Lowering high LDL (“bad”) cholesterol can curb your risk of heart disease. If a heart-healthy diet doesn’t work, prescription drugs can slash LDL. Do over-the-counter supplements also work?

Optimal LDL is below 100 milligrams per deciliter. (If you already have heart disease, the goal is to get it under 70 mg/dL.) At the other end, “an LDL of 160 or more is a signal that we need to get it down,” says Michael Miller, a cardiologist at Penn Medicine.

What if your LDL falls between 100 and 159? “It depends on your risk of a heart attack or stroke,” says Miller. And that risk reflects your age, gender, blood pressure, and more.

“Let’s say you’re a 58-year-old woman, a former smoker, you have high blood pressure but it’s being treated, you don’t have diabetes, and your LDL puts your 10-year risk of a heart attack or stroke between five and 10 percent. At 10 percent, we might treat you with a statin. At less than five percent, we definitely wouldn’t.” (You can calculate your risk with this tool.)

Why a statin? “Depending on the type and dose, statins lower LDL by 25 to 60 percent,” says Miller.

“Few medications in the history of medicine have been tested so extensively,” he adds. Yet despite their very good safety profile, “a lot of people are very fearful of taking statins.”

“The most commonly reported side effect is muscle achiness,” says Miller. Muscle aches occur in 1 in 100 statin takers when trials compare their complaints to those of placebo takers.

“The most problematic is rhabdomyolysis,” he adds. “The muscle tissue breaks down, which can lead to kidney failure.” Rhabdomyolysis strikes 1 in every 10,000 statin takers.

“And statins don’t work for 5 to 10 percent of people,” Miller notes. If that’s you, or if you don’t want to take prescription drugs or don’t need to lower your LDL much, some supplements may offer modest help.

That said, “supplements are not regulated by the FDA like pharmaceuticals,” cautions Miller. So you can’t be sure about their purity or potency. Here’s the evidence on the most widely studied supplements.

Red yeast rice

The major active ingredient in red yeast rice, monacolin K, is chemically identical to the drug lovastatin. “Studies show about a 20 percent drop in LDL with red yeast rice,” says Miller.

In one review of 13 trials, taking 1,200 to 3,600 milli­grams a day of red yeast rice (which contained 4.8 to 24 mg of monacolin K) slashed LDL by 40 mg/dL more than a placebo.

Just don’t expect the same bang from the red yeast rice you buy off the shelf. Researchers found that only six of 28 store-bought brands had at least 4 mg of monacolin K per dose. None of the supplements listed monacolin K levels. (That’s because they couldn’t. If they did, the FDA would treat them as unapproved drugs.)

What’s more, if you’re worried about the safety of statins, worry more about red yeast rice. The FDA has logged hundreds of unconfirmed adverse events (including muscle aches and rhabdomyolysis) in red yeast rice takers. And ConsumerLab.com found citrinin—a toxin that may cause kidney damage—in three of the 10 red yeast rice supplements it tested in 2022. (To find out which ones, you need a ConsumerLab membership.) 

In March, three red yeast rice supplements were recalled in Japan after five deaths and over 100 hospitalizations were linked to the supplements (the products are not sold in the United States). Then, in June, the number of reported deaths rose to 80. It's not clear if citrinin is to blame. In an interview with CNN in March, a spokesperson for the manufacturer said that the supplements had tested negative for citrinin in February 2024. However, the company did detect another toxic contaminant: puberulic acid, a compound found in blue mold.

Bottom line: A generic prescription statin provides a consistent dose (with no potential toxin). And it often costs less than red yeast rice.

Psyllium

“I don’t hesitate to recommend psyllium to my patients,” says Miller. The soluble fiber that’s found in supplements like Metamucil “binds to cholesterol in the gut, so the cholesterol isn’t absorbed,” he adds. “You can get about a 5 to 10 percent reduction in LDL.”

In an analysis of 28 trials, LDL dropped by 13 mg/dL in people who took an average of 10 grams of psyllium a day for three to 52 weeks compared to those who took a placebo. That’s what you’d get in three rounded teaspoons of Metamucil powder.

You’d need 20 Metamucil capsules to get the 7 grams a day that the FDA requires for a “may reduce the risk of heart disease” claim. (It’s often in tiny print.) Metamucil Fiber Thins crackers have too little psyllium. Its gummies have none.

Heads up: Psyllium also works as a laxative, so introduce it slowly.

Berberine

Berberine is a compound found in plants like goldenseal, barberry, and Oregon grape.

In 14 trials in people who took 900 to 1,500 mg a day of berberine for one to six months, LDL dropped by 18 mg/dL more than in those who took a placebo. No serious risks have been reported, though berberine may cause constipation, diarrhea, or nausea.

When researchers tested 15 berberine supplements they bought online, nine had different levels than the bottle declared. On average, they had only 75 percent of what the label promised.

Phytosterols

Phytosterols occur naturally in plants and are added to buttery spreads like Benecol. They’re structurally similar to cholesterol, so they block some cholesterol from being absorbed in the gut.

In an industry-funded analysis of 124 studies, getting 2 to 3.5 grams of phytosterols a day (mostly from foods with added phyto­sterols) lowered LDL by 8 to 12 percent. (Most people get about 0.2 to 0.4 grams a day of phyto­sterols from their usual diets.)

The FDA allows foods and supplements with at least 0.4 grams of phytosterols consumed twice a day with meals to claim that they may lower the risk of heart disease. Benecol’s chews and buttery spreads both fit the bill.

High-dose niacin

Though niacin is usually taken to boost HDL (“good”) cholesterol, a daily dose of 500 to 3,000 milligrams (either alone or in addition to a statin) can lower LDL (and triglycerides). However, in clinical trials, the B vitamin failed to lower the risk of heart attack, stroke, or dying early.

What’s more, high doses can cause unpleasant (though not dangerous) flushing, burning, tingling, and itching. And high-dose niacin is linked to an increased risk of high blood sugar, atrial fibrillation, gout, and liver problems that can range from elevated blood levels of liver enzymes to acute liver failure. Skip it.