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Hypercholesterolemia
Table of Contents > Conditions >
Hypercholesterolemia
Also listed as: Cholesterol - high; High
cholesterol
Signs and Symptoms
Causes
Risk Factors
Diagnosis
Preventive Care
Treatment Approach
Other Considerations
Supporting Research
Hypercholesterolemia, or high cholesterol, occurs when there is too much cholesterol in the
body. Cholesterol is a soft, waxy, fat-like substance that is a natural component of all the cells of
the body. Your body makes all the cholesterol it needs. Any added cholesterol, which comes
through the foods you eat, can cause harm.
High cholesterol raises your risk for heart disease, heart attack, and stroke. When there is too
much cholesterol circulating in the blood, it can create sticky deposits (called plaque) along the
artery walls. Plaque can eventually narrow or block the flow of blood to the brain, heart, and
other organs. And blood cells that get caught on the plaque form clots, which can break loose
and completely block blood flow through an artery, causing heart attack or stroke.
The normal range for total blood cholesterol is between 140 and 200 mg per decilitre (mg/dL) of
blood (usually just expressed as a number). However, the total number doesn't tell the whole
story: There are two types of cholesterol -- HDL (high density lipoproteins, or "good" cholesterol)
and LDL (low density lipoproteins, or "bad" cholesterol). The amount of HDL relative to LDL is
considered a more important indicator of your heart disease risk. There is a third kind of fatty
material, triglycerides, found in the blood. They also play a role (generally as triglyceride levels
rise, "good" HDL cholesterol falls). When you have high cholesterol, it usually means you have
high levels of LDL cholesterol, normal or low levels of HDL cholesterol, and normal or high levels
of triglycerides.
More Americans are diagnosed with high cholesterol every year. While heredity may be a factor
for some people, the main culprits are lack of exercise and diets high in saturated fat. High
cholesterol can be prevented, sometimes with lifestyle changes (diet and exercise) alone. If
these do not work, your doctor may recommend medications to lower your cholesterol levels.
Signs and Symptoms
There usually aren't any symptoms of high cholesterol, especially in early stages. The only way
to tell if your cholesterol is high is through a blood test.
Causes
In some cases, high cholesterol levels may be inherited -- your liver may make too much
cholesterol, or your body may not remove LDL from your blood as efficiently as normal. High
cholesterol or triglycerides can also be associated with other diseases, such as diabetes. But
most often high cholesterol is caused by eating foods high in saturated fat and not getting
enough exercise. High cholesterol is more common in people who are overweight or obese, a
condition that affects almost half of U.S. adults.
Risk Factors
Some factors increase a person's risk of having high cholesterol. While some of these cannot be
changed, many can be. The most important risk factors for high cholesterol are:
Being overweight or obese
Eating a diet high in saturated fat and trans fatty acids (found in processed and fried foods)
Not getting enough exercise
Family history of heart disease
High blood pressure
Smoking
Diabetes
Diagnosis
Most people don't have any symptoms of high cholesterol. A blood test is the only way to check
levels of cholesterol in your blood. If your levels are above 200 mg/dL or your HDL is below 40,
your doctor may do a fasting lipid profile (a test performed after you abstain from food for 12
hours).
Although cholesterol levels above 200 are generally considered high, what's considered safe for
each person depends on whether you are at risk for, or have, heart disease.
Total cholesterol levels:
Desirable: Below 200 mg/dL
Borderline high: 200 - 239
High: Above 240
LDL cholesterol levels:
Optimal for people with heart disease or who are at high risk: Below 70 mg/dL
Optimal for people at risk of heart disease: Below 100
Optimal: 100 - 129
Borderline high: 130 - 159
High: 160 - 189
HDL cholesterol levels:
Poor: Below 40 mg/dL
Acceptable: 40 - 59
Optimal: 60 or above
Triglyceride levels:
Optimal: Below 150 mg/dL
Borderline high: 150 - 199
High: Above 200
Adults with normal total and HDL cholesterol levels should have their cholesterol checked every 5
years. If you have high cholesterol, you should be checked every 2 - 6 months. You should have
liver function tests as well if you are on cholesterol-lowering medication.
Preventive Care
Most people can lower cholesterol levels by eating a well balanced diet, getting regular exercise,
and losing any excess weight.
Diet
A healthy diet can help you lose any extra pounds. Even losing just 5 or 10 pounds may help
lower your cholesterol. To eat a healthy diet:
Cut down on saturated fats and trans fats. No more than 10% of your daily calories should
come from saturated fat, and you should avoid trans fats completely. Based on data from 4
studies, it is estimated that a 2% increase in energy intake from trans fats increases the
incidence of heart disease by 23%. Choose unsaturated fats, such as olive oil and canola oil,
instead.
Eat whole grains -- whole wheat bread and pasta, oatmeal, oat bran, and brown rice.
Eat more fruits and vegetables, which are high in fiber and can help lower cholesterol levels.
Studies show that plant based diets are associated with decreases in total cholesterol and LDL
cholesterol of up to 15%.
Limit cholesterol in your diet. The highest amounts are found in egg yolks, whole milk
products, and organ meats.
Eat fatty fish. The American Heart Association recommends that people eat at least 2 servings
of fatty fish (such as salmon or herring) each week.
Eat phytosterols and stanols found in nuts, seeds, vegetable oils, and fortified food products,
such as orange juice, yogurt, margarine spreads, and salad dressing. Studies show that eating
spreads enriched with phytosterols per day reduced total cholesterol by up to 11% and LDL
cholesterol by up to 15%.
The American Heart Association (AHA) has developed dietary guidelines that help lower fat and
cholesterol intake and reduce the risk of heart disease. The AHA does not recommend very low
fat diets, because new research shows that people benefit from unsaturated ("good") fats, such
as those found in olive oil, in their diet.
Many fad diets are popular, but they may not help you lose weight and keep it off -- and in some
cases, they may not even be healthy. Any healthy diet will include a variety of foods. If a diet
bans an entire food group (such as carbohydrates), it's probably not healthy.
For healthy eating, eat a balanced diet that emphasizes fruit and vegetables:
Grains: 6 - 8 servings per day (half should be whole grains)
Vegetables: 3 - 5 servings per day
Fruits: 4 - 5 servings per day
Fat free or low fat dairy: 2 - 3 servings per day
Lean meat, poultry, seafood: 3 - 6 oz. per day (about the size of a deck of cards)
Fats and oils: 2 - 3 tbsp. per day (use unsaturated fats such as olive oil or canola oil)
Nuts, seeds, legumes: 3 - 5 servings per week
Sweets, sugars: 5 or fewer servings per week (the fewer, the better)
In addition, the American Heart Association also recommends eating 2 servings of fatty fish
(such as salmon, herring, or lake trout) per week; holding sodium (salt, including salt already
added to food) to less than 2,400 mg per day; and limiting alcohol intake to 1 drink a day for
women and 2 for men. However, moderate alcohol consumption may help lower triglyceride
levels and increase HDL levels.
The TLC (therapeutic lifestyle changes) diet is recommended for people who have high
cholesterol. With the TLC diet, less than 7% of your daily total calories should come from
saturated fat, and only 25% -35% of your daily calories should come from fat, overall. Sodium
should be limited to 2,400 mg per day. If these steps don't lower your cholesterol, your doctor
may suggest adding more soluble fiber to your diet, along with plant sterols (found in cholesterol
lowering margarines and salad dressings).
The Mediterranean style diet concentrates on whole grains, fresh fruits and vegetables, fish,
olive oil, and moderate, daily wine consumption. This diet is not low fat. It is low in saturated fat
but high in monounsaturated fat. This diet is naturally rich in fiber, antioxidants, and omega-3
fatty acids. It appears to be heart healthy: In a long term study of 423 patients who had a heart
attack, those who followed a Mediterranean style diet had a 50 - 70% lower risk of recurrent
heart disease compared with people who received no special dietary counseling.
Losing Weight
Being overweight increases risk of high cholesterol and heart disease. Even a 5 - 10 pound
weight loss can lower LDL twice as much as diet alone. Weight loss often results in lower
triglyceride levels and increased HDL, too. To maintain a healthy diet, you should aim for a
gradual, weekly weight loss of 1/2 to 1 pound.
Getting Exercise
Regular exercise both reduces the risk of death from heart disease and helps lower LDL
cholesterol levels, especially when combined with a healthy diet. Just 30 minutes of moderate
exercise 5 times per week can help you lose weight or maintain a proper weight, reduce LDL and
triglyceride levels, and increase levels of HDL. And studies show that for every 10 minute
prolongation of exercise per session is associated with a 1.4 mg/dL increase in HDL cholesterol.
Exercise may also lower blood pressure. Talk with your doctor before starting a new exercise
plan.
Treatment Approach
Lowering your cholesterol level reduces your risk of heart disease and stroke. Studies have
shown that for every 1% reduction in cholesterol levels there is a 2% reduction in the rate of
heart disease. People who already have heart disease or are at higher risk benefit most from
lowering their cholesterol.
Changes in lifestyle -- improved diet, more exercise -- are the most effective means of both
preventing and, in less severe cases, treating high LDL cholesterol levels. In addition to
recommending lifestyle changes, physicians often prescribe specific cholesterol lowering
medications.
Medications
If your LDL cholesterol remains high, after changing your diet and exercise habits, your doctor
may prescribe medications to lower it. If your cholesterol is very high (more than 200 mg/dL),
you may start drug therapy at the same time you improve your diet and exercise habits. Drugs
commonly used to treat high cholesterol include:
Statins -- These are usually the drugs of choice as they are easy to take and have few
interactions with other drugs. Side effects can include myositis (inflammation of the muscles),
joint pain, stomach upset, and liver damage. People who are pregnant or have liver disease
should not take statins. Statins include:
Lovastatin (Mevachor)
Pravastatin (Pravachol)
Rosuvastatin (Crestor)
Simvastatin (Zocor)
Atorvastatin (Lipitor)
Fluvastatin (Lescor)
Niacin (nicotinic acid) -- In prescription form, niacin is sometimes used to lower LDL cholesterol.
It can be more effective in raising HDL cholesterol than other medications. Side effects may
include redness or flushing of the skin (which can be reduced by taking aspirin 30 minutes before
the niacin), stomach upset (which usually subsides in a few weeks), headache, dizziness, blurred
vision, and liver damage. Dietary supplements of niacin should not be used instead of
prescription niacin, as it can cause side effects. Only take niacin for high cholesterol under a
doctor's supervision.
Bile acid sequestrants -- These are used to treat high levels of LDL. Common side effects include
bloating, constipation, heartburn, and elevated triglycerides. People who have high levels of
triglycerides (fats in the blood) should not take bile acid sequestrants. These drugs include:
Cholestyramine (Prevalite, Questran)
Colestipol (Colestid)
Colesevelam (WelChol)
Cholesterol absorption inhibitors -- The medication ezetimibe (Zetia) limits how much LDL
cholesterol can be absorbed in the small intestine. Side effects include headaches, nausea,
muscle weakness. Ezetimibe is combined with simvastatin in the drug Vytorin.
Fibric acid derivatives -- These medicines are effective at lowering triglyceride levels, and
moderately effective at lowering LDL. They are used to treat high triglycerides and low HDL in
people who cannot take niacin. Side effects include myositis, stomach upset, sun sensitivity,
gallstones, irregular heartbeat, and liver damage.
Gemfibrozil (Lopid)
Fenofibrate (Tricor, Lofibra)
If you do not respond to one class of drugs, you doctor may use a combination of drugs from 2
classes.
Nutrition and Dietary Supplements
In addition to eating a healthy diet -- low in saturated fat, with plenty of whole grains, fruits, and
vegetables -- some specific foods and supplements may help lower cholesterol.
Fiber -- Several studies have shown that soluble fiber (found in beans, oat bran, barley, apples,
psyllium, flaxseed, and glucomannan) lowers LDL cholesterol and triglycerides. Fiber can also
help you lose weight because it makes you feel full faster. Your doctor will encourage you to get
more fiber in your diet. You may also take a fiber supplement. Men should get 30 - 38 g of fiber
per day. Women should get 21 - 25 g.
Beta-glucan -- is a type of soluble fiber found in oat bran and other plants. It slightly reduces
LDL cholesterol, which is why oat bran is touted as a cholesterol reducing food.
Soy -- Many studies have shown that eating soy protein (tofu, tempeh, miso), rather than animal
meat, helps lower blood cholesterol levels, especially when you eat a diet low in saturated fat.
One study found that as little as 20 g of soy protein per day is effective in reducing total
cholesterol, and that 40 - 50 g shows faster effects (in 3 weeks instead of 6). Another study
showed that soy can help reduce triglyceride levels. The AHA recommends that people with
elevated total and LDL cholesterol add soy to their daily diet, and that soy is safe when
consumed as part of your regular diet. Before you take soy supplements, however, talk to your
doctor. Soy isoflavones may have estrogen like effects on the body, which might lead to an
increased risk of breast and other cancers.
Omega-3 fatty acids, found in fish oil -- There is good evidence that omega-3 fatty acids (namely
EPA and DHA) found in fish oil can help prevent heart disease, lower blood pressure, and reduce
the level of triglycerides (fats) in the blood. However, fish oil can also raise levels of both HDL
and LDL slightly. When taken as a supplement, it can also act as a blood thinner, so people who
already take blood thinning medication should only take a fish oil supplement under their
doctor's supervision. One preliminary study found that people with high cholesterol who took fish
oil and red yeast rice lowered cholesterol levels about as much as people who took simvastatin
(Zocor). The AHA recommends that people eat at least 2 servings of fatty fish (such as salmon)
per week, and that fish is safe when consumed as part of your regular diet. If you have high
cholesterol, talk to your doctor before taking a fish oil supplement.
Alpha-linolenic acid (ALA) -- ALA is another omega-3 fatty acid that may protect the heart
against heart disease. However, studies have shown conflicting results about its ability to lower
LDL, and it does not appear to lower triglyceride levels.
Vitamin C (100 - 200 mg per day) -- Several studies suggest that eating a diet high in vitamin C
can help lower cholesterol levels, but there is no evidence that taking extra vitamin C through a
supplement will help.
Beta-sitosterol (800 mg to 6 g per day in divided doses about 30 minutes before meals) -- Betasitosterol is a plant sterol, a compound that can stop cholesterol from being absorbed by the
intestines. Several well designed scientific studies have shown that beta-sitosterol does lower
"bad" LDL cholesterol levels in the body. Beta-sitosterol may lower the amount of vitamin E and
beta-carotene absorbed by the body, so you may want to ask your doctor if you need to take
extra vitamin E or carotene.
Policosanol (5 - 10 mg 2 times per day) -- Policosanol is a mix of waxy alcohols usually derived
from sugar cane and yams. Several studies have indicated it may lower "bad" LDL cholesterol
and maybe even raise "good" HDL cholesterol. One study found that policosanol was equivalent
to fluvastatin (Lescol) and simvastatin (Zocor) in lowering cholesterol levels. It may also inhibit
blood clots from forming. However, almost all the studies have been conducted in Cuba or Latin
America using a proprietary form of policosanol, so it is hard to evaluate the evidence.
Policosanol may increase the risk of bleeding, and should not be taken by people who also take
blood thinning medication.
Coenzyme Q10 (CoQ10) -- Researchers believe that CoQ10 may boost levels of antioxidants.
One study found that people who received daily CoQ10 supplements within 3 days of a heart
attack were much less likely to experience subsequent heart attacks and chest pain. They were
also less likely to die of the condition than those who did not receive the supplements. Still, more
research is needed to say whether CoQ10 has any role in preventing or treating atherosclerosis.
People who take statins may have low levels of CoQ10. If you take statins, you may want to ask
your doctor about taking a CoQ10 supplement. CoQ10 can interfere with anticoagulant /
antiplatelet drugs.
Polyphenols -- Polyphenols are chemical substances found in plants that have antioxidant
properties. Test tube, animal, and some population based studies suggest that the flavonoids
quercetin, resveratrol, and catechins (all found in high concentration in red wine, and in grape
juice) may help reduce the risk of atherosclerosis by protecting against the damage caused by
LDL cholesterol. However, more studies in humans are needed to confirm these findings.
Resveratrol -- A study in mice found that resveratrol protected against age related damage to
vital organs, including the heart and liver, even when the mice ate a high fat diet. Although this
study is promising, more studies are needed to see whether resveratrol would have the same
effect in humans. No one is sure how much resveratrol is needed to see a benefit. In addition,
resveratrol may have estrogen-like effects, and researchers don't yet know whether it would
pose the same risks as estrogen supplements.
Herbs
The use of herbs is a time honored approach to strengthening the body and treating disease.
Herbs, however, can trigger side effects and can interact with other herbs, supplements, or
medications. For these reasons, you should take herbs with care, under the supervision of a
health care provider.
Hawthorn(Crataegus monogyna, 900 - 1,800 mg per day in 2 - 3 divided doses) -- Hawthorn
contains the polyphenols rutin and quercetin, and was used traditionally to treat cardiovascular
diseases. Animal and laboratory studies show that hawthorn has antioxidant properties that may
help lower high cholesterol and high blood pressure. Talk to your doctor before taking hawthorn,
as it can interact with other drugs taken for heart disease and high blood pressure.
Garlic(Allium sativum, 900 mg per day of garlic powder, standardized to 0.6% allicin) -Previous clinical trials have shown that fresh garlic and garlic supplements may lower cholesterol
levels, prevent blood clots, and destroy plaque. However, more recent studies show no effect on
cholesterol. Garlic can increase the risk of bleeding and should not be taken if you are also taking
blood thinning medication.
Olive leaf extract(Olea europaea, 1000 mg per day) -- One study found that people with mild
high blood pressure (hypertension) lowered cholesterol and blood pressure by taking olive leaf
extract, compared to those who took placebo. More research is needed to confirm this study's
findings.
Red yeast rice(Monascus purpureus, 1,200 mg 2 times per day with meals) -- Several studies
indicate that a proprietary form of red yeast (Cholestin) can lower cholesterol levels, and that the
herb acts like prescription statin drugs (See "Medications" section). For that reason, you should
not take red yeast without a doctor's supervision, especially if you already take statins to lower
cholesterol.
Psyllium(Plantago psyllium, 10 - 30 g per day in divided doses taken 30 - 60 minutes after
meals) -- Taking psyllium, a type of fiber, helps lower cholesterol levels, as well as blood sugar
levels. If you take medicine for diabetes, talk to your doctor before taking psyllium.
Other Considerations
Pregnancy
Cholesterol lowering medications should be avoided during pregnancy.
Prognosis and Complications
Several complications may occur if high cholesterol is left untreated. These include:
Heart disease -- high cholesterol levels more than double the risk of heart attack. Lowering
cholesterol by 1% reduces the risk of coronary artery disease by 2%.
Stroke -- low levels of "good" HDL cholesterol have been associated with an increased risk of
stroke.
Insulin resistance -- 88% of people with low HDL and 84% with high triglycerides also have
insulin resistance (which leads to high blood sugar levels). Many people with insulin resistance
go on to develop diabetes.
Maintaining a proper weight, eating a diet low in saturated fat, and exercising can lower
cholesterol levels and improve long term prognosis.
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