Cholesterol is an oily substance made in the liver and used by your body’s cells. It gives cells flexibility and structure. But too much of a good thing can be bad, and high cholesterol can combine with other substances in the blood and can increase your risk of cardiovascular diseases.
Let’s look at the different forms of cholesterol, what you can do to maintain adequate levels of good and bad cholesterol, and what medications are prescribed to help keep your cholesterol under control.
Different forms of cholesterol
Cholesterol is not only an essential component of your cells, but it is also a building structure for vitamins like Vitamin D and hormones like testosterone, estrogen, and the stress hormone cortisol. Since cholesterol is an oily substance, it does not dissolve in water and, therefore, is not dissolved in the blood. To be transported around the body, cholesterol gets packed into tiny packages surrounded by lipoproteins. Lipoproteins are molecules made of proteins that can carry cholesterol through your blood, and this is measured when you get your blood drawn to check your cholesterol.
When checking your cholesterol levels at the doctor’s, your doctor will check two different levels, referred to as the “good” and the “bad” cholesterol:
- The high-density lipoprotein (HDL) cholesterol level is known as “good” cholesterol. Normal to high levels of HDL Cholesterol has been associated with a lower risk of cardiovascular disease.
- Low-density lipoprotein (LDL) cholesterol is known as the “bad” cholesterol since high levels of LDL cholesterol are associated with a higher risk of cardiovascular disease.
In addition to checking HDL and LDL, your cholesterol blood test will also measure your body’s fat. Triglycerides are the most common fat in the body, and this is how your body stores excess energy. Triglycerides can come from foods like butter, oils, and refined sugars that your body does not need immediately and are stored as extra energy into triglycerides in fat cells. Having high levels of triglycerides also increases your risk of heart disease.
Finally, since triglycerides are fats that do not dissolve in blood, they must be carried by proteins in the blood to your tissues. This protein is called very-low-density lipoprotein (VLDL), which carries triglycerides to your tissues. LDL and VLDL are similar, except that VLDL carries triglycerides and LDL carries cholesterol.
Desired cholesterol levels
When you get your yearly physical exam, your doctor may need to check your cholesterol levels. For many, your cholesterol should be checked every 4–6 years, but people with diabetes or a family history of high cholesterol or cardiovascular diseases should get their cholesterol checked more often. Children should also have their cholesterol checked at least once between the ages of 9 and 11 and then again between the ages of 17 and 21.
When you get your lab results, you will see that the units used to measure cholesterol are mg/dL. The desirable cholesterol levels are as follows:
- Total Cholesterol: less than 200 mg/dL
- LDL Cholesterol: Less than 100 mg/dL
- HDL Cholesterol: Greater than or equal to 60 mg/dL
- Triglycerides: Less than 150 mg/dL
- VLDL Cholesterol: usually one-fifth of your triglycerides, with a range of 2–30 mg/dL
Know your risk
The American Heart Association and the American College of Cardiology developed a risk calculator used to estimate the risk of atherosclerosis cardiovascular disease (ASCVD), especially for people aged 40–79 years of age. The purpose of calculating risk is to estimate your 10-year risk of developing heart disease. Some of the information your doctor will use include:
- Total Cholesterol
- HDL Cholesterol
- Blood pressure (if you use blood pressure medication)
- Diabetes status
- Smoking status
Your doctor will also use your medical history to see if you are already at a higher risk. Some of these risk enhancers include:
- Family history of early heart disease (men <55 years old and women <65)
- Current high cholesterol (LDL 160–189 mg/dl)
- Triglycerides ≥175 mg/dL
- Metabolic syndrome, early diabetes
- Chronic kidney disease
- Chronic inflammatory conditions like rheumatoid arthritis or psoriasis
- History of pre-eclampsia or early menopause
You can check your own risk if you know some basic information like:
- Total Cholesterol level
- LDL and HDL levels
- Blood Pressure
- Past Medical history
Risks from ethnicity and family history
Your family origin can also influence your 10-year risk factor and whether you should be started on treatment sooner than later. For example, according to the Centers for Disease Control and Prevention (CDC), people who are non-Hispanic black or African American are more likely to have high blood pressure, which may also impact your 10-year risk of cardiovascular disease. People of Hispanic ethnicity have been found to have a higher risk of diabetes. Your family history and genetics may also contribute to your cardiovascular risk factors.
Some people with a condition called familial hypercholesterolemia may have a predisposition of having high LDL cholesterol and may be born with high cholesterol levels and as time passes it only worsens. This condition can't be treated with diet and lifestyle changes alone and will need medication.
According to The World Health Organization (WHO), cardiovascular disease has become the number one cause of mortality worldwide. The good news is that many of the risk factors that lead to cardiovascular disease are under your control, and you have many options to help control these risk factors. Some of the lifestyle modifications include:
- Focusing on eating foods low in saturated and trans fats
- Eating plenty of vegetables and fruits
- Eating whole grains
- Eating lean meats and fish rich in omega-3 fatty acids like salmon, trout, tuna, and sardines
- Eating unsalted nuts seeds and legumes
- Cooking with vegetable oils like canola oil, corn oil, safflower, or olive oil
You will also want to limit the following foods:
- High salt or sodium foods
- Red meat
- Sweets or sugary sweetened beverages like colas and processed fruit juices
- Full-fat dairy products like cream, cheese, and ice cream
- Baked goods and fried foods
- Tropical oils like coconut palm and palm kernel oils
If you smoke or use any tobacco products, the AHA recommends that you quit smoking, vaping, and tobacco use to reduce your risk of heart disease. It is also recommended that you lose weight if overweight and focus on maintaining stress under control, including taking walks, increasing fitness activity, getting a better night’s sleep, and meditating or practicing yoga.
Sometimes lifestyle modifications alone may not be enough to keep your cholesterol under control. The first type of medication prescribed is statins, which work in the liver to prevent cholesterol from forming and reduce the amount of cholesterol in the blood. Statins mainly lower LDL cholesterol while at the same time helping to raise the levels of HDL cholesterol. You will be prescribed statin therapy depending on your LDL levels. The three categories are:
- High-intensity statin therapy will lower LDL levels by greater than or equal to 50%
- Moderate-intensity statin therapy will lower LDL levels by 30 to 49%
- Low-intensity statin therapy will lower LDL levels by less than 30%
Some of the statins that are commonly prescribed include atorvastatin (Lipitor®), fluvastatin (Lescol®), lovastatin(Mevacor®), pravastatin (Pravachol®), rosuvastatin(Crestor®), and simvastatin (Zocor®). Your doctor may interchange between statins to see how you respond. According to the American Heart Association, statin therapy is usually well-tolerated and safe, but side effects like muscle pain and inflammation can occur but are rare.
If your doctor feels that statin therapy is not improving your cholesterol levels, you may be started on non-statin therapy. Ezetimibe (Zetia®) is a cholesterol absorption inhibitor and prevents cholesterol from being absorbed in the intestines, therefore excreting it in the feces. Other non-statin therapy includes bile acid-binding agents like cholestyramine(Questran®), colestipol (Colestid®), and colesevelam (WelChol®), which allow the intestine to get rid of more cholesterol. Finally, PCSK9 inhibitors, like alirocumab (Praluent®) and evolocumab (Repatha®), will lower LDL cholesterol levels by binding to and activating a protein in liver cells. These medications are types of medication known as monoclonal antibodies and are usually given as injections. Many of the side effects of these therapies include gastrointestinal discomfort.
Talk to your health care provider
Remember that your health care provider is there to help you reach your life goals, which include keeping you healthy and your cholesterol levels under control. Talk with them about your family history, any risk factors, and whether lifestyle modifications alone can help control your cholesterol or if you need medications depending on your risk factors. If, while at the doctor’s office, you feel like you do not understand something, ask for further clarification to ensure both you and your provider are on the same page. If a statin is prescribed, ask about any possible side effects.
If you are concerned about the cost of your medication, your local pharmacist can help find lower prescription prices with your prescription or Rx savings card. Your prescription savings card is designed to help you find the lowest-cost medication, and your local pharmacist can guide you through this process. Remember, some statin medications have been around for over 30 years and are, thus, available as generic names and will be much cheaper than brand names. Ultimately, make sure that you prioritize self-care to help prevent cardiovascular disease and get yearly checkups.
Gabriel Espinoza, MD, has experience caring for patients in primary care and emergency settings. Some of the topics he has focused on during his medical career include various areas in public health, pediatrics, and wellness. He has co-authored a chapter on the utility of point of care ultrasound in the diagnoses of various eye conditions. The content written by Dr. Espinoza is for informative and educational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment.