Lifestyle Approaches to Cholesterol Management

Cardiovascular disease (CVD) remains the leading cause of premature death and disability worldwide [1]. In Ireland, approximately 10,000 people die each year from CVD – including coronary heart disease (CHD), stroke and other circulatory diseases. While it is not possible to change the non-modifiable risk factors for CVD (such as age, ethnic background and family history), up to 90% of CVD may be preventable through lifestyle change and risk factor modification [2, 3]. When we examine these risk factors which contribute to CVD, we can see that diet explains more than 50% of CV events [2].

High cholesterol is an important modifiable risk factor for the development of CVD. Research has shown that a reduction in total cholesterol (TC) of 1mmol/L is associated with a 33% reduction in CHD deaths in those aged 50–69 years and a 17% reduction in those aged 70–89 years [4]. Despite overall reductions in TC and low-density lipoprotein cholesterol (LDL-C) at a population level, The Irish LongituDinal Study on Ageing (TILDA) reports a failure to control TC and LDL-C in those at highest risk of CVD in the older Irish population [5]. Similarly, the EuroAspire IV survey reports a high prevalence of modifiable risk factors (including high cholesterol), in patients with established CHD and people at high risk of developing CVD [6].

The influence of lifestyle change of the management of high cholesterol has been well documented [3, 7]. Many of these lifestyle changes also contribute to reducing overall CV risk through their influence on other risk factors (e.g. high blood pressure, type 2 diabetes, overweight and obesity). Table 1 outlines the lifestyle factors which have been shown to have the greatest magnitude of effect in terms of improving lipid profiles and are supported by evidence derived from multiple randomised clinical trials or meta-analyses [7]. These lifestyle factors can be broadly grouped as follows: improving dietary habits, increasing physical activity, consuming alcohol in moderation and reducing excess body weight.

In accordance with the shift from evaluating and treating single risk factors (such as cholesterol) to evaluating a person’s total risk profile, more research is now focusing on dietary patterns as opposed to single nutrients or food groups [6]. This move towards dietary patterns allows an estimate of the combined effect of dietary components on CV risk. The dietary pattern that has been more extensively researched in terms of CVD prevention is the Mediterranean diet. A recent systematic review and meta-analysis supports the beneficial effects of the Mediterranean diet on CV outcomes; however, the authors highlight the need for stronger study designs with adequate sample size in order to determine the true effect [8]. Published earlier this year, the SUN (Seguimiento Universidad de Navarra) prospective cohort study found greater adherence to the Mediterranean diet was associated with reduced incidence of all-cause mortality, fatal and non-fatal major CVD, type 2 diabetes, weight gain, metabolic syndrome, depression, cognitive decline, and nephrolithiasis [9].


Table 1. Lifestyle factors with greatest magnitude of effect on lipid profile

Lifestyle interventions to reduce TC & LDL-C levels

Reduce trans fatFound in processed foods such as cakes, biscuits, pastries and deep-fried foods. Avoid foods with ‘hydrogenated fat’ or ‘partially hydrogenated oils’ listed in their ingredients.


Reduce saturated fatFound in cakes, biscuits, pastries, butter, hard margarine, coconut oil, cheese and fatty meat.


Lifestyle interventions to reduce TG levels
Reduce excess body weightInclude regular meals, portion control, limit treat foods, physical activity.


Reduce alcohol intake


Recommended upper limits are 17 units a week for men and 11 units a week for women.


Lifestyle interventions to increase HDL levels
Reduce trans fat


Found in processed foods such as cakes, biscuits, pastries and deep-fried foods. Avoid foods with ‘hydrogenated fat’ or ‘partially hydrogenated oils’ listed in their ingredients.


Increase physical activity

150 minutes/week of moderate intensity (brisk walking, slow cycling) or 75 minutes/week of vigorous intensity (jogging, running).


TC = Total Cholesterol; LDL-C = Low-density lipoprotein cholesterol; TG = Triglycerides; HDL-C = High-density lipoprotein cholesterol



Claire Kerins

Registered Dietitian & SPHeRE PhD Scholar

National University of Ireland Galway


Twitter: @claire_kerins



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