Cholesterol. For many, that single word brings to mind negative health implications often brought on by poor lifestyle choices. “Cholesterol equals bad," they think. But it's more complicated than that.
For starters, everyone has some level of cholesterol in their blood. Most of it is made by your liver. The rest comes from your gut and is influenced by the foods you eat. And you need some amount to maintain good health. In fact, cholesterol helps your body make hormones, vitamin D, and other substances that support proper digestion. So why the concern?
The trouble happens when too much cholesterol builds up in your arteries. Over time, a high level increases your risk for multiple health issues. For this reason, it's a good idea to check your cholesterol numbers with a blood test at least every three to six years.
This blood test, called a lipid panel, includes an overall cholesterol number and several other values that explain your heart disease risk. Understanding these numbers is critical to your long-term health, says Mark D. Berlacher, MD, a preventive cardiologist at The Christ Hospital Heart & Vascular Institute.
Why is cholesterol control important?
High cholesterol plays a part in many potential problems, including heart attacks, strokes, and blocked arteries. Along with smoking and high blood pressure, high cholesterol is one of the top three drivers for atherosclerosis, the hardening and narrowing of blood vessels that may block blood flow. So, it's important to manage your cholesterol.
“Cholesterol control is really critical," Dr. Berlacher says. “If you've never had a heart attack or stroke, controlling cholesterol can help you minimize your risk. We call this primary or primordial prevention, but it also depends on other heart risk factors. Likewise, controlling your cholesterol can also help you minimize your risk if you have already had a heart attack or stroke. We call this secondary prevention."
What numbers does a cholesterol test show?
A standard blood test includes several measurements that explain your cholesterol level.
Total cholesterol: This value measures the total amount of cholesterol in your bloodstream. It includes high-density lipoproteins (HDL), low-density lipoproteins (LDL), and triglycerides. It's typically measured in milligrams per deciliter (mg/dL). Total cholesterol falls into three ranges:
- Desirable: Less than 200 mg/dL
- Borderline risk: 200-239 mg/dL
- High risk: 240 mg/dL and above
Triglycerides: Triglycerides are the most common fat in your body. They come from the foods you eat and the extra calories your body doesn't burn right away. You need triglycerides for energy, but a high level boosts your risk for heart disease and stroke. Ranges are:
- Desirable: Below 150 mg/dL
- Borderline risk: 150-200 mg/dL
- High risk: 200-499 mg/dL
HDL cholesterol: Because HDL helps clear cholesterol out of your arteries, it's traditionally been called “good cholesterol." However, recent research shows that having an HDL level that's too high may also raise your heart disease risk. HDL ranges are:
- Desirable: 40-60 mg/dL 40
LDL cholesterol: For most people, this is the “bad cholesterol" that often raises your risk for heart disease, as a buildup can cause a narrowing of your arteries. Generally speaking, lower is better (there is no such thing an LDL cholesterol that is “too low"!): The ranges are:
- Desirable: Under 70 mg/dL
- Borderline risk: 70-130 mg/dL
- High risk: 130 mg/dL and above
VLDL cholesterol: Very low-density lipoproein contains the highest level of triglycerides. Having a high level increases your risk for heart disease, especially atherosclerosis. A healthy VLDL value is between less than 15 mg/dL.
Lipoprotein (a) or Lp(a): This lipoprotein is identical to an LDL liopoprotein particle, with the only difference being that Lp(a) has an additional protein on its surface, called apolipoprotein(a). 90% of an individual's Lp(a) is genetically determined. and it stays fixed for life. People with a high level—above 125 nanomoles per liter—have a high risk for heart disease and stroke. Current clinical trials are testing medications that could lower Lp(a) levels by 90% or more.
What makes Lp(a) different from other types of cholesterol?
Standard cholesterol blood panels don't yet test for Lp(a). That could change soon because knowing your number contributes to understanding your overall heart disease risk. But this type of cholesterol is tricky.
Even if someone has a low LDL level, their Lp(a) could still be high. In fact, research estimates one in four people have a high Lp(a) level. So, it's important to test for it specifically. Talk to your doctor if this test is not included in your regular panel of testing.
Lp(a) is also complicated because it's inherited. That means changing your diet and exercise won't really help lower your level.
Although researchers are investigating new treatments to reduce Lp(a) levels, there are currently no Food & Drug Administration-approved medications to treat it. It's still important for understanding your overall risk, especially when considered along with other risk factors.
When should you see a preventive cardiologist?
Your heart health is important. A preventive cardiologist can help reduce your risk of developing heart disease or lower your risk of having another heart attack or stroke, Dr. Berlacher says.
“A preventive cardiologist can help anyone who is interested in knowing and potentially acting on their risk of heart disease," he says. “That's a huge chunk of people."
Most patients who schedule preventive cardiology visits have:
- High cholesterol levels
- Family history of heart disease
- High coronary artery calcium (CAC) score (also called a CT calcium score)
- Previous cardiovascular events, such as heart attack or stroke
- Anyone interested in reducing their risk of heart attack or stroke
What lifestyle changes can lower your cholesterol?
Fortunately, you can adjust your lifestyle to help improve your cholesterol numbers, Dr. Berlacher says.
“Whatever lifestyle changes you choose, they must be sustainable," he says. “If not, it won't stick."
To make the biggest impact, he suggests:
1. Eat heart-healthy foods: Choose foods that are high in fiber and low in trans and saturated fats that are often found in red meats and baked goods. Instead, pick a Mediterranean diet that is rich in omega-3 fatty acids, whole grains, vegetables, and olive oil.
2. Quit smoking: For individuals who smoke, successfully quitting is likely the single most important health change they can make. You can find resources to quit smoking at The Christ Hospital.
3. Exercise more: Regular physical activity has been consistently shown to improve cholesterol and improve overall mortality (help people live longer). The American Heart Association recommends at least 150 minutes of moderate activity each week. For example, take a brisk walk. All exercise helps, Dr. Berlacher says, but you'll see the biggest impact when you first get started. More is better.
“If you increase your activity from 300 minutes to 350 minutes, you won't get as much benefit as you did when you first started," he says. “Sedentary people see the biggest change when they first start moving. The key is consistency."
What medications help lower cholesterol?
If lifestyle changes don't improve your cholesterol number, your doctor may recommend a cholesterol-lowering medication. There are many prescriptions to choose from. The main ones include:
- Statins: These medications lower LDLs and triglycerides.
- Cholesterol absorption inhibitors: These prescriptions produce the same effect as statins. Ezetimibe is the most commonly used medication in this class.
- PCSK9 inhibitors: These are medications that are administered by self-injection once or twice a month. They are very effective in lowering LDL cholesterol and have also been shown to modestly reduce Lp(a).
Keep in mind that being on medication doesn't mean you can stop eating a healthy diet, Dr. Berlacher says.
“I tell people that taking a statin doesn't mean you can just eat whatever you want." he says. “A healthy diet is still very important for those that need to be treated with prescription medications to lower their cholesterol. At that same time, quality of life is important too, and you can of course still eat some of the less heart healthy foods that make you happy, but you must do so in moderation."
Seeing your total cholesterol number gives you a broad idea of your heart health. But the complete picture of your heart disease is more complex. Understand your numbers and know how they impact you—it can help you take steps to get your cholesterol under better control.