How to lower cholesterol: what the evidence shows
For most people, cholesterol can be meaningfully improved. Triglycerides often fall by 20–50% with lifestyle change, and LDL cholesterol by around 13–17% with the right eating pattern. Two further tests, ApoB and Lp(a), show your real risk more precisely, so your plan can be built around you rather than a single number.
If your cholesterol has come back high, here's the encouraging part. Cholesterol is one of the most measurable and most changeable risk factors in medicine, and every improvement counts.
There's also something most people aren't told. Two people with the same LDL result can have very different levels of risk. The right tests can tell them apart.
What does your cholesterol test actually tell you?
A standard cholesterol test (lipid panel) reports several numbers, measured in mmol/L in New Zealand:
Marker | What it is | Generally better |
LDL cholesterol | The main carrier that delivers cholesterol into artery walls, where plaque builds up | Lower |
HDL cholesterol | Carries cholesterol away from the arteries | Higher, though raising it isn’t a target (see below) |
Triglycerides | Fats carried in the blood. They rise with sugar, alcohol and excess weight | Lower |
Non-HDL cholesterol | All the cholesterol in potentially harmful particles (total minus HDL) | Lower |
Total:HDL ratio | The figure New Zealand heart risk calculators use | Lower |
These numbers measure how much cholesterol is in your blood. They don't show how many cholesterol-carrying particles there are, or whether you've inherited a riskier type. Two further tests do.
What are ApoB and Lp(a), and why do they matter?
ApoB: counting the particles
Every potentially harmful cholesterol particle carries exactly one molecule of apolipoprotein B, or ApoB. So ApoB counts the particles that can enter artery walls and build plaque. It's the number of particles, not just the cholesterol inside them, that drives risk.
Two people with the same LDL can have very different ApoB levels, especially if they have raised triglycerides, diabetes, insulin resistance or fatty liver. European guidelines support measuring ApoB in these situations (Mach et al., European Heart Journal, 2020).
Lp(a): the inherited factor
Lp(a), or lipoprotein(a), is a cholesterol particle whose level is mostly set by your genes. About one in five people has a raised level, and most don't know it. It barely changes with lifestyle, so it usually only needs testing once. The European Atherosclerosis Society recommends every adult has it measured at least once (Kronenberg et al., European Heart Journal, 2022).
A high Lp(a) isn't a sentence. It's information: it explains risk that would otherwise stay hidden, and shows where effort will count most.
How do these tests lead to a more personalised plan?
A standard panel tends to group everyone with similar numbers together. ApoB and Lp(a) help separate who needs what:
LDL modestly raised, ApoB reassuring: lifestyle change may be the main focus, approached with confidence.
LDL normal, ApoB high: a hidden risk found early, pointing to targeted action on triglycerides, insulin resistance and weight.
Lp(a) high: the factors you can change matter even more, and consensus guidance is to manage them more closely.
Everything in range: clarity, and confirmation that your habits are working.
Either way, you're no longer working from an average. Your plan is built around your own markers, and tracked against them.
Why does lowering LDL cholesterol matter?
Because every reduction counts. Across 26 trials and 170,000 people, every 1.0 mmol/L drop in LDL cholesterol reduced major vascular events, such as heart attacks and strokes, by 22%, with no threshold below which the benefit stopped (Cholesterol Treatment Trialists, The Lancet, 2010).
How much can diet lower LDL cholesterol?
Meaningfully. The best-studied approach is the Portfolio eating pattern, which combines four foods every day:
about 42 g of nuts
about 50 g of plant protein, from soy or legumes
about 20 g of soluble fibre, from oats, barley, psyllium or fruit
about 2 g of plant sterols, from sterol-enriched foods.
Compared with a standard low saturated fat diet, it lowered LDL by about 17%, along with triglycerides, blood pressure and C-reactive protein, a marker of inflammation (Chiavaroli et al., Progress in Cardiovascular Diseases, 2018).
Change | Typical LDL reduction |
Plant sterols, 2 g a day | 13–16% |
Soluble fibre, 5–10 g a day | About 5% |
Portfolio pattern, everyday life | 13–17% |
Chiavaroli et al., Progress in Cardiovascular Diseases, 2018
Swapping fats matters too. Cutting saturated fat for at least two years reduced cardiovascular events by 17%, most when it was replaced with polyunsaturated fats from oily fish, nuts, seeds and vegetable oils (Hooper et al., Cochrane, 2020).
Diet usually lowers LDL less than cholesterol-lowering medication does. But a 15% drop from an LDL of 4.0 mmol/L is worth roughly 13% fewer major vascular events, it adds to any treatment, and it improves blood pressure and blood sugar at the same time.
How do you lower triglycerides?
This is where lifestyle change shines. According to the American Heart Association:
losing 5–10% of your body weight lowers triglycerides by about 20%
cutting added sugars and eating more unsaturated fat can lower them by another 10–20%
combining these with regular activity can lower them by 50% or more.
Miller et al., Circulation, 2011
Can you raise HDL cholesterol, and does it help?
A little, but it isn't the target it was once thought to be. Exercise and weight loss raise HDL modestly, but genetic studies suggest raising HDL by itself doesn't lower heart attack risk (Voight et al., The Lancet, 2012). The focus belongs on LDL, non-HDL cholesterol, triglycerides and ApoB.
What if your cholesterol is partly inherited?
Then knowing early is your advantage. Familial hypercholesterolaemia, an inherited cause of very high LDL, can be treated very effectively once found, and family members can be tested too. A high Lp(a) means every other risk factor can be managed with it in mind.
For some people, medication is part of the plan. Cholesterol-lowering medication is among the best-studied treatments in medicine, and lifestyle change adds to its benefit. Any change to treatment is a decision to make with the doctor who prescribes it.
What simple changes can you start today?
Fats
Swap butter, lard and coconut oil for olive, canola or avocado oil.
Eat oily fish such as salmon or sardines once or twice a week, and cut back on processed meats and pastries.
Fibre and plant foods
Start the day with oats or barley. Their soluble fibre binds cholesterol in the gut.
Eat legumes several times a week, and a small handful of nuts most days.
Consider sterol-enriched foods, such as spreads or milks, eaten daily with a meal.
Triglycerides
Cut back on sugary drinks, refined carbohydrates and alcohol. Triglycerides often respond within weeks.
Movement
Move most days. Activity lowers triglycerides and raises HDL a little, and every kilogram lost helps.
If you take cholesterol-lowering medication, keep taking it. These changes work alongside it.
How does Autonomy approach blood pressure?
Knowing what to change is only half of it. The harder part is making changes that last, and the evidence is clear that this works best with a team. The American Heart Association notes that effective lifestyle programmes are usually delivered by dedicated multidisciplinary teams. A 2019 analysis of 19 randomised trials found the greatest reductions in cardiovascular risk came from teams of three or more disciplines (van Namen et al., 2019).
That's how Autonomy's Metabolic Clinic works:
Doctors interpret your full picture, including ambulatory readings, cortisol rhythm and cardiovascular markers, and build a plan around your own results.
Registered nurses carry out your assessments and testing, and track your blood pressure over time.
Medically led health coaches turn the plan into everyday habits across nutrition, movement, sleep and stress, and help you keep them going.
Where to start
If you'd like to understand your real cardiovascular risk, start with a clinical Discovery Consultation with one of our doctors: 30 minutes, online or in person, $249, with no obligation.
We'll look at your results and history, talk through whether ApoB and Lp(a) testing would sharpen your picture, and explain what the programme would involve. You'll leave knowing where you stand, and what your options are.
Dr Janani Krishnaswami (MD, MPH, DipABLM)
Clinical Director, Autonomy Health
Book a Discovery Consultation today.
References:
1. Cholesterol Treatment Trialists' Collaboration. Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of data from 170,000 participants in 26 randomised trials. The Lancet 2010;376:1670–1681.
2. Chiavaroli L, Nishi SK, Khan TA, et al. Portfolio dietary pattern and cardiovascular disease: a systematic review and meta-analysis of controlled trials. Progress in Cardiovascular Diseases 2018;61(1):43–53. [confirm volume and pages]
3. Hooper L, Martin N, Jimoh OF, et al. Reduction in saturated fat intake for cardiovascular disease. Cochrane Database of Systematic Reviews 2020, Issue 8. CD011737.
4. Miller M, Stone NJ, Ballantyne C, et al. Triglycerides and cardiovascular disease: a scientific statement from the American Heart Association. Circulation 2011;123:2292–2333.
5. Voight BF, Peloso GM, Orho-Melander M, et al. Plasma HDL cholesterol and risk of myocardial infarction: a mendelian randomisation study. The Lancet 2012;380:572–580.
6. Mach F, Baigent C, Catapano AL, et al. 2019 ESC/EAS Guidelines for the management of dyslipidaemias. European Heart Journal 2020;41:111–188.
7. Kronenberg F, Mora S, Stroes ESG, et al. Lipoprotein(a) in atherosclerotic cardiovascular disease and aortic stenosis: a European Atherosclerosis Society consensus statement. European Heart Journal 2022;43:3925–3946.
van Namen M, et al. Supporting lifestyle modification in patients with obesity or hypertension: a systematic review and meta-analysis of randomised trials. 2019.
