Vegan and high cholesterol ... what now?

Below are some suggestions on how to lower your cholesterol values (serum cholesterol concentration) and/or triglycerides (serum triacylglyceride concentration). Enjoy.

What types of cholesterol are there?

The most common test is to assess "total cholesterol", i.e. all types of cholesterol combined. In addition, the so-called good and bad cholesterol values are also assessed. "So-called" because this is a drastic oversimplification.
When we talk about "lowering cholesterol", we are talking about all kinds of cholesterol except HDL cholesterol. If HDL cholesterol is too low (below the reference values), this is considered "bad". However, it is my understanding that focusing on lowering all the bad types of cholesterol (total, LDL, non-HDL, and remnant cholesterol) is most important.
In addition to cholesterol concentrations there is the triglyceride concentrations ("blood fats"; often abbreviated TG or TAG). These are probably less important than the bad cholesterol, but still values that are too high aren't ideal for your arteries.  

What you can do ...

This will likely lower your bad cholesterol:

  • Eat healthy fats daily: nuts, seeds, avocados, olives, cold-pressed "extra virgin" olive oil, cold-pressed rapeseed (canola) oil [Talebi et al. 2020, Schoeneck and Iggman et al. 2021].  
  • Reduce the intake of unhealthy fats: deep-fried foods, fried foods, unhealthy margarine (consider using olive oil or rapeseed oil instead of margarine), hydrogenated fats and especially partially hydrogenated fats, palm fat (palm oil), coconut fat (coconut oil). [Kelly et al. 2021]
  • If you are overweight, lose weight - especially belly fat (abdominal fat).
  • Focus on healthy "carbs" (carbohydrate sources): whole grains (including pseudograins like quinoa, amanranth etc.), sweet potatoes, fresh fruit - also legumes (which have healthy proteins, healthy carbohydrates, and healthy minerals). [Marshall et al. 2020]
  • Reduce the intake of "free sugars" (refined sugar, brown sugar, syrup, fruit juice concentrate, fruit juice) [also honey, if you eat it - honey is not a vegan food strictly speaking]. [Kelly et al. 2021Schoeneck and Iggman et al. 2021]
  • Make sure you are getting plenty of sunshine (if possible), and make sure you are getting enough vitamin D (see point 3 here).

This may also lower your bad cholesterol:

  • Try using dried amla powder (100% dried amla berry powder; ~ 1/2 teaspoon per day). Amla powder may taste very sour. But some amla powder is not sour. It doesn't have much of a taste and you can add it to smoothies, muesli, sauces, etc. And you won't be able to taste it much. Note that some people have reported that amla powder tastes disgusting and that it gave them heartburn. Is suspect that this depends on the amla powder you have. Also, amla powder is traditionally used in Indian cooking (sometimes called "amalaki").  
  • Try using a low-dose zinc supplement: I would suggest about 5 (to 10) mg/day. If you have a higher dose supplement, just break it into pieces. For example, a 25 mg zinc supplement tablet - break it into five pieces roughly, or bite a little piece off. [Khazdouz et al. 2020; Pompano and Boy 2021]
  • Try intermittent fasting [Meng et al. 2020].
  • Avoid unfiltered coffee ("Turkish coffee") [Schoeneck and Iggman et al. 2021].
  • Use turmeric regularly (~ 1/2 teaspoon per day) for cooking or to make "yellow soya milk" [Schoeneck and Iggman et al. 2021Azhdari et al. 2019Yuan et al. 2019Quin et al. 2017].
  • Regularly eat healthy soya foods (tofu, soya milk, tempeh, soya flour, no added sugar soya yogurt, etc.) [Schoeneck and Iggman et al. 2021, Blanco Majia et al. 2019]. [small effect]
  • Drink green tea regularly [Schoeneck and Iggman et al. 2021, Xu et al. 2020]. [small effect]
  • Eat lots of tomatoes (raw and/or cooked). [Li et al. 2020] [small effect]

This will likely lower your triglycerides:

  • Reduce your intake of "free sugars": all types of added sugar (refined sugar, brown sugar, ...) and food with a lot of added sugar, syrup, fruit juice concentrate, honey, etc. Keep your fruit juice intake low [Kelly et al. 2021]. Avoid "juice drinks". Avoid sugar-sweetened beverages. Avoid energy drinks.  
  • Reduce your intake of refined grains [Marshall et al. 2020].
  • Focus on healthy carbs: whole grains, sweet potatoes, fruit, and legumes. [Marshall et al. 2020, Chawla et al. 2020]
  • Avoid excessive fruit or dried fruit intake - don't eat "20 bananas a day".
  • Make sure you are getting an adequate amount of the plant-based omega-3 fatty acid rich foods: flaxseed (linseed) oil, ground flaxseeds (linseeds), chia seeds, rapeseed (canola) oil, or walnuts - and consider taking a vegan (microalgae-based) DHA supplement. For amounts of these foods and the supplement, see here (under point 5). 

This may also lower your triglycerides:

  • Try intermittent fasting [Meng et al. 2020].
  • Take a low-dose zinc supplement (see above).
  • Use turmeric regularly (~ 1/2 teaspoon per day; see above).





Note: this is not a perfect list. It also mostly just focuses on dietary approaches.

Note: lowering your cholesterol and/or triglycerides is a means to an end, i.e. the goal is to lower cardiovascular disease risk (including the risk of heart attack and stroke). Example: tofu may only have a very modest cholesterol-lowering effect, but at the same time it will also have some other (at least modest) beneficial effects on your arteries. So, it's good for your arteries (and heart and brain) in more than one way. Another example: dark chocolate is relatively high in saturated fatty acids, but, at least if consumed in moderate amounts, it may actually slightly lower cardiovascular disease risk.

Note: there are many things you can do to lower your cardiovascular disease risk. A healthy diet is good but not everything. Avoid smoke and air pollution. Relax more, work less, laugh more, move more.

Note: a healthy vegan (or other type of plant-based diet) is beneficial for cardiovascular disease risk - not just in terms of cholesterol-lowering effects. You should make sure to take a vitamin B12 supplement (see here under point 1) because vitamin B12 deficiency will also increase your cardiovascular risk.

Note: everyone should make sure to get enough omega-3 fatty acids (see here under point 5).

Note: if your cholesterol and/or cardiovascular disease risk is very high, you may also require cholesterol-lowering medication (statins, ezetimibe, PCSK9 inhibitors, and/or bempedoic acid) - a medical doctor/cardiologist should advise you in this regard. Get nutrition advice from a nutrition scientist. Get medical advice from a medical doctor.


What's total cholesterol? What are the others?

Total cholesterol:
Basically, total cholesterol is made up of: LDL cholesterol + HDL cholesterol + remnant cholesterol.
Common abbreviation: TC

Measured LDL cholesterol: 
Bad cholesterol; often LDL cholesterol is not actually assessed but only calculated (see below). The measured LDL cholesterol value is typically quite a bit higher than the calculated LDL.
Common abbreviation: LDL-C or LDL-c

Calculated LDL cholesterol:
See above; bad cholesterol. Calculated LDL is typically calculated with the Friedewald formula, based on total cholesterol, HDL cholesterol, and triglycerides: LDL-C ​= ​TC - HDL - (TG/5) for mg/dl ["-" is a minus] [Pradhan et al. 2020]
Common abbreviation: LDL-C or LDL-c

non-HDL cholesterol:
Non-HDL cholesterol is literally what the name says: "total cholesterol" - "HDL cholesterol" ["-" is a minus].
Common abbreviation: nonHDL-C or nonHDL-c (Your doctor will likely not give you this value, but you can calculate it yourself.)

Remnant cholesterol:
Again, the name practically says what it is: all the rest apart from LDL cholesterol and HDL cholesterol. So the calculation is: total cholesterol - LDL cholesterol - HDL cholesterol ["-" is a minus]. I would use the "measured LDL cholesterol" for calculating, if you have it. But basically, the lower the remnant cholesterol is, the better!
Note that this number may be 0 or even negative (lower than 0) because it's just a calculated number.
Common abbreviation: REM-C or REM-c (Your doctor will likely not give you this value, but you can calculate it yourself.)

HDL cholesterol:
This is the "good" cholesterol. But that does not mean "the higher the better". Also, HDL cholesterol tends to be a bit lower with a healthy plant-based diet, which is unlikely to be a disadvantage. The reason may just be that the HDL functionality is higher (i.e. "the HDL works better"). Again, it's more important to focus on lowering the bad cholesterol.

Note: there are other way to create subgroups of cholesterol (VLDL, small dense LDL, subtypes of HDL, etc.). But this is less relevant here.

Triglycerides (TAG):
This is not a type of cholesterol. Nothing to calculate. Your doctor will give you this number.
Note that with cholesterol values it may not matter too much if you are "in a fasted state" (haven't eaten anything) when the blood sample is taken, except for calculated LDL. With TAG this is really important, i.e. you should eat dinner in the evening, then sleep and eat nothing all night long, and then go to your doctor (or whoever takes the blood sample) in the morning. Only after having the blood sample taken you will eat breakfast. Drinking water or tea beforehand is OK.

Precision

Note that the numbers your doctor will give you are typically not extremely precise. So you should interpret these values to be a more of a rough estimate.