You’ve probably heard that eating a diet high in cholesterol-rich foods isn’t the best practice for heart health, but this may leave you wondering about foods like fish. Does fish have cholesterol? Yes, but that doesn’t mean it should be put on the “no” list. 

In fact, fish has plenty of nutritional benefits that work in favor of your heart health. Understanding the association between fish and your heart can help you design a healthy diet that includes your favorite seafood.

Why Dietary Fats Matter

Fats have received a conflicting and often negative reputation over the past several decades. But the truth is that dietary fat is essential for the everyday functioning of your body as well as your long-term health outcomes. We need fats in order to absorb nutrients like vitamins A, D, E, and K, and specific antioxidants like carotenoids, to produce hormones and vitamins, protect organs, regulate body temperature, and provide energy. Your body even makes its own cholesterol for some of these purposes. 

In order to design a heart-healthy diet that incorporates enough fat, and the best kinds, it’s important to understand the types of fats and how they may influence risk factors like your blood cholesterol levels.

The main types of dietary fats are as follows: 

• Saturated fat: Saturated fat is predominantly found in animal products as well as palm oil and coconut oil. A high intake of saturated fat has been associated with increased cholesterol levels. Specifically, high saturated fat intake may promote increased LDL “bad” cholesterol, atherogenic lipoproteins, while decreasing HDL “good” cholesterol.1 
• Trans fat: While still naturally occurring in some animal products, man made trans fats have been banned in many countries because of their strong link to heart disease. 
• Unsaturated fat: This includes both monounsaturated and polyunsaturated fats (the best known being omega-3s), found primarily in plant foods. Unsaturated fats have a protective effect on heart health.2,3 
• Cholesterol: Found in animal products, but also naturally produced by the body and needed to make hormones and vitamins. Too much cholesterol from the diet may contribute to a higher risk for heart disease, as cholesterol-rich foods tend to also be high in saturated and trans fats. 

Assessing heart health includes looking at biomarkers like total cholesterol, LDL “bad” cholesterol, HDL “good” cholesterol, and triglycerides. But your non-HDL cholesterol, which is all of your bad cholesterol minus your HDL cholesterol, helps assess atherogenic cholesterol and can be a better predictor than individual numbers on their own. Ideally, your non-HDL cholesterol should be as low as possible, aiming to be below 80-100 mg/dL.

Keep in mind that one single food or nutrient isn’t going to have the ultimate effect on your heart health one way or the other. It’s about the overall quality and makeup of your diet, as well as other lifestyle factors. Let’s talk about where fish falls in terms of its fat and cholesterol content and how that may influence your heart health. 

Does Fish Have Cholesterol? 

All animal products contain cholesterol, and this includes fish. But this doesn’t mean that fish isn’t heart healthy. In fact, incorporating fish into your diet can help support your heart health. 

For example, a 2004 study published in Circulation involved 4815 adults ≥age 65 years and examined their fish consumption and incidence of atrial fibrillation (AF) over 12 years. AF is one of the leading causes of strokes, so prevention is important. The intake of tuna or other broiled and baked fish was inversely associated with AF incidence. Those that ate fish had a 28% lower risk when consumed 1-4 times per week, and a 31% lower risk with an intake of at least 5 times per week.4

Furthermore, a 2020 meta-analysis of 22 studies published in Nutrients concluded that fish consumption is associated with a lower risk for coronary heart disease. The authors found that for every 20 gram per day increase in fish consumption, there was a 4% lower risk of coronary heart disease incidence and mortality.5

And a 2020 cohort study published in JAMA Internal Medicine examined how eating unprocessed red meat, poultry, or fish affected cardiovascular disease risk and all-cause mortality. The authors found that “…higher intake of processed meat, unprocessed red meat, or poultry, but not fish, was significantly associated with a small increased risk of incident coronary vascular disease.”6 Remember that all of these foods contain cholesterol, but fish was the only one found not to have negative heart health effects.

Best Fish for Heart Health

When choosing which types of fish to include in your diet, prioritize ones that are a good source of omega-3 fatty acids, as these types of fats are known to be beneficial for heart health. EPA and DHA are essential because they can reduce endothelial dysfunction, lower inflammation, and fight oxidative stress, all of which are accelerators of arterial plaque formation. Keep in mind that not all fish will fall into this category.7 

Is salmon high in cholesterol? While it does contain cholesterol, it’s one of the best sources of omega-3 fats and a great fish to add to your heart-healthy diet. In addition to salmon, trout and arctic char are some of the best choices for omega-3s. The American Heart Association also recommends anchovies, herring, mackerel, black cod, sardines, bluefin tuna, whitefish, striped bass, and cobia for omega-3s.8

Are there high cholesterol fish to avoid? Not necessarily, as it’s most important to choose fish that are rich in omega-3s. In order to keep the saturated fat and cholesterol content of fish to a minimum, however, it also matters how you prepare them. For instance, cooking methods like deep-frying or sauteing may add more of these to your meal depending on the type of oil used.

You may be wondering, what about shellfish? Are shrimp high in cholesterol? Shrimp is high in cholesterol and it’s often recommended to minimize or avoid it if you already have high cholesterol levels. 

There is some older research to suggest that while shrimp can raise LDL, it can raise HDL and lower triglycerides to a more significant degree.9 Whether including shrimp in your diet aligns with your individual heart health needs is best determined by a conversation with your registered dietitian.

How Much Fish Should I Eat?

For the most heart health benefit, eating omega-3-rich fish is recommended at least twice per week. The American Heart Association suggests a 3.5-ounce serving at a time or at least 8 ounces of non-fried fish per week.10

Heart-Healthy Fish Recipes

Need inspiration for how to cook fish? Check out some of these healthy fish recipes:

Mediterranean Bowl with Salmon: This recipe combines omega-3-rich salmon with other heart-healthy ingredients, like leafy greens, quinoa, and chickpeas to make a nutrient-dense and craveable bowl. 

Lemon Garlic Sardine Fettuccine: This is a satisfying pasta recipe topped with sardines in a flavorful sauce, which you can serve alongside bitter greens tossed in a light vinaigrette. 

Trout with Skillet-Roasted Peppers: This is an easy skillet dish using trout fillets, tomatoes, peppers, and plenty of flavors. 

What if I Don’t Eat Fish?

While fish and seafood are the richest sources of omega-3 fats, there are also some plant-based sources — such as flax seeds, chia seeds, and walnuts. Plants primarily contain ALA (alpha-linolenic acid), which is converted into EPA and DHA in the body. However, the conversation rate is low and inconsistent.

Some research suggests that the conversion rate is less than 5-10% for EPA and 2-5% for DHA.11 An omega-3 supplement may be warranted if you don’t consume fish in your diet. But the need for one should be properly evaluated in regards to any medical conditions you have, medications you use, and other individual health and lifestyle factors. 

This is because when it comes to fish oil supplements, which are a concentrated dose of omega-3s, more isn’t always better. One meta-analysis and systematic review of randomized controlled studies looking at 81,200 individuals found that omega-3 supplementation was associated with an increased risk of AF. This was more likely among people who supplemented with over 1000 grams per day.12 

If you think an omega-3 supplement would be beneficial for your heart health but don’t consume fish, there are some vegan omega-3 supplements that are made using algae instead. Please be sure to consult with your registered dietitian and physician before you add a supplement to your diet to ensure it works for your medical conditions, medications, and with evaluation of your complete diet.

Planning a Heart-Healthy Diet

When determining if a specific food is right for your health, a personalized recommendation is always best. Speak with your doctor and registered dietitian who specializes in heart disease to determine the best course of action to reduce high cholesterol and protect your heart. I’m available for 1:1 counseling to help you design an effective heart-healthy diet that you love.

References

1. Soliman GA. Dietary Cholesterol and the Lack of Evidence in Cardiovascular Disease. Nutrients. 2018 Jun 16;10(6):780. doi: 10.3390/nu10060780. PMID: 29914176; PMCID: PMC6024687. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6024687/ 
2. Clifton PM, Keogh JB. A systematic review of the effect of dietary saturated and polyunsaturated fat on heart disease. Nutr Metab Cardiovasc Dis. 2017;27(12):1060-1080. doi:10.1016/j.numecd.2017.10.010. https://pubmed.ncbi.nlm.nih.gov/29174025/ 
3. Tindall AM, Kris-Etherton PM, Petersen KS. Replacing Saturated Fats with Unsaturated Fats from Walnuts or Vegetable Oils Lowers Atherogenic Lipoprotein Classes Without Increasing Lipoprotein(a). J Nutr. 2020;150(4):818-825. doi:10.1093/jn/nxz313. https://pubmed.ncbi.nlm.nih.gov/31909809/ 
4. Mozaffarian D, Psaty BM, Rimm EB, et al. Fish intake and risk of incident atrial fibrillation. Circulation. 2004;110(4):368-373. doi:10.1161/01.CIR.0000138154.00779.A5. https://pubmed.ncbi.nlm.nih.gov/15262826/ 
5. Zhang B, Xiong K, Cai J, Ma A. Fish Consumption and Coronary Heart Disease: A Meta-Analysis. Nutrients. 2020;12(8):2278. Published 2020 Jul 29. doi:10.3390/nu12082278. https://pubmed.ncbi.nlm.nih.gov/32751304/ 
6. Zhong VW, Van Horn L, Greenland P, et al. Associations of Processed Meat, Unprocessed Red Meat, Poultry, or Fish Intake With Incident Cardiovascular Disease and All-Cause Mortality. JAMA Intern Med. 2020;180(4):503-512. doi:10.1001/jamainternmed.2019.6969. https://pubmed.ncbi.nlm.nih.gov/32011623/  
7. “Omega-3 Fatty Acids.” NIH.gov. Office of Dietary Supplements. Available from: https://ods.od.nih.gov/factsheets/Omega3FattyAcids-HealthProfessional/ 
8. “Fish and Omega-3 Fatty Acids”. American Heart Association. Reviewed 1 Nov 2021. Available from: https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/fats/fish-and-omega-3-fatty-acids 
9. The Rockefeller University. “Shrimp OK for Heart Healthy Diets.” Published 25 Oct 1996. Available from: https://www.rockefeller.edu/news/4463-shrimp-ok-for-heart-healthy-diets/ 
10. American Heart Association.”Cooking to Lower Cholesterol.” Reviewed 11 Nov 2020. Available from: https://www.heart.org/en/health-topics/cholesterol/prevention-and-treatment-of-high-cholesterol-hyperlipidemia/cooking-to-lower-cholesterol 
11. Davis BC, Kris-Etherton PM. Achieving optimal essential fatty acid status in vegetarians: current knowledge and practical implications. Am J Clin Nutr. 2003;78(3 Suppl):640S-646S. doi:10.1093/ajcn/78.3.640S 
12. Gencer B, Djousse L, Al-Ramady OT, Cook NR, Manson JE, Albert CM. Effect of Long-Term Marine ɷ-3 Fatty Acids Supplementation on the Risk of Atrial Fibrillation in Randomized Controlled Trials of Cardiovascular Outcomes: A Systematic Review and Meta-Analysis. Circulation. 2021;144(25):1981-1990. doi:10.1161/CIRCULATIONAHA.121.055654. https://pubmed.ncbi.nlm.nih.gov/34612056/