Familial hypercholesterolemia (FH) is an inherited condition that causes high levels of LDL cholesterol (“bad” cholesterol). This increases the risk of heart disease.
FH almost always requires medication to bring LDL levels to an optimum level. However, diet can be an important part of managing this condition, too. Pairing healthy lifestyle choices such as eating a heart-healthy diet can help reduce the cardiovascular risks that come with FH.
This article will discuss diet strategies that have been shown to lower LDL cholesterol, including filling up on fiber-rich foods, favoring lean protein sources, and more.
Benefits of a Heart-Healthy Diet
The goal in the treatment of HF is to minimize the risk of complications such as heart disease. FH does not have a cure, but a combination of appropriate medications and healthy lifestyle habits can help manage LDL levels. This, in turn, can help reduce the risk of heart problems.
There isn’t a specific “FH diet,” but rather people with FH should follow the guidelines for heart-healthy eating meant for anyone at risk of heart disease. These guidelines are healthy for most people in general. So, you can get the whole family on board.
The American Heart Association (AHA) recommends an eating pattern that emphasizes:
- Eating a variety of fruits and vegetables
- Choosing whole grains
- Choosing low-fat dairy products
- Choosing skinless poultry and fish
- Eating nuts and legumes
- Using nontropical vegetable oils
The organization recommends limiting:
- Saturated fat
- Trans fat
- Red meat
- Sugar-sweetened beverages
While following a specific, named diet plan isn’t necessary, three diet programs follow similar guidelines to promote heart-healthy eating, including:
- The DASH (Dietary Approaches to Stop Hypertension) eating plan
- The Mediterranean diet
- The TLC (Therapeutic Lifestyle Changes) program
What Does “Diet” Mean?
“Diet” is often used to denote a short-term, calorie-restricted eating practice aimed at losing weight.
In the context of this article, “diet” refers to eating patterns.
The combination of foods and beverages a person consumes over time constitutes their eating pattern, or dietary pattern.
The “diets” referenced here describe overall healthy-eating patterns and guidelines meant for long-term health habits rather than short-term weight loss.
How It Works
The main purpose of following the heart-healthy dietary guidelines for FH is to lower LDL cholesterol.
Eating the foods that are recommended (and avoiding the ones that are not) can also have other benefits, such as lowering or preventing high blood pressure and promoting weight loss for those who need it.
FH is a lifelong condition that requires ongoing treatment. The dietary guidelines for people with FH are meant to be adopted as a lifestyle, even if symptoms are under control.
While important for both FH and overall health, healthy eating is not a substitute for medical treatment. High LDL in people without FH can often be controlled or managed with lifestyle changes alone, but this is not effective for people with FH.
What to Eat
The foods that are recommended for people with FH are fairly straightforward, as are the ones to be limited or avoided.
Fruits (especially apples, grapes, strawberries, and citrus fruits)
Low-fat dairy products
Whole grains (especially oats and barley)
Fish (especially fatty fish)
Unsaturated fats (as a substitute for saturated or trans fats)
Foods fortified with sterols and stanols
Foods high in soluble fiber
Red meat (limit and choose lean cuts)
Sugary foods and beverages
Egg yolks (two or fewer per week, including as an ingredient in baked goods and other foods)
Note: Serving suggestions are based on the DASH diet’s recommendations for a 2,000-calorie-per-day diet. These amounts will vary based on factors such as individual caloric needs.
- Fruits and vegetables: Aim for four or five daily servings of each. These are high in soluble fiber. A 2020 study showed that two whole apples a day reduced total and LDL levels in adults with mildly elevated cholesterol levels.
- Whole grains: Go for seven or eight servings daily. Whole grains such as oats and barley are high in soluble fiber. Choose whole grains over refined grain products such as white bread and pasta and baked goods that are also high in fat and sugar.
- Fish: Enjoying fatty fish, such as salmon, trout, and herring, two or three times a week is a great replacement for red meat and other meats that contain saturated fat. It has healthy fats, such as omega-3s, that can help protect the heart.
- Nuts and seeds: Two ounces of nuts per day can slightly lower LDL and help protect the heart. Three large prospective cohort studies showed that a higher intake of any type of nuts was associated with lower total cardiovascular disease and coronary heart disease.
- Beans and legumes: Legumes and beans, such as navy beans, kidney beans, lentils, garbanzos, and black-eyed peas, are high in soluble fiber, which can help lower LDL and help you feel full longer. They are also high in protein, making them helpful when eating a low-meat or meat-free diet.
- Soy: A 2015 meta-analysis indicated that regularly eating soy products, such as soy milk, tofu, and soybean or edamame, was associated with lower LDL cholesterol levels. The study also showed soy helped increase HDL “good” cholesterol by an average of 3%.
- Unsaturated fats: Replace saturated and trans fats with unsaturated fats, which come from plants and trees growing olives, nuts, and seeds. Monounsaturated fats, which are found in avocado, olives and olive oil, almonds, and safflower oil, have been shown to be especially effective at lowering LDL.
- Soluble fiber: Soluble fiber slows digestion by turning into a thick gel in the intestines. This gel traps cholesterol and eliminates it from the body, reducing the amount circulating in the blood. A 2016 report showed that increasing intake of soluble dietary fiber by 5-10 grams per day was associated with about a 5% reduction in LDL cholesterol. Soluble fiber can be found in foods such as oatmeal, beans, lentils, and many fruits. It also comes in supplement form.
Foods Emphasized by the Mediterranean Diet
The Mediterranean diet has similar guidelines to other heart-healthy plans such as DASH and TLC, with a few exceptions, which are:
- It emphasizes olive oil as a primary fat source.
- Animal products (such as dairy, meat, and eggs) are suggested in lower amounts, especially red meat.
- Red wine is recommended (for those who can consume it safely) in low to moderate amounts, usually at meals.
A review of studies has shown that following the Mediterranean diet is associated with lowered total and LDL cholesterol levels, and better health outcomes.
Another meta-analysis indicated that the Mediterranean diet may be more effective for the improvement of long-term cardiovascular risk factors than a low-fat diet.
More research is needed on how the Mediterranean diet affects LDL cholesterol.
A healthy diet for FH includes lots of fiber—but start slowly. Gradually increasing your servings of fruits, veggies, and other fiber-rich foods will give your digestive system a chance to adjust and reduce the temporary bloating and diarrhea that can come with an increase in fiber intake.
Choose fruits and vegetables for snacks between meals. This will help you get your total number of servings, it spreads out your servings, and it gives you a low-calorie, high nutrition way to stay satisfied between meals.
How you prepare your food makes a big difference to the health benefits.
Some tips to getting the most out of your heart-healthy diet include:
- Choose skinless poultry and fish, and don’t batter or fry it.
- Use a variety of spices instead of salt to reduce your sodium intake.
- Cook with oils with unsaturated fat instead of butter or lard.
- Cook beans and legumes from dry or, if not practical, rinse canned beans and legumes to remove some of the sodium (low-sodium options are also available).
- Choose a variety of foods and eat the rainbow to get a wider array of nutrients.
- Check labels, paying close attention to the ingredients, the nutrient information, and the serving sizes to which the information applies.
The serving sizes and number of servings recommended depend on the individual’s caloric needs. What determines a person’s caloric needs is influenced by several factors, including:
- Age (including child versus adult)
- Activity level
- Body size
- Sex or gender
- Whether a person is pregnant or breastfeeding
- If a person is trying to gain, lose, or maintain body weight
- Other dietary needs
Check with your healthcare provider before making any dietary changes to make a plan that meets all of your nutrition needs and goals.
While meat and animal products are included in the guidelines for eating with FH, this eating plan can be adjusted for vegetarian or vegan lifestyles.
This eating plan relies on an overview of foods to eat and foods to limit, making it easy to adjust to personal tastes. Foods such as whole grains, vegetables, beans, and other recommended foods can be used in a wide variety of recipes. Unsaturated fats and proteins can be supplied with plant-based foods instead of foods like dairy or fish.
The National Heart Lung and Blood Institute offers a website filled with heart-healthy recipes.
These guidelines promote long-term lifestyle practices. The goal is to change your eating habits to healthy ones such that it becomes a way of life.
Making changes gradually can help your body adjust to these changes and make the new habits easier to incorporate.
What you eat and how much you eat can change over time. At first, some people with FH may find after discussing a treatment plan with their healthcare provider that losing weight would be beneficial for them.
This eating plan can be adjusted for weight loss by choosing lower-calorie foods, increasing the servings of vegetables, and decreasing the servings of meat.
Once a target weight has been reached, calorie guidelines can be adjusted to maintain a weight that is healthy for you.
Moderation is key as well. While unsaturated fats are healthier than saturated or trans fats, they have the same number of calories and should not be used in excess.
Similarly, foods such as sugar, saturated fats, or alcohol should be consumed sparingly, but allowing for occasional indulgences is important for long-term sustainability. For example, the DASH diet has a recommended allowance of up to five servings of sweets per week, depending on caloric needs.
These servings may look like:
- 1 tablespoon of sugar
- 1 tablespoon of jelly or jam
- 1/2 ounce of jelly beans
- 8 ounces of lemonade
You can also choose healthier options for your limited foods when you do consume them. The AHA recommends no more than one alcoholic drink per day for women and no more than two for men. Red wine is considered a particularly heart-healthy option.
Before starting this or any new diet plan, consult with your healthcare provider. They can help you determine your caloric needs and if any changes need to be made to the plan to accommodate for other health conditions or allergies you may have.
Tell your healthcare provider of any medications you are taking or plan to take, including over-the-counter drugs and supplements. Some foods can interact with medications. Some medications and supplements need to be taken with food. Your healthcare provider can help you manage any conflicts between your medication and your new eating plan.
More Than Diet
Getting enough exercise goes hand in hand with diet and medication treatments for FH.
The AHA recommends getting at least 150 minutes of moderate physical activity or 75 minutes of vigorous physical activity (or an equal combination of both) each week.
Speak with your healthcare provider before beginning an exercise program to ensure the activities are right—and safe—for you.
Adopting a heart-healthy diet in combination with medication and guidance from your healthcare practitioner can go a long way toward managing familial hypercholesterolemia (FH). To get started, fill up your plate mostly with fruit and vegetables, whole grains, beans, nuts, and lean protein sources like fish and poultry. You’ll also want to limit red meat, full-fat dairy, and processed and packaged foods.
A Word From Verywell
While people with FH will need medication to control their LDL levels, eating a heart-healthy diet is a great way to complement your treatment protocol and improve overall health.
A diet rich in high-fiber foods like fruits, vegetables, whole grains, lentils, and beans combined with unsaturated fats found in foods such as olive oil, some nuts, and fatty fish can help reduce LDL and protect your heart.
Limiting saturated and trans fats, sugars and refined grains, and sodium can help reduce the cardiovascular risks that come with FH.
Talk to your healthcare provider about lifestyle and dietary changes you can make to optimize your treatment for FH.