people with elevated triglyceride levels if they have very high levels (>500 to 1000 mg/DL); also have high LDL cholesterol or low HDL cholesterol levels; have a strong family history of CHD; have other risk factors for CHD.

Diabetes: people with diabetes (type 1 or 2) are at high risk of heart disease. Thus, an LDL level below 100 mg/dL (2.59 mmol/L) is recommended in many people with diabetes.

Natural methods to lower cholesterol


  • Exercise regularly.

  • Aerobic exercise daily, a minimum of 30 minutes an optimally 60 to 90 minutes, alternating moderate-intensity days with vigorous intensity days.

  • Full-body resistance routine two to three times weekly.

  • Stretching exercises daily to greatly enhance your overall flexibility and ability to exercise more freely.

  • Loose excess weight, especially weight around the middle.


  • Mediterranean Diet appears to reduce the risk of cardiovascular events and improve cholesterol levels.

    The Mediterranean Diet is rich in fruits, vegetables, whole grains, beans, nuts, and seeds and include olive oil as an important source of fat; there are typically low to moderate amounts of fish, poultry, and dairy products, and there is little red meat.

    Multiple studies support the Mediterranean Diet eating lifestyle for the prevention of cardiac disease, and improved cholesterol levels.

    A good resource for Mediterranean Diet is  

  • Therapeutic Lifestyle Changes  Developed by The National Cholesterol Education Program (NCEP)

    No more than 25 to 35 percent of daily calories from total fat; up to 20 percent as monounsaturated, 10 percent as polyunsaturated, and less than 7 percent as saturated fats.

    Carbohydrates and proteins should provide 50-60 percent and 15 percent, of total calories, respectively.

    Optional dietary guidelines include the addition of 10-25 grams of soluble fiber, and 2 grams of plant sterols per day.

    Total calories are adjusted to maintain body weight and prevent weight gain, and enough moderate exercise to burn at least 250 calories per day is recommended.

  • DASH (Dietary Approaches to Stop Hypertension) eating plan encourages many of the same heart-healthy eating habits.

  • Calorie Restriction  The dramatic reduction of dietary calories (by up to 40%), to a level short of malnutrition.

    Restriction in energy intake slows down the body’s growth processes, causing it to instead focus on protective repair mechanisms; the overall effect is an improvement in several measures of wellbeing.

    Moderate CR (22-30% decreases in caloric intake from normal levels) improves heart function, reduces markers of inflammation (C-reactive protein, tumor necrosis factor (TNF)), reduces risk factors for cardiovascular disease  and reduces diabetes risk factors (fasting blood glucose and insulin levels).

  • GARLIC: Consumption of garlic may result in small reductions of cholesterol and can also reduce systolic- and diastolic- blood pressure (SBP and DBP) in hypertensive individuals, and systolic blood pressure in persons with normal blood pressure.

  • NUTS: Small randomized trials have shown that walnuts, which are rich in polyunsaturated fatty acids, have a beneficial effect on serum lipids. Other trials demonstrated similar lipid lowering effects with almonds and pistachios and other nuts. In a review from the prospective Adventist Health Study, individuals who consumed nuts more than four times per week had significant reductions in mortality from coronary heart disease compared to those who consumed nuts less than once per week.

  • TEA: A 2013 meta-analysis of seven randomized trials found that consumption of tea reduced LDL. There was moderate heterogeneity across the trials.

  • POMEGRANATE: Contains high levels of polyphenols. Consumption of pomegranate polyphenols can lower total and LDL cholesterol concentrations while maintaining HDL levels in individuals with elevated cholesterol profiles. those seeking to achieve ultimate HDL functionality should drink unsweetened 100% pomegranate juice and/or take 400-500 mg of standardized pomegranate supplements that provide the active constituents of eight ounces of pomegranate juice.

  • CRUCIFEROUS VEGETABLES: Broccoli, watercress, and cabbage may enhance HDL functionality via several mechanisms.

  • PREBIOTICS: A subset of soluble fiber and due to their ability  to be selectively fermented by gut flora for a diversity of potential health-promoting benefits. The fermentation of prebiotic fibers into short-chain fatty acids such as acetate, butyrate, or propionate may inhibit cholesterol synthesis in the liver. In human trials, the prebiotic fibers inulin and dextrin have induced reductions in serum levels of total cholesterol and LDL-C.

  • PROBIOTICS: Increasingly recognized for their critical role in regulating immune activity, reducing inflammation throughout the body, and have attracted interest for their ability to reduce LDL cholesterol and cardiovascular risk.

Hormone balance

It is important to assure proper thyroid function when addressing cholesterol. Addressing other sex steroid hormones such as testosterone and estrogen may also be beneficial.


  • FISH OIL AND OMEGA-3 FATTY ACIDS: Populations with high intakes of omega-3 polyunsaturated fatty acids (such as the Inuit) have low rates of heart disease; this observation has increased interest in the possible benefit of fish oils. Rich sources of omega-3 fatty acids come from fatty fish, especially salmon, and plant sources such as flaxseed and flaxseed oil, canola oil, soybean oil, and nuts. Fish oil can lead to reductions in the risk of cardiovascular mortality and non-fatal cardiovascular events; can significantly reduce serum triglycerides.

  • FLAXSEED:  Interventions using flaxseed appear to reduce LDL, but these may be limited to flaxseed and flaxseed lignans; flaxseed oil does not clearly lower LDL. Flaxseed and flaxseed derivatives do not seem to reduce triglyceride levels.

  • SOY: An excellent source of protein, also contains isoflavones, which are phytoestrogens. Isoflavones are micronutrient substances that, in nonhuman primates, have properties similar to estrogen, including an effect on cholesterol levels. It has been suggested that the lower risk of heart disease among Asian compared to Western populations is due to the high consumption of soybean products. It is possible that intake of soy proteins has other vascular benefits.

  • RED YEAST RICE: Red yeast rice is a fermented rice product that has been used in Chinese cuisine and medicinally to promote "blood circulation". The product contains varying amounts of a family of naturally occurring substances called monacolins that have HMG CoA reductase inhibitor activity. Other active ingredients in red yeast rice that may affect cholesterol lowering include sterols (beta-sitosterol, campesterol, stigmasterol, sapogenin), isoflavones, and monounsaturated fatty acids. Treatment with red yeast rice 1800 mg twice daily may result in significant reductions in LDL.Not all strains of red yeast rice are alike and results of these clinical trials may not generalize to different preparations. There is substantial variability across commercial preparations. 

  • POLYPHENOLS: Polyphenols are substances found primarily in plants, and foods made from plants such as tea, coffee, cocoa, olive oil, and red wine, that appear to have antioxidant effects. They also appear to have immunomodulatory and vasodilatory properties that could contribute to cardiovascular risk reduction. Polyphenols include flavonoids and flavonoid derivatives, lignans, phenolic acids, and stilbenes. Resveratrol, a polyphenol (a stilbene) that occurs naturally in several plants, in particular in the skin of red grapes, has been ascribed a number of health benefits, especially against atherosclerosis.

  • FIBER: Certain soluble fibers (psyllium, pectin, wheat dextrin, and oat products) will reduce LDL. In a meta-analysis, every gram increase in soluble fiber reduced LDL-C by an average of 2.2 mg/dL, this effect was similar with various soluble fibers. A meta-analysis of randomized trials found that whole grain diets reduce LDL and total cholesterol, and that whole grain oats were particularly effective. The addition of psyllium supplementation may result in small further reductions in LDL.  Therapy that combines soluble fiber with plant sterols may also be of benefit. In a randomized crossover trial in adults with initial LDL concentrations between 100 and 160 mg/dL,  four weeks of therapy with cookies that provided 2.6 g/day of plant sterols and 10 g/day psyllium (7.7 g/day soluble fiber) decreased LDL levels by 10 percent. Studies have shown that 9 to 10 grams daily of psyllium, the equivalent of about 3 teaspoons daily of Metamucil, reduced LDL levels.

  • PLANT STEROLS: Plant sterols are similar in chemical structure to cholesterol, differing in their side chain configuration. The mechanism by which they lower cholesterol is thought to involve inhibition of cholesterol absorption. Ingestion of naturally occurring plant sterols may be associated with a reduced risk of cardiovascular events. These should be addressed with some caution however. A study of dietary supplementation with plant sterols in mice found harmful vascular effects including impaired endothelial function and increased atherogenesis. Local accumulation of plant sterols has been observed in patients with aortic valve lesions.

  • CALCIUM: Human and animal studies have suggested that calcium intake may affect the serum lipid concentration by binding to fatty acids and bile acids in the gut, thereby interfering with lipid absorption. In addition, at least two randomized, controlled trials have found that calcium supplementation causes potentially beneficial changes in circulating lipids. The risk of cardiovascular disease with calcium supplementation must also be balanced.

  • PANTETHINE:  A derivative of pantothenic acid (vitamin B5), and can serve as a source of the vitamin and can significantly reduce  total- and LDL cholesterol (up to 13.5%), triglycerides, and elevation of HDL-C in individuals with elevated cholesterol and also in those who are diabetic when taken at 900-1,200mg/day, although significant effects on triglycerides have been observed at dosages as low as 600 mg / day.

  • COENZYME Q 10 (CoQ10): CoQ10 can help to limit arterial damage.

  • VITAMIN E. Natural tocopherols and tocotrienols together form vitamin E and are known to protect against some cardiovascular events. It is important that individuals supplement with gamma tocopherol; human studies have demonstrated that 100 mg per day of gamma tocopherol showed resulted in a reduction in several risk factors for vascular disease such as platelet aggregation and LDL cholesterol levels.

  • CURCUMIN: An anti  inflammatory, it has a variety of protective roles in CVD, potentially reducing oxidative stress, inflammation.  It may also reduce serum cholesterol by increasing the production of the LDL receptor.

  • NIACIN/VITAMIN B3: Prescription niacin treatments can significantly raise HDL and  can also change the distribution of LDL. It is important to note that based on human studies, niacin alone, while it increases HDL, does not necessarily prevent cardiac disease. Niacin in doses of 1,000-2,000 mg a day will significantly lower total cholesterol, LDL, and triglycerides while boosting beneficial high-density lipoprotein (HDL

  • ALPHA-CYCLODEXTRIN: A soluble fiber from corn; when combined with fat-containing meals can results in  significant reductions in levels of total cholesterol, LDL cholesterol, and weight.

  • INDIAN GOOSEBERRY: Functions as an antioxidant and can reduce LDL and elevate HDL.

  • GYNOSTEMMA PENTAPHYLLUM: An Asian herb which activates adenosine monophosphate-activated protein kinase, which affects glucose metabolism and fat storage. In animal studies supplementation led to weight loss and improvements in glucose metabolism and cholesterol levels. Mice treated with 150 mg/kg (about 900 mg for an adult human) or 300 mg/kg (about 1800 mg for an adult human) of the extract had total cholesterol reductions of 14.2% and 7.1%, respectively, compared with the control group,

  • HESPERIDIN: Related flavonoids are found in a variety of plants, but especially in citrus fruits, particularly their peels. This class of compounds are powerful free radical scavengers and have demonstrated anti-inflammatory, insulin-sensitizing, and lipid-lowering activity  Treatment with 500 mg of hesperidin per day can lead to a 33% reduction in median levels of the inflammatory marker high-sensitivity C-reactive protein (hs-CRP), as well as significant decreases in levels of total cholesterol, apolipoprotein B (apoB), and markers of vascular inflammation, relative to placebo.


  • Optimal cardiovascular protection requires a multi-modal approach and requires a combination of interventions. It also requires a through evaluation of your cardiac risks based on family history, personal health history, lifestyle and metabolic factors. Any nutritional plan and supplement usage should be evaluated with your physician in order to assure the possibility for the best outcomes and safety. Recommendations should be individualized.

  • Calculate your risk of cardiac disease based on your cholesterol values and other factors with the Framingham and Q-RISK calculators.

  • Set goals for your cholesterol, weight, exercise and overall healthful lifestyle.

  • Review with your health care provider whether pharmacologic approaches are absolutely required, or if a trial of natural approaches to an elevated cholesterol are reasonable.

  • Achieve your optimal weight.

  • Exercise for at least 30 minutes each day.

  • Limit intake of foods full of saturated and trans fats and dietary cholesterol.

  • Consume a Mediterranean diet, with lots of fresh fruits and vegetables, fish and soy as protein sources, and omega-3 and monounsaturated fats (olive oil), while avoiding saturated fats, refined carbohydrates, cholesterol-laden foods, excess omega-6 fats, and most animal products.

  • Inclusion of specific cholesterol-lowering foods in one’s diet can markedly lower LDL and total cholesterol levels. Cholesterol-lowering foods with documented proven efficacy include almonds, soy protein, fiber, and plant sterols.

  • Eat more fiber rich foods.

  • Choose protein rich plant foods – such as beans, nuts and seeds.

  • Consider the following supplements:

Red rice yeast – resource -

Fish oil – resource - Supplement with at least 2,000 mg of EPA/DHA (omega-3 fats) each day.

Fiber supplements – resource - Depending on the type of soluble fiber you choose, taking two to eight grams (2,000-8,000 mg) before each meal is a reasonable target to attain. 

Plant sterols – resource -

Calcium (500 mg per day)

Niacin in doses of 2,000-3,000 mg a day may be an effective way to increase HDL - resource -

Curcumin - resource -

Probiotic - resource -

Pantethine - resource -