Having high cholesterol, or trying to prevent it, is a worry for many Americans. It's a well-known fact that high lipid levels can increase your risk for a heart attack or stroke. But how do you treat high cholesterol, or better yet, prevent it? Follow along with this Cholesterol Overview to better understand your risk of high cholesterol, types of fats, the causes of high lipids, your diagnosis, treatment, and recommended lifestyle changes.
What is cholesterol?
Cholesterol is a waxy substance that is made by the body and has a specific purpose: to help with cell growth and function. All the cholesterol we need is made in our body. Cholesterol is important to help make hormones, vitamin D, and certain enzymes.
About a quarter of cholesterol comes from our diet from foods like eggs, meat, cheese, and whole milk. When these levels get too high, cholesterol can block blood vessels and lead to serious outcomes like a heart attack or stroke.
Other names for the condition "high cholesterol" include:
- lipid disorders
How did I get high cholesterol?
Lipid disorders (hyperlipidemia) occur when you have too many fatty substances in your blood. These substances include cholesterol and triglycerides. The fat substances can build up on the walls of your arteries, block your blood vessels and prevent the proper flow of blood and oxygen throughout your body. Diet is the primary source of high cholesterol for most people, but genetics (your inherited genes and family history) can play a role too.
- Having a lipid disorder makes you more likely to develop atherosclerosis (hardened arteries) and a disease of blood vessels that go to the heart disease (coronary artery disease). This may lead to a heart attack.
- Blockage of blood vessels that supply the brain can lead to cerebrovascular disease. This can cause a stroke.
- Hardening of vessels that supply the limbs such as the legs and arms is called peripheral vascular disease.
Cholesterol can be bound to fat and protein at different levels. The main types of fat include:
- low-density lipoproteins (LDL) -- often called "bad" cholesterol. This type of cholesterol clogs your arteries. Diet high in fats such as saturated fats and trans fats will cause LDL levels to increase.
- high-density lipoproteins (HDL) -- often called "good" cholesterol. HDL is actually protective for the heart. HDL helps to clear bad cholesterol from the blood and helps to prevent artery disease. That is why it is better to have high levels of HDL.
- triglycerides -- triglycerides are stored in fat cells, and come from alcohol, sugar, and excess carbs. Typically they are released for energy.
In general, you want your LDL and triglycerides to be low, and your HDL to be high. Your doctor has a range of optimal numbers for these lipid levels, but will also review your risk for heart disease or stroke based on other factors. These factors may include your family history, weight, lifestyle habits like smoking, exercise, attempt to lose weight, and other important high cholesterol risk factors.
How many Americans have high cholesterol?
Many people struggle with high cholesterol levels. Children, younger adults and older Americans can have high cholesterol. In fact, according to the CDC, about 38% of Americans have unhealthy total cholesterol levels at or above 200 mg/dL.
The good news is that a diagnosis of high cholesterol involves a simple blood test and a discussion of your risk factors with your primary care doctor. A healthy diet and regular exercise also plays a role in controlling your lipids. There are many effective treatments available for high cholesterol. Some of the most common medications, known as statins, are also very affordable.
Risk factors for high cholesterol
There are many factors that can lead to high cholesterol:
- eating a diet high in saturated fat and trans fats.
- high cholesterol, high triglycerides, low HDL and other lipid disorders can be inherited (genetic).
- lifestyle factors, including excessive alcohol use, lack of exercise, and being overweight or obese.
- older age
Can medications increase my cholesterol?
Yes, some medications such as certain hormones or high blood pressure drugs may increase your lipid levels. However, it may be important for you to continue to take these medications. Your doctor can follow your lab tests and determine if you need further medications to help adjust your cholesterol or triglyceride levels while still safely using these medications.
Medicines that may affect your elevate your lipids include:
- birth control pills (estrogen and progestin)
- corticosteroids like prednisone
- anabolic steroids such as testosterone
- certain diuretics (thiazide diuretics and loop diuretics)
- protease inhibitors used in HIV treatment
- beta-blockers used in heart disease
This is not a complete list of medicines that may affect your cholesterol level. Do not stop any medication without talking to your doctor first.
There are no symptoms linked with high cholesterol by itself, but heart disease can lead to a development of plaques in your arteries called atherosclerosis. These plaques block proper blood flow and oxygen delivery which can affect your heart, brain, and blood vessels throughout your body. If heart disease develops, you may have chest pain (angina). A stroke or peripheral artery disease are other outcomes.
Starting around age 20, adults should have their first cholesterol test (known as a lipid profile). If they are of average risk, a repeat test should be performed every 5 years. Men 45 to 65 years of age and women ages 55 to 65 years should be screened every 1 to 2 years.
A fasting lipid test (lipoprotein test) breaks down cholesterol into four groups:
- total cholesterol: levels below 200 mg/dL are preferable.
- low density lipoproteins (LDL or bad cholesterol): it is best to have LDL cholesterol under 100 mg/dL, but it may need to be lower (< 70 mg/dL) if you have heart disease.
- high density lipoproteins (HDL or "good" cholesterol): best if 60 mg/dL and above.
- triglycerides: best of levels are 150 mg/dL or lower; higher numbers can elevate your risk for heart disease and diabetes.
In general, a total cholesterol value over 200 mg/dL may indicate a greater risk for heart disease. However, LDL levels are a better predictor of heart disease and determine how your high cholesterol should be treated.
Many patients have their cholesterol levels drawn in the morning. You may be asked not to eat or drink anything (other than water) for nine to 12 hours before your lab appointment (this is called "fasting). Blood is drawn from a vein, usually from your arm, and it's a quick and simple test.
Some patients may only have their total cholesterol levels checked, along with their HDL levels. This is also a simple blood test and it does not require fasting. Be sure to ask your doctor which test you are having and if you need to fast.
Screening in children begins at ages 9 to 11 and should be repeated at ages 17 to 21, but may start earlier in children with high risk factors (obesity, diabetes, family history).
How you are treated may depend on whether you have any of these additional risk factors, such as:
- coronary artery disease
- high blood pressure
- a smoker
- male and over age 45 or female and over age 55
- have a first-degree female relative diagnosed with heart disease before age 65 or a first-degree male relative diagnosed before age 55
- metabolic syndrome (high triglycerides, low HDL, and obesity)
Discuss your results with your health care provider to determine the best therapy for your history, medical conditions, and lifestyle. The most recent guidelines focus more on your risk for heart disease, heart attack and stroke and focus less on a target number.
There are several types of lipid lowering drugs. Some are better at lowering LDL cholesterol and some are more effective for reducing triglycerides. Some drugs are more potent than others, and they can have different side effects.
The choice of treatments will depend upon your risk factors, family history, age, additional medical conditions and costs.
Statins are also known as HMG-CoA reductase inhibitors. They are the most effective drugs in lowering LDL cholesterol, and are usually selected as the first treatment in most people. Most of these drugs are now available generically and are affordable.
- Common statin examples include: atorvastatin (Lipitor), fluvastatin (Lescol XL), and rosuvastatin (Crestor).
Some statins are available in combination for ease of administration; however, because doses are fixed it may be difficult to adjust doses. Common products include:
- Caduet (amlodipine and atorvastatin)
- Roszet (ezetimibe and rosuvastatin)
- Vytorin (ezetimibe and simvastatin)
PCSK9 inhibitors (proprotein convertase subtilisin/kexin type 9 inhibitors) are a newer class of injected medications to help dramatically lower cholesterol.
- PCSK9 inhibitors include the injections alirocumab (Praluent) and evolocumab (Repatha).
Cholesterol absorption inhibitors
Cholesterol absorption inhibitors work by reducing the absorption of dietary cholesterol through the intestines.
- Ezetimibe (Zetia) reduces total cholesterol and LDL (bad) cholesterol by blocking the absorption of dietary and naturally-made cholesterol.
Bile acid sequestrants
Bile is used for digestion. Bile acid sequestrants work in the intestine after oral administration to bind to bile acids from the liver and reduce serum cholesterol levels.
- Common examples of bile acid sequestrants include: colestipol (Colestid), cholestyramine (Prevalite) and colesevelam (Welchol).
Fibrates (fibric acid derivatives)
Fibrates are regarded as broad-spectrum lipid lowering drugs; however, they are especially helpful for people with high triglyceride levels.
- Common examples of fibrates include: gemfibrozil (Lopid) and fenofibrate (Fenoglide, Lipofen, Tricor),
Nicotinic acid (niacin)
Nicotinic acid (also known as niacin or vitamin B3) lowers both total and LDL cholesterol and triglyceride concentrations by inhibiting synthesis. It also increases HDL cholesterol. Niacin use is limited by its side effect profile, especially vasodilatation (flushing).
- Common products include: niacin immediate-rlease (Niacor), and niacin extended-release (Niaspan).
Adenosine triphosphate-citrate lyase (ACL) inhibitors
ACL inhibitors lower LDL-C by inhibition of cholesterol synthesis in the liver. These products are used in conjunction with a statin. Nexlizet (bempedoic acid and ezetimibe) is a combination ACL inhibitor and cholesterol absorption inhibitor
- Common products include: Nexletol (bempedoic acid), bempedoic and ezetimibe (Nexlizet)
Angiopoietin-like 3 (ANGPTL3) inhibitors
ANGPTL3 inhibitors block ANGPTL3, a protein that plays a key role in lipid metabolism.
- Common products are: Evkeeza (evinacumab-dgnb).
Dietary supplements are bought over-the-counter (OTC) and marketed to help lower cholesterol.
- Using these agents by themselves may not be enough to lower your cholesterol levels.
- Check with your doctor for recommendations about use of supplements.
- Common products selected as dietary supplements include: plant sterols or stanol, fish oil, soy, and garlic.
Possible complications of high cholesterol include:
- atherosclerosis (fatty deposits that clog your arteries)
- angina (chest pain)
- coronary artery disease (fatty deposits in arteries to the heart), also called heart disease
- chronic kidney disease
- peripheral artery disease (fatty deposits in veins of legs, arms)
- blood clot (thrombus)
- heart attack (myocardial infarction)
When to contact a healthcare provider
Adults should have their cholesterol checked every 5 years or so, starting around the age of 20. If you have high cholesterol or other risk factors for heart disease, make appointments as recommended by your doctor. As you get older, you'll need to have your cholesterol checked more frequently, usually at least once per year.
If you experience chest pain (heart attack) or the symptoms of a stroke, contact emergency medical services or call 911 immediately.
To help prevent high cholesterol and maintain a healthy heart by following these tips:
- keep your body weight in a healthy range
- eat a well-balanced, low-fat diet
- focus on fruits and vegetables in your diet
- limit cholesterol intake
- exercise most days of the week for at least 30 minutes (such as brisk walking, swimming, or biking)