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Module Title
Cholesterol lowering dietModule Author
MediLearningCPD points
1.5Module Type
TutorialCardiovascular disease
Atherosclerosis, the result of atheroma (fatty deposits) building up on the walls lining the arteries, particularly those that supply the heart or brain, is the main cause of coronary heart disease, as well as the majority of heart attacks and strokes.1,3 Having high levels of low-density lipoprotein (LDL)-cholesterol in the blood leads to atherosclerosis.3
Coronary heart disease (previously called ischaemic heart disease) is the main type of cardiovascular heart disease and the number one cause of death worldwide.4

Cardiovascular disease risk factors
While there are a number of nonmodifiable risk factors for cardiovascular disease, such as age, sex, family history and ethnicity, as well as social deprivation and poverty, many cardiovascular diseases can be prevented by addressing modifiable risk factors, which include:1,2
- Smoking
- Hypertension
- Cholesterol levels
Addressing modifiable risk factors at an early age can help reduce the risk of cardiovascular disease. It has been estimated that the elimination of health risk behaviours would make it possible to prevent at least 80% of CVDs.3
Behaviours that should be tackled as early as possible include: unhealthy diet, physical inactivity, smoking and excess alcohol consumption. Such behaviours may lead to cardiovascular disease and other related morbidities including hypertension, type 2 diabetes, hyperlipidaemia and obesity.1,2
Smoking cessation, reducing the amount of salt in the diet, eating a healthy diet containing lots of fruits and vegetables, engaging in regular exercise and consuming alcohol at sensible levels are all known to reduce the risk of cardiovascular disease.1
Lowering LDL-cholesterol
In order to lower the risk of developing atherosclerosis and cardiovascular disease, early detection and management of high LDL-cholesterol levels is key.1 Systematic reviews have shown that the greater the reduction of LDL-cholesterol levels, the greater the reduction in cardiovascular disease risk.5
In fact, elevated levels of plasma LDL-C are deemed causal to atherosclerosis, and reduction of LDL cholesterol decreases cardiovascular events.3
According to European guidelines, plasma target levels of LDL-cholesterol should be tailored to the specific cardiovascular disease risk of the patient, with those at very high cardiovascular risk ideally aiming for a lower target level (Box 1).3

Lifestyle changes
While drug therapy with statins may be necessary to lower LDL-cholesterol in higher-risk patients, all patients should be counselled about lifestyle changes that may help reduce LDL-cholesterol levels to a healthy level as a first step. Healthcare professionals should explore all available options for cardiovascular risk reduction with patients, outlining the benefits of lifestyle changes and cholesterol-lowering options, before and alongside statin treatment.2,6,7 Cognitive behavioural techniques can be useful in helping patients to make healthy lifestyle changes.3
Important! Around 20% of patients eligible for statin therapy for the primary prevention of cardiovascular disease will choose not to take statins after discussions with a healthcare professional.
Benefits of lowering risk factors
There is strong evidence that dietary changes can reduce the risk of cardiovascular disease and they should always be the first step in cardiovascular disease risk prevention. In particular, the Mediterranean diet, which includes high levels of fresh fruit and vegetables, wholegrain cereal products, as well as nuts, legumes, fish and extra virgin olive oil, has been proven to reduce the risk of cardiovascular disease.5 Saturated fat can increase cholesterol levels and its intake should therefore be limited and swapped, where possible, for unsaturated alternatives.6
The 2019 ESC/EAS guidelines recommendations for a cardioprotective diet provide sensible guidelines for people who want to lower their LDL-cholesterol levels.3 They suggest that people who have or who are at high risk of cardiovascular disease should be advised to maintain their total fat intake at 30% or less of their total energy intake, with saturated fats making up 7% or less of their total energy intake.3 For an energy intake of 2,000 calories per day, this would equate to 15 grams of saturated fat.
The 2019 European guidelines for the management of dyslipidaemias and the European guidelines on cardiovascular disease prevention in clinical practice in Box 2.3

It may be useful to give patients some simple ideas for healthier food swaps that they can try (Figure 2).

Role of plant stanols and sterols in lowering cholesterol
Plant stanols and sterols are found naturally in vegetable oils and in smaller quantities in vegetables, fruits, grains and legumes. Their structure resembles cholesterol so they interfere with intestinal absorption of cholesterol, and reduce serum levels of total and LDL-cholesterol.5
Plant stanols and sterols are esterified in order to be incorporated in foods, making plant stanol or sterol esters the main ingredient that helps to lower cholesterol.
Plant stanol ester adds to the cholesterol-lowering effect of a healthy diet.


Normal levels of plant stanols and sterols consumed in a typical diet are around 250mg/day, though often this is much lower. It has been proven that increasing the amount eaten daily to 2g can lower total and LDL-cholesterol levels by 7–10%.5 A dose dependent benefit can be obtained with a daily intake of 1.5-3g plant stanols or sterols.3,8 The cholesterol-lowering effect of phytosterols has been shown to be in addition to the response obtained from eating a low-fat diet or using statins.3
However, it is not possible to consume enough phytosterols simply by eating the right kinds of foods because they would need to be consumed in vast quantities to make use of their cholesterol-lowering properties. Therefore phytosterols are added to some foods and supplements to give them cholesterol-lowering properties. Examples of such functional foods are spreads, yoghurt, and yoghurt drinks.9 Functional foods need to contain the ingredient ‘plant stanols or sterols’.
Recommendations
European guidelines recommend the use of functional foods containing plant stanols or sterols (at least 2g/day with the main meal) particularly for:5,8
- People with high cholesterol levels who are at low or intermediate cardiovascular risk who do not qualify for statin therapy
- High- and very high-risk patients, such as patients with diabetes, in addition to statin therapy if they fail to achieve LDL-cholesterol goals on statins alone, or are statin intolerant
- Adults and children older than six years who have familial hypercholesterolaemia
In general, all patients with high cholesterol levels in the absence of any contraindications are able to use plant stanols or sterols.
When taken by patients also taking statins, functional foods with added plant stanols or sterols can increase the reduction of LDL-cholesterol levels by up to 5–10% and they have been shown to be well-tolerated and safe in combination with statins.5
Key learning points
- High levels of LDL-cholesterol put people at risk of coronary heart disease, heart attack and stroke.
- Behavioural risk factors, such as unhealthy diet, physical inactivity, smoking and excess alcohol consumption, should be addressed at an early age to reduce cardiovascular disease risk in all patients.
- For all patients, target plasma LDL-cholesterol levels should be below 3 mmol/l, while those at higher risk of cardiovascular disease should ideally aim for levels lower than 1.8 mmol/l.
- A percentage of patients will refuse to take statins so it is even more important to engage them in a discussion about lifestyle changes to help them reduce their cardiovascular risk.
- Giving patients ideas of how to make healthy food swaps may be more helpful than general advice to lower saturated fats.
- 2g a day of plant stanols and sterols will reduce LDL-cholesterol levels by around 10%.
- Functional foods can be used by patients taking statins to lower their LDL-cholesterol by a further 10%.
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