Last week I did an inventory of my blog, and realized I haven’t written anything here on cholesterol. I have a basic overview of using food to address heart disease risk factors like high blood pressure, pre-diabetes, and a discussion of why I don’t focus on weight loss.
But not cholesterol. It’s complicated. Controversial. Easier to discuss in person and individualize. But it matters, and more people are signing up for this blog every day (yay!), so here goes.
We’re talking LDL cholesterol
First, just to make sure we’re all on the same page, I’m going to talk about dietary strategies that specifically target LDL (aka the lousy) cholesterol, which can increase your risk for heart disease.
How low should your LDL cholesterol be? That’s different for everyone, so talk to your doctor.
How much can you really lower your cholesterol with food?
The best answer to that question comes from the Portfolio Diet studies, where researchers threw everything in the LDL-lowering toolbox at participants. Under perfect conditions, where all of the food was provided to participants, LDL went down by 21-29%, comparable to a low-dose statin medication (and without weight loss). Under real world conditions, however, we’d expect more like a 8-14% drop.
In the grand scheme, that’s not a lot. Our cholesterol levels are largely genetically determined, with lifestyle potentially having a small impact. So you might be asking…
Can’t I just lower it with medication?
Yes, for some that’s the way to go. That’s for you to decide, with guidance from your doctor.
This post is for those who want to get as much LDL-lowering as possible from food, so they can minimize or avoid medications. For many people, a combination of medication and dietary change makes sense, especially given that many of these foods have other cardiac and general health benefits.
And sometimes, for some people, it makes sense to take meds too, and there’s no shame in that.
Why does cholesterol really matter?
Let’s not lose sight of what really matters here. Why bother with trying to lower your LDL anyhow? The real goal is to lower your risk of having a heart attack or other artery-related health problem. The best evidence we have for that is the Mediterranean dietary pattern.
So whatever we do for LDL, let’s make sure it is also consistent with that, and health in general, mental as well as physical.
Our LDL cholesterol lowering toolkit
The reason I like the toolkit analogy for this is because not every food on this list will be right for everybody. Figure out which ones work for you, and leave the rest on the wall.
1. Peanuts, walnuts, cashews, pecans, sunflower seeds…
Pretty much any nut or seed you like (and aren’t allergic to) deserves a starring role on your daily menu. 
Why? Dietary patterns with 30 grams or more a day of nuts (a good-sized handful) have been shown to lower LDL-cholesterol by 5-7% (that detail is in the supplementary material). Nuts were part of the Portfolio Diet study discussed above, with 42 grams of nuts for every 2000 calories, or a good 1/4 cup or so every day.
And it helps in the long run too: One analysis showed that people who eat the most nuts have a 35% reduced risk of coronary heart disease.
You might wonder… aren’t nuts high in fat and calories? We’re talking about an extra 200 calories or so here. Should that worry you?
Nope. We need calories. Calories are just a measure of the energy provided by a food. If you need to get through the day, you need calories.
Yes, it’s possible to eat more calories than your body needs, and that’s a factor in weight gain, although heaven knows there’s much more to it than that.
But people assigned to eat more nuts in clinical studies don’t generally gain more weight. Large population studies show that people who eat more nuts actually weigh less, on average.
This is likely because nuts and seeds are so satiating – they help us feel full and satisfied, relative to other foods. When you’re eating them, you’re likely unconsciously eating less of other things to compensate. There’s even some evidence that not all of the calories in nuts are absorbed by our bodies. (Read more here if you’re still skeptical.)
2. Barley, psyllium, kidney beans, chia seeds, oats…
What we’re after here is soluble (also called viscous) fibre. 
It’s another component of the Portfolio Diet, and by itself, enough soluble fibre (10 grams or more per day) can drop LDL cholesterol by 5-10%. The Portfolio Diet used 20 grams a day (at the 2000 calorie level).
So a lot. Fibre fibre fibre.
The tricky thing is that our food labels don’t require soluble fibre to be listed separately. You just see a total for fibre, which includes both soluble and insoluble. So instead of worrying about counting it up, just take a peek at this list of high soluble fibre foods and see what else is there that you like. (Oranges! Pears!) If cholesterol is high on your priority list, it may help to include several of these foods each day.
If you’re just looking for heart health in general, both kinds of fibre seem to help, so don’t stress about getting exactly the right amount of each.
How does soluble fibre work? Recall that “soluble” means it dissolves in water. If you’ve ever made chia pudding or left Metamucil (made from psyllium) sitting in a glass of water or juice, you’ll know what I mean. It forms kind of a gel. And when that thick liquid passes through your gut, it binds to cholesterol it encounters there and literally carries it out of you and into the toilet.
Too much information? Sorry, I want you to understand the magic! Now you won’t forget.
3. Sprouted grain bread, sweet potato, lentils…
Eating these and other lower glycemic index (GI) foods may only nudge LDL cholesterol down by about 5%, but they’re worth exploring, because they’re another category of foods that may improve long-term cardiovascular outcomes, when eaten in place of saturated fat (and here and here). 
That may be in part because they help with blood sugar control, so if that’s on your to-do list also, this may be an especially good tool for you.
Aside from the examples I’ve listed here, lower GI foods include some of the soluble fibre rich foods I mentioned above – barley and oats – as well as beans, lentils, and other pulses. Here’s a more complete list.
The trick with glycemic index is to not get overly fixated on it. It’s just one of many considerations, and it makes the most difference with foods that deliver lots of carbohydrates, like grains and starchy vegetables.
People get worked up about the high glycemic index of foods like watermelon and carrots, but the actual amount of carbohydrates you’d typically eat with those foods isn’t that high, plus they’re packaged with lots of vitamins and minerals and fibre and water to help slow you down. So instead of looking at GI as a do/don’t eat list, just look at the lower GI foods and see if there are some in there you might like to experiment with eating more often.
That’s it for part 1. Next week, in part 2, I’ll look at fats and their effect on LDL cholesterol and heart health outcomes. Brace yourself.
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