Let’s Talk About High Cholesterol

Most of us have an idea of what cholesterol is—a fatty, waxy substance that ends up in our blood vessels and something we don’t want clogging up the works. Problems arise when too much of the bad kind of cholesterol circulates in the bloodstream. That’s when the buildup of deposits can threaten to block arteries, setting the stage for some serious problems. Learn more about what it really means to have high cholesterol, and how to take control of your health.

High Cholesterol

Our Pro Panel

We tapped some of the nation’s top experts in heart health to bring you the most up-to-date information possible.

Suzanne Steinbaum, M.D.

Director of Women’s Cardiovascular Prevention, Health and Wellness

Mount Sinai Hospital

New York, NY

Eric Brandt, M.D.

Cardiologist and Lipidologist

Michigan Medicine Frankel Cardiovascular Center

Ann Arbor, MI

Eduardo Hernandez, M.D.

Attending Cardiologist and Assistant Professor of Medicine

Texas Heart Medical Group and Medical Director of Diagnostic Heart Center of St. Luke’s, Baylor College of Medicine

Houston, TX

What Exactly Is Cholesterol?

Cholesterol is a fatty, waxy substance produced by the liver that moves through the body, using the bloodstream as its very own lazy river. Just like all fats aren’t bad, cholesterol itself isn’t inherently bad. In fact, it plays several vital roles in your functioning, such as helping build cells, producing hormones, and making vitamins that the body needs. There are different types of cholesterol, and the various levels of each of them determine whether your cholesterol can be classified as too high.

The Main Types of Cholesterol

Though we tend to think of cholesterol as one thing, there are two main types: high-density lipoproteins (HDL) and low-density lipoproteins (LDL).

HDL Cholesterol

High-density lipoprotein (HDL) is the “good” cholesterol. It acts like Pacman in your bloodstream, snatching up LDL cholesterol and delivering it back to the liver where it’s broken down and eventually passed out of the body. HDL cholesterol can’t eliminate all LDL cholesterol, but having a high HDL level can be protective against heart problems like stroke or heart attack, according to the American Heart Association.

LDL Cholesterol

Low-density lipoprotein (LDL) is referred to as “bad” cholesterol because it can build up on the walls of the arteries. As the deposits accumulate, they can restrict blood flow. This is a condition known as atherosclerosis, and it can lead to other heart and health problems. There’s also very low-density lipoprotein (VLDL) cholesterol, which carries triglycerides through the bloodstream. Triglycerides are fats derived almost entirely from the foods we eat, and they can cause problems similar to LDL cholesterol. Like LDL, lower levels of triglycerides are better.

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How Are Cholesterol Levels Measured?

The routine blood test that checks for cholesterol, called a lipid profile or lipid panel, reports your results as four different components:

• Total cholesterol

• LDL cholesterol

• HDL cholesterol

• Triglycerides

In the United States, all results are given in milligrams of cholesterol per deciliter of blood (mg/dL). Here’s what all those numbers mean for you:

Total cholesterol. This number represents the sum of your LDL, your HDL, and 20% of your triglyceride level, according to the American Heart Association. For total cholesterol:

• Below 200 mg/dL is normal.

• 200-239 mg/dL is borderline high.

• 240 mg/dL and above is high.

LDL cholesterol. What’s considered high depends on your unique circumstances.

If you don’t have heart disease or risk factors for developing heart disease:

• Below 100 mg/dL is optimal.

• 100-129 mg/dL is near optimal.

• 130-159 mg/dL is borderline high.

• 160-189 mg/dL is high.

• 190 mg/dL and above is very high.

If you have heart disease such as coronary artery disease or heart failure:

• Below 70 mg/dL is optimal.

• 70-99 mg/dL is near optimal.

• 100-159 mg/dL is high.

• 160 mg/dL and above is very high.

HDL cholesterol. With HDL (the “good kind”) a higher number is better:

• 60 mg/dL and above is optimal.

• 40-59 mg/dL in men or 50-59 mg/dL in women is considered good.

• Below 40 mg/dL for men and below 50 mg/dL for women is considered poor.

Triglycerides. For levels of these blood fats:

• Below 150 mg/dL is desirable.

• 150-199 mg/dL is borderline high.

• 200-499 mg/dL is high.

• 500 mg/dL and above is very high.

Your doctor will look at all these numbers along with your medical history to determine whether you have high cholesterol and how to manage it.

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Why High Cholesterol Is So Dangerous

A total cholesterol above 200 mg/dL, LDL cholesterol above 130 mg/dL, or triglycerides above 150 mg/dL are each considered high, and these levels increase your risk of cardiovascular problems related to the buildup of cholesterol in your bloodstream.

As with high blood pressure—another heart disease risk factor—high cholesterol typically has no symptoms. Though arteries could be getting clogged with fatty cholesterol deposits called plaque, you’re unlikely to have any idea until it’s too late.

Without a blood test to measure your cholesterol levels, the “warning sign” could be chest pain or even a major cardiac event, such as a heart attack or a stroke, states the American Academy of Family Physicians. That’s why regular blood tests are so important. According to the Mayo Clinic, the recommendation is to have a first lipid profile test at age 18, and then every five years, or more frequently if you have certain risk factors.

What Causes High Cholesterol?

High cholesterol can result from factors both within and beyond your control, according to the American Heart Association. High cholesterol can be hereditary, a condition known as familial hypercholesterolemia that affects one in 500 people. More often, lifestyle choices play a role in your cholesterol count, which means that making some tweaks can have a big impact on numbers. Let’s explore the things that nudge cholesterol up.

A Diet High in Fats

High blood cholesterol isn’t always from foods high in dietary cholesterol. Over the last few years, there have been many studies both implicating and refuting the role of eggs, one of the top sources of dietary cholesterol, in high blood cholesterol.

Because some animal foods have both saturated fat and cholesterol, it’s not always easy to know where to point a finger, according to the American Heart Association. Yet up to 25% of the population could be sensitive to dietary cholesterol. For them, there’s a link between eating an egg every day and having a higher risk of heart disease, a study published in 2019 in JAMA found.

The effect of eating two key types of fats on cholesterol levels is more definitive.

• Saturated Fat. This type of fat, found in red meat, cheese, butter, and cream, is the most common high cholesterol-inducing culprit, according to the Mayo Clinic. Eating too much saturated fat and not enough unsaturated fat (the healthy kind, found in avocado, nuts and vegetable oils) changes how the liver processes cholesterol. The liver’s cells have LDL receptors that remove cholesterol from the blood and ferry it back to the liver to be broken down. A diet high in saturated fat blunts these receptors, so they’re not as sensitive and don’t perform as well.

• Trans Fat. Even more dangerous are trans fats, which you’ll often see under the ingredient name “partially hydrogenated oils” on packages. These fats also have a direct and negative influence on cholesterol levels. Trans fats are now banned by the U.S. Food and Drug Administration (FDA), but the Mayo Clinic points out that trace amounts are still permitted—a food package can say it has 0 trans fat even if it has up to 0.5 grams per serving, so check the ingredient list. That might not seem like much, but those numbers could add up, depending on how much of the food you eat and how often. Foods to watch include non-dairy creamers, packaged baked goods and margarine.

Lack of Exercise

Exercise can impact LDL cholesterol, as well as lower triglycerides and raise levels of good HDL cholesterol, both of which are beneficial to your overall cholesterol profile. Aim for aerobic exercise like walking, jogging, cycling, or swimming on most days of the week, with your doctor’s approval if you haven’t exercised lately or have any chronic health conditions.

Being Overweight or Obese

Carrying extra pounds or having obesity increases the risk for both high cholesterol and other heart diseases. Having a BMI in the overweight (25.0-29.9) or obese (30.0 and above) range, or a waist circumference over 40 inches for men or 35 inches for women can raise the risk for high total cholesterol, LDL cholesterol, and triglycerides, as well as low HDL cholesterol. Use a BMI calculator to determine your number using your height and weight.

Smoking or Exposure to Tobacco Smoke

Add high cholesterol to the list of why smoking is so bad for you. Smoking (as well as vaping) can lower good HDL cholesterol, and smokers who already have high cholesterol have a greater risk of developing coronary artery disease, according to The American Heart Association. Smoking can also raise blood pressure and increase other heart disease risk factors.

Age

According to the Cleveland Clinic, age is a major factor. Unfortunately, it’s natural for LDL cholesterol levels to go up and HDL cholesterol levels to go down as you grow older. Although women tend to have lower cholesterol levels than men, these same shifts also seem to occur in women after menopause.

What Lifestyle Changes Help Lower Cholesterol

Your doctor will base your treatment strategy on the results of your blood tests, as well as your own personal and family history with high cholesterol, cardiovascular disease, and other risk factors. If you’re borderline high, you might be able to manage your cholesterol through lifestyle changes. If this isn’t enough to rein them in, cholesterol-lowering medication may need to become part of your overall approach. These healthy habits can have a big impact on cholesterol levels.

Time to Quit Smoking

Smoking has been shown to not only lower HDL cholesterol levels, but also heighten the risk of coronary artery disease in people who already have high cholesterol. Smoking cigarettes also increases blood pressure and other risk factors for heart disease. This might be the hardest change to make, but it could be one of the most impactful. Talk to your doctor about what smoking cessation strategy would work best for you.

Drink Less Alcohol

While moderate alcohol consumption may actually raise HDL levels, drinking too much can raise triglycerides and also elevate a number of other heart risks, including high blood pressure, according to The American Heart Association. It’s time to cut back if you drink more than the general guidelines of no more than one drink a day for women of any age and men older than 65, and no more than two drinks a day for men age 65 or younger.

Lose Some Weight

Dropping just a few extra pounds can start swinging your cholesterol level in the right direction, according to Mayo Clinic. Specifically, it can lower total cholesterol, LDL cholesterol, and triglycerides, and raise levels of good HDL cholesterol. Consider the next two components on this list—diet and exercise—as the keys to accomplish this.

Clean Up Your Diet

Make the foundation of what you feast on each day sources of protein, abundant fruits and vegetables, and whole grains while limiting high-saturated fat and high-sugar processed foods. The Mayo Clinic recommends cutting back on red meat and whole-fat dairy products because their high levels of saturated fat can raise LDL cholesterol. What to add in?

• Omega-3 fatty acids, which can help raise HDL cholesterol and reduce blood pressure. A few great sources:

  • walnuts

  • flaxseeds

  • fatty fish like salmon, herring, and mackerel

• Soluble fiber, which sweeps cholesterol out of the bloodstream. Great sources:

  • oatmeal

  • pears

  • apples

Get in Gear With Exercise

Moving more can lower your LDL and raise your HDL, according to the Cleveland Clinic. Exactly how exercise does this is still being researched, but there are a few possibilities. Working out might increase the size of your LDL particles so they pose less of a heart disease risk, studies have shown. It might also speed the delivery of cholesterol to the liver, studies in mice have suggested. Exercise might also reduce the amount of cholesterol absorbed into the bloodstream.

Burning more calories can also, of course, help you drop pounds, which has benefits for all elements of your cholesterol profile. Aim to get in:

• At least 150 minutes a week of moderate-intensity aerobic activity or 75 minutes of vigorous aerobic activity (or a combination of the two) every week

• Muscle-building, weight-training workouts at least two days a week

If this seems like a lot, don’t get overwhelmed—you can start where you are and build up gradually from there. In fact, you can exercise in short nuggets throughout the day to chip away at your weekly goals. An activity as simple as a brisk daily walk or yard work is a good place to begin getting some more movement into your life. What matters is that you try to make exercise part of your everyday life.

What Are Medications For High Cholesterol?

If lifestyle changes alone aren’t having an impact on your numbers, your doctor may recommend medication. Here are the most effective types at cholesterol-lowering.

Statins

Statins are the most frequently prescribed cholesterol medication, according to the American Heart Association. They prevent cholesterol from forming in the liver and can lower LDL cholesterol and triglycerides, as well as raise HDL cholesterol.

Studies have shown just how effective statins are. In the Jupiter Trial, with more than 15,000 patients, statins lowered LDL cholesterol by 50 percent, reduced the risk of stroke by 48% and heart attack by 54%, among other positive benefits.

Statins are not recommended for pregnant women or people with liver disease. They also may not be effective for everyone. Frequently, people with existing heart disease who can’t get their cholesterol low enough with statins alone may be prescribed additional medications.

Possible side effects:

• Muscle pain and soreness

• Increased blood sugar levels

• Nausea

• Constipation

• Diarrhea

• Stomach cramps

However, these symptoms are typically mild, and they should ease over time.

Bile Acid Sequestrants

Bile acid sequestrants, also called bile acid resins, manage cholesterol by binding to bile in the intestines and making it unusable for digestion. This sets off a chain of events that leads to the liver using more cholesterol to make more bile, releasing less cholesterol into the bloodstream. These medications are typically prescribed if, for example, you experience severe side effects from statins and can’t take them or you don’t experience a significant enough reduction in cholesterol from statins alone.

A 2015 review article of studies with more than 7,000 patients noted that bile acid sequestrants lowered LDL cholesterol by more than 20 points and appeared to significantly lower the risk of heart disease.

Possible side effects:

• Nausea

• Heartburn

• Gastrointestinal issues like constipation, gas, and bloating

Cholesterol Absorption Inhibitors (CAIs)

These drugs prevent the small intestine from absorbing fats in the food you eat and releasing them into the bloodstream. The end result is that more cholesterol leaves the body as waste rather than returning to the bloodstream. CAIs have been shown to reduce LDL cholesterol by 18 to 25%. One might be prescribed in addition to a statin to help get your cholesterol to healthier levels. CAIs are not recommended if you’re pregnant.

Possible side effects:

• Fatigue

• Muscle soreness

• Stomach pain

PCSK9 Inhibitors

If other drugs are ineffective or LDL levels are very high due to genetic factors, your doctor may recommend one of these newer injectable medications, Praluent (alirocumab) or Repatha (evolocumab). Known as PCSK9 inhibitors, these are monoclonal antibodies or manmade proteins that bind to a protein in the liver, preventing the release of excess LDL cholesterol into the bloodstream. Some research has shown that these drugs may be able to reduce LDL cholesterol by 50 to 70%.

Possible side effects:

• Hives or rash

• Swelling of nasal passages

• Problems at the injection site, like swelling or redness

High Triglyceride Medications

High triglycerides respond to one or more of these medications:

Omega-3 Fatty Acids

Prescription-strength omega-3s, formulated with 4 grams of EPA or EPA and DHA, are effective in lowering high levels of triglycerides (above 500 mg/dL) by up to 30%.

Possible side effects:

• Indigestion

• Bleeding

• Reduced blood sugar control

Fibrates

These medications target VLDL cholesterol, the source of triglycerides, by speeding up its removal from the bloodstream. They can cut your triglyceride level anywhere from 25 to 50%. but you’ll need regular monitoring if you also take statins, as they can raise your risk for some side effects of statins. Note: If you have any liver, kidney, or gallbladder conditions, you shouldn’t take fibrates.

Possible side effects:

• Headaches

• Nausea

Niacin

Prescription-strength niacin, which is a B vitamin, can cut production of both VLDL and LDL cholesterol in the liver, lowering triglycerides by 20 to 50%, as well as boosting good HDL. Note: If you have heart disease, diabetes, liver issues, or bleeding problems, you shouldn’t take this drug.

Possible side effects:

• Flushing

• Itching

• Upset stomach

• Increased blood sugar levels

Living Better With High Cholesterol

Managing high cholesterol involves making important changes, and that calls for serious commitment. It might take time to switch from a diet based on red and processed meats and full-fat dairy to one built around fish, chicken, low-fat dairy, and fruits and vegetables.

Exercise is a must, but it also brings many benefits beyond heart health, like stress management. Quitting smoking and limiting alcohol intake may be harder to achieve if they’ve been a part of your life for a long time, and you might need help from your medical team to reach these goals.

By making these changes, you’ll improve your overall health and hopefully live a long, fulfilling life—and who doesn’t want that?

Where Can I Find My High Cholesterol Communities?

Living with high cholesterol doesn’t mean you’re alone—far from it. Many people live—and thrive—with this condition, and find support on their journey through sme of the following communities and organizations:

Top Cholesterol Podcasts

• Love Your Heart: A Cleveland Clinic Podcast: A Cleveland Clinic Podcast: All your heart-related questions, answered weekly by top experts on the subject.

• Cholesterol Podcasts from the American Heart Association: Advice for dealing with challenges related to high cholesterol.

Top Cholesterol Resources

• American Heart Association: America’s foremost authority on everything related to heart health, has a section of their site dedicated to high cholesterol, including tools and resources, plus a support network with forums where you can connect with people in the same boat.

• WomenHeart: Find out about heart issues, including cholesterol, specifically faced by women. Go to their Find Support section to connect with others through one-on-one connections and virtual meetings or join their online community.

Meet Our Writer

Wyatt Myers

Wyatt Myers is a health and fitness writer in Olathe, Kansas. For over 20 years, Wyatt has contributed to dozens of books, magazines and websites, including HealthDay, Men’s Health, Prevention and more.

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