Vegan and high cholesterol ... what now?

Updated 21 February 2024

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].  
  • A dietary pattern based on legumes and whole grains, plus nuts daily (for example, two handfuls) is probably best - these three food groups might be the most important dietary factors [Schwingshackl et al. 2018]. A daily (more or less) intake of nuts seems to lower cholesterol levels by about 5 to 10 mg/dl (0.1 to 0.3 mmol/l). There does not seem to be a clear difference between different types of nuts [Houston et al. 2023, Guasch-Ferré et al. 2023, Asbaghi et al. 2021, Liu et al. 2020, Mukuddem-Petersen et al. 2005].
  • 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) [Kirkpatrick et al. 2023].
  • 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. 2021, Schoeneck 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).
  • Try eating a little bit more protein (tofu, tempeh, beans, chickpeas, nuts, seeds, seitan, etc.) [Kirkpatrick et al. 2023].
  • Eat more fibre (found whole non-animal foods like whole grains, legumes, fruit, vegetables (don't forget tomatoes, cucumber, bell peppers, etc. - easy to eat raw and tasty in salads), nuts, seeds, and mushrooms) [Kirkpatrick et al. 2023].
The use of phytosterol-enriched margarine to lower cholesterol is controversial. It is likely to lower cholesterol levels and it is currently recommended by the European Atherosclerosis Society, but some researchers have criticized this recommendation because they perceive phytosterols as potentially harmful (promoting atherosclerosis rather than preventing it - human studies, however, do not support this for the LARGE majority of humans) [Poli et al. 2021, Makhmudova et al. 2021].

There's more:
  • Try to exercise (physical activity) regularly and try to sit less (reduce sitting time). If you do have to sit for long periods of time, try to break up the sitting time by getting up regularly and moving around a little bit (go to the bathroom, get some water/tea etc.).

This may also lower your bad cholesterol:

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. [Writing Committee et al. 2021]. 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).
It is also frequently recommended to reduce the intake of alcohol or (if triglycerides are very high) to not drink alcohol at all, to exercise regularly, to lose body weight (body fat), and (if triglycerides are very high) to keep fat intake moderate to low [Writing Committee et al. 2021]. 





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. Try to also avoid noise pollution (especially at night) and get some good sleep.

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 is total cholesterol? What other relevant markers?

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.

How fast can cholesterol levels change?

I would say it makes sense to have your cholesterol levels tested again about two months (but at least four weeks [Nishi et al. 2023]) after you have made the abovementioned dietary changes. That does not mean that health-promoting changes aren't happening earlier. Beneficial changes might be happening even within a few days or a week [Mazidi et al. 2016].


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.



Official guidelines

Also see the "Heart-Healthy Eating – Plant-Based Style" guidelines (2021) by the National Lipid Association (USA).