Your body needs cholesterol, a waxy substance made in the liver and intestines, to build cell membranes in every cell, produce certain hormones, and digest food. Cholesterol is transported in your blood by lipoproteins, which include lipids (aka fats) and proteins. Lipoproteins act as carriers that hold together cholesterol, certain lipids, and triglycerides — a type of fat found in the blood. One commonly tested form of cholesterol is low-density lipoprotein (LDL), often known as “bad” cholesterol because it’s associated with increased cardiovascular risk. Another is high-density lipoprotein (HDL), also referred to as “good” cholesterol because it’s protective and associated with good health. Although having elevated LDL may raise your risk for heart attack and stroke, high HDL may protect you against these risks, notes the American Heart Association (AHA). Until very recently, patients had been told to fast for 9 to 12 hours before being tested. Now, new research involving more than 300,000 people, published in April 2016 in the European Heart Journal, says it’s not necessary to do a cholesterol test on an empty stomach, though some doctors still recommend it. A cholesterol test measures HDL, LDL, and triglycerides; other lipoproteins may be tested by a lipid specialist. A lab report may list your results for each of these, with additional information showing desirable targets in milligrams per deciliter (mg/dL): Total Cholesterol
Less than 200: desirable200–239: borderline high240 and above: high
HDL
Less than 40 (men), less than 50 (women): increased risk of heart diseaseGreater than 60: some protection against heart disease, for men and women
LDL
Less than 100: optimal100–129: near optimal130–159: borderline high160–189: high190 and above: very high
Triglycerides
Less than 150: normal150–199: borderline high200–499: highAbove 500: very high
Cholesterol Ratio This measures your level of HDL cholesterol in relation to your total. (You divide HDL into your total.) An optimal ratio is less than 3.5 to 1. A higher ratio means you’re more at risk for heart disease.
Do You Need Medication to Control High Cholesterol?
Whether you’ll need to take medication to lower your cholesterol depends on your levels, as well as on your other risk factors for heart disease, including your sex, age, health history, and family medical history. “Until recently, doctors decided whether or not to treat high cholesterol based on these numbers,” explains Holly Andersen, MD, an attending cardiologist at NewYork-Presbyterian Hospital/Weill-Cornell Medical Center in New York City. Now, when it comes to deciding if you’d benefit from taking medication to lower your cholesterol, “your score [cholesterol level] is no longer a solo consideration,” Dr. Andersen says. The change is a result of the November 2013 guideline on the assessment of cardiovascular risk issued jointly by the American Heart Association and the American College of Cardiology. These recommendations advise doctors to consider a patient’s overall health for heart disease, not just cholesterol numbers. Some of the factors used to measure your heart disease risk are:
Your age, gender, and raceWhether you smokeBlood pressure (and whether it’s being treated)Whether you have diabetes
Your physician may plug your numbers and other factors into the ACC/AHA ASCVD Risk Estimator to determine your 10-year risk of heart disease or stroke. If you have the data, you can calculate the risk yourself using an online tool like this Heart Risk Calculator. The drugs most commonly prescribed for high cholesterol are statins, such as Lipitor (atorvastatin), Zocor (simvastatin), and Crestor (rosuvastatin). If you have very high cholesterol, a newer medication like Praluent (alirocumab), a PCSK9 inhibitor the FDA approved in 2015, may be needed as well. According to guidelines, if your score for heart attack risk over the next 10 years is 7.5 percent or higher, you could benefit from taking a cholesterol-lowering statin. Depending on how great your risk is, you might need a “high-intensity” or “moderate-intensity” statin, says Michael Rocco, MD, medical director of cardiac rehabilitation and stress testing at the Cleveland Clinic in Ohio. “In very high-risk patients — someone who already has cardiovascular disease, for example, or who has familial hypercholesterolemia — we still focus on target numbers.”
Preventive Steps for High Cholesterol and Heart Health
When you have high cholesterol, staying heart-healthy requires more than a regimen of statins. Even if you’re on medication, it is absolutely essential to make lifestyle changes: Stop smoking (if you’re still a smoker), drink alcohol only in moderation, eat well, build exercise into your life, and get to a healthy weight, Dr. Rocco says. “Smoking cessation alone can boost HDL 5 percent, while for every 7 pounds you lose, you’ll see a 1 mg increase in HDL.” Regular moderate-intensity exercise raises HDL as much as 6 percent, he adds. Contrary to prior nutritional information, there is not a clear link between dietary intake of cholesterol and increased cardiovascular risk; the focus is on lowering saturated fat and trans fat in the diet. The new 2015 dietary guidelines by the U.S. government removed the limitation on cholesterol in the diet. A heart-healthy diet is vital to lowering LDL cholesterol, and you have a variety of choices, including vegan, DASH (Dietary Approaches to Stop Hypertension), and the Mediterranean diet, a favorite for its ease and inclusion of popular foods. In a Spanish trial lasting almost five years, researchers found that people who consumed a traditional Mediterranean diet, which includes olive oil and nuts, saw a 30 percent reduction in risk of cardiovascular disease compared with participants who were simply advised to follow a low-fat plan. This was true even among older people and those who were treating a variety of heart risk factors — elevated cholesterol, high blood pressure, diabetes — with medication. And even though participants were not calorie-restricted, they did not gain weight on the plan, according to the results published in Advances in Nutrition in May 2014. Features of a Mediterranean diet include:
Eating primarily plant-based foods (fruits, vegetables, legumes, whole grains, nuts)Limiting red meat (a few times a month is okay)Limiting full-fat dairy productsUsing olive oil (or canola) in place of butterEnjoying fish and poultry at least twice a week
“Adopting this kind of diet, along with exercise, pays off not just in terms of heart disease, but overall,” Andersen says. “It’s really an anti-aging plan.”
