Let’s Talk About High Cholesterol Treatment
If you have high cholesterol, treatment may involve a combination of lifestyle changes and medications. Here’s what to know.by Wyatt Myers
Symptoms of high cholesterol aren’t always visible, so it can be a massive surprise when your doctor suddenly tells you that you have it (or that your levels are borderline). If you’re wondering what this diagnosis means for you, know there are a variety of treatments your doctor might recommend you try. These can range from minor to major lifestyle changes, to taking certain medications to help keep your cholesterol in check. We break down treatment for high cholesterol and all that’s involved so that you can take smart steps toward better health.
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
Lifestyle changes, including committing to a healthy diet, increasing daily exercise, and losing weight if overweight, can all help lower total and LDL cholesterol while raising HDL cholesterol. It's also important to quit if you smoke cigarettes and to watch your alcohol intake. If these changes are working, but still not having the desired difference, your doctor may prescribe medication in addition.
By far the biggest culprits for causing high cholesterol are the saturated fats found in red meat and full-fat dairy products. Trans fats—which can still be found in trace amounts in some packaged foods under the ingredient name “partially hydrogenated oils”—are another cause of high cholesterol.
Several factors have been shown to raise levels of good HDL cholesterol, including regular exercise, quitting smoking, and drinking alcohol in moderation (no more than one drink a day for women, two for men). Some medications for lowering cholesterol or triglycerides, such as niacin and fibrates, may also have the secondary benefit of raising HDL levels.
The results can vary widely based on factors ranging from how quickly you lose weight to the type of cholesterol medication you’re taking. If you’re overweight, losing even five to 10 pounds can lead to lower total cholesterol, LDL cholesterol, and triglycerides, according to The American Academy of Family Physicians. And according to research published in the European Heart Journal, you can achieve a significant decrease in LDL within four weeks of starting treatment with a statin or cholesterol absorption inhibitor.
What Is Cholesterol Again?
Let’s get straight on what cholesterol actually is. The fatty, waxy substance is produced by the liver and moves through the bloodstream. It helps your body build cells, as well as produce needed vitamins and hormones. There are two types of cholesterol, and they’re about as far apart as you can get:
HDL (high-density lipoprotein) and LDL (low-density lipoprotein)
HDL is often referred to as “good” cholesterol. It grabs up LDL in the bloodstream and carries it back to the liver to be processed and removed as waste.
LDL, the bad kind, can build up in artery walls if levels become too high. Eventually, this buildup can set the stage for heart disease, heart attack, or stroke.
A third type, very low-density lipoprotein (VLDL) cholesterol, carries triglycerides through the bloodstream. Triglycerides are fats derived almost entirely from the foods we eat. High levels of these fats in your bloodstream can cause problems similar to LDL cholesterol.
What Do My Cholesterol Numbers Mean?
The routine blood test that checks for high cholesterol, called a lipid profile or lipid panel, reports your results as four components:
Total cholesterol (the sum of your LDL, HDL, and 20% of your triglyceride level)
Doctors typically suggest keeping total cholesterol below 200 mg/dL and LDL cholesterol below 100 mg/dL, but if you have existing heart problems, your LDL cholesterol should be even lower—the goal is below 70 mg/dL. That’s because when levels are higher, those extra fats can start getting deposited in your arteries, causing blockages that could lead to heart disease, heart attack or stroke.
Here are the numerical ranges for each component. Your doctor interprets your numbers to determine if you have high cholesterol (or high triglycerides).
Below 200 mg/dL is the goal.
200-239 mg/dL is borderline high = time to take action.
240 mg/dL and above is high = a comprehensive plan is a must.
For people without heart disease or an elevated risk of 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.
For people with heart disease or coronary artery disease:
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.
Below 40 mg/dL for men and below 50 mg/dL for women is considered poor.
40-59 mg/dL in men or 50-59 mg/dL in women is considered good.
60 mg/dL and above is ideal for everyone.
Below 150 mg/dL is optimal.
150-199 mg/dL is borderline high.
200-499 mg/dL is high.
500 mg/dL and above is very high.
Your doctor will consider your medical history and gender along with your various numbers to determine whether you have high cholesterol and how to manage it.
Why Is Treating High Cholesterol So Important?
Left unchecked, excess cholesterol not only continues to accumulate in the bloodstream, but also ultimately lines the walls of the arteries in the form of deposits called plaque.
Though the goal of high cholesterol treatment is broadly to “lower cholesterol,” it’s more nuanced than that. While you want to lower total cholesterol levels as well as levels of bad LDL cholesterol and triglycerides, you also want to raise levels of good HDL cholesterol because it’s protective.
The best high cholesterol treatment for you will be based on a variety of personal factors. These include:
Whether your cholesterol is borderline high, high, or very high
Whether you have a personal or family history of high cholesterol and heart disease
Whether you smoke
There’s not one solution for everyone. If your cholesterol is borderline high and you have no other risk factors, lifestyle changes alone may be enough to move the needle. If the lifestyle changes aren’t making the desired difference in your cholesterol levels, your doctor may begin recommending cholesterol medications.
If you have a strong family history of high cholesterol or have several risk factors for heart disease, your doctor may recommend a combination of medication and healthy lifestyle changes from the start.
What Are the Treatments for High Cholesterol?
A variety of approaches and can nudge numbers into a healthy change. Your doctor will likely start with the least aggressive treatment first—recommending tweaks to your daily way of living. One huge bonus: These are the same principles that are known to be good for anyone wanting to live a long, healthy life. From upgrading your diet to getting more exercise, these are a few of the things you may discuss.
Limit Saturated Fats
Foods high in saturated fat have the greatest impact on raising cholesterol levels, according to the Mayo Clinic in Rochester, MN. Saturated fat is primarily found in red and processed meats, full-fat dairy, and a few plant-based foods:
Salami and other cured deli meats
Poultry with the skin
Whole or 2 percent dairy
Some baked goods and fried foods
It’s best to cap your saturated fat intake to 5 to 6% of your daily calories, according to the American Heart Association. That amounts to 13 grams of saturated fat per day on a 2,000-calorie diet.
Curb Trans Fat
Trans fats, which used to be plentiful in packaged foods like cookies, crackers, and margarine under the ingredient name “partially hydrogenated oil,” are a major contributor to high cholesterol. Although the U.S. Food and Drug Administration has banned its widespread use in packaged foods, trace amounts of trans fats are still permitted. The package label can state “0 trans fat” even when the food has up to 0.5 grams per serving, and those potential amounts of trans fat can add up, so check ingredient lists.
Trans fats may still be found in the following types of foods:
Non dairy coffee creamer
The goal is to get your intake of trans fats as close to zero as possible.
Enjoy Eggs, if You Want
Interestingly, eggs, which have the most dietary cholesterol of common foods and have long been the subject of debate around whether they’re healthy or unhealthy, don’t raise cholesterol levels — at least not for everyone. Current research has shown that for three out of four people, eating up to seven eggs a week will not increase the risk of heart disease. However, because studies are ongoing, the Mayo Clinic suggests limiting egg intake to around one large egg a day might be best. You can also remove the yolks and eat just the egg whites if you want the protein without cholesterol.
Eat More Omega-3s
Foods rich in omega-3 fatty acids—such as walnuts, flaxseeds, and fatty fish—have heart-healthy benefits. They can lower triglycerides, raise HDL cholesterol, reduce blood pressure, and reduce the risk of dying from heart disease, according to a recent analysis in the British Medical Journal.
Fish is a great protein source and the American Heart Association recommends eating two 3.5-ounce servings of fish every week. Fish high in omega-3 fatty acids include:
Be sure to have your fish baked, grilled, or very lightly sauteed—not fried and/or breaded.
Fill Up on Fiber
Both soluble and insoluble fiber are all-stars for health, but soluble fiber is especially helpful for high cholesterol. Soluble fiber isn’t absorbed in the intestine, so it binds to LDL cholesterol there and removes it from the body as waste, according to the National Lipid Association. Getting 5 to 10 grams of soluble fiber a day, along with drinking plenty of water, can lower total and LDL cholesterol levels by as much as 11 points. Good choices for soluble fiber include:
Fuel Up on “Whole” Foods
Eating a healthy diet rich in vegetables, fruits, whole grains, and lean sources of protein rather than fatty, sugary, and processed foods helps with weight and overall health, along with improving cholesterol levels.
Making all of these dietary changes may seem like a tall order, but adopting even one small change at a time can make a big difference. Once you’ve mastered one healthy diet tweak, move on to the next. If you need help putting all this advice into action, ask your healthcare provider to recommend a registered dietitian that you can work with to reduce cholesterol levels even more.
Break a Sweat
Regular exercise is an excellent idea for everyone, but especially you have high cholesterol. Exercise not only lowers LDL cholesterol and triglycerides, it even raises levels of good HDL cholesterol — that’s the trifecta of cholesterol benefits. We still don’t know exactly how exercise works this magic, but it’s thought to increase certain enzymes that boost HDL cholesterol as well as prompting muscles to draw on fats for energy, lowering the amount of fats in the bloodstream, according to a study in Sports Medicine.
Aim for 150 minutes of moderate exercise or 75 minutes of vigorous exercise, spread across every week, but more minutes and/or more vigorous activity is even better, if you’re healthy enough to handle it. Talk to your health care provider about any concerns before undertaking an exercise program on your own. If you need a place to start, a daily walk still offers benefits. Add more challenging activities to your workout schedule as your stamina increases.
Lose a Little Weight
If you can successfully make the diet and exercise changes above, this third recommendation should come naturally (though not necessarily quickly). Carrying just a few extra pounds can contribute to high cholesterol, the Mayo Clinic notes, so map out a plan to reach the ideal weight for your height and frame. You can start by determining your body mass index (BMI) by using a BMI calculator.
If losing weight takes longer than you’d like, try not to get frustrated. Stay consistent in your food choices and exercise routine — eventually your patience will pay off. Think of your ideal weight as a long-term goal, one you can ultimately reach by aiming for small losses along the journey. Losing 5 to 10% of your body weight will start to lower total cholesterol, LDL cholesterol,triglyceride levels, and other risk factors for heart disease.
Cut Out Tobacco and Curb Alcohol
Smoking is bad in more ways than can be counted, but one definitive result is that it lowers levels of good HDL cholesterol, notes the Cleveland Clinic. How so? The oxidative stress caused by cigarette smoke has a negative effect on both the amount and function of HDL cholesterol, robbing it of its heart-protective quality. That’s yet another reason to look into a smoking cessation strategy.
The relationship between drinking and cholesterol levels is a little more complicated. Some research has shown that moderate alcohol consumption can actually give good HDL cholesterol levels a boost. Don’t look at this as permission to glug with abandon though. The suggested upper limits, even for those at peak health, are two drinks a day for men aged 65 and younger and one drink a day for women or men over 65, according to the Mayo Clinic.
Even small changes to your health can have a big impact over time. Don’t feel like you have to do everything from the list above at once. Just focus on one heart-healthy, cholesterol-lowering habit at a time. You and your doctor will see how your numbers change as a result.
What About Medication for High Cholesterol?
When lifestyle changes alone are simply not effective enough for managing cholesterol levels, medications will be added to the plan. If you have a family history of high cholesterol or your levels are high or very high, they may be prescribed from the start along with lifestyle changes (which are still vital!).
A statin is usually the first cholesterol medication prescribed. Statins work by preventing excess cholesterol from forming in the liver in the first place. They have been shown to lower LDL cholesterol and triglycerides, raise HDL cholesterol, and reduce the risk of heart attack and stroke. According to the Jupiter Trial, which looked at the effects of statins in a group of more than 15,000 patients, statins lowered LDL cholesterol by as much as 50 percent, reduced the risk of heart attack by 54 percent, and lowered the risk of stroke by 48 percent.
Common statins include:
Possible side effects of statins include:
Muscle pain and soreness
Increased blood sugar levels
Symptoms are typically mild and go away over time.
Statins are not recommended for pregnant women or people with liver disease. It’s important to note that statins don't work for everyone and may not be able to lower cholesterol levels enough—you might benefit from an additional medication.
Bile Acid Sequestrants
Also called bile acid resins, these lower cholesterol in a unique way. Bile is an acid produced by the liver, and is critical for digestion. When you take bile acid sequestrants, however, the medications bind to bile and render it ineffective. This causes the liver to use cholesterol to make more bile, thus keeping the excess cholesterol out of the bloodstream, and lowering cholesterol levels.
If you experience severe side effects from statins or don’t see a significant reduction in cholesterol from statins alone, your doctor might prescribe a bile acid sequestrant. These drugs lowered LDL cholesterol by more than 20 points and appeared to significantly lower the risk of heart disease, a 2015 review article of studies with more than 7,000 patients noted.
Bile acid sequestrants include:
Possible side effects include:
Cholesterol Absorption Inhibitors
These drugs prevent the small intestine from absorbing fats in the food you eat and releasing them into the bloodstream. The result? More cholesterol leaves the body as waste rather than returning to your bloodstream. CAIs have been shown to reduce LDL cholesterol by 18 to 25%. You may be prescribed a CAI along with a statin if the statin doesn’t lower your cholesterol to an acceptable level on its own. The most prescribed CAI is Zetia (ezetimibe).
Possible side effects include:
Some people develop a hypersensitivity to the medication and must discontinue it.
This medication is for people with a genetic condition that causes very high LDL levels, as well as those with a history of heart disease. PCSK9 inhibitors work by binding to a protein in the liver and preventing the release of excess LDL cholesterol into the bloodstream. PCSK9 inhibitors are given by injection from your doctor every two to four weeks. Some research indicates that they can reduce LDL cholesterol by as much as 50 to 70%.
PCSK9 inhibitors include:
Possible side effects include:
Swelling of nasal passages
Problems at the injection site
Some people develop a hypersensitivity to the medication and must discontinue it.
If you have high triglycerides in addition to high total cholesterol or high LDL cholesterol, or if only triglycerides are high, your doctor may prescribe a medication aimed at lowering triglycerides. These include fibrates, niacin, and prescription omega-3 fatty acids; all three have been shown to decrease triglycerides and possibly increase HDL cholesterol as well.
These medications lower levels of VLDL cholesterol (the source of triglycerides) produced by the liver. They also speed up its removal from the bloodstream. They’re effective and can reduce triglycerides by 25 to 50 percent, but you’ll need regular monitoring if you also take statins, as they can increase the risk for certain statins side effects. They’re not for people with liver, kidney, or gallbladder issues.
Fibrate medications include:
Antara, Lipofen (fenofibrate)
Possible side effects of prescription fibrates include:
Prescription-strength niacin, one of the B vitamins, can reduce the liver’s production of both VLDL and LDL cholesterol and improve HDL. It can lower triglycerides 20-50%. However, it’s not meant for people with heart disease, diabetes, liver problems, or bleeding problems, among other medical conditions.
Niacin medications include:
Possible side effects include:
Increased blood sugar levels
Prescription Omega-3 Fatty Acids
Omega-3s are available in over-the-counter supplements and prescription formulas, but only the prescription variety is regulated by the FDA. Over-the-counter omega-3 fatty acids, along with dietary changes, may be enough to help you control mildly high triglycerides, while prescription omega-3 fatty acids, which contain 4 grams of EPA or EPA and DHA, are FDA-approved for very high levels of triglycerides (above 500 mg/dL), though an American Heart Association advisory panel found them also effective for people with high levels, between 200-499 mg/dL. Prescription-strength omega-3s can cut triglyceride levels by up to 30%.
Prescription omega-3 fatty acids include:
Possible side effects include:
Reduced blood sugar control
While lowering high cholesterol can feel overwhelming, requiring you to adjust some of your daily habits, along with perhaps taking a new medication, know that small changes over time can have a profound effect on your numbers—and your entire health outlook. Adapt new habits one at a time, stay consistent, and check in with your doctor regularly to see what else might be needed. Eventually, your new way of living won’t feel like work, but rather simply your way of life!
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Cholesterol Types: American Heart Association. (2017). “HDL (Good), LDL (Bad) Cholesterol and Triglycerides.” heart.org/en/health-topics/cholesterol/hdl-good-ldl-bad-cholesterol-and-triglycerides
High Cholesterol: American Heart Association: “What Your Cholesterol Numbers Mean.” heart.org/en/health-topics/cholesterol/about-cholesterol/what-your-cholesterol-levels-mean
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Eggs: Mayo Clinic. (2020). “Eggs: Are they good or bad for my cholesterol?” mayoclinic.org/diseases-conditions/high-blood-cholesterol/expert-answers/cholesterol/faq-20058468
Eggs: American Heart Association. (2020). “Making sense of cholesterol — the good, the bad and the Dietary.” heart.org/en/news/2020/09/16/making-sense-of-cholesterol-the-good-the-bad-and-the-dietary
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Weekly Fish Recommendation: American Heart Association. (2018). “Eating fish twice a week reduces heart stroke risk.” heart.org/en/news/2018/05/25/eating-fish-twice-a-week-reduces-heart-stroke-risk#:~:text=To%20get%20the%20full%20benefits,of%20flaked%20fish%2C%20every%20week
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Medications: Circulation: Genomic and Precision Medicine. (2015). “Effect of Bile Acid Sequestrants on the Risk of Cardiovascular Events.” ahajournals.org/doi/full/10.1161/circgenetics.114.000952
Medications: Fh Foundation. (2012). “Cholesterol Absorption Inhibitor.” thefhfoundation.org/fh-treatments/cholesterol-absorption-inhibitor
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HDL Cholesterol: Mayo Clinic. (2020). “HDL cholesterol: How to boost your ‘good’ cholesterol.” mayoclinic.org/diseases-conditions/high-blood-cholesterol/in-depth/hdl-cholesterol/art-20046388
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