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 Table of Contents  
Year : 2021  |  Volume : 8  |  Issue : 1  |  Page : 6-12

Effectiveness of altering hypercholesterolaemia without drugs: Evidence of lifestyle modifications: A narrative review

1 Dietetics and Nutrition Department, Hamad Medical Corporation Doha; State of Qatar, Qatar
2 Columbus County Department of Public Health, North Carolina, USA

Date of Submission23-Aug-2020
Date of Decision29-Nov-2020
Date of Acceptance30-Nov-2020
Date of Web Publication29-May-2021

Correspondence Address:
Ms. Lubna A. G. Mahmood
Dietetics and Nutrition Department, Hamad Medical Corporation Doha, State of Qatar, Qatar

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jhrr.jhrr_27_20

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Background: Dyslipidemia is a situation of abnormal blood lipids. It is considered as a major risk factor for cardiovascular disease (CVD). Healthy diet is found to be effective in reducing serum cholesterol; thus, using foods that are high in components and that help in reducing cholesterol is recommended. These foods include fruits, green vegetables, avocado, almond, nuts, and fish oil. The aim was to provide an overview of existing research studies and their approaches regarding the effect of dietary and lifestyle modifications in reducing hypercholesterolemia. Materials and Methods: A search of periodical literature by the author involving dietary therapy and soybean was carried out. Items were identified initially through health-oriented indexing services such as Medline, Health STAR, and Cinahl, looking up for articles published in the English language, from 2010 to 2020. Keywords included “Cholesterol,” “Lipid,” “Dyslipidemia,” “Diet,” “and Health.”Results: Those consuming a daily average of 78g of almonds showed a reduction of LDL-cholesterol by 9.4% whereas those consuming 37g/day showed a reduction of LDL-cholesterol by 4.4%, with a significant increase in HDL levels and a decrease in lipoprotein A. It appears that the consumption of soluble fibers can promote a moderate effect in lowering cholesterol in patients with hypercholesterolemia. Studies have shown that fibers seem to act synergistically at the recommended intake dose of total fiber 25g, including 6g from soluble fibers intake. Conclusion: Dietary modification is found to be a powerful nonpharmacological approach that helps in improving blood lipids. Lipid profiles can be improved indirectly through changing the unhealth, performing physical activity, and reducing body weight.

Keywords: Cholesterol, diet, dyslipidemia, health, lipid

How to cite this article:
Mahmood LA, Matthews L. Effectiveness of altering hypercholesterolaemia without drugs: Evidence of lifestyle modifications: A narrative review. J Health Res Rev 2021;8:6-12

How to cite this URL:
Mahmood LA, Matthews L. Effectiveness of altering hypercholesterolaemia without drugs: Evidence of lifestyle modifications: A narrative review. J Health Res Rev [serial online] 2021 [cited 2023 Jun 7];8:6-12. Available from: https://www.jhrr.org/text.asp?2021/8/1/6/317212

  Introduction Top

Reducing elevated serum cholesterol (hypercholesterolemia) is a key public health challenge. Dietary cholesterol has been suggested to increase the risk of CVD.[1],[2] Improved dietary fat quality can be achieved by replacing saturated fat with unsaturated fat, which reduces low-density lipoprotein (LDL)-cholesterol and can increase high-density lipoprotein (HDL)-cholesterol, further improving blood lipid profiles.[3],[4] In clinical studies where all foods were provided, LDL-cholesterol was reduced by 22–30%, and HDL-cholesterol was increased.[5] By careful food type selection, suitable for the individual and with good compliance, the effect of including at least these two components in the diet could bring about a sustainable 10% reduction in LDL-cholesterol; which is enough to make a significant impact on cholesterol management naturally and reduce the need for pharmaceutical intervention.[6],[7] The aim of this article is to provide an overview of existing research studies and their approaches regarding the effect of dietary and lifestyle modifications in reducing hypercholesterolemia.

  Materials and Methods Top

Research criteria and methodology

A search of periodical literature by the author involving dietary therapy and soybean was carried out. Items were identified initially through health-oriented indexing services such as Medline, Health STAR, and Cinahl, looking up for articles published in the English language, from 2010 to 2020. Keywords included “Cholesterol,” “Lipid,” “Dyslipidemia,” “Diet,” “and Health.” An extensive search was also carried out on the educational database ERIC through an electronic search [Figure 1].
Figure 1: Flow diagram of article selection

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  Result Top

The question cited earlier includes the PICO elements

  • P (Problem or Patient or Population): population with hypercholesterolaemia

  • I (intervention/indicator): lifestyle modifications

  • C (comparison): lifestyle modifications; no lifestyle modifications

  • O (outcome of interest): reduced or managed hypercholesterolaemia

  • Risk of bias

    The data selected may be influenced by publication bias. Publication bias is understood as the tendency to publish results that are systematically different from reality. Failure to publish results may be due to the decision of the author or funder of the study, who does not submit for publication unfavorable findings, or from editors of scientific journals, who may not be interested in disclosing negative (with no statistical relevance) findings. That is why, it is essential to ensure that the studies included have comparable methodological quality and the necessary information to ensure the identification of selection, gauging and confounding biases were avoided. In addition, the basic data to identify whether the populations surveyed in the studies are comparable are also critical.

      Discussion Top

    What is “Cholesterol?”

    Cholesterol is a lipid molecule and an essential structural component of cell membranes biosynthesized by animal cells that is required for maintaining both membrane structural integrity and fluidity.[1] Since animal fats are complexes of triglycerides, cholesterol, and phospholipids, all foods containing animal fats contain cholesterol. The major dietary sources of cholesterol include beef, poultry, shrimp, cheese, egg yolk, and whole milk.[2] Cholesterol and lipoprotein have different classifications, and each one has a different role in the body. [Table 1] provides more information on these components: total cholesterol (TC), HDL, LDL, and triglycerides (TG).
    Table 1: Cholesterol/ lipoprotein classes

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    “Dyslipidemia” is a term that refers to abnormal blood lipid levels. This condition has become a public health concern all over the world. In 2008, the global prevalence of increased TC among adults (≥ 5.0 mmol/l) was 39%. [Table 2] provides lipid guidelines. Dyslipidemia is considered to be one of the major risk factors of heart disease.[3],[4] Excess cholesterol builds up in the arterial walls, and this buildup leads to atherosclerosis, a disease in which blood flow is impaired as a result of narrowed arteries. In advanced stages, when the blood supply to the heart is completely blocked, the result is often a heart attack.[5],[6]
    Table 2: Cholesterol guidelines. Dallinga-Thie et al.[38] Fifty studies were identified

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    Dyslipidemia can lead to stroke, fatty liver, and kidney and eye damage.[7] Dyslipidemia can also be associated with different conditions and health problems that include hypertension, genetic predisposition, diabetes, and obesity. Sedentary lifestyle, smoking, and fatty food consumption can all play a major role in developing dyslipidemia.[8],[9]

    Cholesterol-lowering foods

    Almonds and nuts

    Some randomized controlled studies investigated the effects of almonds on blood lipid measures that have been conducted in subjects with normal blood lipid levels. One of the studies was a six-week study, whereas the other two were four-week studies.[10],[11] These researchers cumulatively suggested that the daily consumption of 68g of almonds (about 1/3 of a cup) for a period of four weeks actually improved the blood lipid profiles by significantly reducing TC levels, LDL levels, and the ratio of LDL to HDL.[12] Further, one study has demonstrated that patients who were consuming a daily average of 78g of almonds showed a reduction of LDL-cholesterol by 9.4% whereas those consuming 37g/day showed a reduction of LDL-cholesterol by 4.4%, with a significant increase in HDL levels and a decrease in lipoprotein A (a unique lipoprotein subclass that has emerged as an independent risk factor for developing vascular disease) and Apo B (Apolipoprotein, an important component of many lipoproteins that are involved in atherosclerosis and CVD) levels.[13] One randomized control study found that the intake of 44.5g of almonds in the breakfast meal resulted in significant reductions in blood glucose levels in the morning and throughout the day.[14],[15] However, a 16-week study has shown that those who consumed 60g/day of almonds experienced significant improvements in both fasting insulin and measures of insulin resistance relative to subjects who consumed the ADA diet without almonds.[16]

    Researchers have identified significant health benefits of almonds. They are a rich source of healthy fats, including 66% of total fat as unsaturated fats that are predominantly monounsaturated fat, and only about 7% of total fat present as saturated fat. As with all other plant foods, they are also cholesterol free. Almonds contain natural plant sterols (172  of plant sterols per 100g of almonds) that are able to help lower cholesterol levels via reducing the cholesterol reabsorption process in the intestine.[17] Another study found that introducing almonds into the diet for a month may lead to a reduction in oxidized LDL-cholesterol, which is found as a sticky substance that can block the arteries. Almond skins are rich sources of antioxidants called polyphenols, which might help in preventing the oxidation process of cholesterol, particularly in conjunction with the antioxidant vitamin E.[18] Another study supported the moderating effects of almond consumption on postprandial glycemia when subjects were given serum glucose 60min after breakfast and lunch. Glucose concentrations were observed to be lower when 43g of almonds were ingested with the meals, which may be attributable to the fiber and fat content of almonds.[19]

    Almonds and other tree nuts are rich in several beneficial compounds, such as (omega); ω-6, ω-9, and ω-3 fatty acids, which have demonstrated beneficial effects on blood cholesterol and lipoprotein profiles. The highly unsaturated ω-23 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are significantly responsible for this effect. In addition, metabolic studies have shown that consumption of n-6 PUFA (polyunsaturated fatty acid) lowers circulating cholesterol levels.[20] Nuts are complex plant foods that are rich sources of unsaturated fat and contain several nonfat constituents, including plant protein, fiber vitamins such as A, C, E, micronutrients such as copper and magnesium, plant sterols, and phytochemicals, that provide additional protective effects that have shown favorable lipid-altering activity.[21] A possible explanation can be related to the presence of lipid-altering phytochemicals such as plant sterols that are found in almonds. Also, nuts contain significant amounts of phytosterols and other phytochemical compounds, polyphenols, and ellagic acid (a natural phenol antioxidant found in numerous fruits and vegetables). The major phytosterol component is β-sit sterol, which is one of the several plant sterols implicated in lowering of cholesterol. Researchers have shown that 2g of plant sterols per day can significantly reduce cholesterol absorption, which, in turn, can decrease both plasma TC and LDL-C concentrations.[22] Nuts contain a variety of phenolic compounds that are localized principally in their skin, including flavonols, anthocyanins, procyanidins, Riboflavin (B2), Niacin (B3), and phenolic acids. Flavonols have been shown to be bioavailable and contribute to the antioxidant protection against LDL-C oxidation both in vitro and in vivo.[23]


    Ten studies have reported that a diet given to hypercholestrolemic rats containing differing amounts of avocado led to a significant decrease in TG, LDL, and TC by 28.29%, 14.16%, and 27.58% respectively. A significant increase in HDL-cholesterol, about 30%, was also reported.[24] These results may be due to avocado’s antioxidant contents, which can scavenge free radicals and inhibit the lipid oxidation process. In addition, the soluble fiber contents of avocado can bind to the bile acids in the small intestine, which alters micelle formation and decreases their absorption in the small intestine, so bile acid will be excreted in the feces.[25] Avocado has been shown to modulate postprandial inflammatory responses to a hamburger meal and postprandial vascular reactivity in healthy volunteers. Hypolipidemic effects of avocado have also been indicated in a hypercholesterolemic mouse model. A recent experimental study found that an avocado oil supplement can attenuate the alterations induced by type I diabetes mellitus along with oxidative stress in electron transfer at the complex II-complex III segment of the electron transport chain in rat kidney mitochondria. In addition, many beneficial effects of avocado have been found in vitro, in human oral cancer cell lines, where avocado extracts induced apoptosis via an ROS-mediated mechanism.[26]


    The beneficial effects of dietary fish oil on prevention or retardation of atherosclerosis have been addressed in different studies. They are believed to be related to the high quantities of omega-3 polyunsaturated fatty acids, which are found in many types of fish. These fatty acids are also believed to have immunosuppressive and anti-inflammatory effects. Other benefits appear to increase erythrocyte deformability, reduce platelet aggregation and monocyte adhesion. They also appear to stimulate endothelium-derived relaxing factor synthesis, improve fibrinolysis, alter prostaglandin synthesis, lower blood pressure, plasma triacylglycerol, and very low-density lipoprotein, and protect against peroxidation.[27] According to researchers, fish and their oil are rich in omega-3 fatty acids (n-3 FA), which are considered beneficial in the prevention of heart disease (i.e. Tuna, Salmon, Sardines). Supplementation of the eicosapentaenoic acid (EPA) along with docosahexaenoic acid (DHA) has consistently been shown to reduce the concentration of TG- and LDL-cholesterol in the plasma by inhibition of hepatic TG synthesis, which can lead to reduced synthesis and secretion of very low density lipoprotein (VLDL-C). The reduction of VLDL-C usually decreases the formation of LDL-cholesterol, which is a major risk factor in heart disease. However, high doses of omega-3 fatty acids increase HDL-C, which is inversely related to the incidence of CVD.[28] A large volume of medical literature has indicated that fish oils containing omega-3 fatty acids can prevent and help to improve or prevent arteriosclerosis, heart failure, strokes, and peripheral vascular diseases. Omega-3 fatty acids have been reported to lower bad cholesterol by around 25% and triglycerides by 65%.

    Another source of omega-3 fatty acids is found in flax seed oil, which also has the ability to make platelets less sticky and, consequently, reduce the tendency of the blood to clot.[29]

    Green vegetables

    Dietary fiber in green vegetables is widely prescribed, alone or associated with lipid-lowering therapies. There is evidence suggesting that soluble fibers can interfere with lipid and/or bile acid metabolism. Based on clinical trials, it is hypothesized that soluble fiber intake can reduce plant sterol absorption among subjects who are receiving highly effective lipid-lowering therapy. The role of fiber intake was tested in different lipid-lowering strategies and chosen to attain similar changes in lipid profile through distinct mechanisms.[30] It appears that the consumption of soluble fibers can promote a moderate effect in lowering cholesterol in patients with hypercholesterolemia. Studies have shown that fibers seem to act synergistically at the recommended intake dose of total fiber 25g, including 6g from soluble fibers intake. Fiber supplementation has shown an inverse relationship between fiber intake and weight loss. Studies have demonstrated a reduction in fasting and postprandial glucose, and glycated hemoglobin levels are associated with soluble fiber intake.[31] Patients with diabetes are advised to increase their intake of dietary fiber because in the NHANES study, their average daily intake was found to be only 16g. The mechanisms of the improved glycemic control that are associated with high fiber intake remain undefined. Whether this effect is due to an increase in soluble fiber, insoluble fiber, or both is unclear. It may be related to increased fecal excretion of bile acids and malabsorption of fat. However, other studies suggest that the degree of reduction in the absorption of fat was insignificant. Another possibility is that dietary fiber can improve glycemic control by reducing or delaying the absorption of carbohydrates.[32] The action of soluble fiber in the small intestine plays a major role in regulating whole body cholesterol absorption in both animal and human studies. This capacity of fiber to reduce cholesterol absorption and its possible interruption of the enterohepatic circulation of bile acids appear to cause a significant reduction of hepatic free and esterified cholesterol pools.[33]


    A number of fruits and berries are well known for their concentration of antioxidant components, for example, polyphenols, vitamin C, and carotenoids. They have the highest antioxidant capacity of commonly eaten foods. There are key areas where berries may positively influence glycemic control for patients with diabetes: They can suppress glucose release from the liver, improve glucose uptake in peripheral tissues such as muscles, inhibit starch digestion and absorption, and protect the pancreatic beta cells from glucose-induced toxicity and oxidative stress.[34] Evidence reported that berry components can influence parameters that are relevant to heart disease, for example, raspberry juice was found to help in reducing risk factors for atherosclerosis in hypercholesterolemic hamster models.[35]

    Berry anthocyanin has been found to improve the endothelium-dependent vasodilation in individuals with elevated serum cholesterol levels. This berry was found to improve serum lipid profiles and decrease markers of inflammation. Intake of berries has been noted to have anti-inflammatory effects that can improve a range of conditions where inflammation is part of the development of disease. The intake of various berries was also associated with decreased heart disease risk factors in overweight women. Heart disease risk factors were also decreased after blueberry intake in a group of obese subjects with metabolic syndrome, including significant decreases in blood pressure.[36] Another study has reported that the consumption of fruit was inversely related to LDL-cholesterol concentration in men and women groups. In subjects with the highest intake of fruits, their LDL concentration was about 6% lower than in those with lower fruit intake after an eight-week intervention period.[37]

      Conclusion Top

    Dietary modification is a powerful approach for improving blood lipids. Research has indicated that the top dietary recommendations for lowering cholesterol are to eliminate or at least drastically limit the foods that contain saturated fats, trans-fats, dietary cholesterol, and refined carbohydrates. Vegetables and some fruits, avocado, nuts, and almonds, along with fish oil have shown to have a significant role in lowering or managing total lipid profile such as greens. The percentages by which these foods lower cholesterol reflect people who have high levels of cholesterol greater than 200 /dL, and have been diagnosed with hypercholesterolemia. Changing the unhealthy eating habits along with physical activity can improve lipid profiles; however, when weight loss occurs in conjunction with activity, LDL and TC are usually lowered. Thus, cholesterol-lowering foods should be incorporated into everyone’s diet for optimal health.

    This special article can help future cholesterol investigators plan their study, incorporating parameters provided here, in their plan and analysis. It would be desirable to adopt a universal definition of healthy diet for the sake of comparability among different studies in the future. The use of different definitions does not help to assess the consistency among studies nor to translate the scientific research into practical recommendations for the general population. We hope that in future studies we can look at how changes in diet over the long term may impact this risk for heart disease.


    This research was supported/ partially supported by Hamad Medical Corporation, dietetics department. The authors are thankful to their colleagues who provided expertise that greatly assisted the research.

    Financial support and sponsorship


    Conflict of interest

    There are no conflicts of interest.

    Authors’ contribution

    Extensive review of previous research + writing the article.

    Ethical approval and consent to participate

    Not applicable.

    Data availability statement

    The data that support the findings of this study are available from the corresponding author, [LM], on reasonable request.


      References Top

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      [Figure 1]

      [Table 1], [Table 2]


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