A Cardiologist's Diet Built for Improving Cholesterol

As a cardiologist, patients often ask me for ways to lower their cholesterol without taking statins. They wonder how effective and viable alternatives can be and what strategies they can use to lower their cholesterol in other ways.

I often tell my patients at the Ohio State University Wexner Medical Center that diet is key. A focus on a plant-based diet, reducing saturated fat, and increasing fiber with vegetables and whole grains, has been shown to reduce cholesterol levels with or without the use of statins. Those levels can drop further by incorporating supplements like soluble fiber products or plant sterols and stanols.

So several months ago, when my own LDL cholesterol climbed above the optimal range (<100 mg/dL in primary atherosclerotic cardiovascular disease prevention), I decided to find out for myself.

I'm 34, and have few traditional risk factors for atherosclerotic disease, aside from a family history. But because LDL cholesterol levels are so tightly associated with heart disease risk, I wanted to take action and change the way I eat.

Major portions of my diet, growing up in Ohio, including the standard American fare of bacon, eggs, and toast for breakfast, a sandwich, and chips at lunch, and then "meat and potatoes"-based dinners. I indulged in pork barbecue, complete with Southern-style fixings, during medical training in North Carolina. So, I feel equipped to commiserate with my patients by sharing my personal journey down a new path.

I cut back on steaks and burgers and replaced them with more greens and fish. At home, we switched to cooking with plant-based oils, such as grapeseed or sunflower. I began eating more vegetables and grains and added over-the-counter plant sterol/stanol as well as high-potency fish oil supplements.

I expected to see an improvement due to my changes, but when I checked the results after 6 months, even I was surprised. I had reduced my LDL cholesterol by 29%, which is similar to the effect of low- or moderate-intensity statin treatment. Along the way, I learned it's a plan my family and I can work into our normal routine, and one that I believe would potentially be effective for anyone who isn't underweight or dealing with digestive diseases.

Here's how I built a diet I would recommend to anyone trying to lower their cholesterol...

Predominantly Pescatarian: My Modified Mediterranean Diet

Benefits of the Mediterranean diet are generally well-accepted, despite some scrutiny of the scientific rigor of the PREDIMED trial, and it's likely a good basis for many individuals. I appreciate the emphasis on fish and healthful oils, but I think putting olive oil on a health pedestal is extreme. Olive oil's monounsaturated fatty acids are clearly more beneficial for health than saturated fat but likely not as metabolically helpful as certain polyunsaturated fats like alpha-linoleic acid or omega-3 polyunsaturated fatty acids.

I also appreciate the focus on limiting land-based meat, but I think the average American's diet still includes more saturated fat than I aim for, particularly in preparations involving poultry skin. Low-fat vegetarian diets have long been touted as capable of reversing atherosclerotic plaque, but I often see that accompanied by increased carbohydrate intake, which can lead to weight gain and metabolic syndrome at the expense of potentially healthy fats.

Less Red Meat

Like many, I'm disappointed by the recent NutriRECS Consortium recommendation that people should "continue current [levels of] processed meat and unprocessed red meat consumption" despite cited information that a reduction in such consumption likely has health benefits. An analysis of multiple studies involving hundreds of thousands of people concluded that diets with less red and/or processed meat were associated with a reduction of approximately 14% in cardiovascular mortality over a period of 4 to 26 years.

The Consortium suggested that these benefits of red/processed meat reduction "probably do not outweigh the undesirable effects (impact on the quality of life, the burden of modifying cultural and personal meal preparation and eating habits)." My own experience is a rebuttal to this argument. I have enjoyed challenging my historical dietary norms and have already realized significant cholesterol reduction and some weight loss as a result. Unfortunately, I can't prove that I'm preventing a heart attack from occurring.

Not Quite Vegan

Though I do support reduced meat consumption on a societal level, I didn't become fully vegan because I accept many dairy and seafood products, particularly fish, as part of a healthy diet, assuming one pays attention to dietary sources of cholesterol such as egg yolk and shrimp.

My family would describe me as adventurous with plant-based protein sources like tofu, quinoa, and chia seeds, but I still crave a protein-dense option that, I've found, can only be satisfied by fish. In addition, omega-3 polyunsaturated fatty acids in fatty fish such as salmon and sardines have proven health benefits. I have nothing against a vegan diet, but I personally don't want to miss out on the dietary satisfaction and potential health benefits from fish.

Fewer Carbs, Not Zero Carbs

I appreciate the benefits of promoting carbohydrate reduction in individuals who are overweight, particularly if they have a cardiometabolic profile of prediabetes that includes hyperglycemia and hypertriglyceridemia. However, I don't promote strict, very-low-carb diets in individuals of normal weight who have elevated cholesterol, given that many low-carb or "ketogenic" diets may actually raise LDL cholesterol.

One patient of mine adopted the ketogenic diet to lose weight and found that her LDL cholesterol tripled, likely because she replaced the carbohydrates with a lot of breakfast meat such as bacon and pork sausage. The choice of fats that replace carbs in the diet needs very special attention in people contemplating a ketogenic diet. These low-carb diets may severely restrict nutrient-dense foods that offer cardiovascular benefits and show mixed effects on LDL cholesterol levels.

I tell my patients that we celebrate small successes in change together, as something as fundamental to identity as dietary choices usually take a long time to evolve.

M. Wesley Milks, MD, is a cardiologist and clinical assistant professor of medicine at Ohio State University Wexner Medical Center in Columbus. He has a focus in cardiovascular disease prevention, which includes management of lipid disorders and advanced cardiovascular risk prediction tools. Milks is a Diplomate of the American Board of Clinical Lipidology.

Milks disclosed no relevant relationships with companies or entities.