What Is High Cholesterol?
There are two major forms of cholesterol: Low-density lipoprotein or LDL, also known as "bad" cholesterol, and high-density lipoprotein or HDL, also called "good" cholesterol. LDL is the main source of artery-clogging plaque. HDL, on the other hand, clears cholesterol from your blood. Besides LDL and HDL, there’s another kind of fat in your blood called triglycerides. Research shows that high levels of triglycerides, just like high levels of LDL, are linked to heart disease. Your body needs cholesterol to build new cells, insulate nerves, and make hormones. Having too much, though, is a major risk for heart disease. Ordinarily, your liver makes all the cholesterol your body needs. But you also get elevated cholesterol from food. You'll find these in many processed foods like doughnuts, frozen pizza, cookies, and crackers. You can also get it from milk, eggs, meat, and other animal products. Over time, without your even being aware, this extra cholesterol collects inside your body and begins to do damage.
Symptoms of High Cholesterol
High cholesterol doesn’t have symptoms. So, you can be unaware that your levels are getting too high. That’s why it’s important to find out what your cholesterol numbers are. If they're too high, lowering them will lessen your risk for getting heart disease. And if you already have heart disease, lowering cholesterol can reduce your odds of a heart attack or of dying from heart disease.
High Cholesterol Diagnosis
If you’re older than 20, your doctor should measure your cholesterol levels at least once every 5 years. All that’s needed for this is a simple blood test called a lipid profile. The test will show you your:
- Total cholesterol level
- LDL level
- HDL level
- Triglycerides level
Children between ages 9 and 11 should be checked once for high cholesterol, too. Kids should have their cholesterol checked earlier -- after age 2 but by age 10 -- if they have any of these risk factors:
- A mother or grandmother who had a stroke, heart attack, or blocked arteries before age 65
- A father or grandfather who had a stroke, heart attack, or blocked arteries before age 55
- Any parent or grandparent who has or had a total cholesterol level over 240
- Unknown family health history because of adoption
- High blood pressure, diabetes, obesity, and any other conditions linked to heart disease.
Children should have a total cholesterol level below 170 and an LDL below 110. High cholesterol in kids is defined as a total cholesterol level of about 200.
Your numbers will help you and your doctor know not only your risk for heart disease but also the best options for lowering it. For instance, an LDL level of 190 or above in adults is considered very high. The doctor will likely talk to you about taking medicine to lower it. And if your HDL level is 60 or above, your risk of heart disease goes down. The goal is a lower LDL and a higher HDL to prevent and manage heart disease. But cholesterol numbers are only one part of a larger equation. The doctor will also look at your age, blood pressure, smoking history, and use of blood pressure medicines. All of these things plus whether you already have heart disease will give a picture of your chance of a major heart problem over the next 10 years. You and your doctor will use that information to create a plan to lower your risk. This could involve lowering your cholesterol level with diet and medicine.
High Cholesterol Causes, Influences and Risk Factors
Lots of things can raise -- or lower -- your cholesterol levels. They include:
Saturated fats and simple carbohydrates. Reducing the amount of saturated fat, simple carbohydrates, and cholesterol in your diet can help lower your blood cholesterol.
Trans fats. Avoid artificial trans fats, which can raise your cholesterol. Check labels on baked goods, snack foods, frozen pizza, margarine, coffee creamer, vegetable shortenings, and refrigerated dough (such as biscuits and cinnamon rolls). Keep in mind that items that say they have "0 g trans fat" can actually have a tiny bit of trans fat in each serving, which adds up. So, check the ingredients list. "Partially hydrogenated" means it has trans fat in it.
Good fats. Unsaturated fats don't raise cholesterol levels. You can find unsaturated fats in foods like nuts, fish, vegetable oil, olive oil, canola and sunflower oils, and avocados. Limit saturated fats, which you find in animal products, and don't eat processed meats.
Sugar. Eating and drinking too much sugar raises your triglyceride levels. High levels of triglycerides make heart disease more likely. Check food and drink labels to see how much sugar has been added, apart from sugars that are naturally part of a food. The average woman should get no more than 5 teaspoons (or 80 calories) per day from added sugars, and men shouldn't get more than 9 teaspoons per day (or 144) calories, according to the American Heart Association.
Fiber. Fiber helps lower your cholesterol level. You get it from plant foods, like whole grains, beans, peas, and many fruits and vegetables.
Weight. Being overweight is a risk factor for heart disease. It also can increase your cholesterol. Losing weight will help lower your LDL, total cholesterol levels, and triglyceride levels. At the same time, it can help you raise your HDL. The best way to do this is to make changes you can live with long-term, instead of going on a crash diet.
Exercise. Regular exercise can lower LDL cholesterol and raise HDL cholesterol. It's also good for your blood pressure and strengthens your heart. Aim to get 2 hours and 30 minutes of moderate aerobic activity per week (like brisk walking), or 1 hour and 15 minutes of harder exercise (such as jogging) per week.
Age and gender. As you get older, your cholesterol rises. Before menopause, women tend to have lower total cholesterol than men. After menopause, though, women's LDL levels tend to rise.
Heredity. High blood cholesterol can run in families.
Medical conditions. Sometimes, a medical condition may cause higher cholesterol levels. Examples include hypothyroidism (an underactive thyroid gland), liver disease, and kidney disease.
Medications. Some drugs, such as steroids and progestins, can increase the "bad" cholesterol and decrease the "good" cholesterol.
Smoking. Tobacco smoke can raise levels of blood fats (triglycerides) and make your “good” HDL cholesterol go down.
The TLC Program to Lower High Cholesterol
The National Heart, Lung, and Blood Institute created the TLC Program, short for Therapeutic Lifestyle Changes, for people who want to control their cholesterol. Even if you take medications to lower your cholesterol, you may want to consider the possible benefits of this program. It has three parts: diet, exercise, and weight control. The goal: Reduce your risk of heart disease. This is not a fad diet. It’s considered a “balanced” plan, and the idea is to change your habits for the long run.
This plan focuses on foods that are low in natural cholesterol and saturated fats but high in the “good fats.” One class of these good fats is monounsaturated fats. You also get a lot of fiber in this diet.
When you follow the program, you shoot for 2 key numbers every day:
- Less than 7% of your calories from saturated fat
- Fewer than 200 milligrams of dietary cholesterol
You do this to lower your LDL level. You can always talk to your doctor or dietician in more detail about how to measure how much fat and dietary cholesterol you’re taking in.
The first step is to manage dietary fats
When you follow the TLC Program, all the fat you eat in one day should not go over 35% of total calories. Try to avoid saturated fats. They can be found in things like:
- Butter
- Egg yolks
- Fatty cuts of meat
- Lard
- Whole milk dairy products
Trans fats can also raise cholesterol. Avoid them when you can. They are found in products such as:
- Fried foods
- Shortening
- Stick margarine
- Sweets
Foods made with hydrogenated oil or partially hydrogenated oil should also be limited. When you’re grocery shopping, be sure you’re reading labels.
Good fats
Up to 20% of your calories can come from monounsaturated fats. They can help lower your LDL levels. Plus, these fats don’t lower your good, or HDL, cholesterol levels.
Some sources include:
- Avocados
- Olive, canola, and almond oils
- Peanut butter
About 10% of your calories can come from polyunsaturated fats. Use these in moderation. While they lower LDL levels, which you want to happen, they can also lower HDL levels, which is what you don’t want. Some choices:
- Fatty fish such as salmon, mackerel, herring, and trout
- Pumpkin and sunflower seeds
- Soybean, safflower, sunflower, cottonseed, and corn oils
Dietary cholesterol
Your body makes cholesterol, but you also get it from food. Animal products such as red meat, shellfish, and egg yolks, for example, all contain cholesterol. With the TLC Program, you must keep your intake of dietary cholesterol to less than 200 milligrams a day. Choose lean meat and reduced-fat dairy products as often as you can.
Protein
It’s important for growth and helps your body repair cells. Protein-rich foods should make up about 20% of your daily total calories. But here’s the catch. Many protein sources are also high in cholesterol and saturated fat.
You have options beyond lean meats and reduced-fat dairy. They include:
- Beans
- Lentils
- Seeds
- Soy products
The right carbs
Carbohydrates are an important part of good nutrition, but you need to choose the right kind. The program calls for about 50% to 60% of your calories to come from them. Aim for carbs that are complex, meaning they are not heavily processed and are high in fiber. That’s important, because the TLC diet calls for about 20 to 30 grams of fiber a day.
Some great choices:
- Beans
- Fruit
- Lentils
- Quinoa
- Vegetables
- Whole grain and whole wheat sources
That’s a whole lot of information about food to take in, but there are two more pillars to the program.
Exercise
Physical activity is also part of the plan. You should try to get at least 30 minutes of moderate exercise most, if not all, days of the week.
Brisk walking is a great place for many people to start. Some other suggestions:
- Bicycling
- Bowling
- Dancing
- Gardening
Of course, you should talk with your doctor before you start an exercise plan.
Weight
The third part of the TLC Program is about shedding unwanted pounds. Besides the cholesterol, extra fat can increase your chances for high blood pressure, diabetes, heart disease, and other issues. If you’ve improved your diet and exercise but are still struggling with weight, the program suggests checking with your doctor.
It also offers ideas to help with your goal of weight loss:
- Slow down while you eat; it takes the brain a while to get the message you’re full
- Eat more fruits and vegetables; they make you feel full
- Serve your food on smaller plates
- Eat three meals a day; don’t skip any
TLC Program how-tos
The TLC Program works best when you work directly with your doctor or dietician, who can also guide you to become more active, manage your weight, and reach your cholesterol goals. With this program, you start out meeting with your doctor every 6 weeks to track how well lifestyle changes are working for you. Your doctor can also help you control other things that make heart disease more likely, including quitting smoking and controlling high blood pressure, for example. For some people, lifestyle changes alone may not be enough. You may need medication, too. But with lifestyle changes such as the TLC Program, you may be able to take lower doses.
Medications to Lower High Cholesterol
The goal of cholesterol treatment is to help you prevent a heart attack or stroke. So, the drugs your doctor prescribes also depend on your chances for heart disease.
The higher your risk, the more important it is to get your levels down. Your doctor will look at all of your risk factors and decide which medications will help you the most.
Cholesterol-lowering drugs include:
- Statins
- Niacin
- Bile-acid sequestrants
- Fibrates
- Cholesterol absorption inhibitors
- PCSK9 inhibitors
Cholesterol-lowering drugs work best when combined with a low-cholesterol diet and an exercise program.
Statins
Statins block the production of cholesterol in the liver. They lower LDL and triglycerides and can slightly raise HDL. These drugs are the first treatment for most people with high cholesterol. If you already have heart disease, statins reduce the chances of heart attacks. Side effects can include diabetes, liver damage, and, in a few people, muscle tenderness or weakness. If your doctor prescribes statins, you should ask them the percentage by which you should lower your cholesterol. Generally, it will be between 30% and 50%. Commonly used statins include:
- Atorvastatin (Lipitor)
- Fluvastatin (Lescol, Lescol XL)
- Lovastatin (Altocor, Altoprev, Mevacor)
- Pitavastatin (Livalo)
- Pravastatin (Pravachol)
- Rosuvastatin (Crestor)
- Simvastatin (Zocor)
Niacin
Niacin is a B vitamin. It's found in food, but you can get high doses by prescription. It lowers LDL cholesterol and raises HDL cholesterol. The main side effects are flushing, itching, tingling, and headache. Aspirin can reduce many of these symptoms. Speak with your doctor first, though, before taking aspirin. Research suggests that even though niacin may improve your cholesterol numbers, it doesn’t appear to lower your risk of heart disease, especially if you’re already taking a statin.
Bile acid sequestrants
These drugs work inside the intestine, where they bind to bile and prevent your circulatory system from reabsorbing it. Bile is made largely from cholesterol, so these drugs work by reducing the body's supply of cholesterol. That then lowers both total and LDL cholesterol. The most common side effects are constipation, gas, and upset stomach. Commonly used bile acid sequestrants include:
- Cholestyramine resin (Prevalite, Questran, and Questran Light Questran Light)
- Colesevelam (WelChol)
- Colestipol (Colestid)
Fibrates
Fibrates lower triglyceride levels and can increase HDL and lower LDL. Scientists think fibrates help your body break down triglyceride-rich particles and stop it from putting out certain blood fats. Commonly used fibrates include:
Cholesterol absorption inhibitors
Ezetimibe (Zetia) lowers LDL by inhibiting the absorption of cholesterol in the intestines. Vytorin is a drug that combines ezetimibe and a statin. It can decrease total and LDL cholesterol and raise HDL levels.
PCSK9 inhibitors
You get this newer type of cholesterol-lowering drug as a shot. Doctors use it to treat people with a genetic form of high cholesterol called familial hypercholesterolemia.
Combination drugs
Some people with high cholesterol get the best results with combination drugs. These are pills that contain more than one medication. Commonly used combination drugs include:
- Advicor: Lovastatin and niacin (nicotinic acid)
- Caduet: Atorvastatin and amlodipine
- Liptruzet: Atorvastatin and ezetimibe
- Simcor: Simvastatin and niacin (nicotinic acid)
- Vytorin: Simvastatin and ezetimibe
Multiple medications
Sometimes, one cholesterol medicine just won’t cut it. Even if you live a healthy lifestyle and take your pills the way you should, you may need extra help getting your levels to a healthier range. But that doesn’t mean you have to live with high cholesterol. Help can come in the form of a second or even a third medication. Your doctor might recommend adding a medication if:
- Your statin hasn’t helped. Statins are a mainstay of cholesterol treatment. But they don’t work well enough for everyone who takes them. If that’s the case for you, your doctor might recommend that you add another medicine to your treatment.
- You have side effects from statins. These drugs can cause muscle pain, liver damage, and other problems that make it hard for some people to take them. Doctors can prescribe a lower dose to ease side effects, but that means adding another medication to bring down cholesterol.
- You have a genetic form of high cholesterol. Familial hypercholesterolemia (FH) is a condition that causes very high levels of cholesterol -- so high that one drug and lifestyle changes won’t do enough. People with FH usually take a statin and one or two other drugs.
- You can’t take a statin. The pills aren’t safe for people with liver disease or women who are pregnant or breastfeeding. Doctors will rely on other types of drugs to lower cholesterol.
- You have high triglycerides. Some drugs do a better job of bringing down these blood fats than others. Your doctor might add another drug that targets them.
Side Effects of Cholesterol-Lowering Drugs
The side effect you need to be most concerned about is muscle aches. They could be a sign of a life-threatening condition. If you have muscle aches, call your doctor immediately.
Other side effects of cholesterol-lowering drugs include:
- Abnormal liver function
- Allergic reaction (skin rashes)
- Heartburn
- Dizziness
- Abdominal pain
- Constipation
- Decreased sexual desire
- Memory loss
Foods or Other Drugs to Avoid
Ask your doctor about the other drugs you’re taking, including herbals and vitamins, and their impact on cholesterol-lowering medications. You shouldn’t drink grapefruit juice while taking cholesterol-lowering drugs. It can make it harder for your liver to process these medications.
Complications of High Cholesterol
When you have too much cholesterol, it builds up in the walls of your arteries, causing them harden -- a process called atherosclerosis. It also narrows your arteries, which slows and even blocks the flow of blood. That’s where the problem starts. Your blood is supposed to carry oxygen to all parts of your body, including your heart muscle. Without enough oxygen, your body’s parts won’t work the way they’re supposed to.
Complications of high cholesterol include:
- High blood pressure. If clogged arteries make it hard for blood to move to and from your heart, the heart has to pump harder, and your blood pressure will go up.
- Chest pain. If your heart muscle doesn’t get enough blood and oxygen, you'll have chest pain.
- Heart attack or stroke. If a piece of plaque breaks off or forms a clot, it can cut off the blood supply to a portion of your heart, causing a heart attack or stroke. If you have heart disease risk factors (like smoking, diabetes, or high blood pressure), you’re especially at risk of this complication.
- Peripheral artery disease (PAD). A cholesterol buildup can block blood flow to the arteries in your legs and feet. PAD may also affect arteries in your kidneys.
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