The first four steps to reduce cholesterol are usually: While these lifestyle changes are very important to help manage high cholesterol, they aren’t always enough for everyone. Plus, there may be some surprising culprits that are undermining your efforts.

12 Sneaky Causes of High Cholesterol

If you’re doing all you can to lower your cholesterol, but your numbers are still high, know that you’re not alone. Here are some of the most common reasons.

  1. You have a genetic risk of high cholesterol. “If you’re someone who has a relatively healthy lifestyle and your cholesterol levels are high — if you have an LDL greater than 160 — you probably have some genetic component that leads to high cholesterol,” says Raj Khandwalla, MD, cardiologist and director of digital therapeutics at Smidt Heart Institute at Cedars-Sinai in Los Angeles. Familial hypercholesterolemia (FH) is an inherited condition that leads to cholesterol accumulating in the bloodstream, according to the FH Foundation. Once you receive a diagnosis of high cholesterol, your doctor may prescribe a statin, a type of medication that blocks a substance your body uses to make cholesterol. “Statins help lower LDL cholesterol, which reduces the risk of stroke or death from a heart attack,” Dr. Khandwalla says.
  2. You’re following a trendy diet. Khandwalla emphasizes that people who have high cholesterol should avoid the keto diet, a high-fat, low-carbohydrate diet touted for weight loss. (Overloading your diet with meat can increase your intake of saturated fat, which can raise your cholesterol levels, according to the AHA.) “The most effective diets to lower cholesterol are a plant-based diet or vegan diet in which you decrease your dietary intake of cholesterol,” says Khandwalla. If you still want to include meat in your diet, stick to lean proteins, such as chicken, turkey, and fish.
  3. You have hidden fats in your diet. While it makes sense to cut cholesterol, that isn’t the only aspect of a heart-healthy diet. It’s also important to limit not just saturated fats but also trans fats, both of which raise LDL, according to the AHA. Cut these unhealthy fats by eating less red and processed meat (like sausage), butter, and full-fat dairy.
  4. You expect your diet alone to cure high cholesterol. A healthy diet is essential, but it may not be enough, especially if you’re genetically predisposed to high cholesterol or if you’re diagnosed with familial hypercholesterolemia. “With dietary changes, you can expect around a 5 to 10 percent decrease in how much they can lower your cholesterol, but the results are variable,” says Khandwalla. Exercise — and possibly medication — is also important.
  5. You’re not making your own food. When you dine out, you’re not fully in control of your diet: Even if you’re trying to make healthy choices, you don’t know how your food is being cooked or which ingredients are being used. Plus, portion control can be more challenging. The easiest way to make sure you stick to a heart-healthy diet is to prepare food yourself. And make restaurant meals an occasional treat!
  6. You’re not doing the right type of exercise. While any physical activity is good, aerobic or cardiovascular exercise is what’s been proven to help lower LDL and raise HDL, according to the American College of Sports Medicine. Consider walking, biking, swimming, dancing, or other cardio activities you can do at moderate intensity.
  7. You’re taking medications that raise cholesterol. Certain drugs — including steroids, retinoids, and progestin — used to treat other conditions can raise cholesterol levels, Khandwalla says. Make sure your doctor knows all of the medications you’re taking. There may be alternative treatments that won’t affect your cholesterol.
  8. You’re drinking too much alcohol. While you don’t have to give up drinking entirely, imbibe in moderation. Too much alcohol can raise cholesterol and triglycerides as well as contribute to weight gain. The AHA recommends that men have no more than two drinks a day and women, one.
  9. You’re not taking statins as prescribed. “Statins have made a tremendous impact on saving lives,” Khandwalla says. But in order to be effective, they have to be taken exactly as prescribed. Make sure you know when to take them and at what dose. Your pharmacist can answer any questions you have.
  10. Statins are potentially not effective for you. “There are a subset of folks who are unable to tolerate statin medications,” Khandwalla says. For patients who’ve already had heart disease or a stroke, ezetimibe may be added. There is one other class of medication that also can be used to help lower LDL called PCSK9 inhibitor, but it is generally only recommended in patients at very high risk of heart attack or stroke.
  11. You’re expecting results too soon. If you just recently made lifestyle changes or started taking medication, it may be too early to see results. Remember, you didn’t develop high cholesterol overnight, so it may take some time to get it back down to healthy levels. Keep working with your doctor and following your treatment plan to see results.
  12. You’re relying on medication without making lifestyle changes. A study published in February 2020 in the Journal of the American Heart Association found that people with high cholesterol tended to gain more weight and exercise less once they were prescribed statins. Although statins and other cholesterol-lowering medications are highly effective, they aren’t meant to be the only way you manage high cholesterol. If you need help making lifestyle changes, your healthcare team can give you guidance and support. If you’re doing all you can to lower your cholesterol, including lifestyle changes and/or statins, but it’s not enough, talk to your doctor. There are many treatments to help manage high cholesterol and reduce your risk of heart attack and stroke so you can be healthy for years to come.