Bite-sized learning: Understanding diet and cholesterol

Raised cholesterol is a major, modifiable risk factor for cardiovascular disease but the role of a healthy diet in reducing cholesterol levels is often neglected in a busy consultation

It is easy to overlook the basics when advising patients about healthy dietary choices. However, diet remains a key modifiable factor in the management of cholesterol and overall cardiovascular risk, and even modest changes can result in clinically meaningful reductions in LDL cholesterol.

Practice nurses are well placed to deliver brief, targeted dietary advice as part of routine cardiovascular risk management. This guide provides a concise, evidence-based overview to support those conversations.

What’s the problem?

Raised cholesterol is a major modifiable risk factor for cardiovascular disease and is often asymptomatic.¹

Dietary patterns in the UK remain suboptimal with average saturated fat intake exceeding recommended levels, contributing to elevated cholesterol and increased cardiovascular risk. UK guidance recommends that saturated fat should contribute no more than 10% of total energy intake, yet most adults exceed this level.¹

In addition, diets high in ultra-processed foods, and low in fibre, fruit and vegetables, are common. These patterns are associated with poorer lipid profiles and increased cardiovascular risk.²

Dietary risk is not evenly distributed. Health inequalities, food affordability, and cultural dietary patterns all influence both risk and the ability to make changes. As a result, those at highest cardiovascular risk are often least able to access or sustain healthier dietary choices.³

Detection

Patients who may benefit from dietary advice include those with raised cholesterol, existing CVD, diabetes, hypertension, CKD, obesity, or a family history of hypercholesterolaemia. Opportunistic conversations during routine reviews are key.

Diagnosis

Diagnosis is based on lipid profile testing (total cholesterol, LDL, HDL, triglycerides). Results should be interpreted alongside overall cardiovascular risk.

Management

Dietary modification should be addressed alongside pharmacological management where indicated. Advice should be individualised, taking into account cultural dietary patterns, food preferences and access to healthier food choices, to support realistic and sustainable change.

Diet and lifestyle

Reduce saturated fat intake

Advise reduction of foods high in saturated fat, including fatty and processed meats, butter, ghee, cream, cheese, and full-fat dairy products. Reinforce limiting pastries, cakes, biscuits and takeaway foods. Promote practical swaps such as replacing butter with unsaturated spreads and choosing leaner cuts of meat.

Replace with healthier fats

Recommend use of unsaturated fats such as olive, rapeseed and sunflower oils. Advise inclusion of nuts and seeds. Recommend consumption of oily fish (e.g. salmon, mackerel, sardines) at least once per week. Note that oily fish does not significantly reduce LDL cholesterol but contributes to overall cardiovascular risk reduction.

Increase fibre intake

Advise increased intake of fibre-rich foods, including wholegrains, oats, fruit, vegetables, beans and lentils. Soluble fibre (e.g. oats, pulses) contributes to LDL reduction.

Consider plant sterols and stanols

Consider use in selected patients. Advise that intake of 1.5–2.4g per day can reduce LDL cholesterol by 7–10%. Use as an adjunct to, not a replacement for, wider dietary modification.⁴

Limit ultra-processed foods

Advise reducing intake of energy-dense, highly processed foods high in fat, salt and sugar (e.g. fast foods, confectionery, pastries, sugary drinks), which are associated with weight gain and adverse lipid profiles.

Assess and support weight management

Assess weight and discuss sensitively where appropriate. Reinforce that modest weight loss can improve lipid profile. Support realistic, individualised and sustainable goals.

Address alcohol and smoking

Advise moderation of alcohol intake in line with UK guidelines and support smoking cessation as part of overall cardiovascular risk reduction.

Promote physical activity

Recommend at least 150 minutes of moderate intensity physical activity per week.⁵ Support patients to identify achievable ways to integrate activity into daily routines.

Top 5 patient messages

• Swap saturated fats for healthier oils and spreads
• Eat more fibre – especially oats, beans, and lentils
• Include nuts and oily fish regularly
• Limit highly palatable, energy dense ultra processed foods
• Focus on long-term habits, not quick fixes as small, consistent changes make a real difference

Expected LDL reduction from key dietary components

The magnitude of cholesterol reduction varies by dietary component and intake. The following estimates can be used to support brief, evidence-based discussions with patients:⁵

• Plant sterols/stanols: Reduce LDL by 7–12%
• Soluble fibre (oats, barley, pulses): Reduces LDL by 4–6%
• Soya protein: Reduces LDL by ~3–4%
• Nuts: Reduce LDL by ~3%

Oily fish does not significantly reduce LDL cholesterol but contributes to cardiovascular risk reduction through its effects on triglycerides

Review

Reinforce dietary advice at routine reviews and tailor recommendations based on patient progress and preferences. Monitor lipid levels in line with guidance and alongside pharmacological management where appropriate (e.g. statins).⁶ Celebrate positive changes and revisit goals where needed. Consider referral to dietetic services for additional support.

References

1. NICE PH25. Cardiovascular disease prevention; 2010. https://www.nice.org.uk/guidance/ph25
2. Reynolds A, Mann J, Cummings J, et al. Carbohydrate quality and human health: a series of systematic reviews and meta-analyses. Lancet 2019;393(10170):434-445
3. The Health Foundation (2023). Briefing: Food insecurity – what can local government do? 2023. https://www.health.org.uk/reports-and-analysis/briefings/food-insecurity-what-can-local-government-do
4. HEART UK. Diet and lipid management: module 5 of 5. https://www.heartuk.org.uk/elearning/nutrition-5/#/
5. NHS. Physical activity guidelines for adults aged 19 to 64; last reviewed 2024. https://www.nhs.uk/live-well/exercise/physical-activity-guidelines-for-adults-aged-19-to-64/
6. NICE NG238. Cardiovascular disease: risk assessment and reduction, including lipid modification; 2023. https://www.nice.org.uk/guidance/ng238