Understanding Cholesterol

Cholesterol often gets a bad reputation, but it’s actually essential for your body to function properly. The key is maintaining the right balance. Understanding cholesterol, what your numbers mean, and how to keep them in a healthy range can significantly reduce your risk of heart disease and stroke.

What Is Cholesterol?

Cholesterol is a waxy, fat-like substance found in all cells of your body. Your liver produces all the cholesterol your body needs to build cells, make hormones, and produce vitamin D. Cholesterol also comes from animal-based foods you eat, such as meat, poultry, and dairy products.

Cholesterol travels through your bloodstream attached to proteins. These combinations of cholesterol and protein are called lipoproteins. High cholesterol affects nearly 94 million American adults, and many don’t know they have it because high cholesterol has no symptoms until it causes serious problems like heart attack or stroke.

Types of cholesterol:

• LDL (Low-Density Lipoprotein) - Often called “bad” cholesterol because it can build up in artery walls, forming plaque
• HDL (High-Density Lipoprotein) - Often called “good” cholesterol because it helps remove LDL from arteries
• VLDL (Very Low-Density Lipoprotein) - Carries triglycerides and contributes to plaque buildup
• Triglycerides - A type of fat in the blood that, when elevated, increases cardiovascular risk

Causes and Risk Factors

Several factors influence your cholesterol levels. Some you can control, while others you cannot.

Non-modifiable risk factors:

• Age (cholesterol levels typically rise with age)
• Gender (before menopause, women often have lower total cholesterol than men of the same age)
• Genetics and family history (familial hypercholesterolemia)
• Race/ethnicity

Modifiable risk factors:

• Diet high in saturated and trans fats
• Obesity or overweight
• Physical inactivity
• Smoking
• Diabetes
• Excessive alcohol consumption

Medical conditions that affect cholesterol:

• Type 2 diabetes
• Hypothyroidism
• Kidney disease
• Liver disease
• Certain medications (steroids, some blood pressure medications)

Understanding Your Numbers

A lipid panel blood test measures your cholesterol levels. Here’s what the numbers mean:

Total Cholesterol:

• Desirable: Less than 200 mg/dL
• Borderline high: 200-239 mg/dL
• High: 240 mg/dL and above

LDL Cholesterol (“Bad”):

• Optimal: Less than 100 mg/dL
• Near optimal: 100-129 mg/dL
• Borderline high: 130-159 mg/dL
• High: 160-189 mg/dL
• Very high: 190 mg/dL and above

HDL Cholesterol (“Good”):

• Low (risk factor): Less than 40 mg/dL for men, less than 50 mg/dL for women
• Good: 40-59 mg/dL
• Optimal: 60 mg/dL and above

Triglycerides:

• Normal: Less than 150 mg/dL
• Borderline high: 150-199 mg/dL
• High: 200-499 mg/dL
• Very high: 500 mg/dL and above

Your doctor will consider your numbers along with other risk factors like blood pressure, smoking status, diabetes, and family history to assess your overall cardiovascular risk.

Common Symptoms

High cholesterol itself has no symptoms. You can have dangerously high cholesterol for years without knowing it. This is why it’s often called a “silent” condition.

Signs that high cholesterol has caused damage:

• Chest pain or angina (from coronary artery disease)
• Heart attack symptoms
• Stroke symptoms
• Pain while walking (from peripheral artery disease)
• Xanthomas (yellowish deposits under the skin, particularly around eyes, tendons, and joints) - more common in familial hypercholesterolemia

Because high cholesterol is symptom-free, regular screening is essential. Adults should have their cholesterol checked every 4-6 years, or more frequently if they have risk factors or are on treatment.

Diagnosis

Cholesterol is diagnosed through a simple blood test called a lipid panel or lipid profile.

What to expect:

• You may need to fast for 9-12 hours before the test
• Blood is drawn from a vein in your arm
• Results are typically available within a few days
• Your doctor will review your numbers and overall cardiovascular risk

Screening recommendations:

• Adults 20 and older: Every 4-6 years if at low risk
• Men 45-65 and women 55-65: Every 1-2 years
• Anyone with risk factors: More frequent screening
• Children: At least once between ages 9-11 and again between 17-21

Treatment Options

Treatment depends on your cholesterol levels, overall cardiovascular risk, and individual factors.

Lifestyle modifications (first-line treatment):

• Heart-healthy diet
• Regular physical activity
• Weight management
• Smoking cessation
• Limiting alcohol

Medications:

• Statins - The most commonly prescribed cholesterol medications; highly effective at lowering LDL (atorvastatin, simvastatin, rosuvastatin)
• Ezetimibe - Reduces cholesterol absorption in the intestine
• PCSK9 inhibitors - Injectable medications for high-risk patients or those who can’t tolerate statins
• Bile acid sequestrants - Bind bile acids, prompting the liver to use cholesterol to make more
• Fibrates - Primarily lower triglycerides
• Niacin - Lowers LDL and triglycerides, raises HDL
• Bempedoic acid - Newer option for those who can’t take statins
• Omega-3 fatty acid supplements - Prescription-strength for very high triglycerides

For many people, a combination of lifestyle changes and medication provides the best results.

What You Can Do

Lifestyle modifications can significantly improve your cholesterol levels and overall heart health.

1. Adopt a heart-healthy diet - Limit saturated fats (found in red meat, full-fat dairy) and eliminate trans fats (found in many processed and fried foods). Choose healthier fats from olive oil, avocados, nuts, and fatty fish.

2. Increase fiber intake - Soluble fiber reduces LDL cholesterol absorption. Good sources include oatmeal, beans, lentils, apples, pears, and Brussels sprouts. Aim for 25-30 grams of fiber daily.

3. Eat more omega-3 fatty acids - Found in salmon, mackerel, sardines, walnuts, and flaxseed. Omega-3s don’t affect LDL but reduce triglycerides and have heart-protective benefits.

4. Exercise regularly - Aim for at least 150 minutes of moderate aerobic activity per week. Exercise raises HDL cholesterol and improves overall cardiovascular fitness.

5. Lose excess weight - Even losing 5-10% of your body weight can improve cholesterol levels. Excess weight contributes to higher LDL and lower HDL.

6. Quit smoking - Smoking lowers HDL cholesterol. Within weeks of quitting, HDL levels begin to improve. Within a year, your heart disease risk drops significantly.

7. Limit alcohol - Moderate alcohol consumption may raise HDL, but the risks outweigh benefits. If you drink, limit to one drink per day for women and two for men.

8. Choose plant sterols and stanols - Found in fortified foods like certain margarines, orange juice, and yogurt drinks. They can reduce LDL by blocking cholesterol absorption.

9. Manage stress - Chronic stress may indirectly affect cholesterol through unhealthy coping behaviors. Find healthy stress management techniques.

10. Take medications as prescribed - If your doctor prescribes cholesterol medication, take it consistently. Don’t stop without consulting your doctor, even if your numbers improve.

When to See a Doctor

Consult a healthcare provider if:

• You haven’t had your cholesterol checked in several years
• You have risk factors for heart disease
• You have a family history of high cholesterol or early heart disease
• Your previous cholesterol levels were borderline or high
• You’re starting or changing cholesterol medications
• You experience side effects from cholesterol medications

Seek immediate medical attention for symptoms of heart attack or stroke:

• Chest pain or discomfort
• Shortness of breath
• Pain radiating to arm, jaw, or back
• Sudden numbness or weakness, especially on one side
• Sudden confusion or difficulty speaking
• Sudden severe headache

Key Takeaways

• Cholesterol is essential for body function, but too much LDL (“bad”) cholesterol increases heart disease and stroke risk
• High cholesterol has no symptoms, making regular screening essential
• Both lifestyle modifications and medications can effectively lower cholesterol
• A heart-healthy diet, regular exercise, maintaining a healthy weight, and not smoking are the foundations of cholesterol management