What really works to lower cholesterol?

High cholesterol is a known risk factor for serious illnesses such as heart disease and stroke. 

There are lots of factors that can affect your cholesterol levels. Some - such as your age, genetics, ethnicity and gender - are outside of your control. But diet and lifestyle play an important part too, and these are modifiable. 

But are foods or supplements containing plant stenols or sterols worthwhile? And who should consider statins?

We explain what you need to know, from how to access free health checks to what really works, with insight from top health experts.

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What is high cholesterol and why does it matter?

Cholesterol is a type of fat in your body used to make cell membranes, hormones and vitamin D. 

There are two main types: 

• LDL (low-density lipoprotein) - often referred to as 'bad' cholesterol. Too much in your blood narrows and hardens your arteries making it tougher for blood to flow through.
• HDL (high-density lipoprotein) - 'good' cholesterol, carries cholesterol away from your cells and artery walls to the liver where it's broken down and excreted. 

When people talk about having 'high cholesterol' they mean high non-HDL levels which includes LDL. 

Your non-HDL cholesterol should be below 4mmol/L (millimoles per litre). Your HDL cholesterol should be above 1.0 mmol/L if you're male, and above 1.2mmol/L if you're female. 

Your total cholesterol (all of your cholesterols combined) should be below 5mmol/L.

How do you know if your cholesterol is high?

You won't necessarily know if you have high cholesterol as there aren't usually symptoms. The only way to tell is by having a blood test. 

If you have concerns you can raise these with your GP any time. 

If you're over 40 you should be invited for a free NHS health check (and reassessed every five years after that). During this you will have your height, weight and blood pressure measured and a blood sample taken, and your risk of heart disease, a stroke, type 2 diabetes or kidney disease is calculated.

You can also buy cholesterol self-testing kits in high street pharmacies or online. These cost between £13.50 and £66 depending on the type of kit and the level of detail it gives. 

Some are skin-prick tests which give instant topline results whereas others send your blood sample to a lab and provide more detailed results.

However, it's worth bearing in mind when we've asked experts about these tests in the past they've had reservations about the detail and helpfulness of the results. Some had poor instructions, and may give you a false sense of security - or cause undue concern.

It's important to follow up any concerns you have with a health professional.

Who's most at risk of high cholesterol?

Up to age 44 typically men are more likely than women to have high cholesterol, but after 45 it affects more women than men due to hormonal changes related to the menopause.

People of South Asian origin are more susceptible to high cholesterol and heart disease than people from other ethnic backgrounds, so should keep a closer eye on their levels. 

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Lifestyle changes that can help manage cholesterol levels

• Keep active - this helps raise HDL and lower LDL cholesterol. Aim for 150 minutes of moderately intense or 75 minutes of vigorous activity a week. But even exercising once or twice a week can be beneficial.
• Eat more fibre - fruit, vegetables, lentils, pulses, wholegrains, nuts and seeds are good sources.
• Eat oats and barley - eating 3g of beta-glucan fibre a day is proven to lower cholesterol. A bowl of porridge has around 1g. Other sources include oatbran, oatcakes and pearl barley.

Avoid or limit:

• Saturated fat - limit your intake of red and processed meat, cheese, processed food and takeaways.
• Being overweight - if you are overweight, losing 10% of your bodyweight can lower cholesterol, triglycerides, blood pressure and risk of type 2 diabetes.
• Smoking - smoking makes LDL cholesterol 'stickier' so that it clings to your artery walls and lowers HDL cholesterol.
• Alcohol - don't drink more than 14 units of alcohol a week (roughly six pints of beer or medium-sizes glasses of wine).

Find out how to eat enough fibre to reach the recommended 30g a day intake

Can plant stanols, sterols and beta-glucan help?

Plant stanols and sterols reduce the absorption of bad cholesterol from the food we eat. While they are naturally found in foods, it's hard to get the amount needed to impact cholesterol levels through diet alone. 

Enriched foods and supplement versions of these phytosterols are available, and consuming 1.5-3g (max) daily can lower total and non-HDL cholesterol blood levels by around 10%.

Foods that contain added phytosterols include spreads such as Flora ProActiv, Benecol yoghurt and yoghurt drinks. 

The cost of these can vary. We found the cheapest way to reach your daily dose was with Flora ProActiv spread (24p) however this involves consuming 3 x 10g portions each day so you need to think about how realistic this is for you.

A Benecol daily yoghurt drink costs 72p and a Benecol yoghurt, 88p. Both of these contain the daily amount of phytosterols needed. 

A daily dose of Vitabiotics Ultra plant sterols (three capsules) costs £1 and Nature's Best plant sterols (two tablets) costs 33p, but again, swallowing multiple supplement tablets per day won't be for everyone

Lynne Garton, dietetic adviser at HEART UK, told us: 'You need to take these consistently to see a benefit and as part of a healthy, balanced diet'. She adds ' Most of the studies that have shown a positive effect have used foods and drinks such as yoghurts and spreads. There's less evidence available for the effectiveness of supplements'.

These products can be taken in addition to beta-glucan (found in oats and barley) as they work in different ways to reduce cholesterol, and can have a cumulative effect.

Where to buy:

• Flora ProActivspread is available at most major supermarkets including Tesco, Sainsbury's, Asda, Morrisons, Waitrose and Ocado.
• Benecol spread, yoghurts and yoghurt are also available in Tesco, Sainsbury's, Asda, Morrisons, Waitrose and Ocado.
• Vitabiotics Ultra plant sterols are available to buy directly from Vitabiotics and often have three for two offers on. They are also available at Holland & Barrett.  
• Nature's Best plant sterols can be bought directly from the Nature's Best website.

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What about statins?

Statins are the main group of medicines used to lower cholesterol and they are effective at doing so.

If your risk of heart disease or stroke is high or you've previously suffered one of these, dietary changes alone are unlikely to be enough and you will probably need to take statins too.

Professor Sir Rory Collins, Professor of Medicine and Epidemiology, British Heart Foundation Centre of Research Excellence, says: 'It's important to think about someone's overall risk of cardiovascular disease and not their cholesterol in isolation. Two people can have the same cholesterol levels but their treatment plan could be different depending on other risk factors.'

He adds: 'We know that each mmol/L reduction in LDL cholesterol reduces someone's relative risk of heart attack and stroke in the next five years by 20%. And the more you reduce LDL cholesterol, the more you lower the risk'.

Some people are hesitant to take statins or are worried about the side effects. But Professor Collins points out they're one of the most studied treatments available, and the number of people affected by side effects is very small. 

Possible side effects can include muscular issues, but these can resolve over time, or can be prevented by using a different dose or different statin. If you experience unwanted side effects it's important to go back to your GP.

Be aware of potential interactions between statins and other medication, supplements or foods. For example, people on certain statins should avoid grapefruits and grapefruit juice (which can interact with many medicines). Find out more in our guide to everyday food and drink that can affect popular medications.

For more information, see the NHS guide to high cholesterol.

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