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 blood cholesterol levels 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. Any beneficial effect of increasing HDL cholesterol is extremely uncertain.
In addition to cholesterol concentrations (levels) in the blood, there is the triglyceride concentration (i.e., "blood fats"; triglycerides are often abbreviated as TG or TAG, the latter is for triacylgylcerol, which is the technically "more correct" way of saying it). Triglyceride levels are probably less important than the bad cholesterol, but still values that are too high (see below) aren't ideal for your arteries.
Your arteries (see picture above) are all over your body (deep inside, not the veins you can see superficially, for example on your arms). Arteries carry blood that comes from your heart and, therefore, there is a lot of pressure inside of them and against the artery walls. This pressure (blood pressure) is one factor that over the course of a lifetime, starting in childhood (or even in utero) that will damage your artery walls, leading to atherosclerosis (also called arteriosclerosis). The amount of cholesterol and the number of cholesterol particles floating around in your blood (and therefore arteries) is another very important factor in "creating" atherosclerosis, i.e., accelerating the lifelong process of atherosclerosis. If you can manage to slow down this process of artery damage so much that - theoretically - you would have your first heart attack at 150 years old (no one lives that long), that would be great, because even if you end up living to 110 years old, you would never have a heart attack. It's not just the final "end problem" (such as heart attack or stroke) that can result from atherosclerosis but also the problems "on the way" such as loss of energy as we get older and impaired function or practically all of our organs. Slowing down atherosclerosis is basically slowing down aging (to put it simply).

What you can do ...

This will likely lower your bad cholesterol:

  • Eat healthy fats daily: nuts, seeds, avocados, olives (they can be salty, remove salt as much as you can and don't eat all that many), cold-pressed "extra virgin" olive oil, cold-pressed rapeseed (canola) oil (keep it in the fridge), hemp seed oil, linseed (flaxseed) oil, Camelina sativa oil [Manninen et al. 2019], etc. [Talebi et al. 2020, Schoeneck and Iggman et al. 2021]. Oils that can effectively lower LDL cholesterol in most people seem to be rapeseed oil, linseed oil, and hempseed oil [WHO 2024]. Store oils in a cool, dark place, i.e., not in clear bottles exposed to light and/or in a warm place. 
  • A dietary pattern based on - apart from vegetables and fruit - legumes and whole grains, plus nuts daily (for example, two handfuls of nuts) is probably best - these three food groups (legumes, whole grains, nuts) might be the most important dietary factors to lower cholesterol levels [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. 2023Guasch-Ferré et al. 2023Asbaghi et al. 2021Liu et al. 2020Mukuddem-Petersen et al. 2005]. But, be aware that Brazil nuts are different from other nuts (in terms of their selenium, barium, and radium levels) - so don't eat more than around two of these per day (on average; it's OK to eat more occasionally).
  • Reduce the intake of unhealthy fats: deep-fried foods, fried foods, unhealthy margarine (consider using olive oil or rapeseed oil instead of margarine; margerines are generally much healthier than they used to be but the hard margarines generally have a large percentage of coconut fat, palm fat, or sometimes shea butter - all of which are high in saturated fatty acids and will probably rather increase than decrease your cholesterol levels), hydrogenated fats and especially partially hydrogenated fats, palm fat (palm oil), and coconut fat (coconut oil) [Kelly et al. 2021].
  • If you are overweight, lose weight - especially belly fat (abdominal fat) [Kirkpatrick et al. 2023]. This might be the most important recommendation - if you are overweight.
  • If you are not overweight, avoid becoming overweight.
  • Focus on healthy "carbs" (carbohydrate sources): whole grains (brown rice, whole wheat pasta, whole grain bread [bread can be high in salt, so, use less salt if you bake yourself or avoid eating too much bread], and [pseudograins] like buckwheat, quinoa, amanranth, etc.), sweet potatoes, fresh fruit - also legumes (which have healthy proteins, healthy carbohydrates, and healthy vitamins and 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).
  • Try eating a little bit more protein (tofu, tempeh, beans, chickpeas, nuts, seeds, seitan, etc.) [Kirkpatrick et al. 2023].
  • Eat more fibre: found in all "whole" non-animal foods like whole grains, legumes, fruit, vegetables (don't forget "vegetable fruits" such as tomatoes, cucumber, bell peppers, etc. - easy to eat raw and tasty in salads or as snacks ... and "vegetable fruits" such as courgettes [zucchini] and aubergines [eggplants] - nice to have cooked/baked), nuts, seeds, 100% nut/seed butters, and mushrooms) [Kirkpatrick et al. 2023].
The use of phytosterol-enriched margarine to lower cholesterol is still 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 - it doesn't have to be "sports") regularly and try to sit less (reduce sitting time: get up, stand up). 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., get up and stretch, look out the window - find an excuse).

This may also lower your bad cholesterol:


This will likely lower your blood triglyceride levels:

Blood triglyceride levels should be measured in fasting blood samples, i.e., your should not eat anything in the morning (it's OK to drink water) and then have a blood sample taken. Only after the blood test, you should eat.
Fasting blood triglyceride levels are considered high if they are >150 mg/dL (i.e., >1.69 mmol/L) or, more strictly, if they are >135 mg/dL (>1.52 mmol/L).
  • Reduce your intake of "free sugars": all types of added sugars (refined sugar, brown sugar, syrups, ...) and foods 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 (white flour, white bread, white rice, added starch such as cornstarch [maize starch], potato starch, tapioca, etc.).[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) EPA/DHA supplement. For amounts of these foods and the supplement, see here (under point 5). If you follow, all/most the advice here and eat plenty of cold-pressed linseed (flaxseed) oil or cold-pressed rapeseed (canola) oil, it's very uncertain whether a EPA/DHA supplement will be beneficial for your arteries and heart health. In fact, DHA may not be helpful at all (or even harmful) while EPA appears to be helpful - but there are very view (hardly any) vegan EPA-only supplements currently available. And eating plenty of linseed oil (rich in the "short"-chain omega-3 fatty acid alpha-linolenic acid [ALA]) may increase your EPA blood levels in a similar way to an EPA-only or EPA/DHA supplement. Particularly, for those with high triglyceride levels and a high cardiovascular risk, EPA-only supplements are generally recommended.

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. Don't smoke, of course. But also avoid smoke (passive smoking) and air pollution. Relax more (stress kills), work less (too much work kills), laugh more, move more. Try to also avoid noise pollution (especially at night - use ear plugs if needed) 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 (by increasing homocysteine levels or maybe in other ways).

Note: everyone should make sure to get enough omega-3 fatty acids (see above, and see here under point 5). Linseed (flaxseed) oil is a particularly rich source of plant-source omega-3s.

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 (including blood tests, and diagnosis, if applicable) from a medical doctor. Be aware that some people (a small minority) high what is called familial hypercholesterolemia (called "FH" in medical slang)  - about 1 in 250 or 1 in 300 people have this, roughly. If you have this, you need to take medication (statins etc.) - the most perfect dietary approaches will not be enough. If you do not want to take statins, discuss the possibility of taking "red yeast rice" with your family physician/cardiologist. Red yeast rice bascially contains "natural statins". "Natural" should not be confused with "totally safe".


What is "total cholesterol"? What are other relevant blood markers for cardiovascular disease risk?

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

Measured LDL cholesterol: 
LDL cholesterol is "bad cholesterol" - really all cholesterol is "bad". Frequently, LDL cholesterol is not actually measured 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 ​= ​total cholesterol - HDL cholesterol - (triglycerides/5) for mg/dL ["-" is a minus; "/" is "divided by"] [Pradhan et al. 2020]
(Common abbreviation: LDL-C or LDL-c)

Non-HDL cholesterol:
The term "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 (see above).

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)
Again, your doctor will likely not give you this value, but you can calculate it yourself (see above).

HDL cholesterol:
This is the so-called "good" cholesterol. But that does not mean "the higher the better". The cholesterol in HDL cholesterol is not good for your arteries at all. It is the HDL particles that carry the HDL cholesterol that can be good. It should be noted that HDL cholesterol levels tend to be a bit lower with a healthy plant-based diet, which is unlikely to be a disadvantage. The reason for this may just be that the HDL functionality is higher (i.e. "the HDL particles work better"). HDL cholesterol levels are not considered a causal factor of atherosclerosis. It is more important to focus on lowering the bad cholesterol, i.e., LDL cholesterol, non-HDL cholesterol, and remnant cholesterol levels.

Note: there are other way to create subgroups of cholesterol (for example, very low density lipoprotein [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 (as the calculation includes TAG). With TAG, however, 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 can 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. 2023Khaw et al. 2018]) 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 one 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).