When Lifestyle Changes Don’t Control Cholesterol
Medication may be a must to protect your heart health, even if you’re doing everything else right.
You take care of yourself. You exercise. You limit the booze, fried fare, and sweet stuff, too. So, why, you ask yourself in the mirror with more than a little frustration, is your cholesterol so out of whack?
High cholesterol, or hyperlipidemia, drives up your risk of a heart attack and stroke. It can be a silent killer, since it has no symptoms. Scary as that sounds, you have it in your power to bring your cholesterol back down. Some people can curb high cholesterol by living healthier lives. But the truth is, if you have high cholesterol, you’ll likely need to take medication, too. The good news? Doing so can save your life.
Let’s take a look at the role cholesterol plays in your body, why a balanced diet and regular exercise don’t always guarantee healthy results, how genetics can be at play, and how best to get your high cholesterol under control.
The Benefits and Dangers of Cholesterol
Cholesterol is a waxy fat that circulates in your bloodstream. While it gets a bad rap, your body actually needs it, and your liver produces a steady supply. Cholesterol forms a protective membrane around every single one of your body’s cells. It also helps your liver make a substance called bile, which aids digestion. And, it’s a vital ingredient for making critical hormones including estrogen, progesterone, and vitamin D.
Still, there’s “good’ cholesterol and “bad” cholesterol, as you no doubt have heard. Low-density lipoprotein (LDL) is the “bad” kind. Unchecked, LDL builds up on the walls of your blood vessels to form dangerous plaques in a process known as atherosclerosis. This can harm you in two ways:
Blockages. It narrows your blood vessels and makes it harder for oxygen-rich blood to flow throughout your body, including to your heart.
Ruptures. It can break apart, causing blockages that cut off your heart’s blood supply. The result: a heart attack. If a blockage cuts off the flow of blood to your brain, you’ll have a stroke.
“Controlling cholesterol is an important cornerstone in preventing atherosclerotic cardiovascular disease (ASCVD), which includes strokes and heart attacks,” says Michael Goyfman M.D., Director of Clinical Cardiology at Long Island Jewish Forest Hills in Queens, NY.
Fortunately, your body also produces “good” cholesterol, a.k.a. high-density lipoprotein (HDL). HDL helps clear excess LDL cholesterol—bluntly, you poop it out—so that dangerous buildups don’t occur. If you can keep your good and bad cholesterol in balance, you’ll do fine. But for some people, maintaining a healthy cholesterol level can be a struggle.
Healthy vs. Unhealthy Cholesterol Levels
Your doctor will order a blood test to measure your cholesterol level. The ideal numbers vary somewhat depending on your age and sex. If you are age 20 or older and don't have cardiovascular disease, you'll want to see numbers in the following ranges:
Total cholesterol: 125 mg/dl to 200 mg/dl
Non-HDL cholesterol: Less than 130 mg/dl
LDL cholesterol: Less than 100 mg/dl
HDL cholesterol: 50 mg/dl or higher for women and 40 mg/dl or higher for men
You are considered to have borderline high cholesterol once your numbers creep higher than the above ranges. Total cholesterol, for example, is considered borderline when it’s between 200 and 239 mg/dl for adult women and men. Above that, you have high cholesterol. Your cholesterol is high if your non-HDL is 130 mg/dl or greater, and your LDL is between 160 and 189 mg/dl. LDL that measures 190 mg/dl or greater is considered to be very high cholesterol.
Balancing Your Lifestyle and Genetics
Diet plays a big role in your cholesterol levels. Eating too many saturated fats from animal products like butter, cheese, and fatty cuts of red meat, for instance, and consuming trans fats from processed foods like microwave popcorn and frozen pizza, can increase your LDL while lowering your HDL. Lack of exercise, smoking cigarettes or vaping, and being overweight can do the same.
However, for about one in every 250 people high cholesterol runs in the family—meaning, you can be a salad-eating marathon runner and still have cholesterol troubles. The condition, known as familial hypercholesterolemia (FH), prevents your body from disposing of LDL, even when your HDL levels are normal, and it causes high cholesterol starting at a very early age. “Children with a family history of familial hypercholesterolemia should be screened as early as 2 years of age,” says Guy L. Mintz, M.D., Northwell Health’s Director of Cardiovascular Health & Lipidology at Sandra Atlas Bass Heart Hospital in Manhasset, NY.
Why? Because, while the average age of a first heart attack is 65 for men and 72 for women, they occur much earlier in people with untreated FH. The Centers for Disease Control and Prevention (CDC) estimates that 50% of men with untreated FH will have a heart attack by age 50, while 30% of women with untreated FH will have one by age 60.
A much rarer form of FH, called homozygous FH, occurs if you inherit FH from both parents. About one in 100,000 people have this diagnosis. It’s even more dangerous, causing extremely high cholesterol and leading to early heart disease. Dr. Mintz says that life expectancy can be as low as 20 to 30 years of age.
Exercise and Diet as Adjunct Treatments
This is not to say that if your high cholesterol is an inherited thing, you can simply blow off taking great care of yourself—you can’t. “Lifestyle changes, including diet and exercise, are the foundation for all patients,” Dr. Mintz insists. But many people must also take medication. (If you have a genetic pre-disposition for high cholesterol, you’ll almost certainly need to do so). Still, it all depends on how high your cholesterol is, as well as the state of your heart health now.
Dr. Mintz says you should be on a statin or other cholesterol-lowering medication if you’ve already had a heart attack or coronary artery bypass surgery. You should also be on a statin if you have high blood pressure, in order to reduce your risk of heart attack or stroke. Other conditions that require medication to control cholesterol include:
A prior stroke or transient ischemic attack, or mini-stroke
Peripheral artery disease
Carotid artery disease
And, of course, FH. With all these conditions medication is a must, no matter how healthy your lifestyle is. Dr. Goyfman says that he addresses this with his patients right away so that they can understand what to expect. “It is important from the beginning to notify patients that lifestyle modification may only be an adjunct to cholesterol treatment,” he says. Need some extra motivation? He says that making the right lifestyle changes may allow you to take a lower dose of medication to control your cholesterol.
Let’s say you’ve done all the right stuff. You’re working out and working up a sweat regularly, you now snack on carrots rather than cheese puffs and have lost weight, and you’ve kicked your smoking habit to the curb. First, congratulations! Because you’re not just lowering cholesterol. You’re improving your overall health. Still, though, your cholesterol may not drop as much as you need it to, despite all your hard work. That’s not your fault. Your genes simply may make it impossible to adequately curb your cholesterol without medication.
You may not like that, but think of what that assist will make possible. As Dr. Mintz puts it, “The goal is to live long and live without a heart attack.”
Your Rx for High Cholesterol
If you do need medication, a statin is the most likely first choice. They are the main medication to lower cholesterol. They also reduce inflammation and help stabilize plaque, making it less likely to rupture.
About one in five people can’t take statins due to side effects such as digestive problems and the muscle pain they can cause. That’s OK! Options exist, such as two PCSK9 inhibitors approved by the FDA. These drugs are also are prescribed for people whose cholesterol can’t be brought down sufficiently with statins alone, says Dr. Mintz. Other drugs that help control cholesterol include:
Sticking with your total high cholesterol treatment plan—including healthy diet, plenty of exercise, and, if prescribed, cholesterol-lowering drugs—is critical to protect your heart health. All will be an ongoing part of your life, so do your best to embrace them. Dr. Mintz is blunt about why: “The stakes are high.”
High Cholesterol: Mayo Clinic. (2019.) “High Cholesterol.” mayoclinic.org/diseases-conditions/high-blood-cholesterol/symptoms-causes/syc-20350800
High Cholesterol: Cleveland Clinic (2020.) “Cholesterol Numbers: What Do They Mean?” my.clevelandclinic.org/health/articles/11920-cholesterol-numbers-what-do-they-mean
High Cholesterol Prevention and Treatment: American Heart Association. (2020.) “Prevention and Treatment of High Cholesterol (Hyperlipidemia).” heart.org/en/health-topics/cholesterol/prevention-and-treatment-of-high-cholesterol-hyperlipidemia
Familial Hypercholesterolemia: CDC. (2020.) “Familial Hypercholesterolemia.” cdc.gov/genomics/disease/fh/FH.htm