Cholesterol is a waxy, fat-like substance that travels throughout the body in the blood.

It has
many important functions and is used by all of the cells in your body. It is part of cell membranes
and helps in the production of testosterone, estrogen, and vitamin D.
Cholesterol comes from two sources. Our liver produces it, and we obtain some cholesterol in
our diet from meat and dairy products.

"High cholesterol"
Your body makes most of the cholesterol you need. This guide is primarily about a problem that
millions of people have, which is excess cholesterol floating around in their blood. (Healthy and
unhealthy cholesterol levels are defined in Step 5, Cholesterol Testing.)
There are steps you can take to keep your cholesterol under control. Starting at about age 20, all
adults should get a blood test on a regular basis to see if their cholesterol levels are in good
shape.
When there is too much cholesterol in the blood, the excess can build up on the inner walls of
arteries throughout the body, forming scar tissue and plaque. This build-up of plaque is referred
to as atherosclerosis.
The plaque deposits harden and narrow the wall of the artery, reducing or stopping blood flow.
In addition, the hard and inflexible artery may tear. The body forms a blood clot to try to repair
the tear, but the clot may block blood flow too.

When blood flow is blocked because of narrowed arteries or a clot, serious tissue damage can
occur. The result can be a heart attack, stroke, or other cardiovascular problem.
Cholesterol does not mix well with blood -- similar to oil and water. To help cholesterol travel
through blood to get where it is needed, the body wraps it within water-soluble proteins. This
mixture of fatty cholesterol and protein is known as a "lipoprotein."
The good and the bad
You will generally hear about two types, often called the "good cholesterol" and the "bad
cholesterol":
 HDL (good) cholesterol -- HDL stands for High-Density Lipoproteins. These are
composed mainly of proteins with only small amounts of cholesterol. HDLs are good
because they remove cholesterol from artery walls and transport it to the liver for
elimination from the body. Higher HDL levels actually protect against cardiovascular
disease.
 LDL (bad) cholesterol -- LDL stands for Low-Density Lipoproteins. These are
composed mainly of cholesterol and have very little protein. They are bad because they
deposit cholesterol on the walls of your arteries. High LDL levels increase the risk for
cardiovascular disease.

You should also be aware of triglycerides -- another type of fat that is transported in your blood.
High triglyceride levels are another risk factor for cardiovascular disease.
When determining heart disease risk, physicians take your whole lipid profile into account, with
particular focus on the LDL value.
Unhealthy cholesterol levels are linked to having a poor diet, lack of exercise, being overweight,
age, heredity, and other factors.
Poor diet
The unhealthy foods most likely to raise your LDL cholesterol are those that contain saturated
fat and trans-fatty acids.
 Saturated fats are found in animal products -- such as beef, lamb, pork, butter, cream, ice
cream, whole milk, cheeses, egg yolks, and foods made with these products.
 Trans-fatty acids are found in fried foods, commercially baked goods (donuts, cookies,
crackers), processed foods, and margarines. Read more about margarine and butter.

Lack of exercise
Lack of physical activity can lead to high LDL cholesterol. On the other hand, regular exercise
can increase good cholesterol, lower bad cholesterol, decrease your risk for heart disease, and
improve your overall health.
Being overweight
Overweight people often don't have enough HDL (good) cholesterol, and their triglycerides are
often too high. Their LDL (bad) cholesterol may be too high as well. Furthermore, obesity
increases the risk for high blood pressure and type 2 diabetes, which are associated with heart
disease.
Older age
Cholesterol levels tend to rise in both men and women as they get older. This is very important
because heart disease is the number one cause of death for both men AND women:
 Men -- on average, men develop cardiovascular disease 10 - 15 years earlier than women.
Men have an increased risk of dying from heart disease at a younger age than women.
 Women -- following menopause, cholesterol levels rise significantly. More specifically,
LDL (bad) cholesterol increases and HDL (good) cholesterol decreases at this phase in a
woman's life, putting her at increased the risk for heart disease.
Heredity
Genetics play an important role in determining your blood cholesterol level. Children and teens
should have their cholesterol checked if family members have had either early heart disease or
total cholesterol levels greater than 240 mg/dL. Early heart disease is defined as a father, brother,
uncle, or grandfather who developed heart disease before age 55, or a mother, sister, aunt, or
grandmother before age 65.

Other causes of high cholesterol

 Type 2 diabetes
 Stress
 Hypothyroidism
 Kidney disease
 Liver disease
 Some medications (progestins, steroids)
 Polycystic ovarian syndrome
Symptoms of high cholesterol

Unfortunately, there are usually no symptoms or obvious warning signs when blood
cholesterol levels are too high. Plaque builds up slowly in your arteries. Without
checking cholesterol levels, people may not know they have high cholesterol and
clogged arteries until they experience angina — chest pain related to heart disease — or
suffer a heart attack or stroke.

People with severely elevated cholesterol may have fat deposits in tendons and skin
(called xanthomas), liver and spleen enlargement (that the doctor will feel on exam), and
abdominal pain if pancreatitis develops.
However, unless your cholesterol is severe, the only way to know if your cholesterol
levels are within desirable ranges is to have your blood tested. Have your cholesterol
checked regularly, and take preventive steps to avoid the complications of high
cholesterol.

Cholesterol screening and testing

Starting at age 20, everyone should have their cholesterol checked at least every 5
years. Children and teens who have a family history of early heart disease or total
cholesterol above 240 mg/dL should be screened sooner.
A fasting lipid profile (also called lipoprotein profile) is a detailed blood test for
cholesterol. You will need to fast for 9 - 12 hours prior to the test. This test includes:
o LDL level -- this is the "bad" cholesterol that sticks to your arteries and can
cause blockage.
o HDL level -- this is the "good" cholesterol that helps to prevent build up in
your arteries.
o Triglyceride level -- this is another type of fat in your blood that can lead to
atherosclerosis.
o Total cholesterol
The lipid profile will be done by drawing a blood sample from your arm and will then
be sent to a laboratory for analysis.

For initial screening, your doctor may take a blood sample even if you have not fasted.
In this case, the doctor will look at only the total and HDL cholesterols. If the total is
200 mg/dL (or above) or the HDL is below 40 mg/dL, the doctor will also order a
fasting lipid profile.
The following charts will help you understand what your blood results mean. Keep in
mind, though, that your underlying risk for heart disease is what gives these numbers
their significance. Virtually all cholesterol levels should be treated for those at the
highest risk.
The term "high" cholesterol generally refers to having high total or high LDL levels.
Remember, your LDL level is usually the one doctors are most concerned about.
LDL cholesterol levels -- bad cholesterol
According to the National Heart, Lung, and Blood Institute, your LDL cholesterol
level is a better indicator of your risk for a heart attack and stroke than total
cholesterol. The lower your LDL, the lower your risk for heart disease or stroke. LDL
cholesterol less than 100 mg/dL is considered optimal. For some people with LDL
levels below 100 mg/dL, statin drugs may still be very useful for preventing heart
disease. Virtually all cholesterol levels benefit from treatment in those who are at the
highest risk for heart disease. If you already have heart disease plus another strong
risk factor for heart problems, like diabetes, current cigarette smoking, poorly
controlled high blood pressure, or the metabolic syndrome (high triglycerides, low
HDL cholesterol, and obesity), you should strive to bring your LDL cholesterol
below 70 mg/dL.
Women who are at high risk for heart disease should lower their LDL cholesterol
below 70 mg/dL, recommends the American Heart Association.
Treatment recommendations for high cholesterol are based on your LDL levels and
whether or not you already have heart disease or any risk factors for heart disease.
Some people can lower their LDL by making basic diet and lifestyle changes. These
changes include:
o Eating less saturated fat and cholesterol
o Following a weight management program
o Increasing physical activity
Other people will need medication to lower their LDL level, as explained in Step 7,
Cholesterol-lowering drugs.
HDL Cholesterol Levels -- "Good Cholesterol"
Women tend to have better HDL cholesterol than men. In general, an increased risk
for heart disease, including heart attack, occurs when the HDL level is less than
40mg/dL. More specifically, men are at particular risk if their HDL is below 37 mg/dL
and women if their HDL is below 47 mg/dL.
HDL Cholesterol Levels
Bad - major risk for heart disease Less than 40 mg/dL
Good - protects against heart disease 60mg/dL and above
Triglyceride levels
High triglyceride levels may also be associated with a higher risk for heart disease and
stroke. This is especially true because people with high triglycerides often have other
conditions, such as diabetes and obesity, that increase the likelihood of developing
cardiovascular disease.
Triglyceride Levels
Normal Less than 150 mg/dL
Borderline High 150-199 mg/dL
High 200-499 mg/dL
Very High 500 mg/dL or above
Total blood cholesterol levels
In general, the lower your total cholesterol the better.
Total
Cholesterol Treatment Recommendations
Level
o Your risk for a heart attack is low, unless
you have other risk factors.
o You should still eat foods low in saturated
below 190 to fat and cholesterol, and maintain an
Desirable
200 mg/dL adequate level of physical activity.
o Have your cholesterol rechecked in 5 years
or sooner for men over 45 and women over
55.
o People who fall in this borderline range need
to be followed closely.
o Recheck in 1-2 years if you have no other
risk factors for heart disease and your HDL
Borderline 200 to 239 is greater than 40mg/dL.
High Risk mg/dL o Recheck sooner if you have risk factors,
including if HDL is less than 40 mg/dL.
o Limit foods high in saturated fat and
cholesterol.
o Keep physically active.
o You are at a high risk for a heart attack and
stroke.
o Discuss your treatment options and lifestyle
changes with your health care provider.
240 or higher
High Risk o Limit saturated fats and cholesterol in your
mg/dL
diet.
o Increase your level of physical activity.
o Take any prescribed medicines consistently.
o Have additional tests, if needed.
Emerging risk factors for coronary artery disease
Your health care provider may soon be using other screening tests for coronary artery
disease to guide treatment:
o Total-to-HDL ration -- This may be more predictive of heart risk than total or
LDL cholesterol values.
o Non-HDL ration -- Total cholesterol minus HDL
o Lipoprotein a -- This is linked to higher levels of LDL.
o Small, dense LDL -- The worst kind of LDL
o Apolipoproteins -- Because the amount of cholesterol varies in LDL and HDL
particles, measuring the apolipoproteins directly may be a better indicator of
risk.
o
Maintain healthy habits

There are steps that everyone can take to help prevent heart disease and heart
attack. Here's the bottom line:
 Choose foods low in saturated fat.
 Exercise regularly.
 Lose weight if you are overweight.
 Get routine health checkups and cholesterol screenings.
If your cholesterol levels are high, these recommendations are very important
steps for bringing your cholesterol under control. (And if your cholesterol
levels are ok now -- congratulations! But these steps still help prevent heart
disease down the road.)
We know that it can be tough to make changes to your lifestyle. Below are
some guidelines for building healthy habits.
Choose foods low in saturated fat
Food labels are one of the best tools for eating healthy. For lowering
cholesterol, pay particular attention to these items on the label:
 Total fat
 Saturated fat
 Cholesterol
 Calories
Of these, the most important by far is saturated fat. (Calories are important
for weight control, which is described later in this step.)
On the food label, look at the column called "%DV". This stands for "Percent
Daily Value." As an example, if the food label for a candy bar says "60%"
next to saturated fat, that means you are getting 60% of that day's entire
recommended allowance of saturated fat in just one serving of that candy
bar. Keep track of what you eat over the day, and try to stay below a total of
100%.

Here are some other considerations about food labels:

 When looking at food labels, pay very close attention to serving size.
These can fool you. At first glance, you might conclude that eating
the whole candy bar gives you 60% of your daily saturated fat -- but
upon closer inspection of the food label, you can see that in this
example a serving is actually half of the candy bar. If you eat the
whole candy bar, you have now consumed over 100% of
recommended saturated fat for the day. (60% x 2 = 120%).
 The U.S. government came up with the %DV as a simple way to
show the good and bad ingredients in a specific food. However, keep
in mind that your individual weight and health risks make a
difference in what you can or should eat. The %DV is based on a diet
 of 2,000 calories a day. You may need to eat more or less than 2,000
calories a day depending on your weight.
 Each day, your total of the "bad ingredients" (fat, cholesterol, sodium)
should not go over 100%. In contrast, your total of the "good
ingredients" (vitamins, fiber, protein) should be at least 100% each
day.
 The %DV on the food label for TOTAL fat is something to watch,
especially because it usually means high calories. It is not as
important as saturated fat, however, because it also may include
unsaturated fats, which are healthier.
More tips for healthy eating
 Choose lean, protein-rich foods such as soy, fish, skinless chicken,
very lean meat, and fat free or 1% dairy products. Substitute soy
protein for animal protein in your diet, particularly if you already
have high cholesterol.
 Eat foods that are naturally low in fat, like whole grains, fruits, and
vegetables. Eating lots of fruits and vegetables (at least 5 servings per
day) provides fiber and other important nutrients, including B
vitamins, minerals, and antioxidants (like vitamin E, vitamin C,
selenium, and beta-carotene).

 Increase soluble fiber in your diet by selecting foods like oats, bran,
dry peas, beans, cereal, and rice. Fiber may also give you a sense of
fullness so that you don't eat as much, making weight loss somewhat
easier.
 Choose soft margarines (liquid or tub) over stick margarine to limit
trans-fatty acids. Margarines made from plant sterols or stanols may
be particularly useful for those who already have high cholesterol.
 Foods rich in omega-3 fatty acids may reduce triglycerides, raise
HDL levels, and reduce your risk of heart disease. Such food sources
include cold-water fish (including wild salmon, tuna, and mackerel),
fish oils, flaxseed and flaxseed oil, canola oil, soybean oil, and nuts
(especially walnuts and almonds).
 Folic acid, also called vitamin B9, may help lower the risk of heart
disease in those with high cholesterol.

Foods to avoid
 Limit your consumption of fried foods, processed foods, and
commercially prepared baked goods (such as donuts, cookies, and
crackers)
 Limit animal products like egg yolks, cheeses, whole milk, cream, ice
cream, and fatty meats. These are all high in saturated fats.
 Look on food labels for words like "hydrogenated" or "partially
 hydrogenated" -- these foods are loaded with saturated fats and trans-
fatty acids, and you should avoid them.
Exercise regularly
You knew regular physical activity was good for you, but did you know that
it helps keep your cholesterol levels healthy? It can actually help raise HDL
(good) cholesterol and lower total and LDL (bad) cholesterol. Try to exercise
at least 60 minutes on most days. Exercising also helps you lose weight,
lowers your blood pressure, strengthens your heart and blood vessels, and
reduces stress.
Start your exercise program slowly. Work to build your endurance up to 60
minutes a day. In the beginning, splitting it up into 20-minute segments may
work best. Consider joining a health club, YMCA, or other exercise group to
help you stay motivated.
You should check with your health care provider for exercise suggestions
appropriate for you.
Try:
 Walking
 Dancing
 Swimming
 Gardening
 Bicycling

Lose excess weight

Overweight people tend to have higher cholesterol levels than people who
maintain a healthy weight. Losing weight can help to lower your LDL
cholesterol. For people who have multiple risk factors for heart disease (such
as high cholesterol, diabetes, and high blood pressure), losing weight is
especially important.
For people with large waists (35 inches or more in women; 40 inches or more
in men) losing weight is important. When excess weight is concentrated in
the abdominal area, your risk for cardiovascular disease, diabetes, and high
blood pressure increases significantly.
The healthiest and longest-lasting weight loss happens slowly, by losing 1 - 2
pounds a week. If you cut 500 calories a day by eating less or burn an
additional 500 calories per day by increasing your physical activity, you
should lose 1 pound (equal to about 3,500 calories) a week.
Check with your health care provider for weight-loss recommendations.
Losing 10% of your weight may improve your cholesterol levels. (For
example, if you weigh 200 pounds, dropping 20 pounds can help your
cholesterol.)

Cholesterol-lowering drugs
There are several types of drugs to help lower blood cholesterol levels, and
they work in different ways. Some are better at lowering LDL (bad)
cholesterol, some are good at lowering triglycerides, while others help raise
HDL (good) cholesterol.
Whether or not you need a medication depends on how high your LDL
levels are, your risk factors for heart disease (or whether you have it
already), age, smoking habits, and other considerations. Unless you are at
high risk, your doctor may try to control your cholesterol through diet,
exercise, and weight loss first, and see if that brings your cholesterol down
sufficiently so that medication is not needed. But, depending on your risks,
your doctor may want you to start medication sooner. Risk factors include:
 Cigarette smoking
 High blood pressure (hypertension)
 Low HDL cholesterol
 Family history of premature heart disease
 Diabetes
 Age (male 45 and older, female 55 and older)
Other risk factors may include:
 Obesity
 Physical activity
 Unhealthy diet
 Lipoprotein a
 Homocysteine
 Small dense LDL particles
 Proinflammatory factors
 Impaired fasting glucose
 Evidence of atherosclerosis (not yet causing symptoms)
Following the latest guidelines, your doctor will start or consider
medication when:
 Your LDL cholesterol is 160 - 189 mg/dL (optional), or 190 mg/dL
or higher (recommended).
 Your LDL cholesterol is 160 mg/dL or higher AND you have one
risk factor for heart disease.
 Your LDL cholesterol is 130 mg/dL or higher AND you have either
diabetes or two other risk factors for heart disease.
 Your LDL cholesterol is 100 mg/dL or higher AND you have heart
disease. (If you have diabetes, even if you don't have known heart
disease, medication may be considered for an LDL cholesterol of
100 mg/dL)
 Your LDL cholesterol is greater than 70 mg/dL AND you have had
a recent heart attack or have known heart disease along with
diabetes, current cigarette smoking, poorly controlled high blood
pressure, or the metabolic syndrome (high triglycerides, low HDL,
and obesity).
 After the publication of official guidelines in 2001, major clinical studies
have suggested that the LDL goal of less than 70 mg/dL is practical and
should be extended to anyone with heart disease or diabetes. The goal of
100 mg/dL should likewise be extended to anyone with just two risk
factors.
If your doctor has established that diet, exercise, and weight control are not
sufficient and that medication is needed, it is possible that you will need to
be on the medication for the rest of your life. That is because high
cholesterol returns quickly once the effective therapies are taken away.
o