How to Lower Cholesterol: Diet, Exercise, Targets and Statin Medicines

Cholesterol is a waxy fat that your body needs to build cells and hormones. Problems start when too much of the "bad" type, LDL cholesterol, circulates in the blood. Over years it builds up in artery walls as plaque, narrowing the vessels and raising the risk of heart attack, stroke and poor circulation in the legs. High cholesterol causes no symptoms, so a blood test is the only way to know. The encouraging news is that it responds well to lifestyle changes and, when needed, to safe, effective medicines.

Understanding your lipid profile

A lipid profile usually reports four numbers:

• Total cholesterol: desirable below 200 mg/dL (5.2 mmol/L).
• LDL ("bad") cholesterol: desirable below 100 mg/dL (2.6 mmol/L) for most people; much lower targets apply after a heart attack or stroke.
• HDL ("good") cholesterol: higher is better; below 40 mg/dL (1.0 mmol/L) in men or 50 mg/dL (1.3 mmol/L) in women is considered low.
• Triglycerides: desirable below 150 mg/dL (1.7 mmol/L). High levels are linked to sugar, refined carbohydrate, alcohol, obesity and diabetes.

Your doctor looks at these numbers together with age, blood pressure, diabetes, smoking and family history to estimate your overall heart risk. The right target depends on that risk, not the number alone.

Why South Asians need to pay attention

South Asians have a higher risk of heart disease at younger ages and at lower body weights. Typical patterns include low HDL, raised triglycerides and abdominal fat, even when LDL appears only mildly raised. Many experts recommend earlier and regular testing, especially with diabetes, high blood pressure or a family history of heart disease.

Eating to lower cholesterol

Replace saturated and trans fats with healthier choices, and add fibre.

• Reduce saturated fat: ghee, butter, coconut milk in large amounts, fatty red meat, processed meat, poultry skin and full-fat dairy. Coconut oil raises LDL, so use it sparingly.
• Avoid trans fats: found in some margarines, bakery items, biscuits and deep-fried short-eats. Check labels for "partially hydrogenated oil".
• Use better oils: rice bran, sunflower, olive or groundnut oil in modest amounts, and cook by steaming, grilling or baking more often than frying.
• Eat soluble fibre: oats, kurakkan, pulses (dhal, chickpeas, green gram), beans, ladies' fingers (okra), apples, guava and citrus. Aim for about 5-10 g of soluble fibre a day, which can lower LDL modestly.
• Eat fish: two portions a week of fish such as mackerel, sardines or tuna provides omega-3 fats that lower triglycerides.
• Handful of nuts: unsalted almonds, walnuts or cashews in small portions.
• Plant sterols: added to some spreads and drinks, they can lower LDL further when used daily.
• Cut sugar and refined starch: sugary drinks, sweets and large portions of white rice, bread and noodles raise triglycerides.
• Limit alcohol: it raises triglycerides.

Simple Sri Lankan swaps

• Fried cutlets and patties → boiled chickpeas or grilled fish.
• Coconut-rich gravies every day → a smaller amount of coconut milk, thinned with water, or tempered curries with more vegetables.
• White bread with butter → whole-grain bread or kurakkan roti.
• Fatty beef or mutton → skinless chicken, fish, egg, dhal.
• Sweetened tea with biscuits → unsweetened tea with fruit or nuts.

Exercise and weight

Regular activity can raise HDL and lower triglycerides and modestly lower LDL. Aim for at least 150 minutes of moderate exercise weekly, such as brisk walking, plus strength sessions twice a week. Losing 5-10% of body weight helps all parts of the lipid profile. Use our TDEE calorie calculator and BMI calculator to set realistic targets.

Other lifestyle steps

• Stop smoking. This raises HDL within weeks and sharply cuts heart attack risk.
• Control blood pressure and diabetes. They multiply the damage cholesterol causes. See our guide to lowering high blood pressure.
• Sleep 7-8 hours and manage stress.

Medicines for cholesterol

Statins (such as atorvastatin and rosuvastatin) are the main treatment. They lower LDL by roughly 30-50% depending on the dose, and reduce heart attacks and strokes in people at high risk. They are recommended for most people with heart disease or stroke, for many people with diabetes, and for people whose overall risk is high.

• Take the tablet at the time advised, usually once daily.
• Mild muscle aches occur in some people; tell your doctor, as changing the dose or drug often helps. Severe muscle pain or dark urine needs urgent review.
• Doctors may check liver tests and sometimes blood sugar.
• Avoid large amounts of grapefruit juice with some statins. Statins are not used in pregnancy.

Other medicines include ezetimibe, bempedoic acid and injectable PCSK9 inhibitors for people who cannot reach targets, plus fibrates or prescription omega-3 for very high triglycerides.

Inherited high cholesterol

Familial hypercholesterolaemia is a genetic condition causing very high LDL from birth. Clues include LDL above about 190 mg/dL (4.9 mmol/L), early heart disease in relatives (men under 55, women under 65), fatty lumps around the eyelids or tendons, or a pale ring around the cornea in young adults. It needs medicines and family screening.

Who should be tested, and how often

Adults should have a lipid profile at least once by their thirties, and then every few years, or yearly if they have diabetes, high blood pressure, obesity, kidney disease or a family history. Children with a family history of very high cholesterol may also need testing. Repeat a test 6-12 weeks after changing treatment to check the response.

Warning signs of heart disease

Chest pain or pressure, pain spreading to the arm or jaw, sudden breathlessness, sweating or fainting need emergency care. Call 1990 or go to the nearest hospital immediately.

When to see a doctor

See your doctor if your cholesterol is above target, if you have diabetes, high blood pressure or a strong family history of heart disease, or if you are unsure whether you need a statin. Do not stop prescribed medicines because your numbers have improved, as this is a sign they are working.

References

• European Society of Cardiology / European Atherosclerosis Society: guidelines for the management of dyslipidaemias
• American College of Cardiology / American Heart Association: cholesterol management guideline
• NICE guideline NG238: cardiovascular disease risk assessment and reduction
• World Health Organization: cardiovascular diseases fact sheet