Medically reviewed by Dr. C.H. Weaver M.D 9/2020

Every day we are bombarded with messages about our food. With so many foods labeled “cholesterol free,” it can be easy to assume that cholesterol is a bad thing. But the truth is that although there is no dietary requirement for cholesterol, this complex fatty substance is vital to our health.

Cholesterol is a substance found in your body and in many foods. It is described as “fat-like” and “waxy.” Cholesterol is essential to your body’s ability to function, but you don’t need cholesterol from food—your body produces the necessary amount.

Cholesterol and Heart Health

Excess, or high, blood cholesterol can be a hazard to your health. High cholesterol can result from diet and lifestyle and can also be hereditary. It can build up in your arteries, inhibiting the passage of blood and raising your risk for heart disease. This extra cholesterol in your arteries is called plaque.Plaque buildup can block the arteries that carry blood to the heart, which causes a heart attack. As well, a heart attack can occur when a deposit of plaque ruptures, creating a clot in the artery. Plaque can also partially block a coronary artery, which reduces blood flow to the heart; in such cases a person may experience chest pain, or angina.

Cholesterol In Depth

LDL and HDL: “Bad” Versus “Good” CholesterolYou may have heard the two types of cholesterol described as “bad” and “good.” The distinction refers to the two kinds of lipoproteins that carry cholesterol in the blood: low-density lipoprotein (LDL) and high-density lipoprotein (HDL).

  • Bad cholesterol, or LDL: When present in high levels, LDL can result in heart disease. LDL makes up the majority of the cholesterol in your blood.
  • Good cholesterol, or HDL: At high levels, HDL can reduce your risk of heart disease because it absorbs cholesterol and carries it back to the liver.

What are the symptoms of high cholesterol?

Only a blood test can detect high cholesterol. It usually has no signs or symptoms.

Risks

Anyone — regardless of age, background, or family history—can be at risk for high cholesterol, though it can also be a hereditary condition (see “Genetics and Cholesterol” below to learn more about hereditary risk).According to the Centers for Disease Control and Prevention (CDC), approximately one in every six U.S. adults, or about 16 percent, has high cholesterol, a condition which doubles the risk of heart disease compared with healthy cholesterol levels. More women than men in the United States have high cholesterol.Diabetes: People with diabetes—a condition involving the body’s use of the hormone insulin and its ability to regulate blood sugar—may be more likely to develop high cholesterol.

What Your Numbers Mean

To determine your cholesterol levels, you must get a blood test from your doctor. One test, called a lipoprotein profile, measures several types of cholesterol as well as triglycerides (a type of fat found in blood; high levels raise risk for heart disease). Another, simpler test measures total and HDL cholesterol.The following, according to the CDC, are healthy, or desirable, cholesterol numbers: Total cholesterol Less than 200 mg/dL LDL (“bad” cholesterol) Less than 100 mg/dL HDL (“good” cholesterol) 40 mg/dL or higher Triglycerides Less than 150 mg/dL

Diet and Cholesterol

Avoiding or minimizing intake of certain foods that may raise cholesterol levels can be beneficial. Foods with saturated fats (such as animal fats and some vegetable oils), trans fatty acids (vegetable oil hardened by a process call hydrogenation; used in many snack foods and fast food), and triglycerides and foods high in dietary cholesterol (like beef, lamb, and eggs) may raise blood cholesterol levels.Other dietary factors that can adversely affect your cholesterol levels include eating too many carbohydrates, which can lower HDL cholesterol and raise triglycerides, and drinking alcohol, which can raise triglycerides and also cause high blood pressure—another risk for heart disease.A dietician can help you learn which foods are most beneficial. Fresh fruits and vegetables, for example, are an excellent addition to any healthy diet; they’re also good sources of fiber, which can help lower cholesterol. You may also be able to lower your cholesterol levels by eating certain fats, including monounsaturated and polyunsaturated; examples of food sources of these include salmon, trout, olives, olive oil, and avocados.

Controlling Cholesterol

Controlling cholesterol is achieved through diet, exercise, and weight maintenance (see “Diet and Cholesterol” above and “Lifestyle Changes” below) and sometimes with medications prescribed by your doctor.The basic steps toward maintaining healthy cholesterol levels are:

  1. Get a blood test to learn your cholesterol levels.
  2. Maintain a healthy diet.
  3. Get regular exercise.
  4. Don’t smoke.
  5. If you have high cholesterol, as indicated by a blood test, talk with your doctor about treating it—possibly with prescription medication (learn more about cholesterol-lowering drugs later in “Medical Treatments”).

Genetics and Cholesterol

High cholesterol can be hereditary, meaning it runs in families. This is called familial hypercholesterolemia, and those affected may develop high LDL levels at a young age. According to the CDC, familial hypercholesterolemia affects one out of every 500 people in the United States. High cholesterol also has a tendency to run in families without familial hypercholesterolemia, which is likely the result of shared genetic and environmental factors; this means family history is always an important consideration when determining risk.People with family members with high cholesterol may want to be especially mindful of their cholesterol numbers and of following lifestyle recommendations. Detecting and treating high cholesterol early can help reduce risk of heart disease among those with a genetic risk, as well as among the general population.

Medical Treatment

Medications may be prescribed to treat high cholesterol. These drugs are aimed primarily at controlling LDL cholesterol levels, and your doctor will take into account your current LDL level to select the appropriate treatment. Your risk of heart disease and stroke (based on high blood pressure, smoking status, age, HDL level, and early heart disease and whether you have diabetes or existing cardiovascular disease) will also guide treatment decisions.

Types of medicine to treat high cholesterol

  • Statin dugs. These work by lowering LDL cholesterol and slowing down the liver’s production of cholesterol. As well, statins can boost the liver’s ability to remove LDL cholesterol from the blood.
  • Bile acid sequestrants. These drugs eliminate bile acids to help remove cholesterol from the blood. The body, which needs bile acids, will then make more and does so by breaking down LDL cholesterol. As a result, LDL levels are reduced.
  • Niacin, or nicotinic acid. Niacin, a B vitamin, can help the body achieve healthy levels of all cholesterols. Nicotinic acid lowers total cholesterol, while also lowering LDL and triglyceride levels and raising HDL levels. These medicines, however, are associated with possible side effects and medical supervision is required.
  • Fibrates. Fibrates are mainly intended to lower triglyceride levels but can also raise HDL levels.

Understanding Statin Guidelines

Your doctor may have recommended healthy lifestyle changes and medications called statins. These drugs are designed to reduce cholesterol that’s too high. A couple of examples include Lipitor® (atorvastatin) and Crestor® (rosuvastatin).Established guidelines can help you and your doctor decide if you might benefit from statins. Researchers are now looking to see how well these guidelines help doctors prescribe statins to the right patients, and in two recent studies, they put the ACC/AHA guidelines to the test.

In the first study, researchers compared the ACC/AHA guidelines with another set of standards for identifying individuals at risk for heart disease—National Cholesterol Education Program’s 2004 Updated Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (ATP III) guidelines. They found that the ACC/AHA guidelines more accurately helped doctors recognize patients at risk for heart disease. (1)

In another study, researchers looked specifically at whether the ACC/AHA guidelines helped doctors and patients make cost-effective decisions about using statins. Cost-effectiveness includes whether statin treatment was worth the money spent and whether patients at lower risk of heart disease and less likely to benefit from statins were spared the expense. The researchers found that the ACC/AHA guidelines for statin use were acceptably cost-effective—good news for anyone currently taking statins and those considering treatment.

Peace of Mind - Your doctor will still use his or her best judgment, based on your personal circumstances, to decide if statin drugs are a good option to help you lower your cholesterol. But it’s reassuring to know that the tools your provider uses to determine your risk for heart disease and eligibility for statin drugs, the ACC/AHA guidelines, stand up when put to the test for accuracy and managing healthcare costs. Don’t forget, however, that in addition to medication, healthy eating and exercise can go a long way to helping you lower your cholesterol and reduce your risk of heart attack and stroke.

Lifestyle Changes

There is good news about healthy cholesterol levels among Americans: according to the CDC, cholesterol levels have been decreasing in recent decades. Lifestyle changes, including avoiding foods high in saturated or trans fats or high in cholesterol, maintaining a healthy weight, staying active, and not smoking can continue to keep cholesterol at healthy levels among the U.S. population.

Diet - See “Diet and Cholesterol” above for a list of substances in foods and examples of foods that may contribute to high cholesterol levels, as well as examples of foods to help you maintain healthy levels. Avoiding cholesterol-raising foods and choosing foods that help control or lower cholesterol will help you keep your cholesterol at healthy levels.

Weight - Maintain a healthy weight—being overweight or obese may raise total cholesterol levels, while raising LDL cholesterol and lowering HDL cholesterol. Your doctor can help you determine whether you’re overweight, and, if so, what your optimal, healthy weight should be.

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Physical Activity - You can help manage your cholesterol levels by staying active. Exercise can help you maintain a healthy weight, which will help to control your cholesterol levels. According to the Surgeon General, you should aim for at least 30 minutes of moderate-intensity activity most days of the week.

Don’t Smoke - Smoking, in addition to raising your risk of lung cancer and several other cancers, raises your risk of heart disease and stroke by damaging the blood vessels and hardening the arteries. If you do smoke, your doctor can help you find a program to help you quit. Also, be aware of secondhand smoke, another risk of heart attack and stroke.

What Is Cholesterol?

Cholesterol is a soft, waxy substance found in the bloodstream and in each cell of your body. It is an important structural component of human and animal cells and serves as a building block for many hormones.2

There are two general sources of cholesterol­­: your body and your food. The liver and other cells in the body produce about 75 percent of the cholesterol that circulates in the bloodstream. The remaining 25 percent is a result of the food you eat.

Cholesterol is essential to life, but, as with anything, too much of a good thing can be bad. Hypercholesterolemia is a medical term that refers to high levels of cholesterol in the blood. The condition is associated with a higher risk of cardiovascular disease and stroke. According to the Centers for Disease Control and Prevention, one in six Americans has high blood cholesterol.

Sometimes people refer to “good” cholesterol and “bad” cholesterol. Low-density lipoproteins, or LDLs, are the “bad” cholesterol that can build up and form plaque that blocks arteries and potentially leads to heart attack or stroke. High-density lipoproteins (HDLs), on the other hand, appear to protect against heart attacks by carrying cholesterol away from the arteries and back to the liver.

What Causes High Cholesterol?

Cholesterol levels are maintained by a number of regulated steps and to a large extent are genetically predetermined. Several lifestyle factors can affect cholesterol levels, however, including diet, obesity, and smoking.

Being overweight or obese can raise blood cholesterol levels, so losing as little as 10 percent of total weight, or 10 to 20 pounds, is often enough to lower the levels into a range that is associated with a reduced risk of heart disease. Tobacco and high blood pressure also raise blood cholesterol levels, so quitting smoking will make a big difference (for a number of health concerns). Type 2 diabetes is an additional risk factor.

When you put all of these risk factors together, the risk of heart disease is elevated six times.

Diet and Cholesterol

Foods that are naturally rich in cholesterol include egg yolks and organ meats. In the United States, most of the cholesterol in our diet comes from meat—especially processed meats, which include organ meats. For many people simply reducing the amount of meat, whole eggs, and dairy products in their diet is enough to bring cholesterol levels into a healthy range.

The National Cholesterol Education Program recommends consuming a diet that contains less than 200 milligrams of cholesterol per day. To put that number in perspective, a large egg yolk has 212 milligrams, so eating an egg each day would exceed this limit. We don’t need to assess day by day, however, but can take an average amount within our usual eating pattern. For example, using this method, eating a couple of eggs twice a week would be within the recommended limit. Of course, if you are eating other food sources of cholesterol, such as meat, you would need to be more careful of your intake of egg yolks. Egg whites have no cholesterol and are an excellent choice for extending eggs in omelets and other breakfast dishes.

Saturated fats, especially those that come from dairy and meat sources, also raise blood cholesterol levels. Saturated fats are described as “solid fat” in newer government guidelines because they are solid at room temperature. The recommended amount depend on a person’s activity level. A very active teenage boy might consume 3,200 calories, with 20 percent coming from extra discretionary calories, but a sedentary woman who burns 1,600 calories a day would have a smaller allowance of 8 percent of “extras.”

Making Healthy Choices

There are three major diet regulators of healthy blood cholesterol levels.

1. Avoid saturated fat. Eating a diet that is low in meat and saturated animal fats (processed meats like sausage and full-fat dairy products, for example) appears to regulate liver production of cholesterol and is more important in some people than in others. Interestingly, the liver is capable of making as much as 80 percent of your cholesterol requirements, so we don’t actually need to consume it in the diet. This is why vegans who don’t consume any cholesterol usually don’t suffer from cholesterol deficiency.

2. Consume dietary fiber. Foods such as vegetables, beans, and fruit contain indigestible carbohydrates called dietary fiber. Fiber helps modify the intestinal environment, providing support for beneficial microorganisms (probiotics), and it appears to benefit overall health. Nuts like almonds or pistachios, which are high in fiber, may be helpful in lowering cholesterol levels by providing dietary fiber as well as healthy oils.

3. Consume plant sterols. Plant sterols, or phytosterols, are the plant version of cholesterol. These compounds, which are found in beans, vegetables, and many other plant foods, appear to compete for cholesterol in the small intestine and thus reduce the overall blood levels.

4. Physical Activity. You can help manage your cholesterol levels by staying active. Exercise can help you maintain a healthy weight, which will help to control your cholesterol levels. According to the Surgeon General, you should aim for at least 30 minutes of moderate-intensity activity most days of the week.

5. Don’t Smoke Smoking, in addition to raising your risk of lung cancer and several other cancers, raises your risk of heart disease and stroke by damaging the blood vessels and hardening the arteries. If you do smoke, your doctor can help you find a program to help you quit. Also, be aware of secondhand smoke, another risk of heart attack and stroke.

Taking Care of Your Cholesterol Levels

Cholesterol is a complicated and active area of nutrition research. Diet appears to affect some people more than others. For most of us, eating a diet that is made up of predominantly plant rather than animal fats is healthy for our hearts and could reduce the risk of other chronic conditions, including many forms of cancer.

Questions to Ask Your Doctor

  • What is my risk of heart disease?
  • What is my blood pressure? What does it mean for me, and what do I need to do about it?
  • What are my cholesterol numbers? [These include total cholesterol, LDL, HDL, and triglycerides—a type of fat found in the blood and in food.] What do they mean for me, and what do I need to do about them?
  • What are my body mass index and waist measurement? Do they mean that I need to lose weight for my health?
  • What is my blood sugar level, and does it mean that I’m at risk for diabetes? If so, what do I need to do about it?
  • What other screening tests do I need to help protect my heart?
  • What can you do to help me quit smoking?
  • How much physical activity do I need to help protect my heart?
  • What’s a heart-healthy eating plan for me? How can I tell if I’m having a heart attack? If I think I’m having one, what should I do?

Medications to Treat High Cholesterol

These drugs are aimed primarily at controlling LDL cholesterol levels, and your doctor will take into account your current LDL level to select the appropriate treatment. Your risk of heart disease and stroke (based on high blood pressure, smoking status, age, HDL level, and early heart disease and whether you have diabetes or existing cardiovascular disease) will also guide treatment decisions.

  • Statin drugs. These work by lowering LDL cholesterol and slowing down the liver’s production of cholesterol. As well, statins can boost the liver’s ability to remove LDL cholesterol from the blood. Could Statins undo the benefits of exercise? Statin Guidelines
  • Bile acid sequestrants. These drugs eliminate bile acids to help remove cholesterol from the blood. The body, which needs bile acids, will then make more and does so by breaking down LDL cholesterol. As a result, LDL levels are reduced.
  • Niacin, or nicotinic acid. Niacin, a B vitamin, can help the body achieve healthy levels of all cholesterols. Nicotinic acid lowers total cholesterol, while also lowering LDL and triglyceride levels and raising HDL levels. These medicines, however, are associated with possible side effects and medical supervision is required.
  • Fibrates. Fibrates are mainly intended to lower triglyceride levels but can also raise HDL levels.

References:

  1. Your Guide to a Healthy Heart. National Heart, Lung, and Blood Institute Web site. Available at:
  2. Cholesterol. The Centers for Disease Control and Prevention Web site. .
  3. Pursnani A, Massaro JM, D’Agostino RB Sr, et al. Guideline-Based Statin Eligibility, Coronary Artery Calcification, and Cardiovascular Events. Journal of the American Medical Association. 2015 July 14;314(2):134-41.
  4. Pandya A, Sy S, Cho S, Weinstein MC, Gaziano TA. Cost-effectiveness of 10-Year Risk Thresholds for Initiation of Statin Therapy for Primary Prevention of Cardiovascular Disease. Journal of the American Medical Association. 2015 July 14;314(2):142-50.