Cholesterol Demystified: Answers To Common Questions

If you have questions about cholesterol, you’re not alone. High cholesterol, also known as hyperlipidemia, is a common condition that is estimated to affect approximately 100 million adults in the United States, or nearly 53% of the population. Only half of those affected are receiving treatment. 

What is High Cholesterol (Hyperlipidemia)?

Hyperlipidemia refers to having too many lipids (cholesterol is a type of lipid) or fats in the bloodstream. Hyperlipidemia can come in several forms, sometimes affecting all the different types of cholesterol in the bloodstream or one part in isolation.

• Several types of lipids are in the bloodstream and each has its own important role. Some lipid types are referred to as cholesterol.  
  
• Low-density lipoprotein cholesterol (LDL-C, “the bad cholesterol”) tends to stick together in arteries to contribute to plaque formation.
  
• High-density lipoprotein cholesterol (HDL-C, “the good cholesterol”) removes the buildup of LDL cholesterol.

Why Should You Know Your Cholesterol Numbers?

An imbalance of these cholesterols can increase plaque buildup in arteries, blocking blood flow to organs downstream. This can lead to acute cardiovascular events such a myocardial infarction (heart attack) and stroke.

Another less common form of hyperlipidemia is pure hypertriglyceridemia. High levels of triglycerides can also increase the risk of cardiovascular events and developing pancreatitis. 

Ideal Cholesterol Numbers

• LDL below 100 mg/dL
• HDL above 40 mg/dL
• Total cholesterol below 200 mg/dL
• Triglycerides below 150 mg/dL 

How Early and How Often Should I Have My Cholesterol Checked?

The timing of checking your cholesterol considers several factors. General recommendations are: 

• Start at age 35 for men and age 45 for women, according to the United States Preventive Services Task Force (USPSTF). Women generally develop cholesterol issues later in life than men due to estrogen’s cholesterol lowering effects. However this protective effect decreases after menopause. 
  
• Start as early as 20 years old for those with a personal history of cardiovascular disease or a strong family history of cardiovascular disease (especially under age 55). 

Other reasons to begin screening include having conditions such as:

• Hypertension
  
• Diabetes mellitus
• Hypothyroidism
• Chronic kidney disease
• Long-term steroid use
• Smoking or drinking alcohol in excess. 

Continued annual cholesterol screening is recommended for those with normal cholesterol numbers. Individuals on medication for hyperlipidemia may require checks every 3-6 months to confirm that the goal levels are reached and maintained. 

In some rare instances, genetic mutations can cause significant hyperlipidemia. These individuals require more intensive treatment and monitoring.

Dangers of Having Uncontrolled Cholesterol

Uncontrolled cholesterol is a significant cardiovascular risk factor. It leads to the accumulation of plaque inside arteries. This can cause inflammation and the formation of a blood clot further limiting blood flow. Specific conditions related to uncontrolled cholesterol include:

• Myocardial infarctions (heart attacks) result from blockages in the coronary arteries that supply the heart. This can cause part of the heart muscle (myocardium) to die and no longer function, leading to heart rhythm problems and heart failure. 
  
• Strokes result from blockages in the arteries of the brain causing part of the brain to die. This can lead to neurologic problems such as extremity weakness, difficulty with speech, swallowing, and many others. 
• Peripheral vascular disease results from plaque buildup in the arteries of the extremities. This can affect blood flow to the muscles with exercise, causing pain and exercise intolerance called claudication. 
• Pancreatitis can result if the triglyceride component of the cholesterol panel is very high (over 1000 mg/dL). 

Treatments for High Cholesterol

Consuming a healthy diet and getting regular exercise are the first steps to treating hyperlipidemia. These lifestyle changes alone can decrease the total cholesterol, LDL, and triglycerides by 10-30%. This can also increase the HDL cholesterol by 10%. 

For exercise, the United States Preventive Services Task Force (USPSTF) recommends at least 150 minutes a week of exercise, such as biking, running, swimming, aerobic, pilates, aerobics, or yoga. In addition to lowering cholesterol, exercise has positive benefits for blood sugar, blood pressure, and mental health.

When it comes to a healthy diet, the fats being consumed play a role in cholesterol levels. There are three types of dietary fats: 

• Saturated fats are generally solid at room temperature. They occur naturally in several foods such as dairy products (i.e. butter, cream, and cheese), red meats (i.e. beef, pork, lamb), and some plant-based foods such as coconut oil. The American Heart Association recommends keeping the daily intake of saturated fats to under 13 grams daily or 6% of a 2000 calorie diet.
  
• Trans fats are also called partially hydrogenated oils. They are created in an industrial process where hydrogen is added to vegetable oils to make them more solid. They can be found in deep fat fried foods, fries, frozen pizzas, pizza dough, microwave popcorn, shortening, pie crusts, pastries, and many mass-produced “junk foods.” Trans fats negatively raise LDL levels and lower HDL levels, increasing the risk of cardiovascular disease. You should strive to completely eliminate trans fats from your diet. 
• Unsaturated fats are considered healthy fats and are classified as either monounsaturated and polyunsaturated. These fats are typically liquid at room temperature and can be found in salmon, avocados, nuts (such as almonds, walnuts, hazelnuts), and liquid vegetable oils (such as soybean, corn, and olive oil). When eaten in moderation, these fats can improve cholesterol numbers.

When is Medication Recommended?

When regular exercise and dietary changes are inadequate, your doctor may suggest adding a medication to improve your cholesterol. When medications are added, significant improvements up to 50% in cholesterol numbers can be seen. 

The first choice is a medication called a statin. Statins such as Lipitor (atorvastatin) and Crestor (rosuvastatin) have been used for treating hyperlipidemia for over three decades. 

These medications work by blocking an enzyme called hydroxymethylglutaryl-coenzyme A in the liver. This decreases the liver’s natural production of cholesterol and lowers bloodstream levels. These medications are taken once daily. The most common side effects include muscle aches and elevated liver enzymes (10% of patients). 

When a statin is inadequate to lower cholesterol levels, another medication called Zetia (ezetimibe) may be added. This works by lowering the small bowel’s reabsorption of cholesterol normally secreted in bile for fat digestion. 

For patients with isolated elevated triglycerides, a medication called fenofibrate may be appropriate. Refractory hyperlipidemia requires special injectable antibody medications to improve cholesterol levels.

Is it Possible to Lower Cholesterol Without Medications?

People often say: “I don’t need medication to lower my cholesterol. I can do it with diet and exercise.” Unfortunately, this is not true for some patients. Family history and genetics play a large role in the production, storage, and turnover of cholesterol molecules. Diet and exercise can improve cholesterol numbers modestly but may be inadequate to lower the risk of cardiovascular disease for some patients.

Reach out to your provider to schedule an appointment if you need to have your cholesterol numbers check or for more questions.