Managing High Cholesterol: A Functional Health Guide
"Cholesterol is necessary for hormone production, cellular repair, and neurological function. It’s about balance, not elimination."
—Dr. Chris Kresser
When most people think of high cholesterol, they picture clogged arteries and heart disease. But cholesterol itself isn’t the enemy—it’s a natural, essential part of how our bodies function. High cholesterol is often a symptom of other issues, from insulin resistance to poor thyroid health or even hidden infections.
Functional medicine looks at cholesterol in context, seeing it as a piece of the metabolic puzzle rather than a standalone villain. In this comprehensive guide, I’ll go beyond the basics to explore the underlying factors that drive cholesterol imbalances and discuss personalized strategies for optimizing cholesterol through diet, lifestyle, and targeted interventions.
What Causes High Cholesterol?
High cholesterol is not a disease itself but rather a symptom of underlying metabolic imbalances, lifestyle factors, or genetic predispositions like familial hypercholesterolemia. Elevated cholesterol levels signal that something is disrupting your body's ability to properly regulate these lipids. In the context of functional medicine, Chris Kresser highlights six core drivers of high cholesterol (although these are not the only ones), emphasizing that it’s not just about diet, but a range of metabolic and genetic influences.
Metabolic dysfunction
Poor thyroid function
Gut dysbiosis
Chronic infections (e.g. H. pylori, latent viral infections)
Environmental toxins (especially heavy metals)
Genetic (e.g. FH)
What to Do About High Cholesterol
If cholesterol is a symptom and there are six main drivers of cholesterol dysregulation then we need to address them at their root. This is Functional Medicine 101. Here are strategies to improve your cholesterol.
1. Achieve Metabolic Health
Metabolic health is determined by five key markers. These optimal (read: not “normal”) values are taken from the book, Good Energy by Casey Means.
Waist Circumference: Optimal for men is under 94 cm (37 in) and for women under 80 cm (31.5 in) in most groups, with lower targets for certain populations more sensitive to abdominal fat.
Blood Pressure: Both normal and optimal blood pressure are below 120/80 mmHg, underscoring the need for consistent monitoring.
Fasting Blood Glucose: Optimal: between 70-85 mg/dL
HDL Cholesterol: Optimal: 50-90 mg/dL offers the lowest risk
Triglycerides: Optimal: below 80 mg/dL
Having 0 markers means you are metabolically healthy. Your risk of cholesterol dysregulation increases significantly for every additional marker you have (0-5). Of course, it‘s also worth measuring your metabolic health biomarkers with these tests: HbA1C, inflammatory markers, fasting insulin, and fasting glucose. Managing these factors comes down to three main pillars: nutrition, fitness, and sleep. Start by focusing on these areas to improve your metabolic health.
Nutrition:
Dietary cholesterol: When we hear "high cholesterol," the immediate response is often to avoid foods like bacon and eggs, however, we only absorb about 15% of the cholesterol we consume. While most people can look beyond the saturated fat content to improve their cholesterol levels, those with conditions like familial hypercholesterolemia (FH) may be more sensitive ("hyperresponders") and should monitor their saturated fat intake. If you experience issues, reduce saturated fats and eliminate trans fats. Since this is such a prevailing myth, I dive more into this at the bottom of this article for those who want to learn more.
Limit Fat Intake in the Absence of Sugar: No natural foods are both high in fat and high in sugar (think about that for a second), indicating that our bodies did not evolve to handle this combination efficiently. When fat is consumed without accompanying sugar or starch, it typically does not lead to increased triglyceride levels or other negative cardiovascular markers. This is because the body metabolizes fats differently from sugars and starches. Consuming high-fat and high-sugar foods together can exacerbate metabolic issues more than either nutrient alone. Therefore, to better manage cholesterol levels and overall heart health, focus on reducing added sugars and refined carbohydrates while moderating fat intake. Examples of foods high in both fat and sugar include cookies, cake, ice cream, chocolate bars, sweetened yogurt, and granola bars.
Sugar, Refined Carbs, and Alcohol
Minimize Fructose Consumption: Fructose, especially in high amounts, can negatively impact cholesterol levels. Fructose is commonly found in high-fructose corn syrup (HFCS), which is prevalent in many processed foods and sugary beverages, as well as in fruit and honey.
Avoid Excess Sugar (Simple Carbs & Sugar Included): Consuming too much sugar, particularly sucrose and high-fructose corn syrup, raises triglyceride levels, VLDL (bad cholesterol), and ApoB. Cutting sugar from your diet reverses these harmful effects, improving your cholesterol profile and overall cardiovascular health. Refined flour and excess simple carbs act like sugar in the body, breaking down into glucose and spiking blood sugar—often more than sugar itself. For example, two slices of whole wheat bread raise blood glucose even higher than two tablespoons of sugar, contributing to insulin resistance and inflammation. These foods encompass a wide range of everyday items, including sugary condiments, sauces, sodas, rice, pasta, chips, crackers, and nearly everything and anything made with flour.
Statins, Fats, & Insulin Resistance: LDL-C is made up of two main types of particles: large, buoyant LDL (Type A) and small, dense LDL (Type B). Large, buoyant LDL particles are larger and less dense, meaning they are less likely to enter arterial walls and cause plaque buildup, making them generally less harmful in terms of heart disease risk. The conventional advice of eating a low-fat diet and taking a statin often works here to reduce this type of LDL but it’s not addressing the entire issue.
Small, dense LDL particles are more likely to penetrate artery walls, oxidize, and contribute to inflammation and plaque buildup. Unlike large LDL particles, they are largely influenced by a high intake of refined carbs, sugars, and alcohol—not fats—and are closely linked to insulin resistance. Standard treatments like statins and low-fat diets don’t effectively reduce these particles, as they fail to address the root cause. Reducing sugar, alcohol, and refined carbs may have a more significant impact on lowering harmful LDL levels.
Interestingly, about 50% of heart attack patients have “normal” overall LDL-C levels but when you look into the types of LDL-C, you find that they have elevated levels of small, dense LDL particles due to insulin resistance, typically stemming from diets high in sugars and refined carbs. For a more accurate assessment of cardiovascular risk, patients can request an NMR Lipoprotein Fractionation Test. This test breaks down LDL particle types, providing a clearer risk profile and guiding targeted interventions specifically aimed at reducing the more harmful small, dense LDL particles.
Fiber: The general recommendation is to aim for 25 grams of fiber daily for women and 38 grams for men, however, optimal ranges may be above 50 grams per day. Include fiber intake with an emphasis on soluble fiber to help reduce cholesterol. Include fiber-rich foods like greens, chia seeds, flaxseeds, and beans.
Be Aware of Low-Carb Diets: Yes, low-carb diets have many benefits but lowering cholesterol isn’t always one of them. About one-third of people who go on a low-carb diet improve insulin sensitivity, inflammatory markers, triglycerides, and HDL-C, however, they increase LDL-C, ApoB, LDL-P, and total cholesterol. In addition to the above recommendations, here are some suggestions for those who want to manage lipids and stay on a low-carb diet:
Don’t go crazy consuming nuts and nut butters (easy to go overboard and they can contain seed oils, sugars, and additives).
Increase MUFA and PUFA (but avoid seed oils)
Incorporate intermittent fasting
Eat Foods Rich in Vitamin K2: Vitamin K2 helps direct calcium from the arteries to the bones. Incorporating foods high in K2, such as fermented foods nd certain meats, can mitigate the adverse effects of elevated cholesterol levels. K2 also works with vitamin D and calcium to promote bone health and reduce arterial stiffness, both important for maintaining healthy lipid levels.
Consider Supplements: These supplements have been shown to improve lipid profiles in some cases. Talk to your healthcare provider before starting to take any of them.
Be Aware of Dairy: For some unknown reason, dairy is sometimes linked to abnormal cholesterol levels. Consider eliminating all dairy from your diet until your next blood draw to see if it plays a factor in your lipids. If you choose to reintroduce it, consider high-quality dairy options.
Overall Diet: Focus on high-quality, nutrient-dense whole foods. Include plenty of protein, vegetables, fruits, fish, and water. A Primal or Paleo approach with nutrient-rich foods like liver, egg yolks, and leafy greens, which are high in choline and folate, can support healthy cholesterol metabolism.
Track Your Nutrients: These recommendations may seem like a lot so I often recommend tracking both macronutrients and micronutrients for a 2-4 week period to give yourself and your healthcare provider a better idea of what may be impacting your cholesterol. There are many apps that track your macronutrient but the only one I know for micronutrients as well is Cronometer. It’s free to sign up and simple to use.
Fitness:
Regular exercise is key to improving cholesterol and boosting heart health, but sticking to just 10,000 steps or lifting weights isn't enough. Your body needs variety to target different aspects of fitness and metabolism. A well-rounded routine should include walking, strength training, cardiovascular exercise, and high-intensity interval training (HIIT). Learn about the minimum effective doses for each form of exercise as a way to get started. Strive for at least 150 minutes of moderate-intensity or 75 minutes of vigorous exercise each week.
Sleep:
Sleep is critical for every aspect of our health, including our metabolic function. Neglect it and you neglect your quality of life. For that reason, I've written many articles on it. Start with these: 8 Sleep Behavior Tactics for the Perfect Night of Sleep & 8 Simple Strategies To Get Better Sleep.
Body weight:
Maintaining a healthy weight is crucial for lowering your risk of heart disease and managing cholesterol. Learn effective strategies for achieving and sustaining a healthy weight here.
2. Support Your Thyroid Function
Check the Thyroid: Ruling out thyroid dysfunction is important if you have dysregulated cholesterol, as both overt and subclinical hypothyroidism can lead to elevated cholesterol. Consider consuming iodine-rich foods like seafood, seaweed, eggs, and dairy, along with avoiding extreme carbohydrate restriction, as both iodine levels and thyroid activity play a critical role in cholesterol metabolism. Historically, before statins became widely used, doctors would often manage high cholesterol by prescribing low doses of thyroid hormone, even in patients with normal thyroid function, recognizing the thyroid's significant influence on cholesterol regulation. Talk to your doctor about getting a blood test to test your thyroid health.
3. Assess Your Gut Health
Gut Dysbiosis: Imbalances in gut bacteria can disrupt cholesterol metabolism, leading to elevated cholesterol levels and increased inflammation in the body. Testing for gut health through a comprehensive stool analysis or a SIBO Breath Test can help identify bacterial overgrowth or imbalances that may be contributing to poor cholesterol regulation. Learn more about how to improve your gut health.
4. Test for Chronic Infections
Infections: Long-lasting infections, such as H. pylori or latent viral infections like Epstein-Barr virus, can elevate cholesterol levels by causing systemic inflammation. This inflammation signals the body to produce more cholesterol as part of the immune response, which can contribute to higher LDL levels. If you suspect a chronic infection is affecting your health, speak with your doctor about testing options, which may include blood tests or a stool test to help diagnose and treat the underlying cause.
5. Test for Toxins
Heavy Metals: Testing for environmental toxins, particularly heavy metals, can help identify if toxic exposure is impacting cholesterol levels. The rise of these environmental toxins can interfere with liver function, disrupt lipid metabolism, and contribute to higher cholesterol levels, among impacting many, many other health concerns. A recent study found that high levels of hevy metals (urinary cadmium, tungsten, uranium, and cobalt) were significantly associated with increased coronary artery calcification over a 10-year period, suggesting a potential link between heavy metals and atherosclerosis. Tests may include a blood test or Urine Heavy Metal Panel to assess your exposure and guide detoxification strategies. This topic is so important that I wrote a book about the issues, simple ways to address it, and recommendations for products better than you're possibly using.
6. Monitor Liver Health
Check for Non-Alcoholic Fatty Liver Disease (NAFLD): NAFLD occurs when fat builds up in the liver, unrelated to alcohol use, and it can have a significant impact on cholesterol levels. When the liver becomes fatty, its ability to properly manage cholesterol and other fats is impaired, which can lead to higher levels of LDL cholesterol and triglycerides in the blood. This can increase the risk of cardiovascular disease. If you suspect NAFLD, your doctor may suggest an ultrasound to image the liver or a FibroSURE test (a blood test) to assess liver damage and monitor liver health.
7. Manage Familial Hypercholesterolemia (FH)
If you suspect you have FH then it is important to consult your doctor immediately. Your provider should write you a referral for a specialist such as a cardiologist. Since your risk of a heart attack and other conditions drastically increases with FH, other testing and measurements will likely be necessary.
8. Consider Medication
Over the past couple of decades, advancements in cholesterol management have significantly expanded the options available for treatment. It's essential to consult your healthcare provider to determine the most appropriate approach for your specific situation. Here are some common medications used to manage cholesterol levels:
Statins: The primary treatment option, statins inhibit cholesterol production in the liver.
PCSK9 Inhibitors: These newer medications can lower LDL cholesterol further by preventing its breakdown.
Ezetimibe: This drug limits cholesterol absorption in the intestines and is often used in conjunction with statins for enhanced control.
Bile Acid Sequestrants: These medications promote the excretion of cholesterol in bile and may be prescribed alongside statins.
Evinacumab: An FDA-approved treatment for individuals with homozygous familial hypercholesterolemia (severe FH).
What Not to Do About High Cholesterol
Don’t Panic Over Temporary Increases: Avoid jumping to conclusions if cholesterol rises during liver lipid clearance or weight loss. This can be a sign of metabolic improvement.
Don’t Rely on a Single Reading: Always get multiple cholesterol readings to account for natural fluctuations and ensure accurate results before making any decisions.
Don’t Neglect Thyroid Health: Failing to address thyroid issues can reduce LDL clearance and worsen cholesterol levels.
Don’t Assume All Cholesterol Increases Are Bad: Elevated cholesterol might be a positive sign of resolving NAFLD or other metabolic issues, especially when combined with healthy lifestyle changes.
Don’t Overlook FH: If your cholesterol remains elevated despite dietary changes, consider being tested for familial hypercholesterolemia (FH) as it requires different management strategies.
Does Eating Cholesterol Increase Cholesterol Levels?
Since the 1960s, research has shown that dietary cholesterol has a minimal impact on our blood cholesterol levels; however, this myth continues to run rampant with “lay off the bacon” as one of the number one layperson approaches to managing cholesterol.
Cholesterol in our bodies comes from two sources: dietary intake and internal production. The body regulates cholesterol balance through complex mechanisms. Proteins like NPC1L1 absorb cholesterol in the gut, while ABCG5/ABCG8 expel the excess. Most cholesterol in the gut is recycled internally rather than coming directly from the diet. The liver also converts cholesterol into bile acids, which are excreted through the stool.
Research shows that the body’s systems effectively manage dietary cholesterol. Eating cholesterol-rich foods, such as eggs, accounts for only about 15% of our serum cholesterol and doesn’t usually raise blood cholesterol levels significantly. This is because the body absorbs only a small portion and adjusts its cholesterol production to maintain balance.
That being said, those with conditions like familial hypercholesterolemia (FH) may be more sensitive to dietary cholesterol and should monitor their intake of saturated and trans fats. For them, reducing these fats can help manage cholesterol levels.
What I Do
I keep a close eye on my cholesterol by getting my levels checked annually. So far, my lipid levels have stayed stable, likely thanks to a low-carb, high-fiber, whole-food-focused diet. I avoid most grains and refined carbs and eat plenty of fruits and vegetables, which support heart health and balanced cholesterol. While I follow many of the recommendations listed, peanut butter is my kryptonite—I love the taste and eat too much, something I’m working on. To further support my health, I regularly take a few key supplements, including a high-quality multivitamin, fish oil, and vitamin D3.
Takeaway
High cholesterol isn’t just about diet; it often signals deeper metabolic or lifestyle imbalances. Addressing high cholesterol starts with understanding root causes, from metabolic dysfunction and thyroid issues to gut health and inflammation. A holistic approach, including improved diet, exercise, sleep, and targeted testing, can help bring cholesterol levels into balance and reduce long-term cardiovascular risk. Taking proactive steps, tracking your biomarkers, and working with a knowledgeable healthcare provider can help you create a personalized plan to optimize cholesterol and protect heart health naturally.
FAQ
How does functional medicine approach high cholesterol?
Functional medicine takes a holistic view, focusing on identifying the root causes of high cholesterol rather than just treating the symptoms. This approach includes assessing diet, lifestyle, stress levels, and genetic factors, and may involve personalized treatment plans that include dietary changes, supplements, and lifestyle modifications.
Can medications help manage high cholesterol?
Yes, medications such as statins may be prescribed to help lower cholesterol levels, especially when lifestyle changes alone are not sufficient. It’s important to discuss the benefits and potential side effects with a healthcare provider.
What role does stress play in cholesterol levels?
Chronic stress can contribute to unhealthy behaviors like poor diet and lack of exercise, which can indirectly affect cholesterol levels. Additionally, stress hormones may influence how the body processes cholesterol.
Does dietary cholesterol directly impact blood cholesterol?
In most people, dietary cholesterol has minimal effect on blood cholesterol levels, as the body regulates its own cholesterol production, however, individuals with genetic conditions like familial hypercholesterolemia (FH) may be more sensitive to dietary cholesterol and should monitor intake carefully.
How does sugar intake affect cholesterol?
High sugar intake, especially from refined carbs and sugary foods, can increase triglyceride levels and raise VLDL (very-low-density lipoprotein) cholesterol, both of which are risk factors for heart disease. Reducing added sugars and refined carbs can improve overall cholesterol balance and cardiovascular health.
What role does fiber play in cholesterol management?
Fiber, especially soluble fiber, helps reduce cholesterol by binding to it in the digestive tract, preventing its absorption. High-fiber foods like chia seeds, flaxseeds, and leafy greens are excellent choices for managing cholesterol naturally.
Disclaimer: The information provided in this article is for educational purposes only and is not intended to serve as medical advice. Always consult a qualified healthcare professional before making any changes to your diet, exercise, or treatment plan, especially concerning cholesterol management and blood testing. Individual health needs may vary, and it’s essential to seek personalized guidance based on your unique circumstances.
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