Can you reduce your cholesterol without taking a drug?

It's one of the most common questions people ask their doctors: How do I lower my cholesterol? Many of them hope to avoid taking drugs, while others are interested in natural cholesterol-lowering medications, like the Heart Letter reader who wrote to us recently.

She's an active, slender 76-year-old who follows a heart-friendly diet (mostly organic fruits and vegetables, grains, and lean meats, but no red meat and no alcohol). Her blood pressure and blood sugar levels are normal, but her LDL ("bad") cholesterol is 157 milligrams per deciliter (mg/dL), which is considered borderline high.

In general, there are three main ways to lower LDL to the recommended 100 mg/dL or lower: diet, a dietary supplement, or a prescription medication, such as a statin. Here's how Heart Letter editor in chief Dr. Christopher Cannon counsels patients on this topic.

Dietary changes

What many people don't realize is that only about 20% of the cholesterol in your bloodstream comes from your diet — your liver and intestines make the rest. For most people, the cholesterol present in food doesn't have that much of an effect. However, most of the cholesterol in the average person's diet comes from animal-based foods such as meat and dairy, which are also high in saturated fat. Saturated fat clearly raises LDL cholesterol and should be consumed in limited amounts.

The rest of your diet matters, too. Swap saturated fat for unsaturated fats (such as those found in vegetable oils, avocados, and fatty fish). Eat plenty of plant foods (like vegetables, fruits, beans, and whole grains — especially oats) that are rich in fiber, which helps lower your cholesterol by making dietary cholesterol harder to absorb from your gut.

If you eat cheeseburgers and ice cream regularly but then gradually transition to a healthier diet, you're likely to see your LDL level fall. If your diet is already quite healthy (like the reader described above), further tweaks might not make that much of a difference. "I often tell patients that while some people see modest reductions in their LDL after changing their diet, some do not," says Dr. Cannon. Still, a healthy diet has other cardiovascular benefits, even if your LDL doesn't drop very much, he adds. For example, many of the compounds found in whole, unprocessed plant foods help dampen inflammation, discouraging plaque buildup.

Supplements

Many dietary supplements sold in the United States claim to benefit heart health. But only three may help drive down LDL cholesterol, and only by a modest amount.

Psyllium husk. Derived from the seeds of the Plantago ovata plant, this fiber supplement is best known as a treatment for constipation (Metamucil is one familiar brand). The powder is mixed with a liquid to make a thick gel. Psyllium husk or powder is also available in wafers, bars, and capsules. It's thought to absorb bile acids and cholesterol, which are then eliminated from the body during bowel movements. The suggested daily dose is 5 to 10 grams. An April 2024 review article in the journal Nutrients found that taking psyllium daily for a month or two can lower LDL by about 6 points, on average.

Plant sterols. Found naturally in the cell membranes of plants like nuts, soybeans, peas, and rapeseed (the source of canola oil), these compounds (also call phytosterols) have a structure similar to cholesterol. Eating them helps limit the amount of cholesterol your body can absorb. Manufacturers offer many types of foods with added plant sterols, including margarine (such as Benecol), mayonnaise, bread, breakfast and snack bars, milk, and juice. Phytosterols are also available in capsule form. Some studies show that consuming 2 grams of plant sterols per day for at least eight weeks can lower LDL by up to 10%. However, a recent, carefully controlled four-week trial — the Supplements, Placebo, or Rosuvastatin Trial, or SPORT —  found only a 4.4% LDL reduction from plant sterols.

Red yeast rice. Made by steaming white rice with the yeast Monascus purpureus, this red-hued extract contains monacolin K, the same active ingredient in the prescription cholesterol-lowering drug lovastatin. Some studies suggest that supplements containing 4 milligrams (mg) to 10 mg of monacolin K can lower LDL between 20% and 25%. But SPORT reported a mere 6.6% LDL reduction from red yeast rice.

"I have several patients who've been able to lower their LDL a little bit with psyllium, which is a safe, inexpensive product," says Dr. Cannon. The problem with the plant sterols and red yeast rice is the same as with all dietary supplements: the amount of active ingredient is not regulated and may vary from batch to batch. If you want to try these products, do so only under a doctor's supervision and use brands tested and vetted by ConsumerLab.com, an independent testing company.

Statins

Unlike dietary supplements, drugs in the class known as statins contain a known amount of the active ingredient — a compound that both decreases the amount of cholesterol the body makes and boosts the liver's ability to clear cholesterol from the blood. These drugs can lower LDL between 25% and 55%.

Note that simply having elevated LDL cholesterol doesn't necessarily mean you should be taking a statin, Dr. Cannon notes. The ultimate goal is to lower your risk of heart disease, and other factors (like your age and other health conditions) affect your risk. He recommends using the American College of Cardiology's risk calculator. The calculator provides treatment advice about managing your LDL and other heart disease risk factors, which you can then discuss with your physician. For our reader, a moderate-intensity statin may be reasonable, according to the calculator's recommendation.

When people are reluctant to start taking a statin, a coronary calcium score can help them make a more informed decision. Our reader's calcium score is 116, which suggests she has a small amount of plaque in her coronary arteries (see "Should I get a calcium score?" in the April 2023 Heart Letter for information about this test). "But any number above zero means that the person has coronary artery disease," Dr. Cannon explains. Anyone with that diagnosis should get their LDL down to 70 or lower, which will prevent additional plaque buildup, he says. For someone with an LDL of 157, a statin is the most effective means to reach that goal.

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