Cedars-Sinai Blog
Why Is My Cholesterol High, and What Can I Do About It?
Pop quiz: What critical substance helps your body produce vitamin D, hormones such as estrogen and testosterone, and bile, which enables you to digest fats and other nutrients?
If you guessed cholesterol, you’ve been studying your biology.
But if cholesterol does all this important and good stuff for the body, why does it get such a bad rap?
Why Cholesterol Gets a Bad Rap
The body makes all the cholesterol it needs, mostly in the liver. But it’s also found in foods derived from animal sources, such as meat, fish, dairy and eggs. It’s a waxy, fat substance that travels throughout the bloodstream in small fat/protein bundles called lipoproteins. There are two main types: low-density lipoprotein (LDL) and high-density lipoprotein (HDL).
LDL is what’s commonly referred to as the “bad” cholesterol. That’s because when we have too much of it in the blood, it can gather on arterial walls, along with other fats and blood cells, and create plaque. The buildup of plaque—a process called atherosclerosis—leads to reduced blood flow and increases the risk of heart attack, stroke and other vascular diseases.
HDL, “good” cholesterol, collects “bad” cholesterol and plaque and brings them back to the liver for disposal.
Your Cholesterol Is Too High!
You’ve had your annual physical, including a “lipid panel” that measures lipoprotein levels in the blood, and your doctor tells you, “Your cholesterol is too high.”
What does that really mean?
One number in your lipid profile will be your total cholesterol level, including both LDL and HDL. The recommended goal for total cholesterol is to keep it under 200—that’s 200 milligrams of total cholesterol per deciliter of blood. But since LDL is the cause for concern, your doctor’s main focus will be the “bad” cholesterol.
“The magic number for an optimal LDL level is under 100,” explained Cedars-Sinai cardiologist Seth Lichtenstein, MD.
Seth J. Lichtenstein, MD
The more your LDL level exceeds that magic number, the greater your risk of developing atherosclerosis.
“But that bloodwork is just a snapshot,” Lichtenstein pointed out. “What we’re really concerned about is cumulative exposure over time—year after year—to high cholesterol levels.”
Since HDL helps protect the cardiovascular system from LDL, its levels should be kept high. Lichtenstein says the minimum recommended is 40mg/dL for men and 50 for women.
“HDL is protective,” assured Lichtenstein, “but if your LDL level is high, we’d still want either further testing or to establish the right lipid goal for you.”
Why Is My Bad Cholesterol High, and What Can I Do About it?
The primary factors driving cholesterol levels are a lack of exercise, obesity, smoking and diet.
“We always tell people to strive for a Mediterranean diet low in saturated fats,” Lichtenstein said.
There is also a genetic component, he explained. High cholesterol can run in families.
And age is a factor.
“We’re born with an LDL of 40-60. As we age, that number increases and the related risks also increase.”
The first line of defense against high LDL levels is lifestyle choices: maintaining a healthy weight and diet, getting regular exercise, not smoking and not drinking alcohol to excess.
“What we’re really concerned about is cumulative exposure over time—year after year—to high cholesterol levels.”
Statins
Medications called statins have proven very effective at lowering bad cholesterol levels and are widely used. As of 2018-2019, some 92 million Americans reported taking statins, which inhibit a liver enzyme involved in the production of cholesterol.
“We’ve had studies dating back 20 to 30 years or more, and we’ve had great outcomes with them,” Lichtenstein said.
Beyond lowering LDL levels, statins can also solidify soft plaque, Lichtenstein says, which makes it less likely to rupture and cause dangerous complications. He says there is some evidence statins may even help remove soft plaque and make blood vessels healthier.
There have been studies suggesting some statins can cause cognitive impairment, while other studies find statins reduce the risk of dementia and Alzheimer’s disease. The jury is still out on these results.
Lichtenstein says the largest and most trustworthy studies indicate no negative cognitive effects from statin use, though he points out they can cause some muscle weakness and aches and pains for some people.
“The benefits in reducing the risk of heart attack and stroke are very clear,” he said, “and they far outweigh any negative side effects.”
Read: The Lowdown on Statins
New and Better Technology
The lipid panel that provided a snapshot of your cholesterol levels is the standard measure of risk. But there is new and better testing technology available.
“We can now use ultrasounds to look for early soft-plaque buildup in the carotid arteries,” Lichtenstein said.
There is also a test for coronary calcium, which is soft plaque that has calcified, or hardened, over time—usually in people over the age of 40.
The cardiologist says these newer tests—carotid ultrasound and calcium score—are better risk predictors than lipid panels and should be used with the bloodwork to provide a more complete picture of a patient’s cardiovascular health.
A Word on Diet and Cholesterol
Diet is one factor influencing your cholesterol levels that you have some control over.
Foods to Avoid
Foods high in saturated or trans fats will raise your LDL or “bad cholesterol” levels:
- Beef and pork, particularly fatty cuts such as ribs
- Chicken skin
- Butter, cheese and other full-fat dairy products
“A serving of cheese is about size of your thumb—that’s an ounce,” said Cedars-Sinai registered dietitian Meghan Laszlo. “Most folks eat a lot more than that if they’re eating a cheese plate, for example.”
Dairy also contains nutrients such as calcium, and it’s often fortified with vitamin D. So, eating dairy is OK, but try to stick to the low- or non-fat varieties. Consider non-dairy alternatives such as soy milk and cashew yogurt. Just be sure to verify they have added calcium and vitamin D.
Sugar lowers HDL levels and raises triglycerides, which are another type of fat in the bloodstream.
“And stay away from ultra-processed foods, which are often high in added sugars, salt, saturated fats and chemical additives,” said Laszlo.
Surprisingly, foods containing cholesterol, such as eggs, shrimp and shellfish, don’t have much effect on most people’s LDL level and are OK in moderation.
Meghan Laszlo, RD
Meghan Laszlo, RD
The Good Fats
Some fats—the unsaturated kind—are healthy and can increase your HDL, the “good cholesterol”:
- Avocados
- Nuts
- Seeds
- Olive oil and most vegetable-based cooking oils
- Fish (salmon, trout, tuna, anchovies, sardines)
Laszlo is a big fan of foods with fiber.
“The recommendation is for 30 grams of fiber a day. It’s great for lowering cholesterol and reducing your risk of chronic diseases.”
If you’re wondering how to keep track of all these things in your diet, read food labels to figure out if the food is packed with cholesterol-lowering ingredients—or the opposite. Most individuals with high cholesterol should limit saturated fat to less than 11g per day.
What About the Keto Diet?
Ketogenic diets, which are high in fat, paradoxically help people reduce weight by making the body more efficient at burning fat and protein—a process called ketosis.
But what does eating all that fat mean for cholesterol levels?
“With a keto diet, you have this significant initial elevation in your LDL level,” said Lichtenstein. “But when we look for the increased risk and plaque presence, it just isn’t there.”
In fact, there is evidence a ketogenic diet can, over time, decrease LDL and increase HDL, though the mechanism causing this outcome is not clearly understood.
