How To Lower Cholesterol Without Medications
When standard drug therapy options are not an option.
A common patient I see is someone with high cholesterol who is reluctant to go on cholesterol-lowering therapy.
Most of these patients just need some additional time and an overview of the data that supports the utility of such an approach.
While lifestyle measures will get some of these patients to acceptably low cholesterol levels, many will have persistently high cholesterol.
And a small percentage of patients choose not to go on cholesterol-lowering treatment.
Ultimately, this is their choice.
And the guidelines support this decision.
A fact that many clinicians are unaware of.
The 2021 European Cardiology Society guidelines on prevention state quite clearly that when it comes to primary prevention:
“Treatment recommendations are never imperative for high-risk patients, nor are interventions ever prohibited for patients at low-to-moderate risk.”
Let me be 100% clear.
The evidence that high LDL cholesterol CAUSES coronary artery disease is overwhelmingly clear, and also that lowering cholesterol reduces cardiovascular risk1.
However.
Some patients chose, despite the evidence, not to take cholesterol-lowering medications, and WE MUST respect that choice if made in an informed manner.
However, many of these patients are open to lowering their cholesterol using non-drug means.
For these patients, there are some options.
I do not consider them ideal options, and most have nowhere near the evidence base compared to the standard therapies we use.
So, what works?
Soluble Fibre
A diet higher in soluble fibre (psyllium husk) has been long known to lower cholesterol levels. Multiple studies have demonstrated its utility in lowering LDL-cholesterol in isolation and also in combination with other drug therapies2.
In isolation, 5g of psyllium twice daily has been shown to reduce total and LDL cholesterol levels by approximately 5-7% over a 6-month period3.
When combined with statin therapy, it has been consistently shown to even further reduce cholesterol levels, including total, LDL cholesterol and APOB4.
However, even higher doses have shown an increasing LDL cholesterol-lowering effect5.
Red Yeast Rice
Red yeast rice is one of the most commonly used over-the-counter supplements to lower LDL cholesterol. The most important point to highlight with this therapy is that it contains the active ingredient, monacolin K, which is the same active ingredient as the statin therapy, lovastatin.
In general, if red yeast rice is something my patient is already taking (and tolerating), I usually highlight that the active ingredients are very similar to statin therapy. Given the greater body of literature supporting statin use, they are likely a better option.
They are, in effect, on an unregulated statin therapy without the safety data.
However, red yeast rice can lower LDL cholesterol levels by 15% to 25%6.
Berberine
Berberine is another commonly used supplement to lower cholesterol.
Multiple studies have evaluated its LDL cholesterol-lowering ability, and although figures vary, reductions of 25% can be achieved 7.
What is most interesting about berberine is that it likely acts via the same mechanism as the injectable PCSK9 inhibitor therapy. For some individuals who share the gene variant that results in higher cholesterol, the effects may be even more potent8.
Taurine
Taurine is an amino acid normally only found in meats. Studies have shown various benefits, from improved blood pressure control and endurance exercise performance910.
Its use has also been shown to lower total cholesterol and triglycerides, but its effect on lowering LDL cholesterol is limited11.
Other commonly used cholesterol-lowering supplements include garlic, turmeric and cinnamon, but all of these have questionable utility12.
Although these over-the-counter supplements sound appealing, every therapy has potential side effects, and supplements are no different.
Just because something is ‘natural’ doesn’t mean it is ‘safe’.
Cyanide is natural.
It is certainly not safe.
However, for some people with high cholesterol, supplements are often the only therapy they might agree to use. And we have to meet people where they are.
A recent randomised study puts many of these options in context by comparing the effectiveness of some of the options listed above to a modest dose of statin therapy.
None of the supplements listed lowered LDL cholesterol significantly compared to a placebo control13. The average LDL cholesterol reduction in the statin arm compared to placebo was 35%.
For some patients, over-the-counter supplementation might be the only acceptable option. Some of these therapies have shown reductions in LDL cholesterol in scientific studies.
However, the greatest body of literature, including safety and efficacy data, is with the approved drug therapies for use today.
To leave these ‘drug' options on the table is missing out on some very big upside.
But we all have to make our own choices.
I just know what I chose.
And they typically require a prescription.
Low-density lipoproteins cause atherosclerotic cardiovascular disease: pathophysiological, genetic, and therapeutic insights: a consensus statement from the European Atherosclerosis Society Consensus Panel. Eur Heart J. 2020 Jun 21;41(24):2313-2330.
Long-term cholesterol-lowering effects of psyllium as an adjunct to diet therapy in the treatment of hypercholesterolemia. Am J Clin Nutr. 2000 Jun;71(6):1433-8.
Long-term cholesterol-lowering effects of psyllium as an adjunct to diet therapy in the treatment of hypercholesterolemia. Am J Clin Nutr. 2000 Jun;71(6):1433-8.
Effect of Combining Psyllium Fiber With Simvastatin in Lowering Cholesterol. Arch Intern Med. 2005;165(10):1161–1166.
Time- and dose-dependent effect of psyllium on serum lipids in mild-to-moderate hypercholesterolemia: a meta-analysis of controlled clinical trials. Eur J Clin Nutr 63, 821–827 (2009).
Red Yeast Rice for Hypercholesterolemia. Methodist Debakey Cardiovasc J. 2019 Jul-Sep;15(3):192-199.
Effects of Berberine on Atherosclerosis. Front Pharmacol. 2021 Nov 26;12:764175.
Berberine: Ins and outs of a nature-made PCSK9 inhibitor. EXCLI J. 2022 Aug 17;21:1099-1110.
The effects of taurine supplementation on obesity, blood pressure and lipid profile: A meta-analysis of randomized controlled trials. Eur J Pharmacol. 2020 Oct 15;885:173533.
The Effects of an Oral Taurine Dose and Supplementation Period on Endurance Exercise Performance in Humans: A Meta-Analysis. Sports Med. 2018 May;48(5):1247-1253.
The effects of taurine supplementation on obesity, blood pressure and lipid profile: A meta-analysis of randomized controlled trials. Eur J Pharmacol. 2020 Oct 15;885:173533.
Comparative Effects of Low-Dose Rosuvastatin, Placebo, and Dietary Supplements on Lipids and Inflammatory Biomarkers. J Am Coll Cardiol. 2023 Jan 3;81(1):1-12.
Comparative Effects of Low-Dose Rosuvastatin, Placebo, and Dietary Supplements on Lipids and Inflammatory Biomarkers. J Am Coll Cardiol. 2023 Jan 3;81(1):1-12.
I am curious about the studies that look at the detriments of lowering cholesterol too much and also looking at just a basic lipid profile with no further exploration as to size of particles (the larger LDLs being ok) before administering medication.
I do respect your willingness to support hour patient’s choice! too many physicians will not even discuss options.
Excellent write-up. We need those who have very high cholesterol to up the fiber in their diet. And eat fish weekly. In the U.S. some supplements are not pure.