Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Lipid lowering with diet or dietary supplements

Christine C Tangney, PhD
Robert S Rosenson, MD
Section Editor
Mason W Freeman, MD
Deputy Editor
Gordon M Saperia, MD, FACC


Lipid alterations can also be effected by a number of dietary approaches or specific dietary supplements [1,2]. Such approaches have been exploited by nutritionists and clinicians as evidence-based and less costly alternatives to several classes of drugs. These differ with respect to mechanism of action and to the degree and type of lipid lowering. Thus, the indications for a particular dietary supplement are influenced by the underlying lipid abnormality.

The characteristics and efficacy of the lipid-lowering dietary supplements or dietary components will be reviewed here.


Populations with high intakes of omega-3 (n-3) polyunsaturated fatty acids (such as the Inuit) have low rates of heart disease; this observation has increased interest in the possible benefit of fish oils [3,4]. Rich sources of omega-3 fatty acids come from fatty fish, especially salmon, and plant sources such as flaxseed and flaxseed oil, canola oil, soybean oil, and nuts. (See "Fish oil and marine omega-3 fatty acids" and "Dietary fat", section on 'Polyunsaturated fatty acids'.)

Fish oil concentrate administered at high doses (>6 g/day) can reduce levels of triglycerides through inhibition of the synthesis of VLDL-triglycerides and apolipoprotein B [5,6]. In hypertriglyceridemic subjects, fish oils (in a dose of 15 g/day) lower triglyceride levels by approximately 50 percent [7,8]. Similarly large reductions in triglyceride levels with fish oil have also been seen in patients with HIV and hypertriglyceridemia. (See "Management of cardiovascular risk (including dyslipidemia) in the HIV-infected patient", section on 'Fish oil'.)

Since fish oil lowers plasma triglyceride concentrations, which in turn is a determinant of small dense LDL, it is possible that fish oils will decrease the concentration of small LDL. Support for this hypothesis comes from the observed reduction of cholesteryl ester transfer activity following fish oil therapy [9]. In addition, several studies have observed an increase in overall LDL particle size with 4 g purified docosahexaenoic acid [10-12]. In contrast, 2.5 g of omega-3 fatty acids daily for two months did not significantly change this fraction in 16 noninsulin-dependent diabetics when compared to placebo [13].


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: Feb 4, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Vogel JH, Bolling SF, Costello RB, et al. Integrating complementary medicine into cardiovascular medicine. A report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents (Writing Committee to Develop an Expert Consensus Document on Complementary and Integrative Medicine). J Am Coll Cardiol 2005; 46:184.
  2. Varady KA, Jones PJ. Combination diet and exercise interventions for the treatment of dyslipidemia: an effective preliminary strategy to lower cholesterol levels? J Nutr 2005; 135:1829.
  3. Rissanen T, Voutilainen S, Nyyssönen K, et al. Fish oil-derived fatty acids, docosahexaenoic acid and docosapentaenoic acid, and the risk of acute coronary events: the Kuopio ischaemic heart disease risk factor study. Circulation 2000; 102:2677.
  4. Harper CR, Jacobson TA. The fats of life: the role of omega-3 fatty acids in the prevention of coronary heart disease. Arch Intern Med 2001; 161:2185.
  5. Grey AB, Stapleton JP, Evans MC, Reid IR. The effect of the anti-estrogen tamoxifen on cardiovascular risk factors in normal postmenopausal women. J Clin Endocrinol Metab 1995; 80:3191.
  6. Nestel PJ, Connor WE, Reardon MF, et al. Suppression by diets rich in fish oil of very low density lipoprotein production in man. J Clin Invest 1984; 74:82.
  7. Harris WS, Connor WE, Illingworth DR, et al. Effects of fish oil on VLDL triglyceride kinetics in humans. J Lipid Res 1990; 31:1549.
  8. Sullivan DR, Sanders TA, Trayner IM, Thompson GR. Paradoxical elevation of LDL apoprotein B levels in hypertriglyceridaemic patients and normal subjects ingesting fish oil. Atherosclerosis 1986; 61:129.
  9. Abbey M, Clifton P, Kestin M, et al. Effect of fish oil on lipoproteins, lecithin:cholesterol acyltransferase, and lipid transfer protein activity in humans. Arteriosclerosis 1990; 10:85.
  10. Mori TA, Burke V, Puddey IB, et al. Purified eicosapentaenoic and docosahexaenoic acids have differential effects on serum lipids and lipoproteins, LDL particle size, glucose, and insulin in mildly hyperlipidemic men. Am J Clin Nutr 2000; 71:1085.
  11. Contacos C, Barter PJ, Sullivan DR. Effect of pravastatin and omega-3 fatty acids on plasma lipids and lipoproteins in patients with combined hyperlipidemia. Arterioscler Thromb 1993; 13:1755.
  12. Suzukawa M, Abbey M, Howe PR, Nestel PJ. Effects of fish oil fatty acids on low density lipoprotein size, oxidizability, and uptake by macrophages. J Lipid Res 1995; 36:473.
  13. Patti L, Maffettone A, Iovine C, et al. Long-term effects of fish oil on lipoprotein subfractions and low density lipoprotein size in non-insulin-dependent diabetic patients with hypertriglyceridemia. Atherosclerosis 1999; 146:361.
  14. Pan A, Yu D, Demark-Wahnefried W, et al. Meta-analysis of the effects of flaxseed interventions on blood lipids. Am J Clin Nutr 2009; 90:288.
  15. Lissin LW, Cooke JP. Phytoestrogens and cardiovascular health. J Am Coll Cardiol 2000; 35:1403.
  16. Anderson JW, Johnstone BM, Cook-Newell ME. Meta-analysis of the effects of soy protein intake on serum lipids. N Engl J Med 1995; 333:276.
  17. Crouse JR 3rd, Morgan T, Terry JG, et al. A randomized trial comparing the effect of casein with that of soy protein containing varying amounts of isoflavones on plasma concentrations of lipids and lipoproteins. Arch Intern Med 1999; 159:2070.
  18. Teixeira SR, Potter SM, Weigel R, et al. Effects of feeding 4 levels of soy protein for 3 and 6 wk on blood lipids and apolipoproteins in moderately hypercholesterolemic men. Am J Clin Nutr 2000; 71:1077.
  19. Sacks FM, Lichtenstein A, Van Horn L, et al. Soy protein, isoflavones, and cardiovascular health: an American Heart Association Science Advisory for professionals from the Nutrition Committee. Circulation 2006; 113:1034.
  20. Figtree GA, Griffiths H, Lu YQ, et al. Plant-derived estrogens relax coronary arteries in vitro by a calcium antagonistic mechanism. J Am Coll Cardiol 2000; 35:1977.
  21. Nestel PJ, Yamashita T, Sasahara T, et al. Soy isoflavones improve systemic arterial compliance but not plasma lipids in menopausal and perimenopausal women. Arterioscler Thromb Vasc Biol 1997; 17:3392.
  22. Walker HA, Dean TS, Sanders TA, et al. The phytoestrogen genistein produces acute nitric oxide-dependent dilation of human forearm vasculature with similar potency to 17beta-estradiol. Circulation 2001; 103:258.
  23. Teede HJ, McGrath BP, DeSilva L, et al. Isoflavones reduce arterial stiffness: a placebo-controlled study in men and postmenopausal women. Arterioscler Thromb Vasc Biol 2003; 23:1066.
  24. Squadrito F, Altavilla D, Crisafulli A, et al. Effect of genistein on endothelial function in postmenopausal women: a randomized, double-blind, controlled study. Am J Med 2003; 114:470.
  25. Chan YH, Lau KK, Yiu KH, et al. Isoflavone intake in persons at high risk of cardiovascular events: implications for vascular endothelial function and the carotid atherosclerotic burden. Am J Clin Nutr 2007; 86:938.
  26. Teede HJ, Dalais FS, Kotsopoulos D, et al. Dietary soy has both beneficial and potentially adverse cardiovascular effects: a placebo-controlled study in men and postmenopausal women. J Clin Endocrinol Metab 2001; 86:3053.
  27. Li CL, Zhu Y, Wang Y, et al. Monascus purpureus-fermented rice (red yeast rice): a natural food product that lowers blood cholesterol in animal models of hypercholesterolemia. Nutr Res 1998; 18:71.
  28. Patrick L, Uzick M. Cardiovascular disease: C-reactive protein and the inflammatory disease paradigm: HMG-CoA reductase inhibitors, alpha-tocopherol, red yeast rice, and olive oil polyphenols. A review of the literature. Altern Med Rev 2001; 6:248.
  29. Heber D, Yip I, Ashley JM, et al. Cholesterol-lowering effects of a proprietary Chinese red-yeast-rice dietary supplement. Am J Clin Nutr 1999; 69:231.
  30. Wang J, Lu Z, Chi J, et al. Multicenter clinical trial of the serum lipid lowering effects of Monascus purpureus (red yeast) rice preparation from traditional Chinese medicine. Cur Ther Res 1997; 58:964.
  31. Becker DJ, Gordon RY, Halbert SC, et al. Red yeast rice for dyslipidemia in statin-intolerant patients: a randomized trial. Ann Intern Med 2009; 150:830.
  32. Heber D, Lembertas A, Lu QY, et al. An analysis of nine proprietary Chinese red yeast rice dietary supplements: implications of variability in chemical profile and contents. J Altern Complement Med 2001; 7:133.
  33. Gordon RY, Cooperman T, Obermeyer W, Becker DJ. Marked variability of monacolin levels in commercial red yeast rice products: buyer beware! Arch Intern Med 2010; 170:1722.
  34. Red yeast rice. Med Lett Drugs Ther 2009; 51:71.
  35. Szapary PO, Wolfe ML, Bloedon LT, et al. Guggulipid for the treatment of hypercholesterolemia: a randomized controlled trial. JAMA 2003; 290:765.
  36. Nityanand S, Srivastava JS, Asthana OP. Clinical trials with gugulipid. A new hypolipidaemic agent. J Assoc Physicians India 1989; 37:323.
  37. Singh RB, Niaz MA, Ghosh S. Hypolipidemic and antioxidant effects of Commiphora mukul as an adjunct to dietary therapy in patients with hypercholesterolemia. Cardiovasc Drugs Ther 1994; 8:659.
  38. Soman CR. Indo-Mediterranean diet and progression of coronary artery disease. Lancet 2005; 366:365.
  39. Mann J. The Indo-Mediterranean diet revisited. Lancet 2005; 366:353.
  40. Horton R. Expression of concern: Indo-Mediterranean Diet Heart Study. Lancet 2005; 366:354.
  41. White C. Suspected research fraud: difficulties of getting at the truth. BMJ 2005; 331:281.
  42. Chen JT, Wesley R, Shamburek RD, et al. Meta-analysis of natural therapies for hyperlipidemia: plant sterols and stanols versus policosanol. Pharmacotherapy 2005; 25:171.
  43. Gouni-Berthold I, Berthold HK. Policosanol: clinical pharmacology and therapeutic significance of a new lipid-lowering agent. Am Heart J 2002; 143:356.
  44. Berthold HK, Unverdorben S, Degenhardt R, et al. Effect of policosanol on lipid levels among patients with hypercholesterolemia or combined hyperlipidemia: a randomized controlled trial. JAMA 2006; 295:2262.
  46. Nevin KG, Rajamohan T. Beneficial effects of virgin coconut oil on lipid parameters and in vitro LDL oxidation. Clin Biochem 2004; 37:830.
  47. Marina AM, Che Man YB, Nazimah AH. Chemical properties of virgin coconut oil. J Am Oil Chem Soc 2009; 86:301.
  48. Dauqan EMA, Sani HA, Abdullah A, et al. Fatty acids composition of four different vegetable oils (red palm olein, palm olein, corn oil and coconut oil) by gas chromatography. In: 2nd International Conference on Chemistry and Chemical Engineering, Chengdu, China 2011. p.31.
  49. Nicolosi RJ, Rogers EJ. Regulation of plasma lipoprotein levels by dietary triglycerides enriched with different fatty acids. Med Sci Sports Exerc 1997; 29:1422.
  50. Spady DK, Dietschy JM. Interaction of dietary cholesterol and triglycerides in the regulation of hepatic low density lipoprotein transport in the hamster. J Clin Invest 1988; 81:300.
  51. Stucchi AF, Terpstra AH, Nicolosi RJ. LDL receptor activity is down-regulated similarly by a cholesterol-containing diet high in palmitic acid or high in lauric and myristic acids in cynomolgus monkeys. J Nutr 1995; 125:2055.
  52. Müller H, Lindman AS, Blomfeldt A, et al. A diet rich in coconut oil reduces diurnal postprandial variations in circulating tissue plasminogen activator antigen and fasting lipoprotein (a) compared with a diet rich in unsaturated fat in women. J Nutr 2003; 133:3422.
  53. Isaacsohn JL, Moser M, Stein EA, et al. Garlic powder and plasma lipids and lipoproteins: a multicenter, randomized, placebo-controlled trial. Arch Intern Med 1998; 158:1189.
  54. Superko HR, Krauss RM. Garlic powder, effect on plasma lipids, postprandial lipemia, low-density lipoprotein particle size, high-density lipoprotein subclass distribution and lipoprotein(a). J Am Coll Cardiol 2000; 35:321.
  55. Adler AJ, Holub BJ. Effect of garlic and fish-oil supplementation on serum lipid and lipoprotein concentrations in hypercholesterolemic men. Am J Clin Nutr 1997; 65:445.
  56. Steiner M, Khan AH, Holbert D, Lin RI. A double-blind crossover study in moderately hypercholesterolemic men that compared the effect of aged garlic extract and placebo administration on blood lipids. Am J Clin Nutr 1996; 64:866.
  57. Warshafsky S, Kamer RS, Sivak SL. Effect of garlic on total serum cholesterol. A meta-analysis. Ann Intern Med 1993; 119:599.
  58. Gylling H, Radhakrishnan R, Miettinen TA. Reduction of serum cholesterol in postmenopausal women with previous myocardial infarction and cholesterol malabsorption induced by dietary sitostanol ester margarine: women and dietary sitostanol. Circulation 1997; 96:4226.
  59. Gardner CD, Lawson LD, Block E, et al. Effect of raw garlic vs commercial garlic supplements on plasma lipid concentrations in adults with moderate hypercholesterolemia: a randomized clinical trial. Arch Intern Med 2007; 167:346.
  60. Zern TL, Fernandez ML. Cardioprotective effects of dietary polyphenols. J Nutr 2005; 135:2291.
  61. Hollman PC, Cassidy A, Comte B, et al. The biological relevance of direct antioxidant effects of polyphenols for cardiovascular health in humans is not established. J Nutr 2011; 141:989S.
  62. Tangney CC, Rasmussen HE. Polyphenols, inflammation, and cardiovascular disease. Curr Atheroscler Rep 2013; 15:324.
  63. Mink PJ, Scrafford CG, Barraj LM, et al. Flavonoid intake and cardiovascular disease mortality: a prospective study in postmenopausal women. Am J Clin Nutr 2007; 85:895.
  64. Covas MI, Nyyssönen K, Poulsen HE, et al. The effect of polyphenols in olive oil on heart disease risk factors: a randomized trial. Ann Intern Med 2006; 145:333.
  65. Hooper L, Kay C, Abdelhamid A, et al. Effects of chocolate, cocoa, and flavan-3-ols on cardiovascular health: a systematic review and meta-analysis of randomized trials. Am J Clin Nutr 2012; 95:740.
  66. Sahebkar A. Effects of resveratrol supplementation on plasma lipids: a systematic review and meta-analysis of randomized controlled trials. Nutr Rev 2013; 71:822.
  67. Zambón D, Sabaté J, Muñoz S, et al. Substituting walnuts for monounsaturated fat improves the serum lipid profile of hypercholesterolemic men and women. A randomized crossover trial. Ann Intern Med 2000; 132:538.
  68. Sabaté J, Fraser GE, Burke K, et al. Effects of walnuts on serum lipid levels and blood pressure in normal men. N Engl J Med 1993; 328:603.
  69. Ros E, Núñez I, Pérez-Heras A, et al. A walnut diet improves endothelial function in hypercholesterolemic subjects: a randomized crossover trial. Circulation 2004; 109:1609.
  70. Sabaté J, Haddad E, Tanzman JS, et al. Serum lipid response to the graduated enrichment of a Step I diet with almonds: a randomized feeding trial. Am J Clin Nutr 2003; 77:1379.
  71. Gebauer SK, West SG, Kay CD, et al. Effects of pistachios on cardiovascular disease risk factors and potential mechanisms of action: a dose-response study. Am J Clin Nutr 2008; 88:651.
  72. Sabaté J, Oda K, Ros E. Nut consumption and blood lipid levels: a pooled analysis of 25 intervention trials. Arch Intern Med 2010; 170:821.
  73. Del Gobbo LC, Falk MC, Feldman R, et al. Effects of tree nuts on blood lipids, apolipoproteins, and blood pressure: systematic review, meta-analysis, and dose-response of 61 controlled intervention trials. Am J Clin Nutr 2015; 102:1347.
  74. Estruch R, Ros E, Salas-Salvadó J, et al. Primary prevention of cardiovascular disease with a Mediterranean diet. N Engl J Med 2013; 368:1279.
  75. Fraser GE, Sabaté J, Beeson WL, Strahan TM. A possible protective effect of nut consumption on risk of coronary heart disease. The Adventist Health Study. Arch Intern Med 1992; 152:1416.
  76. Albert CM, Gaziano JM, Willett WC, Manson JE. Nut consumption and decreased risk of sudden cardiac death in the Physicians' Health Study. Arch Intern Med 2002; 162:1382.
  77. Bao Y, Han J, Hu FB, et al. Association of nut consumption with total and cause-specific mortality. N Engl J Med 2013; 369:2001.
  78. Luo C, Zhang Y, Ding Y, et al. Nut consumption and risk of type 2 diabetes, cardiovascular disease, and all-cause mortality: a systematic review and meta-analysis. Am J Clin Nutr 2014; 100:256.
  79. Zhou D, Yu H, He F, et al. Nut consumption in relation to cardiovascular disease risk and type 2 diabetes: a systematic review and meta-analysis of prospective studies. Am J Clin Nutr 2014; 100:270.
  80. Afshin A, Micha R, Khatibzadeh S, Mozaffarian D. Consumption of nuts and legumes and risk of incident ischemic heart disease, stroke, and diabetes: a systematic review and meta-analysis. Am J Clin Nutr 2014; 100:278.
  81. Luu HN, Blot WJ, Xiang YB, et al. Prospective evaluation of the association of nut/peanut consumption with total and cause-specific mortality. JAMA Intern Med 2015; 175:755.
  82. Hartley L, Flowers N, Holmes J, et al. Green and black tea for the primary prevention of cardiovascular disease. Cochrane Database Syst Rev 2013; :CD009934.
  83. Kuriyama S, Shimazu T, Ohmori K, et al. Green tea consumption and mortality due to cardiovascular disease, cancer, and all causes in Japan: the Ohsaki study. JAMA 2006; 296:1255.
  84. Arab L, Khan F, Lam H. Tea consumption and cardiovascular disease risk. Am J Clin Nutr 2013; 98:1651S.
  85. American Heart Association Nutrition Committee, Lichtenstein AH, Appel LJ, et al. Diet and lifestyle recommendations revision 2006: a scientific statement from the American Heart Association Nutrition Committee. Circulation 2006; 114:82.
  86. Judd JT, Clevidence BA, Muesing RA, et al. Dietary trans fatty acids: effects on plasma lipids and lipoproteins of healthy men and women. Am J Clin Nutr 1994; 59:861.
  87. Lichtenstein AH, Ausman LM, Jalbert SM, Schaefer EJ. Effects of different forms of dietary hydrogenated fats on serum lipoprotein cholesterol levels. N Engl J Med 1999; 340:1933.
  88. Dreon DM, Fernstrom HA, Miller B, Krauss RM. Low-density lipoprotein subclass patterns and lipoprotein response to a reduced-fat diet in men. FASEB J 1994; 8:121.
  89. Starc TJ, Shea S, Cohn LC, et al. Greater dietary intake of simple carbohydrate is associated with lower concentrations of high-density-lipoprotein cholesterol in hypercholesterolemic children. Am J Clin Nutr 1998; 67:1147.
  90. Parks EJ, Hellerstein MK. Carbohydrate-induced hypertriacylglycerolemia: historical perspective and review of biological mechanisms. Am J Clin Nutr 2000; 71:412.
  91. Brown L, Rosner B, Willett WW, Sacks FM. Cholesterol-lowering effects of dietary fiber: a meta-analysis. Am J Clin Nutr 1999; 69:30.
  92. Wolever TM, Tosh SM, Gibbs AL, et al. Physicochemical properties of oat β-glucan influence its ability to reduce serum LDL cholesterol in humans: a randomized clinical trial. Am J Clin Nutr 2010; 92:723.
  93. Hollænder PL, Ross AB, Kristensen M. Whole-grain and blood lipid changes in apparently healthy adults: a systematic review and meta-analysis of randomized controlled studies. Am J Clin Nutr 2015; 102:556.
  94. Moreyra AE, Wilson AC, Koraym A. Effect of combining psyllium fiber with simvastatin in lowering cholesterol. Arch Intern Med 2005; 165:1161.
  95. Fernandez ML. Soluble fiber and nondigestible carbohydrate effects on plasma lipids and cardiovascular risk. Curr Opin Lipidol 2001; 12:35.
  96. Roy S, Vega-Lopez S, Fernandez ML. Gender and hormonal status affect the hypolipidemic mechanisms of dietary soluble fiber in guinea pigs. J Nutr 2000; 130:600.
  97. Vuksan V, Whitham D, Sievenpiper JL, et al. Supplementation of conventional therapy with the novel grain Salba (Salvia hispanica L.) improves major and emerging cardiovascular risk factors in type 2 diabetes: results of a randomized controlled trial. Diabetes Care 2007; 30:2804.
  98. Shrestha S, Volek JS, Udani J, et al. A combination therapy including psyllium and plant sterols lowers LDL cholesterol by modifying lipoprotein metabolism in hypercholesterolemic individuals. J Nutr 2006; 136:2492.
  99. Buil-Cosiales P, Irimia P, Ros E, et al. Dietary fibre intake is inversely associated with carotid intima-media thickness: a cross-sectional assessment in the PREDIMED study. Eur J Clin Nutr 2009; 63:1213.
  100. Threapleton DE, Greenwood DC, Evans CE, et al. Dietary fiber intake and risk of first stroke: a systematic review and meta-analysis. Stroke 2013; 44:1360.
  101. Tilvis RS, Miettinen TA. Serum plant sterols and their relation to cholesterol absorption. Am J Clin Nutr 1986; 43:92.
  102. Jones PJ, MacDougall DE, Ntanios F, Vanstone CA. Dietary phytosterols as cholesterol-lowering agents in humans. Can J Physiol Pharmacol 1997; 75:217.
  103. Miettinen TA, Puska P, Gylling H, et al. Reduction of serum cholesterol with sitostanol-ester margarine in a mildly hypercholesterolemic population. N Engl J Med 1995; 333:1308.
  104. Klingberg S, Ellegård L, Johansson I, et al. Dietary intake of naturally occurring plant sterols is related to a lower risk of a first myocardial infarction in men but not in women in northern Sweden. J Nutr 2013; 143:1630.
  105. Weingärtner O, Böhm M, Laufs U. Controversial role of plant sterol esters in the management of hypercholesterolaemia. Eur Heart J 2009; 30:404.
  106. Weingärtner O, Lütjohann D, Ji S, et al. Vascular effects of diet supplementation with plant sterols. J Am Coll Cardiol 2008; 51:1553.
  107. Helske S, Miettinen T, Gylling H, et al. Accumulation of cholesterol precursors and plant sterols in human stenotic aortic valves. J Lipid Res 2008; 49:1511.
  108. Katan MB, Grundy SM, Jones P, et al. Efficacy and safety of plant stanols and sterols in the management of blood cholesterol levels. Mayo Clin Proc 2003; 78:965.
  109. Sanchez-Muniz FJ, Maki KC, Schaefer EJ, Ordovas JM. Serum lipid and antioxidant responses in hypercholesterolemic men and women receiving plant sterol esters vary by apolipoprotein E genotype. J Nutr 2009; 139:13.
  110. Weststrate JA, Meijer GW. Plant sterol-enriched margarines and reduction of plasma total- and LDL-cholesterol concentrations in normocholesterolaemic and mildly hypercholesterolaemic subjects. Eur J Clin Nutr 1998; 52:334.
  111. Blair SN, Capuzzi DM, Gottlieb SO, et al. Incremental reduction of serum total cholesterol and low-density lipoprotein cholesterol with the addition of plant stanol ester-containing spread to statin therapy. Am J Cardiol 2000; 86:46.
  112. Hallikainen MA, Uusitupa MI. Effects of 2 low-fat stanol ester-containing margarines on serum cholesterol concentrations as part of a low-fat diet in hypercholesterolemic subjects. Am J Clin Nutr 1999; 69:403.
  113. Raeini-Sarjaz M, Ntanios FY, Vanstone CA, Jones PJ. No changes in serum fat-soluble vitamin and carotenoid concentrations with the intake of plant sterol/stanol esters in the context of a controlled diet. Metabolism 2002; 51:652.
  114. Mensink RP, Ebbing S, Lindhout M, et al. Effects of plant stanol esters supplied in low-fat yoghurt on serum lipids and lipoproteins, non-cholesterol sterols and fat soluble antioxidant concentrations. Atherosclerosis 2002; 160:205.
  115. Mussner MJ, Parhofer KG, Von Bergmann K, et al. Effects of phytosterol ester-enriched margarine on plasma lipoproteins in mild to moderate hypercholesterolemia are related to basal cholesterol and fat intake. Metabolism 2002; 51:189.
  116. Noakes M, Clifton P, Ntanios F, et al. An increase in dietary carotenoids when consuming plant sterols or stanols is effective in maintaining plasma carotenoid concentrations. Am J Clin Nutr 2002; 75:79.
  117. Spilburg CA, Goldberg AC, McGill JB, et al. Fat-free foods supplemented with soy stanol-lecithin powder reduce cholesterol absorption and LDL cholesterol. J Am Diet Assoc 2003; 103:577.
  118. McPherson TB, Ostlund RE, Goldberg AC, et al. Phytostanol tablets reduce human LDL-cholesterol. J Pharm Pharmacol 2005; 57:889.
  119. Goldberg AC, Ostlund RE Jr, Bateman JH, et al. Effect of plant stanol tablets on low-density lipoprotein cholesterol lowering in patients on statin drugs. Am J Cardiol 2006; 97:376.
  120. Allen RR, Carson L, Kwik-Uribe C, et al. Daily consumption of a dark chocolate containing flavanols and added sterol esters affects cardiovascular risk factors in a normotensive population with elevated cholesterol. J Nutr 2008; 138:725.
  121. Lichtenstein AH, Deckelbaum RJ. AHA Science Advisory. Stanol/sterol ester-containing foods and blood cholesterol levels. A statement for healthcare professionals from the Nutrition Committee of the Council on Nutrition, Physical Activity, and Metabolism of the American Heart Association. Circulation 2001; 103:1177.
  122. Cholesterol-lowering margarines. Med Lett Drugs Ther 1999; 41:56.
  123. Govers MJ, Van der Meet R. Effects of dietary calcium and phosphate on the intestinal interactions between calcium, phosphate, fatty acids, and bile acids. Gut 1993; 34:365.
  124. Denke MA, Fox MM, Schulte MC. Short-term dietary calcium fortification increases fecal saturated fat content and reduces serum lipids in men. J Nutr 1993; 123:1047.
  125. Bell L, Halstenson CE, Halstenson CJ, et al. Cholesterol-lowering effects of calcium carbonate in patients with mild to moderate hypercholesterolemia. Arch Intern Med 1992; 152:2441.
  126. Reid IR, Mason B, Horne A, et al. Effects of calcium supplementation on serum lipid concentrations in normal older women: a randomized controlled trial. Am J Med 2002; 112:343.
  127. Bostick RM, Fosdick L, Grandits GA, et al. Effect of calcium supplementation on serum cholesterol and blood pressure. A randomized, double-blind, placebo-controlled, clinical trial. Arch Fam Med 2000; 9:31.
  128. Laclaustra M, Stranges S, Navas-Acien A, et al. Serum selenium and serum lipids in US adults: National Health and Nutrition Examination Survey (NHANES) 2003-2004. Atherosclerosis 2010; 210:643.
  129. Stranges S, Laclaustra M, Ji C, et al. Higher selenium status is associated with adverse blood lipid profile in British adults. J Nutr 2010; 140:81.
  130. Salonen JT, Salonen R, Seppänen K, et al. Relationship of serum selenium and antioxidants to plasma lipoproteins, platelet aggregability and prevalent ischaemic heart disease in Eastern Finnish men. Atherosclerosis 1988; 70:155.
  131. Rayman MP, Stranges S, Griffin BA, et al. Effect of supplementation with high-selenium yeast on plasma lipids: a randomized trial. Ann Intern Med 2011; 154:656.
  132. Bjelakovic G, Nikolova D, Gluud LL, et al. Antioxidant supplements for prevention of mortality in healthy participants and patients with various diseases. Cochrane Database Syst Rev 2012; :CD007176.
  133. Lippman SM, Klein EA, Goodman PJ, et al. Effect of selenium and vitamin E on risk of prostate cancer and other cancers: the Selenium and Vitamin E Cancer Prevention Trial (SELECT). JAMA 2009; 301:39.
  134. Jenkins DJ, Kendall CW, Marchie A, et al. Effects of a dietary portfolio of cholesterol-lowering foods vs lovastatin on serum lipids and C-reactive protein. JAMA 2003; 290:502.
  135. Jenkins DJ, Jones PJ, Lamarche B, et al. Effect of a dietary portfolio of cholesterol-lowering foods given at 2 levels of intensity of dietary advice on serum lipids in hyperlipidemia: a randomized controlled trial. JAMA 2011; 306:831.
  136. Appel LJ, Sacks FM, Carey VJ, et al. Effects of protein, monounsaturated fat, and carbohydrate intake on blood pressure and serum lipids: results of the OmniHeart randomized trial. JAMA 2005; 294:2455.
  137. Nordmann AJ, Suter-Zimmermann K, Bucher HC, et al. Meta-analysis comparing Mediterranean to low-fat diets for modification of cardiovascular risk factors. Am J Med 2011; 124:841.
  138. Knoops KT, de Groot LC, Kromhout D, et al. Mediterranean diet, lifestyle factors, and 10-year mortality in elderly European men and women: the HALE project. JAMA 2004; 292:1433.
  139. Martínez-González MA, García-López M, Bes-Rastrollo M, et al. Mediterranean diet and the incidence of cardiovascular disease: a Spanish cohort. Nutr Metab Cardiovasc Dis 2011; 21:237.
  140. King DE, Mainous AG 3rd, Geesey ME. Turning back the clock: adopting a healthy lifestyle in middle age. Am J Med 2007; 120:598.
  141. Fung TT, Rexrode KM, Mantzoros CS, et al. Mediterranean diet and incidence of and mortality from coronary heart disease and stroke in women. Circulation 2009; 119:1093.
  142. Tortosa A, Bes-Rastrollo M, Sanchez-Villegas A, et al. Mediterranean diet inversely associated with the incidence of metabolic syndrome: the SUN prospective cohort. Diabetes Care 2007; 30:2957.
  143. Paletas K, Athanasiadou E, Sarigianni M, et al. The protective role of the Mediterranean diet on the prevalence of metabolic syndrome in a population of Greek obese subjects. J Am Coll Nutr 2010; 29:41.
  144. De Lorgeril M, Salen P, Martin JL, et al. Effect of a mediterranean type of diet on the rate of cardiovascular complications in patients with coronary artery disease. Insights into the cardioprotective effect of certain nutriments. J Am Coll Cardiol 1996; 28:1103.
  145. Esposito K, Marfella R, Ciotola M, et al. Effect of a mediterranean-style diet on endothelial dysfunction and markers of vascular inflammation in the metabolic syndrome: a randomized trial. JAMA 2004; 292:1440.
  146. Estruch R, Martínez-González MA, Corella D, et al. Effects of a Mediterranean-style diet on cardiovascular risk factors: a randomized trial. Ann Intern Med 2006; 145:1.
  147. Fitó M, Guxens M, Corella D, et al. Effect of a traditional Mediterranean diet on lipoprotein oxidation: a randomized controlled trial. Arch Intern Med 2007; 167:1195.
  148. Montori VM, Devereaux PJ, Adhikari NK, et al. Randomized trials stopped early for benefit: a systematic review. JAMA 2005; 294:2203.
  149. Bassler D, Briel M, Montori VM, et al. Stopping randomized trials early for benefit and estimation of treatment effects: systematic review and meta-regression analysis. JAMA 2010; 303:1180.
  150. Guyatt GH, Oxman AD, Kunz R, et al. GRADE guidelines 6. Rating the quality of evidence--imprecision. J Clin Epidemiol 2011; 64:1283.
  151. Akesson A, Weismayer C, Newby PK, Wolk A. Combined effect of low-risk dietary and lifestyle behaviors in primary prevention of myocardial infarction in women. Arch Intern Med 2007; 167:2122.
  152. Chrysohoou C, Panagiotakos DB, Aggelopoulos P, et al. The Mediterranean diet contributes to the preservation of left ventricular systolic function and to the long-term favorable prognosis of patients who have had an acute coronary event. Am J Clin Nutr 2010; 92:47.
  153. Gardner CD, Coulston A, Chatterjee L, et al. The effect of a plant-based diet on plasma lipids in hypercholesterolemic adults: a randomized trial. Ann Intern Med 2005; 142:725.
  154. Djoussé L, Gaziano JM. Breakfast cereals and risk of heart failure in the physicians' health study I. Arch Intern Med 2007; 167:2080.
  155. Champagne CM. Dietary interventions on blood pressure: the Dietary Approaches to Stop Hypertension (DASH) trials. Nutr Rev 2006; 64:S53.
  156. Obarzanek E, Sacks FM, Vollmer WM, et al. Effects on blood lipids of a blood pressure-lowering diet: the Dietary Approaches to Stop Hypertension (DASH) Trial. Am J Clin Nutr 2001; 74:80.
  157. Azadbakht L, Fard NR, Karimi M, et al. Effects of the Dietary Approaches to Stop Hypertension (DASH) eating plan on cardiovascular risks among type 2 diabetic patients: a randomized crossover clinical trial. Diabetes Care 2011; 34:55.
  158. Fung TT, Chiuve SE, McCullough ML, et al. Adherence to a DASH-style diet and risk of coronary heart disease and stroke in women. Arch Intern Med 2008; 168:713.
  159. Chen ST, Maruthur NM, Appel LJ. The effect of dietary patterns on estimated coronary heart disease risk: results from the Dietary Approaches to Stop Hypertension (DASH) trial. Circ Cardiovasc Qual Outcomes 2010; 3:484.