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What is high cholesterol?
Cholesterol is a waxy substance, called a lipid, that is normally made by your liver. Cholesterol is used by your cells for many important functions and processes, like making hormones and building new cells. You can also get cholesterol from food, especially animal products like meats and dairy products.
If certain types of cholesterol in your blood get too high, it can create deposits inside your blood vessels, called plaques. These deposits eventually lead to narrowing of your blood vessels. It can also cause blockages, ruptures, and clots, and possibly a heart attack or stroke.
How is high cholesterol diagnosed?
Your doctor will order a blood test, which includes a lipid profile. It measures blood levels of total cholesterol and two specific types of cholesterol, called low density lipoprotein (LDL) and high density lipoprotein (HDL).
LDL (known as the “bad cholesterol”) builds up in blood vessels and is the main culprit in heart attacks and strokes. In general, an LDL level less than 100 mg/dL is ideal. As it rises above that, it is considered high, but your doctor will suggest treatments based on your other risk factors for heart disease. LDL levels above 190 mg/dL are considered very high and will usually need to be treated with medication, regardless of other risk factors.
HDL (the “good cholesterol”) is believed to be protective because it clears excess cholesterol from the blood and takes it back to the liver. Generally, an HDL level above 60 mg/dL is ideal. The lipid panel test also includes the level of triglycerides, or fat, in the blood. Having high triglyceride levels can also increase your risk for heart disease.
Pro Tip
It can be hard to “treat” something that doesn’t cause you any pain, discomfort, or other symptoms. But treating high cholesterol with important changes to your diet and exercise, as well as medication if recommended by your doctor, can add years to your life and prevent devastating complications years down the line. —Dr. Sunny Varshney
Symptoms of high cholesterol
High cholesterol does not cause any noticeable symptoms until it builds up in blood vessels. This can lead to low blood flow to your heart and chest pain, or something more serious like a stroke or heart attack.
Guidelines recommend that people get a lipid panel tested at regular intervals, based on their age and medical history. Knowing your levels and treating it early can help reduce buildup of plaque in your blood vessels and reduce your risk for complications.
Pro Tip
Often, people underestimate how healthy their diet is and overestimate how active they are. Even then, some people who maintain a heart-healthy diet and regularly exercise can still have elevated cholesterol levels simply because they are aging, and their liver is getting less efficient at clearing LDL cholesterol out of the blood. —Dr. Varshney
High cholesterol quiz
Take a quiz to find out what's causing your high cholesterol.
Causes
The leading causes of high cholesterol are:
- An unhealthy diet of foods high in cholesterol, saturated fats, and trans fats
- Being overweight or obese (having a body mass index of 30 or higher)
- Lack of regular exercise or being sedentary
- Cigarette smoking
- Aging. With age, your liver gets less efficient at removing excess cholesterol from your blood.
- Other chronic conditions like diabetes, hypothyroidism, and chronic kidney disease can also increase the risk of developing high cholesterol
- While rare, some people inherit genes that can cause very high cholesterol levels at an early age. This is called familial hypercholesterolemia and is caused by a genetic defect that prevents your liver from removing LDL from the bloodstream.
High cholesterol foods
Eating foods high in cholesterol, saturated fats, or trans fats contributes to high cholesterol levels. Cutting back on these types of foods can significantly lower your risk of developing high cholesterol:
- Red meats (like steak and ground beef)
- Egg yolks
- Full-fat dairy products (like whole milk or yogurt)
- Processed snacks and desserts
- Deep-fried foods (like potato chips)
- Certain tropical oils (like palm oil)
Dr. Rx
Statins have repeatedly been shown to reduce bad cholesterol levels, risk of heart attack, risk of stroke, and risk of death in different groups of people while being very safe. This has been shown in many, many randomized-controlled trials, which are the best way to evaluate the benefits and side effects of drugs. —Dr. Varshney
How to lower cholesterol
Depending on your cholesterol levels, age, and medical history, you can lower LDL and increase HDL through changes in your habits and lifestyles. These include changing your diet, exercising regularly, getting to a healthy weight, and stopping smoking.
It takes several weeks to months of consistent lifestyle changes to see a difference in cholesterol levels. Your doctor will typically wait 4–6 weeks before re-checking your lipid panel after you’ve made these changes.
Increase foods that lower cholesterol
Data show that following a Mediterranean diet can help lower LDL cholesterol and your risk of plaque buildup. The diet is high in vegetables, fruits, legumes, nuts, whole grains, and fish. Eat at least 8 oz of non-fried fish that is high in omega-3 fatty acids (like salmon or trout) each week.
Other foods that are known to lower LDL cholesterol include oatmeal, almonds, walnuts, and avocados.
Cut back on foods that raise cholesterol
- Limit red meat and choose vegetable and other animal protein substitutes.
- When eating meat, reduce the amount of saturated fats by eating lean cuts of meat, trimming all visible fat from meat before cooking, removing skin from poultry, and limiting processed meats (like sausage, bologna, and hot dogs).
- Cut back on butter, lard, and shortening, and replace with healthy oils like olive oil.
- Drink (and cook with) skim or 1% milk.
Increase your exercise
Exercise for at least 30 minutes most days. The American Heart Association recommends that adults get at least 150 minutes of moderate-intensity aerobic exercise or at least 75 minutes of high-intensity aerobic exercise each week to support good cardiovascular health.
Moderate-intensity exercise includes activities like walking at least 2.5 miles per hour, gardening, or cycling at a gentle pace (less than 10 miles per hour). High-intensity aerobic exercise includes running, singles tennis, skipping rope, or faster-pace cycling. Additionally, limit your time spent sitting and add in some resistance training at least 2 days per week.
Stop Smoking
Completely quitting smoking (not just smoking less frequently) can lower cholesterol levels and improve your overall health. Nicotine replacement with gums, lozenges, or patches can help people quit. There are also medications to help stop smoking, and support groups. Electronic cigarettes or vaping has not been shown to be a healthy alternative to cigarette smoking.
Lose weight
Getting your weight down to a healthy range can lower cholesterol and have other health benefits. A healthy weight is defined as a body mass index (BMI) of 18.5-24.9 kg/m2. You can calculate your BMI based on your weight and height with an online calculator.
For people trying to lose weight, guidelines recommend a diet of 1200–1500 calories per day for women and 1500–1800 calories per day for men. Even if you lose just 3-5% of your weight and maintain it, you can lower your LDL levels.
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Treating cholesterol with medication
There are medications, such as statins, that can lower HDL cholesterol. But not everyone with LDL over 100 needs to take them. Whether you need medications depends on your cholesterol levels and other risks.
- Candidates for cholesterol-lowering medication include people who know they have plaque buildup in the arteries of their heart, neck, or legs, and those who have had a heart attack or stroke. It does not matter what the LDL cholesterol level is.
- Other high-risk individuals include those ages 40–75 years old with diabetes and an LDL level of 70 mg/dL or higher.
- In general, for people with an LDL level of 190 mg/dL or higher, the goal is to reduce LDL levels by at least 50% with a combination of medications and lifestyle changes.
- People who have an elevated overall 10-year risk of developing plaque in their arteries or risk of heart attack or stroke are also advised to take medications. This 10-year risk is based on a number of risk factors. In general, people with 20% or greater 10-year risk of these conditions benefit from medication. However, these decisions should always be made with your doctor.
- In people with lower levels of risk, additional tests may be done (like a coronary artery calcium score) to try to figure out if you will be helped by taking medications along with making lifestyle changes.
Medications
The most effective medications to treat high cholesterol are statins. These have repeatedly been shown to reduce LDL cholesterol levels and decrease the risk of heart attacks and strokes in at-risk people and people who have had a heart attack or stroke in the past.
Statins work by lessening the activity of a specific enzyme in liver cells, so the liver produces less cholesterol. Some examples of the more commonly prescribed statins include atorvastatin, rosuvastatin, simvastatin, and pravastatin.
The vast majority of people taking statins have no side effects at all. If side effects do occur, they are typically mild and improve with time. You should discuss any possible side effects with your doctor.
Other medications are sometimes used to lower cholesterol. These are typically used with statins when the LDL level is not lowered enough with statins alone. More rarely, they may be used instead of statins if someone has a severe side effect to statin medications.
These medications include ezetimibe (which prevents cholesterol absorption in the intestine) and a newer class of injectable medicines called PCSK9 inhibitors (which increase the liver’s ability to clear LDL cholesterol from the blood).
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