Cholesterol Management

  • Medical Author:
    Benjamin Wedro, MD, FACEP, FAAEM

    Dr. Ben Wedro practices emergency medicine at Gundersen Clinic, a regional trauma center in La Crosse, Wisconsin. His background includes undergraduate and medical studies at the University of Alberta, a Family Practice internship at Queen's University in Kingston, Ontario and residency training in Emergency Medicine at the University of Oklahoma Health Sciences Center.

  • Medical Editor: Charles Patrick Davis, MD, PhD
    Charles Patrick Davis, MD, PhD

    Charles Patrick Davis, MD, PhD

    Dr. Charles "Pat" Davis, MD, PhD, is a board certified Emergency Medicine doctor who currently practices as a consultant and staff member for hospitals. He has a PhD in Microbiology (UT at Austin), and the MD (Univ. Texas Medical Branch, Galveston). He is a Clinical Professor (retired) in the Division of Emergency Medicine, UT Health Science Center at San Antonio, and has been the Chief of Emergency Medicine at UT Medical Branch and at UTHSCSA with over 250 publications.

View the Cholesterol Levels Slideshow

What is cholesterol?

Cholesterol is a chemical compound that the body requires as a building block for cell membranes and for hormones like estrogen and testosterone. The liver produces about 80% of the body's cholesterol and the rest comes from dietary sources like meat, poultry, eggs, fish, and dairy products. Foods derived from plants contain no cholesterol.

Cholesterol content in the bloodstream is regulated by the liver. After a meal, cholesterol in the diet is absorbed from the small intestine and metabolized and stored in the liver. As the body requires cholesterol, it may be secreted by the liver.

When too much cholesterol is present in the body, it can build up in deposits called plaque along the inside walls of arteries, causing them to narrow.

What are the different types of cholesterol?

Cholesterol does not travel freely through the bloodstream. Instead, it is attached to a protein and the two together are called a lipoprotein (lipo=fat). There are three types of lipoproteins that are categorized based upon how much protein there is in relation to the amount of cholesterol.

Low-density lipoproteins (LDL) contain a higher ratio of cholesterol to protein and are thought of as the “bad” cholesterol. Elevated levels of LDL lipoprotein increase the risk of heart disease, stroke, and peripheral artery disease, by helping form cholesterol plaque along the inside of artery walls. Over time, as plaque buildup increases, the artery narrows (atherosclerosis) and blood flow decreases. If the plaque ruptures, it can cause a blood clot to form that prevents any blood flow. This clot is the cause of a heart attack or myocardial infarction if the clot occurs in one of the coronary arteries in the heart.

High-density lipoproteins (HDL) are made up of a higher level of protein and a lower level of cholesterol. These tend to be thought of as “good” cholesterol because they can extract cholesterol from artery walls and dispose of them in the liver. The higher the HDL to LDL ratio, the better it is for the individual because such ratios can potentially be protective against heart disease, stroke, and peripheral artery disease.

Very low-density lipoproteins (VLDL) contain even less protein than LDL.

Total cholesterol is the sum of HDL, LDL, and VLDL.

Quick GuideCholesterol Levels: What the Numbers Mean

Cholesterol Levels: What the Numbers Mean
Cholesterol chart and graph

Cholesterol Levels

What are LDL and HDL Cholesterol?

LDL cholesterol is called "bad" cholesterol, because elevated levels of LDL cholesterol are associated with an increased risk of coronary heart disease, stroke, and peripheral artery disease. LDL lipoprotein deposits cholesterol along the inside of artery walls, causing the formation of a hard, thick substance called cholesterol plaque.

HDL cholesterol is called the "good cholesterol" because HDL cholesterol particles prevent atherosclerosis by extracting cholesterol from the artery walls and disposing of them through the liver. Thus, high levels of LDL cholesterol and low levels of HDL cholesterol (high LDL/HDL ratios) are risk factors for atherosclerosis, while low levels of LDL cholesterol and high levels of HDL cholesterol (low LDL/HDL ratios) are desirable and protect against heart disease and stroke.

Why is high cholesterol dangerous?

Elevated cholesterol levels are one of the risk factors for heart disease, stroke, and peripheral artery disease. The mechanism involving cholesterol in all three diseases is the same; plaque buildup within arteries decreases blood flow affecting the function of the cells and organs that these blood vessels supply.

  • Atherosclerotic heart disease or narrowed coronary arteries in the heart can cause the symptoms of angina, when the heart muscle is not provided with enough oxygen to function.
  • Decreased blood supply to the brain may be due to narrowed small arteries in the brain or because the larger carotid arteries in the neck may become blocked. This can result in a transient ischemic attack (TIA) or stroke.
  • Peripheral artery disease describes gradual narrowing of the arteries that supply the legs. During exercise, if the legs do not get enough blood supply, they can develop pain, called claudication.
  • Other arteries in the body may also be affected by plaque buildup causing them to narrow, including the mesenteric arteries to the intestine and the renal arteries to the kidney.

Where does cholesterol come from?

The liver is responsible for managing the levels of LDL in the body. It manufactures and secretes LDL into the bloodstream. There are receptors on liver cells that can "monitor" and try to adjust the LDL levels. However, if there are fewer liver cells or if they do not function effectively, the LDL level may rise.

Diet and genetics both play a factor in a person's cholesterol levels. There may be a genetic predisposition for familial hypercholesterolemia (hyper=more = cholesterol + emia=blood) where the number of liver receptor cells is low and LDL levels rise causing the potential for atherosclerotic heart disease at a younger age.

In the diet, cholesterol comes from saturated fats that are found in meats, eggs, and dairy products. Excess intake can cause LDL levels in the blood to rise. Some vegetable oils made from coconut, palm, and cocoa are also high in saturated fats.

What are normal cholesterol levels?

Blood tests are required to measure total cholesterol and lipoproteins. For a complete lipoprotein analysis, the patient should be fasting for at least 12 hours.

The National Cholesterol Education Program endorsed by the American Heart Association suggests the following risk guidelines:

Cholesterol Risk Guidelines
Total Cholesterol (mg/dL)
< 200 Desireable
200 to 239 Borderline high
> 240 High
HDL (mg/dL)
< 40 Low
> 60 High
LDL (mg/dL)
< 100 Optimal
100 to 129 Near Optimal
130 to 159 Borderline high
160 to 189 Near high
> 190 High

The goal is to have patients modify lifestyle and diet to maintain cholesterol levels within the normal range. It is important to remember that HDL may protect a patient from heart disease and it may be a treatment goal to raise a too low level of HDL.

Which foods can help lower cholesterol?

The American Heart Association has developed diet guidelines to help lower cholesterol levels. It may be a challenge to read the nutritional contents on food packaging and on restaurant menus or to do the math, but the benefit will decrease the risk of heart attack and stroke.

  • Limit total fat intake to less than 25% to 35% of your total calories each day.
  • Limit saturated fat intake to less than 7% of total daily calories.
  • Limit trans fat intake to less than 1% of total daily calories.
  • The remaining fat should come from sources of monounsaturated and polyunsaturated fats such as unsalted nuts and seeds, fish (especially oily fish, such as salmon, trout, and herring, at least twice per week) and vegetable oils.
  • Limit cholesterol intake to less than 300 mg per day, for most people. If you have coronary heart disease or your LDL cholesterol level is 100 mg/dL or greater, limit your cholesterol intake to less than 200 milligrams a day.

Some food groups may be beneficial in directly lowering cholesterol levels and include foods with plant sterol additives, high fiber foods like bran, oatmeal, and fruits like apples and pears, fish, nuts, and olive oil. Some of these foods like nuts and fruits are also high in calories, so moderation is always advisable.

What other lifestyle interventions help lower cholesterol?

Weight loss and exercise are shown to decrease total cholesterol while increasing levels of HDL, the good cholesterol. Smoking cessation decreases LDL levels plus smoking is a primary risk factor for heart disease and stroke. One drink of alcohol a day may help increase HDL levels, but too much alcohol can damage the liver and increase the risk of elevated LDL.

What medications are available to treat high cholesterol?

There are four classes of medication that can lower cholesterol levels including statins, niacin, bile acid resins, and fibric acid derivatives.

The choice as to what medication is most appropriate is usually individualized by the health care professional in discussion with the patient. These medications often need to be adjusted and monitored for side effects.

While all four medication groups may have a role in controlling cholesterol levels in association with diet, exercise, and smoking cessation, only statins are shown to decrease the risk of heart attack.

The American Heart Association and the American College of Cardiology recommend that statin therapy may benefit patients with a history of heart attack, those with elevated blood LDL cholesterol levels or type two diabetes, and a those with a 10-year risk of heart disease greater than 7.5%. Calculate your risk online with the American Heart Association's CV Risk Calculator.

When monitoring how well statin therapy works, the goal is no longer to reach a specific blood cholesterol level. Instead patients with a high risk of heart disease will aim to decrease their cholesterol levels by 50% and those with a lesser risk will aim to lower their cholesterol levels by 30% to 50%.

Medically reviewed by Robert J. Bryg, MD; Board Certified Internal Medicine with subspecialty in Cardiovascular Disease

REFERENCES:

Greenland, P., et al. "2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines." Journal of the American College of Cardiology 56.25 (2010): e50-e103.

Grundy, S. M., et al. "Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines." Circulation 110.2 (2004): 227-239.

Stone, N. J., et al. "2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines." Journal of the American College of Cardiology 7 Nov. 2013.

Last Editorial Review: 10/27/2015

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Reviewed on 10/27/2015
References
Medically reviewed by Robert J. Bryg, MD; Board Certified Internal Medicine with subspecialty in Cardiovascular Disease

REFERENCES:

Greenland, P., et al. "2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines." Journal of the American College of Cardiology 56.25 (2010): e50-e103.

Grundy, S. M., et al. "Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines." Circulation 110.2 (2004): 227-239.

Stone, N. J., et al. "2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines." Journal of the American College of Cardiology 7 Nov. 2013.

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