Cholesterol isn't entirely the health villain it's made out to be, its name darkly linked to heart attack, stroke, and other types of cardiovascular disease. Our bodies need cholesterol, which is a type of lipid (another name for fat) needed to make cell membranes, key hormones like testosterone and estrogen, the bile acids needed to digest and absorb fats, and vitamin D.

What is "bad" about cholesterol isn't the substance itself — in fact, we can't live without it — but it’s certain types of cholesterol and how much of them are in the bloodstream that matter.

If you have high cholesterol, making changes in your diet can help bring it down into the healthy range. Exercise can help boost the level of HDL (“good” cholesterol). Dietary changes and medication, notably the family of drugs known as statins, can powerfully lower LDL (“bad” cholesterol).


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What is cholesterol?

Cholesterol is a fatty substance that occurs naturally in the body. It performs several vital functions. It is needed to make the walls surrounding the body's cells and is the basic material that is converted to certain hormones. Your body makes all the cholesterol you need. You need only a small amount of fat in your diet to make enough cholesterol to stay healthy.

The fat and cholesterol you eat are absorbed in the intestine and transported to the liver. The liver converts fat into cholesterol, and releases cholesterol into the bloodstream. There are two main types of cholesterol: low-density lipoprotein (LDL) cholesterol (the "bad" cholesterol) and high-density lipoprotein (HDL) cholesterol (the "good" cholesterol).

High levels of LDL cholesterol are linked to atherosclerosis, which is the accumulation of cholesterol-rich fatty deposits in arteries. This can cause arteries to narrow or become blocked, slowing or stopping the flow of blood to vital organs, especially the heart and brain. Atherosclerosis affecting the heart is called coronary artery disease, and it can cause a heart attack. When atherosclerosis blocks arteries that supply blood to the brain, it can cause a stroke.

People with high levels of HDL cholesterol are less likely to develop cardiovascular disease. However, if a person has both a high HDL and high LDL cholesterol level, he or she might still need treatment to lower the LDL level.

The desirable level for LDL cholesterol depends on whether or not a person already has a disease caused by atherosclerosis or diabetes or other risk factors for coronary artery disease. In addition to a high LDL cholesterol level and diabetes, risk factors for coronary artery disease include:

  • Being a male older than 45
  • Being a female older than 55
  • Being a female with premature menopause
  • Having a family history of premature coronary artery disease (a father or brother younger than 55 with coronary artery disease or a mother or sister younger than 65 with coronary artery disease)
  • Smoking cigarettes
  • Having high blood pressure
  • Not having enough good cholesterol (high density lipoprotein or HDL)

What is a normal cholesterol level?

The total blood cholesterol level is determined by the LDL and HDL values, and also the level of triglycerides. Instead of looking at a table, you and your doctor should decide what personal goal numbers you should strive for.

The ideal cholesterol LDL level is less than 70 milligrams per deciliter (mg/dL). If you have coronary artery disease, peripheral arterial disease or have had a stroke from atherosclerosis, this should be your goal.

However, if you do not have cardiovascular disease and no risk factors for it, an LDL cholesterol level of 100 – 130 mg/dL may be acceptable.

Your level of HDL cholesterol also matters. People with levels below 40 mg/dL are more likely to develop atherosclerosis, heart disease and stroke.

In general, a triglyceride level of under 150 mg/dL is a good goal.

Does a high cholesterol level cause symptoms?

Most people with high cholesterol don't have any symptoms until cholesterol-related atherosclerosis causes significant narrowing of the arteries leading to their hearts or brains. The result can be heart-related chest pain (angina) or other symptoms of coronary artery disease, as well as symptoms of decreased blood supply to the brain (transient ischemic attacks or stroke).

About 1 out of every 500 people has an inherited disorder called familial hypercholesterolemia, which can cause extremely high cholesterol levels (above 300 milligrams per deciliter). People with this disorder can develop nodules filled with cholesterol (xanthomas) over various tendons, especially the Achilles tendons of the lower leg. Cholesterol deposits also can occur on the eyelids, where they are called xanthelasmas.

What’s the best diet to lower cholesterol?

There is no consensus on the best diet. The most effective diet to lower total and LDL cholesterol is a vegetarian diet. However, this is not an easy diet to follow.

Many people prefer a “Mediterranean style” diet. There is no strict definition for what should be included in this type of diet. In general, this means:

  • Getting the majority of daily food calories from plant sources, especially fruits and vegetables, grains, beans, nuts, and seeds.
  • Using olive oil as the principal fat, replacing other fats and oils.
  • Having some low fat cheese and/or yogurt daily.
  • Eating fish at least a couple times per week.
  • Limiting processed foods.
  • Drinking alcohol in moderation unless medically not indicated. No more than two drinks per day for men and one per day for women.

To maintain a desirable weight, you should take in only as many calories as you burn each day. If you need to lose weight, you need to take in fewer calories than you burn.

People who aren't sure how to follow such a diet may find it useful to work with a health care professional such as a dietitian, nutritionist, doctor or nurse.

In addition to dietary changes, you should get at least 30 minutes of moderate-intensity exercise, such as brisk walking, daily.

What’s the best drug treatment for high cholesterol?

Whether you need medication to lower your cholesterol level depends on how you respond to diet and your personal risk of heart attack and stroke.

There are five types of cholesterol-lowering medications. However, a statin drug should almost always be the first choice to lower LDL cholesterol.

Statins are also called HMG-CoA reductase inhibitors. They include lovastatin (Mevacor), simvastatin (Zocor), pravastatin (Pravachol), fluvastatin (Lescol), atorvastatin (Lipitor), and rosuvastatin (Crestor).

Statins block an enzyme called HMG-CoA reductase, which is necessary for the production of cholesterol.

Statins do much more than lower your LDL cholesterol number. They lower your risk of developing hardening of the arteries (atherosclerosis) and reduce the chance that you will have a heart attack or stroke.

When a person taking a statin does not reach goal, doctors sometimes add ezetimibe. Ezetimibe inhibits absorption of cholesterol from the intestine. By itself the brand name drug is called Zetia. When combined with simvastatin, it’s known as Vytorin.

Cholesterol lowering therapies called PCSK9 inhibitors are more potent than statins. PCSK9 inhibitors are most useful for people with familial hypercholesterolemia. These people have extremely high cholesterol levels.

People with coronary artery disease who either don’t reach goal with a high dose statin drug or cannot tolerate statins because of side effects may also be candidates for this new therapy.

PCSK9 inhibitors are much more expensive than most statins. Also they are not available as pills. They must be injected.

The most common types of drugs prescribed for people with high triglyceride levels are:

  • Fibrates, including gemfibrozil (Lopid), fenofibrate (Tricor) and clofibrate (Abitrate).
  • Omega-3 fatty acids.  Omega-3 fatty acid ethyl esters (Lovaza) for people with very high triglyceride levels. People with even moderately elevated triglyceride levels and increased risk of cardiovascular disease may benefit from icosapent ethyl (Vascepa).

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