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....................................................................... Table 8 summarizes the currently available evidence on the influences of lifestyle changes and functional foods on lipoproteins, indicating the magnitudes of the effects and the levels of evidence in relation to the impacts on the specific lipoprotein class; for the reasons outlined above, the levels of evidence are not based on RCTs with ASCVD endpoints. Moreover, within the Guidelines on the management of dyslipidaemias, information on the potential to improve plasma lipoprotein profiles by dietary means is clinically relevant, even in the absence of a clear demonstration of CV benefits.

7.1 Influence of lifestyle on total

cholesterol and low-density lipoprotein cholesterol levels Saturated fatty acids (SFAs) are the dietary factor with the greatest impact on LDL-C levels (0.020.04 mmol/L or 0.81.6 mg/dL of LDL-C increase for every additional 1% energy coming from saturated fat).164 Quantitatively, dietary trans fatty acids have a similar elevating effect on LDL-C to that of SFAs; however, while SFAs increase HDL-C levels, trans fats decrease them.137 Trans unsaturated fatty acids can be found in limited amounts (usually <5% of total fat) in dairy products and in meats from ruminants. ‘Partially hydrogenated fatty acids’ of industrial origin represent the major source of trans fatty acids in the diet; the average consumption of trans fatty acids ranges from 0.26.5% of the total energy intake in different populations.165 Unsaturated fat-rich oils from safflower, sunflower, rapeseed, flaxseed, corn, olives, or soybean were shown to reduce LDL-C levels (-0.42 to -0.20 mmol/L) when used in substitution of SFA-rich foods like butter or lard.166 The effects of carbohydrate consumption on LDL-C are described in section 7.4.3.

Body weight reduction also influences TC and LDL-C levels, but the magnitude of the effect is small: in obese people, a decrease in LDL-C concentration of 0.2 mmol/L (8 mg/dL) is observed for every 10 kg of weight loss.147,167 The reduction of LDL-C levels induced by regular physical exercise is even smaller.151,168 The benefits of weight reduction and physical exercise on the CV risk profile likely impact on other risk factors, especially hypertension and diabetes. Table 9 summarizes the possible choices of foods to lower TC and LDL-C levels. Given the cultural diversity of the European populations, they should be translated into practical behaviours, considering local habits and socio-economic factors.

7.2 Influence of lifestyle on triglyceride

levels Weight reduction improves insulin sensitivity and decreases TG levels. Regular physical exercise reduces plasma TG levels over and above the effect of weight reduction.151,168,169 Alcohol intake has a

Table 8 Impact of specific lifestyle changes on lipid levels

Magnitude of the effect Level Reference

Lifestyle interventions to reduce TC and LDL-C levels Avoid dietary trans fats þþ A 129,138 Reduce dietary saturated fats þþ A 129,139 Increase dietary fibre þþ A 140,141 Use functional foods enriched with phytosterols þþ A 142,143 Use red yeast rice nutraceuticals þþ A 144146 Reduce excessive body weight þþ A 147,148 Reduce dietary cholesterol þ B 149,150 Increase habitual physical activity þ B 151 Lifestyle interventions to reduce TG-rich lipoprotein levels Reduce excessive body weight þ A 147,148 Reduce alcohol intake þþþ A 152,153 Increase habitual physical activity þþ A 151,154 Reduce total amount of dietary carbohydrates þþ A 147,155 Use supplements of n-3 polyunsaturated fats þþ A 156,157 Reduce intake of mono- and disaccharides þþ B 158,159 Replace saturated fats with mono- or polyunsaturated fats þ B 129,137 Lifestyle interventions to increase HDL-C levels Avoid dietary trans fats þþ A 129,160 Increase habitual physical activity þþþ A 151,161 Reduce excessive body weight þþ A 147,148 Reduce dietary carbohydrates and replace them with unsaturated fats þþ A 147,162 Modest consumption in those who take alcohol may be continued þþ B 153 Quit smoking þ B 163 The magnitude of the effect (þþþ = >10%, þþ = 510%, þ = <5%) and the level of evidence refer to the impact of each dietary modification on plasma levels of a specific lipoprotein class. HDL-C = high-density lipoprotein cholesterol; LDL-C = low-density lipoprotein cholesterol; TC = total cholesterol; TG = triglyceride. Downloaded from academic.oup.com/eurheartj/article/41/1/111/5556353 by guest on 07 October 2026