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Dietary Cholesterol Does Matter for Some. Hyper-Absorbers at Risk.

Updated: Aug 4

cholesterol hyper absorber responder

For most people dietary cholesterol is not a problem, it does not raise blood cholesterol. However, the US National Lipid Association Recommendations states that there is “marked inter-individual variability” in cholesterol absorption, that some individuals experience a disproportionate rise in LDL-C in response to dietary cholesterol. These people are termed hyper-absorbers' (or responders) and, for them, further dietary cholesterol restriction may be warranted. These people might well be you or me.


As ever, please talk to your doctor or medical practitioner most familiar with your medical history before implementing any changes in diet, exercise or lifestyle, especially if you are under treatment. Links to all studies at bottom of page.

Research indicates that approximately one third of the population are hyper-absorbers of dietary cholesterol. These individuals experience a significantly greater increase in LDL cholesterol levels in response to dietary cholesterol intake compared to the general population. 

This heightened sensitivity is often attributed to genetic factors affecting cholesterol absorption mechanisms in the intestine. For hyper-absorbers, even modest dietary cholesterol intake can lead to significant elevations in LDL-C, potentially increasing cardiovascular risk. Consequently, dietary guidelines often recommend that these individuals limit their cholesterol intake as much as possible to manage their lipid levels effectively.


Identifying hyper-absorbers is not easy. It typically involves monitoring LDL-C responses to dietary changes, as there are currently no simple clinical tests to determine cholesterol absorption efficiency. Healthcare providers may consider a patient's lipid profile response to dietary modifications when assessing their sensitivity to dietary cholesterol.


Statins alone are often insufficient for these individuals, as they mainly target cholesterol synthesis rather than absorption. Identifying hyper-absorbers is not yet routine in clinical care, but early assessment—either via genetic testing or blood biomarkers - could help personalise cholesterol-lowering therapy and reduce cardiovascular risk more effectively.


Recent studies (see Simonen et al, 2023) confirm that genetic variations in intestinal transporters contribute to increased absorption and a higher risk of atherosclerotic cardiovascular disease. Elevated absorption is linked to reduced capacity for cholesterol elimination and the formation of more atherogenic LDL particles. Notably, statin monotherapy has been shown to be less effective in these individuals, with combination therapy using a statin and ezetimibe proving superior for both LDL-C reduction and plaque regression. In light of this, combination lipid-lowering therapy should be considered a first-line approach for anyone prescribed cholesterol-lowering medication, not just those at very high risk. Dietary strategies - such as the inclusion of phytostanols (usually from fortified foods) - may also be beneficial, particularly for primary prevention in individuals with elevated absorption but lower baseline cardiovascular risk. These plant-derived compounds are similar to phytosterols. They work by blocking the absorption of dietary and biliary cholesterol in the intestine.


This phenomenon is not new news, even in 2015 the US National Lipid Association's recommendations advised that:

cholesterol hyper responder absorber
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Final Thoughts


Beware of blanket statements that 'no-one needs to worry about dietary cholesterol'. For many it does. And, as cholesterol in food is often 'packaged' with saturated fat - that raises cholesterol - clinical guidance to reduce intake of foods high in saturated fat often addresses both.


Improving health is about finding motivation, prioritising self-care and taking action. If you want to take effective and targeted steps to that fit into your unique lifestyle, The Whole Health Practice is here to help. Whether you want to improve eating practices, beat chronic illness or enhance your overall well-being, our consultations and programs deliver results that are tailored to your needs.

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Related Studies


Schade DS, Nagamallika Godasi B, Duro T, Adolphe A, Eaton RP. New Insights Into the Importance of Dietary Cholesterol in Preventing Cardiovascular Disease. Endocr Pract. 2024 Jun;30(6):598-600. doi: 10.1016/j.eprac.2024.03.007. Epub 2024 Mar 24. PMID: 38522824.


Simonen P, Öörni K, Sinisalo J, Strandberg TE, Wester I, Gylling H. High cholesterol absorption: A risk factor of atherosclerotic cardiovascular diseases? Atherosclerosis. 2023 Jul;376:53-62. doi: 10.1016/j.atherosclerosis.2023.06.003. Epub 2023 Jun 2. PMID: 37290267.


Porter M, Wellons M. The Impact of Dietary Cholesterol on Low-Density Lipoprotein: Lessons in Absorption and Overconsumption. JCEM Case Rep. 2023 Feb 24;1(2):luad013. doi: 10.1210/jcemcr/luad013. PMID: 37908457; PMCID: PMC10580481.


Schmidt T, Harmon DM, Kludtke E, Mickow A, Simha V, Kopecky S. Dramatic elevation of LDL cholesterol from ketogenic-dieting: A Case Series. Am J Prev Cardiol. 2023 Apr 6;14:100495. doi: 10.1016/j.ajpc.2023.100495. PMID: 37096158; PMCID: PMC10121782.



Vincent MJ, Allen B, Palacios OM, Haber LT, Maki KC. Meta-regression analysis of the effects of dietary cholesterol intake on LDL and HDL cholesterol. Am J Clin Nutr. 2019 Jan 1;109(1):7-16. doi: 10.1093/ajcn/nqy273. PMID: 30596814.


Lütjohann D, Stellaard F, Mulder MT, Sijbrands EJG, Weingärtner O. The emerging concept of "individualized cholesterol-lowering therapy": A change in paradigm. Pharmacol Ther. 2019 Jul;199:111-116. doi: 10.1016/j.pharmthera.2019.03.004. Epub 2019 Mar 12. PMID: 30877023.


Zhu Z, Wu F, Lu Y, Wang Z, Zang J, Yu H, Guo C, Jia X, Shen X, Ding G. The Association of Dietary Cholesterol and Fatty Acids with Dyslipidemia in Chinese Metropolitan Men and Women. Nutrients. 2018 Jul 25;10(8):961. doi: 10.3390/nu10080961. PMID: 30044444; PMCID: PMC6115945.


Jacobson TA, Maki KC, Orringer CE, Jones PH, Kris-Etherton P, Sikand G, La Forge R, Daniels SR, Wilson DP, Morris PB, Wild RA, Grundy SM, Daviglus M, Ferdinand KC, Vijayaraghavan K, Deedwania PC, Aberg JA, Liao KP, McKenney JM, Ross JL, Braun LT, Ito MK, Bays HE, Brown WV, Underberg JA; NLA Expert Panel. National Lipid Association Recommendations for Patient-Centered Management of Dyslipidemia: Part 2. J Clin Lipidol. 2015 Nov-Dec;9(6 Suppl):S1-122.e1. doi: 10.1016/j.jacl.2015.09.002. Epub 2015 Sep 18. Erratum in: J Clin Lipidol. 2016 Jan-Feb;10(1):211. Underberg, James A [added]. PMID: 26699442.


Berger S, Raman G, Vishwanathan R, Jacques PF, Johnson EJ. Dietary cholesterol and cardiovascular disease: a systematic review and meta-analysis. Am J Clin Nutr. 2015 Aug;102(2):276-94. doi: 10.3945/ajcn.114.100305. Epub 2015 Jun 24. PMID: 26109578.


Wolff E, Vergnes MF, Portugal H, Defoort C, Amiot-Carlin MJ, Lairon D, Nicolay A. Cholesterol-absorber status modifies the LDL cholesterol-lowering effect of a Mediterranean-type diet in adults with moderate cardiovascular risk factors. J Nutr. 2011 Oct;141(10):1791-8. doi: 10.3945/jn.111.141333. Epub 2011 Aug 24. PMID: 21865559.


Lecerf JM, de Lorgeril M. Dietary cholesterol: from physiology to cardiovascular risk. Br J Nutr. 2011 Jul;106(1):6-14. doi: 10.1017/S0007114511000237. Epub 2011 Mar 9. PMID: 21385506.


Herron KL, Vega-Lopez S, Conde K, Ramjiganesh T, Shachter NS, Fernandez ML. Men classified as hypo- or hyperresponders to dietary cholesterol feeding exhibit differences in lipoprotein metabolism. J Nutr. 2003 Apr;133(4):1036-42. doi: 10.1093/jn/133.4.1036. PMID: 12672915.


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