1. Overview and Core Mechanisms

1.1. Common Clinical Indicators

• Asymptomatic (most common clinical presentation)
• Xanthomas (lipid deposits in skin or tendons)
• Xanthelasma (yellowish lipid deposits on eyelids)
• Arcus senilis (white or grey ring around the cornea)
• Eruptive xanthomata (associated with severe hypertriglyceridemia)

2. Diagnostic & Functional Testing

2.1. Recommended Lab Panels

2.2. Targeted Measurements & Functional Ranges

3. Therapeutic Interventions

3.1. Clinical Nutrition & Lifestyle Prescriptions

• Dietary Strategy:
  Implementation of the Portfolio Diet or Mediterranean Diet. Focus on high intake of viscous fibers (oats, barley), plant sterols, soy protein, and tree nuts. Minimize saturated fats to <7% of total calories and eliminate trans fats. The Mediterranean dietary pattern is the foundational nutrition strategy for dyslipidemia, supported by the strongest evidence for cardiovascular event reduction. This pattern emphasizes vegetables, fruits, legumes, whole grains, nuts, olive oil, and fish, while minimizing refined carbohydrates and ultra-processed foods. Large randomized trials demonstrate meaningful reductions in major cardiovascular events independent of baseline lipid levels. The Portfolio Diet is a targeted cholesterol-lowering dietary strategy designed to reduce LDL-C through specific food components rather than general macronutrient manipulation. Key elements include viscous soluble fibre (oats, barley, psyllium), nuts, soy protein, legumes, and plant sterols. Controlled trials show LDL-C reductions of ~13–14%, comparable to low-dose statins, though long-term cardiovascular outcome data are lacking. Dietary fat quality is prioritized over total fat reduction. Replacement of saturated fats with unsaturated fats (particularly monounsaturated fats from olive oil and polyunsaturated fats from nuts and seeds) improves lipid profiles and cardiovascular risk markers. Trans fats should be avoided entirely.
• Exercise Prescription:
  Regular physical activity improves lipid profiles, insulin sensitivity, blood pressure, and overall cardiovascular risk. Adults should accumulate at least 150 minutes per week of moderate- to vigorous-intensity aerobic activity, with additional resistance training recommended for metabolic and cardioprotective benefits. Exercise benefits extend beyond lipid changes and include reductions in cardiovascular morbidity and mortality.
• Smoking Cessation:
  Immediate cessation of all nicotine products to improve HDL-C levels and reduce endothelial oxidative stress and arterial wall damage.
• Weight Management:
  Reduction of central adiposity is a primary therapeutic target, as abdominal fat is a stronger predictor of dyslipidemia and cardiovascular risk than BMI alone. Waist circumference targets (<102 cm men, <88 cm women) are emphasized as clinically meaningful goals. Even modest weight loss improves lipid parameters and insulin sensitivity.
• Sleep & Stress:
  Adequate sleep duration (approximately 6–8 hours per night) supports metabolic and cardiovascular health. Chronic stress and depression are associated with poorer lipid control, reduced adherence to lifestyle interventions, and worse cardiovascular outcomes. Stress management and psychosocial support are framed as important adjuncts, even though direct lipid effects are modest.

3.2. Targeted Supplementation Protocol

1. Omega-3 Fatty Acids:
   Combined EPA/DHA to reduce hepatic triglyceride synthesis and lower VLDL levels.
2. Berberine:
   to upregulate LDL receptor expression and improve insulin sensitivity.
3. Red Yeast Rice:
   Standardized to Monacolin K; inhibits HMG-CoA reductase, the rate-limiting enzyme in cholesterol synthesis.
4. Coenzyme Q10:
   particularly important for patients on statins or red yeast rice to prevent myalgias and support mitochondrial function.
5. Plant Sterols:
   Plant sterols competitively inhibit intestinal cholesterol absorption. When consumed consistently (~2 g/day), they can reduce LDL-C by approximately 8–10%.
6. Bergamot:
   Bergamot extract improves lipid profiles by inhibiting HMG-CoA reductase activity, enhancing LDL receptor expression, and reducing hepatic cholesterol synthesis. Clinical studies demonstrate reductions in LDL-C, triglycerides, and total cholesterol, with modest increases in HDL-C, particularly in individuals with insulin resistance or metabolic syndrome. It can be useful in patients with elevated LDL or ApoB who are statin-intolerant, hesitant to use pharmacotherapy, or seeking adjunctive lipid support alongside diet and lifestyle interventions.
7. Dietary Fibre:
8. Psyllium Husk:
   Psyllium is a viscous soluble fibre that lowers LDL-C by binding bile acids and reducing intestinal cholesterol absorption. Meta-analyses show modest but consistent reductions in total cholesterol, LDL-C, and ApoB when used adjunctively with diet. It is emphasized as a low-risk, food-adjacent intervention with meaningful population-level impact.
9. B-Glucan:
   β-Glucan lowers LDL-C and non-HDL-C by increasing bile acid excretion and reducing cholesterol reabsorption. Systematic reviews demonstrate clinically meaningful lipid reductions at doses of ~3 g/day. β-glucan may be one of the strongest fibre-based interventions for dyslipidemia.
10. Glucomannan (Konjac Root):
    Glucomannan is a highly viscous soluble fibre that improves lipid profiles by delaying gastric emptying and reducing cholesterol absorption. Meta-analyses show reductions in LDL-C, triglycerides, and fasting glucose. It is effective but limited by GI tolerability and adherence.
11. Cinnamon:
    Cinnamon modestly lowers fasting glucose and lipid parameters, with inconsistent effects on HbA1c. High heterogeneity and unclear dosing limit clinical applicability. It is low-impact and adjunctive, not a primary lipid intervention.