Many people can bring their cholesterol levels down with diet and exercise alone. But statins are typically more effective and may be an option for people at high risk of heart attack or stroke.

If you have high low-density lipoprotein (LDL), or “bad” cholesterol, your chances of having a heart attack and stroke are higher.

To reduce your LDL levels, a doctor will typically recommend lifestyle changes like diet and exercise. If they determine your risk of a cardiovascular event is high, they may also recommend statins, a type of medication.

But which treatment is more effective at reducing LDL cholesterol? Let’s look at how statins compare to diet and exercise in treating high cholesterol and when medication may be necessary.

Statins are a class of prescription medication recommended for people who have high LDL cholesterol. They work by altering how your liver produces cholesterol. Lower production means less LDL throughout the body.

Doctors don’t recommend statins to everyone with high cholesterol. American Heart Association (AHA) guidelines suggest that statins may be best for people with:

  • LDL levels over 190 milligrams per deciliter (mg/dL)
  • a history of cardiovascular disease
  • adults ages 40 to 75 with diabetes or increased risk of cardiovascular disease

Experts also recommend statins for people whose high cholesterol may be inherited.

About 92 million people in the United States take statins as they’re generally safe and effective. Some statins may reduce LDL levels by as much as 60%.

Statin side effects

Many people who take statins have no side effects, but some people do experience them. Muscle symptoms like pain and stiffness are the most commonly reported. Statins may also carry an increased risk of diabetes or liver problems.

Some people may be more likely to experience side effects from statins, including:

  • females
  • people over age 80
  • people with type 1 diabetes
  • people with liver disease

» MORE: Weighing the Benefits, Risks, and Side Effects of Statins

A heart-healthy diet is an essential part of managing your cholesterol levels. But that doesn’t necessarily mean reducing the cholesterol in your diet. Dietary cholesterol is a significant factor for about 15% to 25% of people, including those with hereditary cholesterol.

Most people will see more significant improvements in their LDL levels by reducing saturated fats and avoiding trans fats. A diet focused on fruits, vegetables, whole grains, and fish can help lower LDL levels.

Eating foods high in soluble fiber, like flaxseed and oats, can also help lower LDL. Fiber binds to cholesterol, helping to remove it from the body.

Changing to a heart-healthy diet shouldn’t have side effects, as long as you’re getting enough calories.

The AHA also stresses physical activity as an important element in treating high cholesterol. While exercise doesn’t directly affect LDL, it can increase and strengthen your “good” high-density lipoprotein (HDL) cholesterol. HDL helps remove LDL from the body.

According to a 2023 research review, several factors influence how much exercise may influence HDL. However, even if the effect is small, regular exercise can contribute to lasting changes.

A 2021 meta-analysis concluded that high intensity exercise plays a strong role in preventing arterial stiffness that may be comparable to statins, if not as effective.

Experts recommend at least 150 minutes of moderate-intensity aerobic exercise each week.

Taking up exercise may be challenging for some people. If you have heart problems, start exercising slowly and stop immediately if you have chest pains or difficulty breathing. If you’re planning on starting vigorous exercise or have a history of heart disease, ask a doctor about doing a stress test prior to starting exercise.

While diet and exercise can help many people with high cholesterol, experts typically agree that statins are most effective when cholesterol levels are very high. Guidelines suggest that statins are also effective in people with a lower risk of a cardiovascular event.

“The beneficial effects of statin drugs extend beyond the measured level of total cholesterol and other lipids such as triglycerides,” says Robert F. DeBusk, MD, professor emeritus of cardiovascular medicine at Stanford University. “The statin drugs markedly reduce LDL and triglycerides, while increasing levels of HDL or ‘good’ cholesterol.”

Robert S. Greenfield, MD, medical director of noninvasive cardiology and cardiac rehabilitation at MemorialCare Health System, agrees that statins reduce cholesterol more than lifestyle changes. “Diet and weight loss can lower total cholesterol between 10% and 20%. But the most potent statins at their highest doses can lower cholesterol by 50%,” he says.

The Food and Drug Administration (FDA) approved several other lipid-lowering drugs, including PCSK9 inhibitors like Repatha (evolocumab) or Praluent (alirocumab). These medications lower LDL cholesterol and are a good option for people who can’t tolerate statins.

A 2019 study found PCSK9 inhibitors to be equally as effective as statins, while avoiding their side effects.

If you prefer not to use medication, diet and exercise will both be essential in managing your cholesterol. However, dietary changes have a more significant effect on your cholesterol levels than exercise alone.

Both doctors highly recommend a heart-healthy diet and regular exercise, even if you do take statins. “Patients who are significantly overweight, or eating too much saturated and trans fats, can lower their cholesterol significantly by eating a Mediterranean diet with caloric restriction and exercise,” says Greenfield.

“Individuals with clinical features of heart disease or a history of heart attack or stroke may benefit substantially by treatment with aspirin,” says DeBusk.

The bottom line?

Almost anyone can improve their heart health and reduce their stroke risk with simple lifestyle changes, like a heart-healthy diet and moderate exercise.

If those activities don’t bring down your cholesterol enough, or if you want to ensure you’re doing everything you can to lower your heart disease and stroke risk, statins are a viable option for most people.

Your choice of medication can depend on multiple factors, including other medical conditions, family history, and LDL level.