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Prioritizing Health | Dietary Approaches For Elevated LDL-C

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Prioritizing Health | Dietary Approaches For Elevated LDL-C

Jul 01, 2025

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Dietary Approaches For Elevated LDL-C

LDL-C is causal for atherosclerotic cardiovascular disease (ASCVD),1 and elevated blood cholesterol affects approximately 100 million U.S. adults.2 Although patients often assume serum LDL-C is entirely genetically predetermined, only a small percentage have severe monogenic disorders. Elevated LDL-C in most adults can be highly impacted by diet quality, the leading behavioral risk factor for preventable death in the U.S.3,4 Professional society guidelines recommend lifestyle management with dietary modification as foundational to management of blood cholesterol in all adults.5-8

According to the ACC/American Heart Association (AHA) guideline, all adults should undergo cholesterol screening to help assess long-term cardiovascular risk.5,6 Serum LDL-C levels <100 mg/dL are considered desirable for adults without ASCVD,5,9-11 though lower levels may further reduce the risk of developing atherosclerosis.12-14 Though non–HDL-C and apolipoprotein B are better predictors of cardiovascular risk,5,15,16 dietary changes that lower LDL-C also lower these measures.

Dietary fats are a major modifier of serum LDL-C. Data from basic science, metabolic ward and cohort studies as well as randomized clinical trials (RCTs) have demonstrated that higher intake of saturated fats (SFA) raises LDL-C and increases the risk of ASCVD when they replace unsaturated fats or high-fiber carbohydates.17-21 For example, a meta-analysis of the highest quality RCTs from an AHA Scientific Statement showed that SFA replacement with unsaturated fats reduced cardiovascular disease risk by approximately 30%.18

SFA are typically solid at room temperature, and high amounts are found in animal products (e.g., fatty meat, pork lard, beef tallow and dairy fat) and tropical oils (coconut and palm oils).22 Though not widely used in home cooking, palm oil is commonly consumed in processed foods and snacks (e.g., cakes, pies, cookies, muffins, doughnuts) and plant-based margarines/butters.

Key Points For Clinicians

  1. Diet and lifestyle modification is the cornerstone of dyslipidemia management and prevention, regardless of cardiovascular risk.
  2. Promote diets rich in fiber from vegetables, fruits, legumes, whole grains, nuts and seeds.
  3. Recommend replacing foods high in saturated fats with those high in unsaturated fats and/or fiber.
  4. High-fiber plant-based diets such as the Portfolio diet have consistently demonstrated the greatest LDL-C reductions, while vegan/vegetarian, DASH and plant-based Mediterranean diets can lead to smaller reductions in LDL-C which also improve ASCVD outcomes.

Key Messages For Patients

  1. Dietary patterns that consistently have the greatest impact on LDL-C reduction have high intake of whole plant foods and are low in saturated fat.
  2. Eat a wide variety of vegetables, fruits, legumes, whole grains and nuts every day, including oats, barley, legumes, soy protein, nuts and other plant-based foods high in soluble fiber.
  3. Reduce and limit or eliminate foods high in saturated fat, including red meat, pork, processed meats (e.g., bacon, ham, salami, sausages, hot dogs), butter, cream and processed foods containing palm oil or coconut oil.
  4. For home cooking and baking, use liquid vegetable oils instead of solid fats like butter or coconut oil.

As a first-line recommendation, the AHA and the National Lipid Association recommend SFA be limited to <7% of total daily calories for all adults.23,24 Industrial trans-fats from partially hydrogenated oils also elevate serum LDL-C, but U.S. intake has fallen dramatically since the enactment of public policy measures.25,26

Unsaturated fats are typically liquid at room temperature and consist of monounsaturated fats (MUFA) and polyunsaturated fats (PUFA). PUFA and to a lesser degree MUFA lower LDL-C when replacing equivalent calories from SFA.17-21 Plant-based sources of PUFA/MUFA include nuts, seeds, avocado and liquid vegetable oils (e.g., olive, canola, soybean, corn, sunflower). Despite publicized claims that seed oils are inherently harmful, clinical studies consistently demonstrate that they reduce LDL-C and lower cardiovascular risk when used in place of foods high in SFA (e.g., butter, tallow) and do not increase markers of inflammation.17,18,27-39

Dietary fiber also plays an important role in determining serum LDL-C and is found exclusively in plants (fruits, vegetables, legumes, grains, nuts and seeds). Fiber may be soluble or insoluble, and both types are found in most plant foods. Soluble fibers have a greater impact on lowering LDL-C, and are relatively higher in legumes, fruits, vegetables, barley and oats.40,41 Despite the benefits of dietary fiber on LDL-C-lowering and reducing cardiovascular risk, approximately 95% of Americans do not consume the minimum recommended intake of at least 14 grams per 1,000 calories (at least about 25 grams for women and about 38 grams for men daily).23,42

Consistent with the evidence, plant-predominant dietary patterns that are low in SFA and high in fiber result in the greatest LDL-C reductions. The Portfolio diet is a high-fiber (>70 grams/day) plant-based diet that includes multiple foods shown to independently lower LDL-C, including soy protein and legumes, nuts and seeds, vegetables high in viscous fiber, and MUFA. The Portfolio diet can reduce LDL-C by as much as 35%.43-45 Similar or greater LDL-C reductions have been seen with other high-fiber plant-based diets.46-49

More generally, vegetarian, vegan and primarily plant-forward diets can reduce LDL-C compared to most dietary patterns. Meta-analyses show vegetarian diets lower LDL-C by 13 mg/dL in RCTs and are associated with a 23 mg/dL lower LDL-C in observational studies.50,51 The Dietary Approaches to Stop Hypertension (DASH) diet promotes eating fruits, vegetables, whole grains and low-fat dairy, and limiting foods high in SFA, sodium and added sugar.52-54 Compared with a typical American diet, DASH can lower LDL-C by an average of 11 mg/dL.53,54 Although these changes in LDL-C seem small, their cumulative effects over time are likely large based on Mendelian randomization studies.1

The Mediterranean diet promotes high intake of fruits, vegetables, whole grains, nuts, legumes and olive oil; moderate intake of fish, dairy and poultry; and low intake of red meat and sweets.55,56 Although some forms of the Mediterranean diet frequently have little to no effect on LDL-C, more plant-based versions can lower LDL-C and the higher polyphenolic content of the diet likely contributes to nonlipid benefits.57-61

Even though most clinicians are limited by inadequate nutrition education and/or time, diet counseling is foundational to improving LDL-C and ASCVD outcomes. Even brief messages have been shown to improve diet quality, and simple recommendations can include limiting ultra-processed foods, substituting nontropical plant-based fats for animal fats, and eating fiber-rich whole grains in place of refined grains.

Visit CardioSmart.org/EatBetter to download this infographic and learn more.

Lifestyle behavior change can also be facilitated by utilizing SMART goals (Specific, Measurable, Achievable, Relevant and Time-Based). Patients can be referred to a registered dietitian nutritionist (RDN), reimbursable for many adults including Medicare patients with diabetes or chronic kidney disease, or with certain Medicare Advantage plans.

ASCVD patients also should be referred to cardiac rehabilitation, where reducing SFA is emphasized and RDNs typically hold sessions on reading nutrition labels. High fiber and low SFA intake can be tailored to cultural/social preferences, financial considerations and culinary skillsets.

This article was authored by Emily S. Fishman, MD, and Alexander P. Ambrosini, MD, Yale School of Medicine, Yale University, New Haven, CT; Ashley Waring, MD, FACC, Medical University of South Carolina, Charleston, SC; and Karen E. Aspry, MD, MS, FACC, Alpert Medical School, Brown University, Providence, RI; and  Kamil F. Faridi, MD, MSc, Yale School of Medicine.

References

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Resources

Clinical Topics: Dyslipidemia, Prevention, Lipid Metabolism, Nonstatins, Diet

Keywords: Cardiology Magazine, ACC Publications, Diet, Dietary Fats, Heart Disease Risk Factors, Cholesterol, LDL, Atherosclerosis