table of contents
If you have any medical questions or concerns, please talk to your healthcare provider. The articles on Health Guide are underpinned by peer-reviewed research and information drawn from medical societies and governmental agencies. However, they are not a substitute for professional medical advice, diagnosis, or treatment.
Simply put, high cholesterol kills. Elevated cholesterol levels are linked to a higher risk of heart disease (the leading cause of death in America), and according to the Centers for Disease Control and Prevention (CDC), 37% of Americans have elevated LDL cholesterol (that’s the “bad” kind) (CDC, 2020). Yet, according to the same study, only half of the people who should be on cholesterol-lowering meds actually take them.
Why the disconnect for such an obvious health risk? Everybody knows that high cholesterol is bad for you—even potentially fatal—yet many of us ignore high cholesterol as a minor nuisance. The problem is confusion. People don’t really know what cholesterol really is, how it works, and why high cholesterol is so bad for you.
It’s time to take a closer look at cholesterol and answer some basic questions about this vital part of your health. Understanding how cholesterol works and how to read your lipid panel is a first important step toward managing your health. So let’s dive in.
What is cholesterol?
The most confusing thing about cholesterol is that it isn’t inherently bad. In fact, you need cholesterol to survive.
Cholesterol is what’s known as a sterol molecule—a specific chemical structure that’s essential for maintaining your cell membranes. It’s the building block for vitamin D and all your steroid hormones, including testosterone, estrogen, progesterone, and cortisol (among others). It’s also an important part of bile acids, which your body uses to digest dietary fat. So, yeah…cholesterol is important. Which all leads to the central question: If cholesterol is so important to your health, why is too much cholesterol bad for you? It’s complicated, but basically, your cardiovascular health and cholesterol levels are inextricably linked. And it all starts with how your body makes and transports cholesterol in your bloodstream.
Cholesterol in your blood
A quick overview of how you use and distribute cholesterol in your blood can help you understand your latest lipid panel.
Cholesterol is a type of molecule known as a “lipid.” Lipids are fat-soluble, which means they don’t move through your blood very well. But remember that practically every cell in your body needs cholesterol. That means you have to figure out some way to move it around in your body. And you do this with special proteins called apolipoproteins.
These proteins have both water- and fat-soluble parts—kind of like the opposite sides of a magnet. The fat-soluble part bonds to cholesterol, and the water-soluble part interacts with your blood. Once these proteins grab cholesterol particles, we call them “lipoproteins.”
What are lipoproteins?
For simplicity, lipoproteins can be boiled down into two categories based on the way they work in your blood vessels:
Apolipoprotein B (ApoB)
Deposits cholesterol into your blood vessel walls. This makes it the “bad” kind of cholesterol because these deposits contribute to blockages that can lead to heart disease, heart attack, and stroke.
Apolipoprotein A-1 (ApoA-1)
Removes cholesterol from blood vessel walls. This makes it the “good” cholesterol because these lipoproteins protect you from the damage that leads to heart disease and stroke.
The main difference between “good” and “bad” cholesterol is simply about where cholesterol ends up in your body.
The more ApoB lipoprotein particles in your blood, the higher your risk of heart disease. Since most of the cholesterol particles attached to “bad” ApoB are low-density lipoproteins (LDL), healthcare providers use LDL levels as an estimate for all the particles that contribute to cardiovascular disease. This estimate isn’t perfect, but typically people with a higher LDL have a higher risk of heart attack and stroke.
- ApoB lipoproteins are “bad.”
- The more LDL and/or ApoB you have in your system, the higher your risk for heart disease.
Cholesterol levels: LDL, HDL, triglycerides, total cholesterol
How to read your standard lipid panel
The lipid panel is one of the most common ways healthcare providers evaluate your risk for cardiovascular disease. Each lipid panel varies depending on your existing risk factors (age, family history, existing conditions like diabetes, etc.). But, generally speaking, the “normal” values are:
- Normal total cholesterol is <200 mg/dl
- Normal LDL is <130 mg/dl or <100 mg/dl
- Normal high density lipoprotein (HDL) is >39 mg/dl in men and >49 mg/dl in women
- Normal triglycerides is <150 mg/dl
- Normal non-HDL is no higher than 30 mg/dl more than the LDL value
The three most important takeaways from your lipid panel are LDL, non-HDL, and triglyceride levels. Here’s what each one really means:
- High LDL, high non-HDL levels, and high triglycerides all increase your risk for cardiovascular disease
- High triglycerides and low HDL levels indicate insulin resistance
Insulin resistance isn’t a common risk factor associated with high cholesterol, but it’s actually a really big side effect. Insulin resistance itself puts you at greater risk for type 2 diabetes, which is yet another risk factor for cardiovascular disease. Additionally, insulin resistance can skew your LDL results by underestimating your ApoB (“bad” cholesterol) and LDL particle numbers, which can result in underestimating your risk factors.
Healthy ranges vary depending on your other risk factors. Just remember, non-HDL, LDL, and triglycerides are the numbers to watch. If you only track a few metrics, get to know your LDL and non-HDL levels. Triglycerides are an important risk factor for cardiovascular disease (and insulin resistance), but not your chief concern.
(Side note: Sometimes, non-HDL levels are a better predictor than the LDL alone because they include other ApoB containing particles like VLDL, IDL, and Lp(a). These are sometimes referred to as “ugly” cholesterol or remnant cholesterol. If you only consider LDL and not remnant cholesterol, you can actually underestimate the level of risk.
Non HDL cholesterol: what it means for your health
So you have bad cholesterol, now what?
Your lipid panel might have red flags if you exceed healthy normal ranges. That’s ok. When this happens, consult your healthcare provider to discuss treatment and next steps. Your healthcare provider can estimate your risk for cardiovascular disease based on your lipid panel, family history, smoking status, age, blood pressure, and other risk factors like diabetes. This one test isn’t the only factor. However, high LDL numbers may prompt more tests to see if you’re at risk of heart disease, heart attacks, and strokes.
The best follow up test for this is called a coronary calcium scoring. Calcium scoring uses a low-dose computed tomography (CT) scan to see how much calcium is actually in the arteries around your heart. Your healthcare provider may also recommend lifestyle changes and medication to lower your risk of heart attack and stroke.
High cholesterol: Recommended lifestyle changes
It may sound boring, but lifestyle changes are the best way to lower your cholesterol. The American Heart Association (AHA) and American College of Cardiology (ACC) both recommend the following lifestyle changes to naturally lower your cholesterol (ACC/AHA-a, 2013):
- Diet: A diet rich in fruits and vegetables, nuts, poultry, fish, legumes, and low-fat dairy products promotes heart health. Many physicians also recommend lowering your intake of red meat, saturated fats, trans fats, sweets, and sugar-sweetened beverages. The dietary approaches to stop hypertension (DASH) diet and the Mediterranean diet are both great examples of these dietary changes (NHLBI, 2021; Widmer, 2015).
- Use less salt: Lower your sodium intake to less than 2,400 mg per day, especially if you’ve been diagnosed with hypertension.
- Exercise: 40 minutes of moderate-to-vigorously intense physical activity, 3–4 times a week, can reduce cholesterol.
For some, these lifestyle changes can be profound. For others, it just involves cutting out a few guilty pleasure foods and finding the time to stay active. Regardless of where you are with your diet and fitness, pay attention to what you eat, and exercise regularly. They’ll both improve your LDL levels (and your life).
Heart-healthy diet: what is it and 9 tips to following one
While lifestyle changes are usually very effective, they may only take you so far. Cholesterol medications, like statins, are an important part of how many patients manage high cholesterol. The AHA/ACC recommends medication for (ACC/AHA-b, 2013-b):
- People with cardiovascular disease, peripheral vascular disease (atherosclerosis in the blood vessels of the legs), and cerebrovascular disease (atherosclerosis in the blood vessels to the brain)
- Ages 40–75 with diabetes and LDL levels above 70 mg/dl
- Patients with LDL levels above 190 mg/dl
- Anyone with a 10-year calculated risk of 7.5% or more
These guidelines have since been updated, but many providers continue to use the same four criteria to determine whether or not to use statins.
Statins are a family of drugs that work by decreasing your liver’s ability to make cholesterol. Statins essentially reduce cholesterol levels by making your liver pull LDL out of the bloodstream. And while statins have been criticized by many, they’ve been shown to lower the risk of heart attacks and death when taken by the people who need them most (Brugts, 2009).
High cholesterol is a serious problem if left untreated. Luckily, you can do a lot to lower your cholesterol. Learn how to read your lipid panel. Assess recommended lifestyle changes and how they fit into your day. Then talk to your healthcare provider to develop a treatment plan or explore cholesterol medication that works for you.
- American College of Cardiology/American Heart Association Task Force on Practice Guidelines (AHA/ACC-a). (2013). 2013 ACC/AHA Guideline on Lifestyle Management to Reduce Cardiovascular Risk. Retrieved April 3, 2020 from https://www.ahajournals.org/doi/pdf/10.1161/01.cir.0000437740.48606.d1
- American College of Cardiology/American Heart Association Task Force on Practice Guidelines (AHA/ACC-b). (2013). 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. Retrieved April 3, 2020 from https://www.ahajournals.org/doi/pdf/10.1161/01.cir.0000437738.63853.7a
- Brugts, J. J., Yetgin, T., Hoeks, S. E., Gotto, A. M., Shepherd, J., Westendorp, R. G. J., et al. (2009). The benefits of statins in people without established cardiovascular disease but with cardiovascular risk factors: meta-analysis of randomised controlled trials. BMJ, 338: b2376. doi: 10.1136/bmj.b2376, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2714690/
- Centers for Disease Control and Prevention (CDC). (2020, April 2). High Cholesterol Facts. Retrieved April 3, 2020 from https://www.cdc.gov/cholesterol/facts.htm
- National Heart, Lung, and Blood Institute (NHLBI). (2021). DASH Eating Plan. Retrieved from https://www.nhlbi.nih.gov/education/dash-eating-plan
- Widmer, R. J., Flammer, A. J., Lerman, L. O., & Lerman, A. (2015). “The Mediterranean Diet, its Components, and Cardiovascular Disease.” American Journal of Medicine, 128(3): 229-238. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4339461/
Dr. Mike is a licensed physician and the Director, Medical Content & Education at Ro.