Cholesterol: Friend and Foe

Cholesterol isn’t as villainous as it’s often made out to be, despite its strong association with heart attacks, strokes, and cardiovascular disease. Cholesterol is actually a type of fat (lipid) that plays an essential role in maintaining cell membranes, producing key hormones like testosterone and estrogen, aiding in fat digestion through bile acids, and helping synthesize vitamin D.

The problem with cholesterol is not its presence in the body but rather the levels and types of cholesterol in the bloodstream. Specifically, high levels of certain kinds of cholesterol can lead to health problems.

If you have high cholesterol, changing your diet and increasing exercise can help bring it to a healthier level. Exercise can raise HDL (high-density lipoprotein, or “good” cholesterol), while dietary changes and medications, such as statins, can lower LDL (low-density lipoprotein, or “bad” cholesterol).

What is Cholesterol?

Cholesterol is a naturally occurring fatty substance that the body needs for many functions. It helps build cell walls, and it’s the basis for producing certain hormones. Your body makes all the cholesterol it needs, and you only need a small amount of dietary fat to maintain healthy cholesterol levels.

Once dietary fats and cholesterol are absorbed by the intestines, they are transported to the liver, where fats are converted into cholesterol and released into the bloodstream. There are two main types of cholesterol:

LDL (Low-Density Lipoprotein): Often referred to as “bad” cholesterol, LDL is linked to the buildup of fatty deposits in arteries, a condition called atherosclerosis. This can narrow or block arteries, reducing blood flow to the heart, brain, and other vital organs, leading to coronary artery disease, heart attacks, or strokes.
HDL (High-Density Lipoprotein): Considered “good” cholesterol, HDL helps remove excess cholesterol from the bloodstream. Higher levels of HDL are associated with a reduced risk of cardiovascular disease. However, people with high levels of both HDL and LDL may still need to lower their LDL to avoid health issues.

Risk Factors for High Cholesterol

The ideal LDL cholesterol level depends on personal health factors, such as the presence of cardiovascular disease or diabetes. Risk factors for coronary artery disease (CAD) include:

Age: Men over 45 and women over 55 are at higher risk.
Gender: Women with premature menopause are more likely to develop heart disease.
Family history: A family history of early heart disease, particularly a father or brother younger than 55 or a mother or sister younger than 65 with CAD.
Smoking: Smoking increases the risk of cholesterol-related diseases.
High blood pressure: Uncontrolled blood pressure often accompanies high cholesterol.
Low HDL cholesterol levels.

Normal Cholesterol Levels

Total cholesterol is determined by combining the levels of LDL, HDL, and triglycerides (another type of fat). Personal cholesterol goals should be established in consultation with your doctor.

LDL: Ideally, less than 70 milligrams per deciliter (mg/dL) for those with heart disease or atherosclerosis. For those without cardiovascular disease or risk factors, an LDL of 100-130 mg/dL may be acceptable.
HDL: Levels below 40 mg/dL increase the likelihood of atherosclerosis and cardiovascular events.
Triglycerides: A level below 150 mg/dL is generally considered desirable.

Symptoms of High Cholesterol

Most people with high cholesterol experience no symptoms until atherosclerosis causes significant narrowing of the arteries, leading to:

Heart-related symptoms: Chest pain (angina) or other signs of coronary artery disease.
Brain-related symptoms: Reduced blood flow to the brain can cause transient ischemic attacks (TIAs) or strokes.

Some individuals have familial hypercholesterolemia, a genetic condition causing extremely high cholesterol levels (above 300 mg/dL). This can lead to visible cholesterol deposits on tendons (xanthomas) or around the eyelids (xanthelasmas).

Best Diet to Lower Cholesterol

There is no one-size-fits-all diet for lowering cholesterol, but a vegetarian diet is considered the most effective. However, many people find a Mediterranean-style diet easier to follow, which generally includes:

Plant-based foods: Fruits, vegetables, grains, beans, nuts, and seeds should make up the majority of daily calories.
Olive oil: The primary fat source, replacing other oils.
Low-fat dairy: A moderate amount of cheese or yogurt daily.
Fish: Consumed at least twice a week.
Limited processed foods.
Moderate alcohol: If safe, up to two drinks per day for men and one for women.

In addition to dietary adjustments, aim for 30 minutes of moderate exercise (like brisk walking) daily.

Medication for High Cholesterol

The decision to use cholesterol-lowering medications depends on how well lifestyle changes lower your cholesterol and your risk of heart attacks or strokes.

Statins: Usually the first choice for lowering LDL cholesterol. Statins (like atorvastatin, simvastatin, and rosuvastatin) block the enzyme HMG-CoA reductase, which the liver uses to produce cholesterol. Statins not only lower cholesterol but also reduce the risk of atherosclerosis and related cardiovascular events.
Ezetimibe: For those who don’t reach their cholesterol goals with statins alone, ezetimibe (Zetia) is often added. It reduces cholesterol absorption from food.
PCSK9 inhibitors: These are potent cholesterol-lowering drugs used for familial hypercholesterolemia or when statins aren’t enough. PCSK9 inhibitors are more expensive and are given as injections, not pills.

For high triglyceride levels, fibrates (gemfibrozil, fenofibrate) or omega-3 fatty acids (like Lovaza) are commonly prescribed. People with elevated triglycerides and high cardiovascular risk may also benefit from icosapent ethyl (Vascepa).

Managing cholesterol levels often involves a combination of diet, exercise, and medication. For best results, work closely with a healthcare professional to tailor your approach.