Lipid Lowering Tools: Lifestyle and Beyond

Weight Loss –

Event small amounts of weight loss can reduce triglycerides and likely increase HDL.

Lose 3-8% of your total body weight can reduce LDL by 5%, but this is not always a reliable tool.

Exercise –

This will reliably reduce triglycerides as well as increase HDL.

Exercise does not reliably decrease LDL.

Diet – This is your big lifestyle level to pull for LDL. Each intervention can lower LDL by about 5% and the effects can be additive to an extent. Generally, significant dietary change can lead to a 15-20% reduction in LDL.

Increase fiber: whole oats, barley, avocado, berries, legumes, beans, psyllium

Increase mono- and polyunsaturated fats: avocado, nuts, seeds

Decrease saturated fat: butter, lard, animal products (meat, cheese, eggs), fried foods

Increase plant protein intake: legumes, beans, nuts, seeds, tofu, tempeh, whole grains

Incorporate plant sterols and stanols: nuts, seeds, whole grains (particularly rye and wheat), legumes, avocados, apples, broccoli, Brussels sprouts

Supplements – Generally we don’t see more than a 5% decrease in LDL with supplements.

Red yeast rice: statistically significant LDL lowering, but not more than 5% reduction which is not clinically significant. This supplement contains lovastatin (a naturally occurring statin). It can be harmful to the kidneys because concentrations/dose is not monitored/consistent.

Plant sterols: statistically significant LDL lowering in studies, but not more than 5% reduction which is not clinically significant. These can dangerously increase some people’s LDL. Be careful with these.

Berberine: seems to modestly lower LDL in some people, can have GI side effects, should be avoided in liver disease

Pine bark: reportedly lowers LDL, raises HDL, but studies inconclusive and side effects can occur

Omega 3s: these are NOT an LDL lowering supplement. They can lower triglycerides modestly in some people depending on the person and the supplement formulation.

Niacin: this is NOT recommended. Side effects are common, often severe, and can be dangerous. Guidelines recommend against the use of this supplement and prescription for LDL lowering / HDL increase.

*Be careful here. Supplements are not FDA monitored and can be harmful/toxic. They can and often interfere with the metabolism of other medications/supplements. They can also generate side effects, some of which are very serious. Just because they are over the counter does not mean they don’t require monitoring or thought surrounding their use. Always discuss any supplements with your healthcare provider to be sure there are no known risks in your case.

Medications –

Bile acid sequestrants: routinely lower LDL by 15-30%, but have frequent and unpleasant side effects. Not used much anymore.

Statins: routinely lower LDL by 30% (this is often true even at very small doses a few days a week) and up to 50% (often with just the starting dose daily, but reliably at moderate doses). They also lower triglycerides 7-30%.

Ezetimibe: routinely lowers LDL 15-20%

Bempedoic acid: routinely lowers LDL about 30-35%

PCSK9 inhibitors: routinely lowers LDL 50% or greater

All medications for LDL lowering increase LDL clearance (removal of LDL from circulation) but by a variety of different mechanisms. Combining mechanisms can be extremely effective. All lipid lowering drugs on the market are safe. Many have been used for several decades.

Fenofibrate: lowers triglycerides up to 50%. Indicated to prevent pancreatitis when fasting triglycerides are >500mg/dL.

Omega-3-acid ethyl esters: prescription triglyceride lowering medication, indicated to prevent pancreatitis when fasting triglycerides are >500mg/dL.

Icosapent ethyl: this is a mild triglyceride lowering medication but seems to have clinically significant ASCVD risk reduction in patient populations who meet use criteria.