Cholesterol Management

Atherosclerosis is driven by the retention of ApoB-containing lipoproteins in the arterial wall, and the relationship between cumulative LDL exposure and cardiovascular events is causal, dose-dependent and consistent across genetics, observational data and trials. That makes LDL — better still ApoB, which counts particles rather than the cholesterol inside them — the primary treatment target. Around a fifth of people have discordant LDL-C and ApoB, meaning a normal-looking LDL-C conceals a high particle count. Lipoprotein(a), which is genetically determined and unresponsive to lifestyle, should be measured once in a lifetime because it independently raises risk and changes how aggressively other factors are treated.

Replace saturated fat with unsaturated fat rather than with refined carbohydrate — this is the single dietary change with the most consistent LDL effect. Add 5-10 g/day of soluble fibre from oats, barley, legumes and psyllium, which lowers LDL by around 5-10%. Plant sterols and stanols at 2 g/day lower LDL by 8-10% and are among the best-evidenced supplements here. Lose excess weight and cut alcohol to bring triglycerides down. Aerobic exercise raises HDL and lowers triglycerides but does relatively little to LDL. Where drug therapy is indicated, statins remain first line with ezetimibe and PCSK9 inhibitors as additions; supplements do not substitute for them at high risk. Red yeast rice contains monacolin K, chemically identical to lovastatin, so it carries statin-like effects and risks with far less quality control. Berberine at 1000-1500 mg/day lowers LDL modestly. Omega-3s lower triglycerides substantially at 2-4 g/day of EPA and DHA but do not lower LDL.

• •Swapping saturated fat for unsaturated fat
• •5-10 g/day of soluble fibre from oats, legumes and psyllium
• •2 g/day of plant sterols or stanols
• •Losing excess weight
• •Limiting alcohol to lower triglycerides
• •Regular aerobic exercise
• •Stopping smoking, which restores HDL function