Medication? Diet changes? How best to lower high cholesterol levels

The word "cholesterol" typically elicits negative health associations. But this waxy, fat-like substance has many important functions in the body. It stabilizes cell membranes, for instance, supports production of certain hormones and is essential for normal brain development.

Not all cholesterol is the same though. Two types of protein carry it to and from cells, mostly low-density lipoprotein (LDL). LDL (aka "bad") cholesterol contributes to fatty buildups in arteries that can lead to heart disease and stroke. "Good," high-density lipoprotein (HDL) carries some of the cholesterol back to the liver, where it's made, which breaks it down and flushes it from the body.

"High cholesterol levels [in the blood] should always be discussed with a doctor," says Dr Ulrich Laufs, director of the Department of Cardiology at Leipzig University Hospital.

What's the best way to lower them? As Laufs points out, it's the person that's treated, not the cholesterol levels, so any other existing health-risk factors - such as high blood pressure, diabetes, kidney problems or being overweight - must be taken into consideration too.

Being overweight shouldn't be confused with hypercholesterolaemia, the medical term for high cholesterol levels in the blood, says Laufs: "They're different problems, although there's a lot of overlap. Some slim people have high levels, and some obese people have low ones."

High cholesterol is often inherited, he explains.

After consideration of all relevant factors, a decision is made whether to prescribe cholesterol-lowering medications. The most common are statins, which block an enzyme the liver needs to make cholesterol. A frequent side effect is muscle pain.

Muscle pain isn't necessarily caused by taking statin tablets or capsules, however, as "it's particularly common in middle and old age," Lauf says. "Nine of 10 people who report this symptom would have it without taking the medication."

Medications aren't the only means to bring down cholesterol. Dr Anne Fleck, a nutritional medicine specialist, says that making the right lifestyle changes can be an alternative to statin therapy - or at least allow you to take a lower dosage.

Before, and parallel to, any treatment with medications, she recommends individually tailored lifestyle changes, principally to your diet. While your liver makes about 80% of the cholesterol in your body, the rest comes from foods from animals, such as meat, eggs and butter.

Nutritional medicine specialist Dr Michaela Döll, author of a German-language book whose title translates as "Cholesterol Under Control: Natural Alternatives to Risky Cholesterol-Lowering Drugs," cautions that trying to avoid all foods containing cholesterol is ineffective though.

"If you ingest less cholesterol by religiously denying yourself your dearly beloved chicken eggs, for example, your body will simply produce more cholesterol itself, since it needs it," Döll says.

Other dietary changes are more beneficial. According to Fleck, you should make soluble fibre a greater part of your diet, which binds a large amount of cholesterol in your intestines, thereby reducing its absorption into your bloodstream. Supplementing meals with psyllium husk or acacia fibre is one way to do this.

Beta-glucan, the main component of the soluble fibre in oat bran, has also been found to reduce cholesterol levels. Dietary experts have calculated that you need to eat about a 40-gram serving of oat bran flakes before there's a positive effect.

Fleck recommends increasing your intake of omega-3 fatty acids as well. Oily fish and algae oil are particularly rich in the omega-3 fatty acids EPA and DHA, which are especially beneficial to health.

"In addition, it's important to consume as little trans-fatty acids as possible, she says. So it's better to use olive or rapeseed oil than sunflower or maize germ oil.

As a general rule, it's a good idea to hew close to the Mediterranean diet, which emphasizes vegetables, fruit, herbs, nuts, seeds, legumes, whole grains and olive oil, with moderate amounts of seafood, poultry, eggs and dairy products. Red meat is consumed only occasionally.

Keeping your daily calorie intake down to about the number of calories you burn is essential, Laufs says, adding, "Don't smoke, and be physically active."

It's never too late to make lifestyle changes like these. Even if you're over age 70, switching to a plant-based diet and getting more exercise - be it while sitting - can bring benefits, remarks Döll, who says she's certain many people would feel much better if they exercised more and lost excess weight instead of taking medications.

What if your elevated cholesterol levels don't drop despite your best efforts? Then it's time to rethink your strategy, tighten it up - and perhaps resort to some help from medications.