High Cholesterol: Everything You Need to Know
We’ve got the doctor-approved details on causes, symptoms, treatments, and other facts and tips that can make life with this condition easier.
If your doctor tells you that you have high cholesterol, you probably have some idea of what that is—a fatty, waxy substance that ends up in your blood vessels and can clog up the works, literally. But it’s a little more complicated than that. There are different types of cholesterol, both good and bad. Problems arise when too much of the bad kind of cholesterol circulates in the bloodstream. That leads to a buildup of deposits can threaten to block arteries, setting the stage for some serious problems.
Getting a handle on high cholesterol isn’t easy—but it is doable once you understand the causes behind it and the tools available to treat it. Start here.
What Is High Cholesterol?
Cholesterol is a naturally occurring compound 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, produce hormones, and make vitamins that the body needs.
You can have too much cholesterol in your blood, however. That’s called high cholesterol, or hypercholesterolemia, and it can put your heart health at risk. This is especially true if it’s too much of a specific type of cholesterol you may have heard referred to as “bad” cholesterol. We’ll get into what that means in just a moment.
Good Cholesterol vs. Bad Cholesterol
Not all cholesterol is the same. One type of cholesterol, called high-density lipoprotein (HDL) cholesterol, helps you stay healthy. For that reason, it’s often called “good” cholesterol. You want more of it rather than less. The other type boosts your risk of heart disease. It’s called low-density lipoprotein (LDL) cholesterol. That’s the “bad” cholesterol mentioned above.
HDL Cholesterol
High-density lipoprotein acts like Pacman in your bloodstream, binding to 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 (AHA).
LDL Cholesterol
Low-density lipoprotein 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 heart problems and other health issues. 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.
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, cholesterol testing results are given in milligrams of cholesterol per deciliter of blood (mg/dL). Your doctor will look at all four numbers (total cholesterol, LDL, HDL, and triglycerides) along with your medical history to determine whether you have high cholesterol and how to manage it. Here’s what’s considered normal or high for each:
Total Cholesterol
This number represents the sum of your LDL, your HDL, and 20% of your triglyceride level, according to the AHA. For total cholesterol:
Below 200 mg/dL is normal.
200 to 239 mg/dL is borderline high.
240 mg/dL and above is high.
LDL Cholesterol
What’s considered high for LDL 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 to 129 mg/dL is near optimal.
130 to 159 mg/dL is borderline high.
160 to 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 cholesterol, a higher number is better. Unlike with LDL cholesterol, the ranges are the same for all groups:
60 mg/dL and above is optimal.
40 to 59 mg/dL in men or 50-59 mg/dL in women is considered good.
Below 40 mg/dL for men or below 50 mg/dL for women is considered poor.
Triglycerides
For levels of these blood fats:
Below 150 mg/dL is desirable.
150 to 199 mg/dL is borderline high.
200 to 499 mg/dL is high.
500 mg/dL and above is very high.
When to Get Your Cholesterol Checked
Everybody should get a cholesterol test at some point. When and how often depends on your age and whether you have certain health conditions. The U.S. Centers for Disease Control and Prevention (CDC) makes the following recommendations for cholesterol testing in the general population:
Children: At least once between ages 9 and 11
Adolescents: At least once between ages 17 and 21
Healthy adults up to age 40: Every four to six years
Children with obesity or diabetes may need to be tested more often. The same goes for adults who have heart disease, diabetes, or a family history of high cholesterol. Talk to your doctor about the right schedule for you and your children.
After age 40, your doctor will evaluate your risk of having a heart attack or stroke within the next ten years. This risk is based on your current health issues and how well they’re managed, including high blood pressure, diabetes, and your cholesterol level. The results of that evaluation will help your doctor decide how often you should get your cholesterol tested.
You can expect your cholesterol testing to get more frequent as you get older. For example, the National Heart, Lung, and Blood Institute, a division of the NIH, recommends that people older than 65 have their cholesterol tested every year.
What Causes High Cholesterol?
High cholesterol can result from factors both within and beyond your control, according to the AHA. These include:
A high-fat diet
Being overweight or having obesity
Excess alcohol intake
Having familial hypercholesterolemia, a genetic condition that raises your cholesterol
Lack of exercise
Older age
Smoking or exposure to tobacco smoke
What Are the Symptoms of High Cholesterol?
There’s bad news here: High cholesterol has no symptoms. You could have it and not know it until it causes significant heart health problems, such as atherosclerosis, which can lead to chest pain, heart attack, or stroke. The only way to know you that you have high cholesterol is to have a cholesterol test. This is why routine lipid testing is so important, particularly as you get older.
How High Cholesterol Affects the Body
When your cardiovascular system is working properly, oxygen-rich blood flows freely from your heart through a network of blood vessels, called arteries, to all the organs and tissues in your body. High cholesterol can limit or even cut off the flow of blood through certain arteries by contributing to the buildup of a sticky substance on the artery walls called plaque, a process called atherosclerosis.
Plaque can accumulate in any of your arteries. Depending on which part of your body the clogged-up artery was supplying, this can result in:
Coronary artery disease (CAD), caused by plaque buildups in the arteries that supply blood to your heart (called the coronary arteries). CAD can cause a heart attack.
Carotid artery disease, caused by plaque buildups in the arteries that supply blood to the front of your brain. This can cause a stroke.
High blood pressure (hypertension) due to plaque buildups that narrow and stiffen your arteries, requiring greater pressure to pump blood through them.
Peripheral artery disease (PAD), which occurs due to plaque buildups in the arteries that supply blood to your arms and legs. PAD often accompanies CAD.
What Health Conditions Can Affect Cholesterol Levels?
Numerous medical conditions can raise your cholesterol, thereby putting you at higher risk of cardiovascular disease and other issues. Conditions known to increase cholesterol include:
Chronic kidney disease (CKD). Per the Cleveland Clinic, CKD causes you to have a higher level of triglycerides in your blood and also raises the level of very low-density lipoprotein (VLDL) cholesterol. At the same time, CKD causes your level of HDL, the helpful cholesterol, to decrease. Plaque tends to build up more quickly in the arteries of people with CKD, so people with this condition face a greater risk of coronary artery disease. (Conversely, high cholesterol can contribute to the development of chronic kidney disease. So the relationship goes both ways.)
HIV. Inflammation caused by the disease can speed up plaque accumulations in your arteries.
Thyroid disease. When your body produces too little thyroid hormone—a condition called hypothyroidism—it causes a slowdown in metabolism that leads to higher cholesterol levels. This happens through a couple of mechanisms. When thyroid hormone is decreased, the number of receptors for LDL on the surface of the liver also decreases; as a result, the liver can’t remove as much bad cholesterol from the bloodstream and LDL goes up. The reduction of thyroid hormone also decreases the breakdown of fatty acids, leading to higher triglycerides.
Lupus. The ongoing inflammation that characterizes this autoimmune disease raises your bad cholesterol while lowering your good cholesterol (even if you eat a perfectly healthy diet). Chronic inflammation also accelerates the buildup of plaque in your arteries.
Polycystic ovary syndrome (PCOS). This disease causes hormone imbalances and can lead to weight gain, especially in your belly. This can cause a drop in your HDL cholesterol and a rise in triglycerides, increasing your risk of heart disease as well as diabetes, per Johns Hopkins Medicine.
Diabetes. This condition can lower your good cholesterol while raising your bad cholesterol and triglycerides, according to the AHA, leading to what’s known as diabetic dyslipidemia. Dyslipidemia is a term for abnormal cholesterol levels.
Lifestyle Changes That 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.
Clean up your diet. Follow an eating pattern that includes plenty of high-fiber fruits, vegetables, and whole grains. Limit red meat in favor of fatty fish, like salmon. Avoid processed foods that are high in saturated fat, sugar, or both. The Mayo Clinic recommends the Mediterranean diet.
Drink less alcohol. Alcohol raises your cholesterol and your triglycerides, according to the CDC. Guidelines recommend 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.
Get more exercise. Moving more—think a brisk walk or bike ride—can lower your LDL and raise your HDL, according to the Cleveland Clinic. Bonus: it may help you slim down, further lowering cholesterol. Build up to at least 30 minutes a day of aerobic activity, five days a week, plus strength-building exercise twice a week.
Quit smoking if you smoke. Smoking lowers “good” cholesterol levels and heightens the risk of coronary artery disease in people who already have high cholesterol. Visit the American Lung Association to learn how to quit.
Lose weight (even a small amount). Dropping just a few extra pounds can lower total cholesterol, LDL cholesterol, and triglycerides, and raise levels of good HDL cholesterol, according to the Mayo Clinic.
What Medications Are Used to Treat 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 AHA. 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, which included 17,802 men and women, rosuvastatin (sold under the brand name Crestor) lowered LDL cholesterol by 50% and reduced the risk of stroke and heart attack by 48% and 54%, respectively, compared to a placebo.
Statins are not recommended for people with liver disease because they can cause damage to this organ (though this is rare). 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 of statins include:
Constipation
Diarrhea
Increased blood sugar levels
Muscle pain and soreness
Nausea
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. Examples of bile acid sequestrants are cholestyramine and colesevelam.
In a review and meta-analysis of studies including more than 7,000 patients, the authors noted that bile acid sequestrants lowered LDL cholesterol by more than 20 points on average and appeared to significantly lower the risk of developing heart disease.
Possible side effects of bile acid sequestrants include:
Heartburn
Gastrointestinal issues like constipation, gas, and bloating
Nausea
Cholesterol Absorption Inhibitors (CAIs)
These drugs, such as ezetimibe, prevent the small intestine from absorbing fats from the food you eat and releasing them into the bloodstream. The end result is that more cholesterol leaves the body as waste versus ending up in your blood. 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 of CAIs include:
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, which include Praluent (alirocumab) and Repatha (evolocumab). 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 as much as 50% to 70%.
Possible side effects of PCSK9 inhibitors include:
Hives or rash
Problems at the injection site, like swelling or redness
Swelling of nasal passages
Small Interfering RNA (siRNA) Therapy
This new class of medication for high cholesterol uses RNA interference to increase the liver’s ability to remove harmful LDL cholesterol from the blood. It works by preventing the formation of certain proteins, called PCSK9 proteins, that lead to the degradation of LDL receptors on the liver. As a result, these receptors remain intact and are able to remove LDL particles from the blood. Your doctor may prescribe siRNA therapy is addition to statins to help you lower your high cholesterol.
Possible side effects of siRNA therapy are:
Diarrhea
Problems at the injection site, like swelling or redness
Urinary tract infection
High Triglyceride Medications
If your doctor determines that you need medication to help lower your triglycerides, one or more of these will likely be prescribed:
Omega-3 Fatty Acids
Prescription formulations of omega-3s, containing 4 grams of either EPA or EPA and DHA, are effective in lowering very high levels of triglycerides (above 500 mg/dL) by up to 30%. Brand names are Lovaza and Vascepa.
Possible side effects include:
Bleeding
Indigestion
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 fibrates can raise your risk for some side effects of statins. Note: If you have a liver, kidney, or gallbladder condition, you shouldn’t take fibrates.
Possible side effects include:
Headaches
Nausea
Niacin
Prescription-strength niacin, which is a B vitamin, works by blocking the way in which your liver makes cholesterol, according to the National Library of Medicine. It’s been shown to lower triglycerides by 20% to 50% as well as decrease LDL and VLDL levels and boost HDL. Note: If you have heart disease, diabetes, a liver condition, or bleeding problems, you shouldn’t take this drug.
Possible side effects include:
Flushing
Increased blood sugar levels
Itching
Upset stomach
How Can High Cholesterol Be Prevented?
Fortunately, there’s plenty you can do to avoid high cholesterol in the first place. As a bonus, they’re the same healthy steps that can help prevent numerous other health problems, plus help you feel your best in general—both physically and mentally:
Eat a healthy diet, such as the Mediterranean diet. In addition to the traditional version, there’s now a “green” version that’s supercharged with antioxidants, or you can try a Latinx twist.
Exercise regularly.
If you smoke, quit.
Limit or avoid alcohol.
Maintain a healthy weight.
Get regular checkups to monitor your heart health and your overall health.
Takeaway
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. And quitting smoking or limiting alcohol intake may be harder to achieve if those things have been a part of your life for a long time. You may need help from your medical team to reach these goals, and that’s OK. The important thing is to not give up: Remember that each small change you make, in concert with taking any medication your doctor has prescribed, will help you live your best, healthiest life.