Is 220 cholesterol high?


I have very high cholesterol, but very low blood pressure. Does that reduce my risk of heart disease/stroke?

My grandparents and brother died of heart attack/stroke.


The short answer is yes, a normal or low blood pressure will help reduce your risk of heart disease or stroke, compared to someone with your history who has a raised blood pressure.

I would really like to know how old you are, and just how high your cholesterol level is. Also it would be helpful to know how old your grandparents and brothers were when they died.

As your brother has sadly died, I assume that you are probably at least in your forties or fifties. I hope that assumption doesn’t offend you.

If your cholesterol is over 10, then it is possible you may have a condition called familial hypercholesterolaemia. There is often a family history of family members dying of heart attacks at a young age – below 50.

People with this condition also have tiny swellings in their skin called xanthelasma, which are usually yellowish in colour and occur in the skin especially around the eyes, and xanthomas, which are swellings on tendons around the ankles, knees and fingers.

Familial hypercholesterolaemia is a serious problem and needs treatment, which your doctor will advise you about.

If however your cholesterol is not as high as that, and there is no possibility of familial hypercholesterolaemia, then your risk will depend on other factors.

If you smoke, are overweight and take no exercise, then your risk will be quite significant despite your low blood pressure.

In this case you should try and do something about these other risk factors, which might include lowering your cholesterol with drugs.

I hope this helps, but if you are worried about your family history, then you should discuss the situation with your GP.

Yours sincerely

The NetDoctor Medical Team

Last updated 09.12.2014

Cholesterol: High Cholesterol Diseases

High cholesterol increases the risk of other conditions, depending on which blood vessels are narrowed or blocked. Some of these diseases include:

  • Coronary heart disease

The main risk associated with high cholesterol is coronary heart disease (CHD). Your blood cholesterol level has a lot to do with your chances of getting heart disease. If your cholesterol is too high, it builds up on the walls of your arteries. Over time, this buildup is known as atherosclerosis. This condition causes arteries to become narrowed, and the narrowed blood vessels reduce blood flow to the heart. This can result in angina (chest pain) from not enough blood flow getting to the heart, or a heart attack in cases when a blood vessel is blocked completely and the heart muscle begins to die.

  • Stroke

A stroke occurs when a blood vessel that carries oxygen and nutrients to the brain becomes blocked or bursts. A stroke can result if the blood supply to the brain is reduced. When stroke occurs, part of the brain cannot get the blood and oxygen it needs, so it starts to die.

  • Peripheral arterial disease

High cholesterol also has been linked to peripheral arterial disease (PAD), which refers to diseases of blood vessels that are outside the heart and brain. In PAD, fatty deposits build up along artery walls and affect blood circulation, mainly in arteries leading to the legs and feet. The arteries of the kidney can also be affected.

  • Type 2 diabetes

Type 2 diabetes is another disease linked to high cholesterol because diabetes can affect the different cholesterol levels. Even if blood sugar control is good, people with diabetes tend to have increased triglycerides, decreased high-density lipoprotein (HDL), and sometimes increased low-density lipoprotein (LDL). This increases the likelihood of developing atherosclerosis.

  • High blood pressure

High blood pressure (hypertension) and high cholesterol also are linked. When the arteries become hardened and narrowed with cholesterol plaque and calcium (atherosclerosis), the heart has to strain much harder to pump blood through them. As a result, blood pressure becomes abnormally high.

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If You Have High Cholesterol, Will You Also Develop High Blood Pressure?

There are plenty of conditions you can develop that can hurt your heart — and high cholesterol is one of them. Millions of Americans are living with high levels of unhealthy LDL cholesterol every day, and scarily enough, many don’t even realize it. In case you’re unfamiliar with the condition, it develops when you have too much of the waxy substance in your blood. The cholesterol can then go on to clog your arteries.

When it comes to your heart, cholesterol isn’t the only thing that can threaten your health. You’re also probably aware that high blood pressure can increase your risk for heart attacks, coronary diseases, and strokes, too.

So, if you already have high cholesterol, does that automatically mean you have high blood pressure? Here are the facts.

High cholesterol often coexists with high blood pressure — but not always

Cholesterol levels | Donskarpo/iStock/Getty Images

If you know you have high cholesterol levels, it’s important to check with your doctor about how your blood pressure is looking, too. WebMD explains both conditions are often seen together. This is because the plaque from elevated cholesterol levels has hardened and narrowed the arteries, making it harder for your blood to move through your body at a swift pace. This can cause your blood to force through the artery walls at an exceptionally high rate, giving you hypertension.

As Healthline puts it, when you have both conditions, “It’s like your heart has to turn its faucet up to high and blast the blood through to get enough oxygen and nutrients out to all the body organs that need it.” And though it’s possible to have just one condition without the other, researchers have found that high cholesterol often leads to high blood pressure.

If you’ve recently been diagnosed with high cholesterol but your blood pressure is in a normal range, you should act quickly in lowering those first numbers for the sake of your heart.

Your heart is at risk if both numbers are even slightly elevated

Maybe your cholesterol levels are only slightly higher than normal and your blood pressure is hitting prehypertension range. On their own, the numbers themselves may not look too alarming — but together, your heart could be taking some serious damage.

Healthline explains elevated blood pressure levels can cause little tears in arteries and blood vessels. Over time, excess cholesterol can start to build in these small pockets. This can lead to even more plaque buildup and narrower arteries — and suddenly, you have a huge problem on your hands. Not only is your heart affected at this point, but the teamwork of hypertension and cholesterol can also harm your kidneys, eyes, brain and other organs.

How to reduce both levels at once

Woman eating a healthy salad | RossHelen/iStock/Getty Images

In terms of helping both your blood pressure and your cholesterol, there’s good news: You can kill two birds with one stone by adopting some healthier habits. Here’s what you can do every day to lower both numbers.

Go for a walk: Are you getting your 30 minutes of exercise in daily? Both high cholesterol and blood pressure can greatly be helped by getting the recommended amount of activity in per week. Aim for 150 minutes of moderate exercise or 75 minutes of vigorous exercise to hit the mark.

Eat the right foods: Out with the fried foods and sweets and in with the healthy foods. Your diet has a direct correlation to both your blood pressure and cholesterol, so it should be one of the first aspects of your life to change. Good fats, like nuts and fish, and whole grains, leafy greens, and low-sodium foods can all help.

Lower your stress levels: Dealing with anxieties from work, home, and life in general? It may be in your best interest to start meditating for just 10 minutes a day or employing various stress-relieving techniques. Living a high-stress life can lead to unhealthy eating and exercise habits. Not only that, but research has shown your anxiety can lead to higher levels of LDL cholesterol and raised blood pressure levels.

Quit smoking: This habit isn’t just bad for your lungs — it’s also bad for your heart. The chemical changes that smoking leads to can cause a build-up of cholesterol and raised blood pressure. You should also do your best to avoid secondhand smoke, as this can also cause issues.

Skip the alcohol: If you’re headed to happy hour on a regular basis, it may be in your best interest to skip it. Drinking more than a few alcoholic beverages per week has been proven to harm your blood pressure. And while beer doesn’t contain any cholesterol directly, Healthline explains the carbs and alcohol in the drink can raise triglyceride levels.

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Can High Cholesterol Ever Be Healthy?

Total Cholesterol

  • Less than 200: desirable
  • 200–239: borderline high
  • 240 and above: high


  • Less than 40 (men), less than 50 (women): increased risk of heart disease
  • Greater than 60: some protection against heart disease, for men and women


  • Less than 100: optimal
  • 100–129: near optimal
  • 130–159: borderline high
  • 160–189: high
  • 190 and above: very high


  • Less than 150: normal
  • 150–199: borderline high
  • 200–499: high
  • Above 500: very high

Cholesterol Ratio

This measures your level of HDL cholesterol in relation to your total. (You divide HDL into your total.) An optimal ratio is less than 3.5 to 1. A higher ratio means you’re more at risk for heart disease.

Do You Need Medication to Control High Cholesterol?

Whether you’ll need to take medication to lower your cholesterol depends on your levels, as well as on your other risk factors for heart disease, including your sex, age, health history, and family medical history.

“Until recently, doctors decided whether or not to treat high cholesterol based on these numbers,” explains Holly Andersen, MD, an attending cardiologist at NewYork-Presbyterian Hospital/Weill-Cornell Medical Center in New York City. Now, when it comes to deciding if you’d benefit from taking medication to lower your cholesterol, “your score is no longer a solo consideration,” Dr. Andersen says. The change is a result of the November 2013 guideline on the assessment of cardiovascular risk issued jointly by the American Heart Association and the American College of Cardiology. These recommendations advise doctors to consider a patient’s overall health for heart disease, not just cholesterol numbers.

Some of the factors used to measure your heart disease risk are:

  • Your age, gender, and race
  • Whether you smoke
  • Blood pressure (and whether it’s being treated)
  • Whether you have diabetes

Your physician may plug your numbers and other factors into the ACC/AHA ASCVD Risk Estimator to determine your 10-year risk of heart disease or stroke. If you have the data, you can calculate the risk yourself using an online tool like this Heart Risk Calculator.

The drugs most commonly prescribed for high cholesterol are statins, such as Lipitor (atorvastatin), Zocor (simvastatin), and Crestor (rosuvastatin). If you have very high cholesterol, a newer medication like Praluent (alirocumab), a PCSK9 inhibitor the FDA approved in 2015, may be needed as well. According to guidelines, if your score for heart attack risk over the next 10 years is 7.5 percent or higher, you could benefit from taking a cholesterol-lowering statin.

Depending on how great your risk is, you might need a “high-intensity” or “moderate-intensity” statin, says Michael Rocco, MD, medical director of cardiac rehabilitation and stress testing at the Cleveland Clinic in Ohio. “In very high-risk patients — someone who already has cardiovascular disease, for example, or who has familial hypercholesterolemia — we still focus on target numbers.”

Preventive Steps for High Cholesterol and Heart Health

When you have high cholesterol, staying heart-healthy requires more than a regimen of statins. Even if you’re on medication, it is absolutely essential to make lifestyle changes: Stop smoking (if you’re still a smoker), drink alcohol only in moderation, eat well, build exercise into your life, and get to a healthy weight, Dr. Rocco says. “Smoking cessation alone can boost HDL 5 percent, while for every 7 pounds you lose, you’ll see a 1 mg increase in HDL.” Regular moderate-intensity exercise raises HDL as much as 6 percent, he adds.

Contrary to prior nutritional information, there is not a clear link between dietary intake of cholesterol and increased cardiovascular risk; the focus is on lowering saturated fat and trans fat in the diet. The new 2015 dietary guidelines by the U.S. government removed the limitation on cholesterol in the diet.

A heart-healthy diet is vital to lowering LDL cholesterol, and you have a variety of choices, including vegan, DASH (Dietary Approaches to Stop Hypertension), and the Mediterranean diet, a favorite for its ease and inclusion of popular foods. In a Spanish trial lasting almost five years, researchers found that people who consumed a traditional Mediterranean diet, which includes olive oil and nuts, saw a 30 percent reduction in risk of cardiovascular disease compared with participants who were simply advised to follow a low-fat plan. This was true even among older people and those who were treating a variety of heart risk factors — elevated cholesterol, high blood pressure, diabetes — with medication. And even though participants were not calorie-restricted, they did not gain weight on the plan, according to the results published in Advances in Nutrition in May 2014.

Features of a Mediterranean diet include:

  • Eating primarily plant-based foods (fruits, vegetables, legumes, whole grains, nuts)
  • Limiting red meat (a few times a month is okay)
  • Limiting full-fat dairy products
  • Using olive oil (or canola) in place of butter
  • Enjoying fish and poultry at least twice a week

“Adopting this kind of diet, along with exercise, pays off not just in terms of heart disease, but overall,” Andersen says. “It’s really an anti-aging plan.”


Understand your risk

The only way to know if you have high cholesterol levels is to have a simple blood test.

Canadian guidelines recommend having your cholesterol tested if you:

  • Are a male over 40 years of age
  • Are female over 50 years of age and/or post-menopausal
  • Have heart disease, diabetes or high blood pressure
  • Have a waist circumference greater than 94 cm (37 inches) for men and 80 cm (31.5 inches) for women
  • Smoke or have smoked within the last year
  • Have erectile dysfunction
  • Have a family history of heart disease or stroke
Understand your test results

Your test results will include:

  • HDL cholesterol (good cholesterol) – good to have a high number
  • LDL cholesterol (bad cholesterol) – good to have a low number
  • Non HDL cholesterol (total cholesterol – HDL cholesterol) – good to have a low number
  • Triglycerides – high reading may be tracked over time

Your doctor will review your test results along with your risk factors, medical history and present health

Familial hypercholesterolemia or inherited high cholesterol

People with familial or inherited high cholesterol levels have a much higher risk of heart disease early in life.

If you have a personal or family history of premature heart disease and/or a very high cholesterol level at a young age, you should speak to your physician to see if you are a candidate for genetic testing. If you or any of your family members have familial hypercholesterolemia, it is very important to be treated early.

Prevention and management

Making some lifestyle changes is a positive way to control your blood cholesterol levels.

What you eat has a huge impact on your health. Highly processed foods are a major source of saturated fat and are usually high in calories, salt (sodium) and sugar. Saturated fat increases LDL or bad cholesterol levels in the blood.

The Heart and Stroke Foundation recommends that you:

1. Eat a healthy balanced diet.
  • Choose a variety of whole and minimally processed foods at every meal. This means foods that are either not packaged or have few ingredients.
  • Fill half your plate with vegetables and fruit at every meal. Choose vegetables and fruit for snacks. Select fresh, frozen or canned vegetables and fruit. You want them to be plain, without sauce, sugar or salt added.
  • Choose whole grains. Look for whole grain breads, barley, oats (including oatmeal), quinoa, brown rice, bulgur, farro, etc.
  • Mix up the centre of your plate. Choose more vegetarian options such as beans, lentils, tofu and nuts. Include vegetarian options as often as possible in your weekly meal plan. Make sure your meat is lean, poultry without the skin and include fish a couple of times per week. Limit your portion sizes.
  • Choose lower fat dairy products or alternatives with no added sugar. Select 1% or skim milk, plain yogurt and lower fat cheeses.
  • Plan healthy snacks with at least 2 different types of food. For example try: hummus and baby carrots; apple wedges and lower fat cheese or plain yogurt with berries.
  • Drink water or lower fat plain milk to satisfy thirst.
  • Avoid sugary drinks including soft drinks, sports drinks, sweetened milk or alternatives, fruit drinks, 100% fruit juice and ready-to-drink sweetened coffees and teas.
  • Note: If your blood cholesterol level is high, your physician or dietitian may recommend restricting your intake of foods high in dietary cholesterol such as egg yolks, organ meats, full- fat dairy products and processed meats.
2. Cook and eat more meals at home
  • Cooking at home allows you to select whole and minimally processed foods.
  • Develop and share skills in food preparation and cooking with your family.
  • Buy a healthy cookbook or try some of our healthy recipes.
  • Select the top ten recipes your family loves and get everyone involved in the meal preparation.
  • Reduce the amount of sugar, salt and solid fats used in your favourite recipes.
3. Make eating out a special occasion

Eating out usually results in you consuming large amounts of food, more fat, salt and sugar.

  • Try to limit the number of times you eat in a restaurant per month.
  • When you do eat out, choose restaurants that serve freshly made dishes using whole and minimally processed foods and provide nutrition information.
  • Share meals, order the appetizer size or ask for half the meal to be packed up to eat the next day.
4. Achieve and maintain a healthy weight

Being overweight or obese increases your LDL or bad cholesterol level, lowers your HDL or good cholesterol level and raises your triglyceride levels. Reducing your weight is a positive way to reduce your blood cholesterol levels.

5. Physical Activity

Being physically active will help improve your cholesterol levels and general heart health. Aim for 150 minutes a week. That is less than 25 minutes per day!

Choose activities you like. Cycling, swimming, gardening, walking are great ways to keep active.

6. Be Smoke-Free

Smoking is a risk factor for heart disease. It reduces the level of your HDL “good” cholesterol. Once you quit, within a few weeks your HDL levels will start to rise.

Nutrition labelling

Almost every packaged food will have an ingredient listing which is listed in descending order starting with the ingredient in the highest amount.

The package will also contain a Nutrition Facts Table that provides information on a single serving size and the calories and nutrients a serving contains.

All of the nutrient information is based on a single serving. You will find information on the amount of fat, cholesterol, sodium, carbohydrate, fibre, sugars, protein and some vitamins and minerals.

When reviewing the Nutrition Facts Table on a package, always look at the sodium and trans fat values. If you have a high cholesterol level, you may also need to look at the cholesterol value. The % Daily Value on the label will tell you whether there is a lot or a little of a nutrient in a single serving. 15% or more is a lot and 5% or less is a little.

Plant sterols

Research shows that plant sterols can help lower LDL “bad” cholesterol.

Plant sterols occur naturally in small amounts in vegetable oils, nuts, whole grains, vegetables and fruit.

It is recommended that you consume 2g of plant sterols per day to help lower your LDL cholesterol.

It is not possible to obtain enough plant sterols naturally from foods.

Foods in Canada are now allowed to have up to 1g of plant sterols per serving added to them. Look for foods fortified with plant sterols such as mayonnaise, margarine and salad dressing

Dietary fats

Dietary fats and oils provide our bodies with energy, provide essential fats and help absorb fat soluble vitamins such as A, D, E and K.

There are different types of fats:

  • polyunsaturated fats (Omega-3 and 6)
  • monounsaturated fats
  • trans fats
  • saturated fats

Both the quality and amount of fat you eat matters. It is important to not focus on just one nutrient – it is your overall diet that will make the biggest difference to your health. For example, foods marketed as “low fat” can be highly processed and contain lots of refined carbohydrates, calories, sugar and sodium.

Choose more often: polyunsaturated fat (omega-3)

Food sources:

Choose more often: monounsaturated fat

Food sources:

  • fats and oils: olive, canola, peanut, safflower, sesame, non-hydrogenated margarines made from these oils, salad dressings made from these oil
  • nuts, nut butters and seeds: almonds, pecans, hazelnuts, peanuts, pine nuts, sunflower seeds
  • avocados

Eat in moderation: polyunsaturated fats (omega-6)

Food sources:

  • fats and oils: safflower, sunflower, corn
  • legumes: soybeans
  • nuts and seeds

Choose less often: saturated fats

Food sources:

  • fatty meats
  • full-fat dairy products
  • fats and oils: butter, hard margarines, lard, coconut oil, ghee, palm oil
  • highly processed foods are a major source of saturated fat and are also usually high in calories, sodium, sugar and sometimes trans fat:

o processed meats such as sausages, bologna, salami, hot dogs, liver, meat pate

o prepared foods

o snack foods

o chocolates and sugary drinks.

Saturated fat intake should not be an issue if you are eating a healthy, balanced diet and few or no highly processed foods, and appropriate portion sizes.

Medication to lower cholesterol

Sometimes diet and exercise are not enough to lower your blood cholesterol levels. Several drugs are available to lower your blood cholesterol. Your doctor may prescribe medications to including statins and other cholesterol lowering medication

These medications do not cure high blood cholesterol or replace a healthy lifestyle.

Related information

How to manage your cholesterol (PDF)

Find health eating tips here

Learn more about other risk factors for heart disease

Cholesterol is a fat-like substance called a lipid that is found in all body cells. Your liver makes all of the cholesterol your body needs to form cell membranes and to make certain hormones. Extra cholesterol enters your body when you eat foods that come from animals, like meats, eggs, and dairy products.

High blood cholesterol is one of the major risk factors for heart disease. Research has shown that by lowering your blood cholesterol, you will greatly reduce your risk of heart disease.

Cholesterol is a fat-like substance called a lipid that is found in all body cells. Your liver makes all of the cholesterol your body needs to form cell membranes and to make certain hormones. Extra cholesterol enters your body when you eat foods that come from animals, like meats, eggs, and dairy products. Although we often blame the cholesterol found in foods that we eat for raising blood cholesterol, the main culprit is actually saturated fat. Foods rich in saturated fat include butter fat in milk products, fat from red meat, and tropical oils such as coconut oil.

Blood cholesterol levels, which tell how much lipid or fat is in the blood, are expressed in milligrams per deciliter (mg/dL). In general, you want to have a cholesterol level below 200 mg/dL. Between 200 mg/dL and 239 mg/dL, your cholesterol level is elevated or borderline-high and should be lowered if you can. With a level of 240 mg/dL or above, your cholesterol level is high, and there is a need for action. For example, changing your diet, beginning an exercise program, and taking statins or other cholesterol-lowering medicines are all ways to lower your cholesterol level.

High-Cholesterol Country

According to the American Heart Association, more than 43% of American adults have cholesterol levels of 200 mg/dL or higher.

The risk of high cholesterol, or hypercholesterolemia, tends to be greater as we age, and the condition affects more women than men. Obesity of any kind, lack of physical activity, and diabetes are other important risk factors.

The Good, the Bad, and the Total

Cholesterol travels to cells through the bloodstream in special carriers called lipoproteins. Two of the most important lipoproteins are low-density lipoprotein (LDL) and high-density lipoprotein (HDL). Doctors look at how LDL, HDL, and fats called triglycerides relate to each other and to your total cholesterol level.

Low-density Lipoprotein

LDL particles deliver cholesterol to your cells. LDL cholesterol is often called “bad cholesterol” because high levels are thought to lead to heart disease. Too much LDL in the blood causes a fatty buildup (plaque) to form on artery walls, which starts a disease process called atherosclerosis. When plaque builds up in the coronary arteries that supply blood to the heart, you are at greater risk of having a heart attack. Your LDL levels may be high if you eat a diet with a lot of saturated fat, cholesterol, or both. Sometimes, an under-active thyroid (called hypothyroidism) may also increase LDL levels.

High-density Lipoprotein

HDL particles carry cholesterol from your cells back to your liver, where it can be removed from your body. HDL is known as “good cholesterol” because high levels are thought to lower your risk of heart disease. If you have low HDL levels, you have a greater heart disease risk, even if your total cholesterol is below 200 mg/dL. Low HDL is often the result of physical inactivity, obesity, or smoking. It is also common for people who have type 2 diabetes to have low HDL levels. Men generally have lower HDL cholesterol levels than women do, because the female hormone estrogen raises HDL. But when women stop having their monthly menstrual periods, their levels of HDL may decrease.

Triglycerides are fats that provide energy for your muscles. Like cholesterol, they are delivered to your body’s cells by lipoproteins in the blood. If you eat foods with a lot of saturated fat or carbohydrates, you will raise your triglyceride levels. Elevated levels are thought to lead to a greater risk of heart disease, but scientists do not agree that high triglycerides alone are a risk factor for heart disease. People with high triglycerides are often obese or have low levels of HDL cholesterol, high blood pressure, or diabetes, all of which are risk factors for heart disease. Extremely high triglyceride levels (more than 1000 mg/dL) can lead to abdominal pain and a life-threatening disorder of the pancreas called pancreatitis.

Total Cholesterol

A measure of total cholesterol in the blood is found by adding up the cholesterol carried in LDL particles, HDL particles, and other lipoproteins. All adults 20 years or older should have what is called a full lipoprotein profile once every 5 years. You will need to stop eating for 10 to 12 hours before this test, and the only liquid you may drink is water. This full profile will tell your doctors what your total cholesterol, LDL, HDL, and triglyceride levels are. LDL is the most important lipid for predicting your heart disease risk.

If your cholesterol levels were measured from a non-fasting blood sample, meaning you have eaten within 10 to 12 hours of the test, doctors will only be able to calculate your total cholesterol and HDL cholesterol. If the results show that your total cholesterol is high, your HDL cholesterol is low, or if you have other risk factors for heart disease, your doctor will probably order a full lipoprotein profile.

Doctors can then look at the results of your full lipoprotein profile, as well as your other risk factors for heart disease, and use a risk assessment tool to better predict your chances of having a heart attack within 10 years.

The ratio of total cholesterol to HDL cholesterol also gives more information about your risk of heart disease than your level of total cholesterol alone does. The ratio is obtained by dividing the value of total cholesterol by the value of HDL cholesterol. A number higher than 5 shows an increased risk in people who do not have heart disease. People who already have heart disease should not have a number higher than 4.

It is best to have your cholesterol tested by trained medical personnel. Your blood sample should be sent to an approved laboratory for testing. Tests performed at health fairs, at shopping centers, or using home-testing kits may not always give you laboratory-grade results. If you get an unusual result from any source, you should see your doctor. You should keep your normal eating habits, exercise pattern, and weight before cholesterol testing, except for the 10 to 12 hours before having the full lipoprotein profile, when you cannot eat or drink anything but water. You may need to have the test on another day if you have a cold or the flu or have recently changed a medicine. Your doctor may also ask you not to drink alcohol for several days before testing, especially for a true reading of triglyceride levels.

Improving Lipid Levels

A diet low in saturated fat and cholesterol is key to lowering LDL cholesterol levels. A diet with between 25% and 35% of total calories from fat (mostly unsaturated fat) and less than 7% of total calories from saturated fat is recommended.

Other key lifestyle changes for lowering LDL include increasing your physical activity, watching your weight, and eating foods high in fiber. Foods that contain plant stanols and sterols may also help lower LDL. Plant stanols and sterols can be found in special margarines at your grocery store. In some cases, patients find it helpful to see a dietitian, who can help them set up an eating plan.

The key lifestyle changes for increasing low HDL cholesterol are losing weight (if you are overweight), quitting smoking, and increasing physical activity.

Patients with elevated triglyceride levels should control body weight, limit how much alcohol they drink, eat a diet low in saturated fat, and decrease the amount of simple carbohydrates (or sugar) that they eat. The liver changes extra calories from carbohydrates into triglycerides.

A number of medicines are very effective and safe for lowering LDL cholesterol levels. Cholesterol-lowering medicines called statins have been shown to reduce the risk of heart attack and stroke and the need for coronary artery bypass surgery or angioplasty. It is very important that you continue with lifestyle changes even if your doctor gives you cholesterol-lowering medicine. Although cholesterol-lowering medicine can lower your total cholesterol, it does not protect against other risk factors for heart disease, such as obesity and physical inactivity.

Experts from the National Cholesterol Education Program (NCEP) say that more aggressive cholesterol treatment is needed for people at high risk of dying from a heart attack or cardiovascular disease. The basic message of the group’s recommendations is the lower the better when it comes to levels of low-density lipoprotein (LDL) or “bad cholesterol.” The updated recommendations say that almost all high-risk patients with LDL cholesterol levels of 100 mg/dL or higher should begin taking cholesterol-lowering medicine.

Reducing your cholesterol level does not give you complete protection from heart disease, but doctors agree that it is one of the most important ways to reduce your risk.

Tags: cholesterol lowering medicines, HDL, LDL, statins, triglycerides

The findings held up even after accounting for a patient’s history of diabetes, smoking, drinking and LDL levels. Race and gender also didn’t appear to affect the findings.

Dr. Gregg Fonarow is director of the Ahmanson-UCLA Cardiomyopathy Center and co-director of the UCLA Preventative Cardiology Program in Los Angeles. He said that “research from UCLA established more than two decades ago that HDL cholesterol could — in certain individuals (including those with very high levels of HDL) and in certain circumstances — be dysfunctional and pro-inflammatory,” and contribute to narrowing of the arteries.

“In others words, the so-called ‘good’ cholesterol in terms of cardiovascular risk could go ‘bad’ and be associated with excess risk,” added Fonarow, who was not part of the team behind the new study.

Allard-Ratick acknowledged that other studies have revealed a similar HDL problem among people who do not otherwise face a high risk for heart disease. But he said the new study is the first to uncover the same concern among people who are already at high-risk for cardiovascular complications, even if “the mechanism behind this finding remains unclear.”

And, he said, one “surprising aspect of the study was that this association between high levels of HDL and increased risk of death or cardiovascular disease was seen more commonly in women compared to men.”

As to what might constitute a dangerous HDL threshold, Allard-Ratick said that the risk association “likely occurs at (HDL) levels exceeding 80 mg/dL, and perhaps even higher in women.”

Fonarow said a number of prior studies have found that when compared to those with more moderately high HDL levels, people with “very high” HDL levels — meaning a threshold of 90 mg/dL or more — appear to face a greater risk for heart disease.

So what should concerned patients do?

Allard-Ratick said that “as the cause of this finding remains unclear, the appropriate management is not known at this time. Patients with very high HDL cholesterol should continue to address other modifiable risk factors — such as high blood pressure, smoking and obesity — to reduce cardiovascular disease.”

The findings were presented Saturday at the European Society of Cardiology meeting, in Munich, Germany. Research presented at meetings should be considered preliminary until it has been published in a peer-reviewed medical journal.

Too much of a good thing? Very high levels of ‘good’ cholesterol may be harmful

Study author Dr Marc Allard-Ratick, of Emory University School of Medicine, Atlanta, US, said: “It may be time to change the way we view HDL cholesterol. Traditionally, physicians have told their patients that the higher your ‘good’ cholesterol, the better. However, the results from this study and others suggest that this may no longer be the case.”

HDL cholesterol has been considered “good” because the HDL molecule is involved in the transport of cholesterol from the blood and blood vessel walls to the liver and ultimately out of the body, thereby reducing the risk of clogged arteries and atherosclerosis. People with low HDL cholesterol have a greater risk of atherosclerosis and cardiovascular disease. But the protective effect of very high HDL cholesterol has been unclear.

This study, conducted as part of the Emory Cardiovascular Biobank, investigated the relationship between HDL cholesterol levels and the risk of heart attack and death in 5,965 individuals, most of whom had heart disease. The average age of participants was 63 years and 35% were female.

During a median follow-up of four years, 769 (13%) participants had a heart attack or died from a cardiovascular cause. Participants with HDL cholesterol 41-60 mg/dl (1.1-1.5 mmol/L) had the lowest risk of heart attack or cardiovascular death. Risk was increased both in participants with low levels (less than 41 mg/dl) and very high levels (greater than 60 mg/dl) of HDL cholesterol, which produced a U-shaped curve when plotted graphically.

Participants with HDL cholesterol levels greater than 60 mg/dl (1.5 mmol/L) had a nearly 50% increased risk of dying from a cardiovascular cause or having a heart attack compared to those with HDL cholesterol levels 41-60 mg/dl (1.1-1.5 mmol/L).

The associations were consistent even after controlling for other risk factors for heart disease such as diabetes, smoking, and low-density lipoprotein (LDL or “bad”) cholesterol, as well as other factors linked with high HDL cholesterol such as alcohol intake, race, and sex.

The results support findings from several large population-based studies, including a recent publication which found increased cardiovascular and all-cause death when HDL cholesterol reached extremely high levels.2 Dr Allard-Ratick said: “Our results are important because they contribute to a steadily growing body of evidence that very high HDL cholesterol levels may not be protective, and because unlike much of the other data available at this time, this study was conducted primarily in patients with established heart disease.”

He noted that more research is needed to elucidate the mechanisms of this paradoxical association. “While the answer remains unknown, one possible explanation is that extremely elevated HDL cholesterol may represent ‘dysfunctional HDL’ which may promote rather than protect against cardiovascular disease,” he said.

Dr Allard-Ratick concluded: “One thing is certain: the mantra of HDL cholesterol as the ‘good’ cholesterol may no longer be the case for everyone.”

Study says there’s no link between cholesterol and heart disease

“Controversial report claims there’s no link between ‘bad cholesterol’ and heart disease,” the Daily Mail reports, while The Times states: “Bad cholesterol ‘helps you live longer’,”.

The headlines are based on a new review which aimed to gather evidence from previous observational studies on whether LDL cholesterol (so-called “bad cholesterol”) was linked with mortality in older adults aged over 60. The conventional view is that having high LDL cholesterol levels increases your risk of dying of cardiovascular diseases, such as heart disease.

Researchers chose 30 studies in total to analyse. 28 studies looked at the link with death from any cause. Twelve found no link between LDL and mortality, but 16 actually found that lower LDL was linked with higher mortality risk – the opposite to what was expected.

Only nine studies looked at cardiovascular mortality link specifically – seven found no link and two found the opposite link to what was expected.

However, there are many important limitations to this review. This includes the possibility that the search methods may have missed relevant studies, not looking at levels of other blood fats (e.g. total and HDL cholesterol), and the possibility that other health and lifestyle factors are influencing the link.

Most importantly, as the researchers acknowledge, these findings do not take account of statin use, which lowers cholesterol. People found to have high LDL cholesterol at the study’s start may have subsequently been started on statins, which could have prevented deaths.

Where did the story come from?

The study was carried out by researchers from the University of South Florida, the Japan Institute of Pharmacovigilance and various other international institutions in Japan, Sweden, UK, Ireland, US and Italy.

Funding was provided by the Western Vascular Institute. The study was published in the peer-reviewed BMJ Open and, as the journal name suggests, the article is open-access, so can be read for free.

Four of the study authors have previously written book(s) criticising “the cholesterol hypothesis”. It should also be noted that nine of the authors are members of THINCS – The International Network of Cholesterol Skeptics. This is described as a group of scientists who “oppose…that animal fat and high cholesterol play a role “.

If you were playing Devil’s Advocate, you could argue that this represents a preconceived view of the authors regarding the role of cholesterol, rather than the open, unbiased mind you would hope for in the spirit of scientific enquiry. That said, many important scientific breakthroughs happened due to the efforts of individuals who challenged a prevailing orthodoxy of thinking.

In general, the UK media provided fairly balanced reporting, presenting both sides of the argument – supporting the findings, but with critical views from other experts.

What kind of research was this?

This was a systematic review which aimed to gather evidence from cohort studies to see whether LDL – “bad” – cholesterol is associated with mortality in older adults.

It has long been thought that cholesterol is a key cause of the fatty build-up in arteries (atherosclerosis) that causes heart disease. However, the researchers say there are contradictions to this view. Recent research has suggested that total cholesterol becomes less of a risk factor for all-cause or cardiovascular mortality the older people get. Less is known about LDL specifically and that’s what this research aimed to look at.

A systematic review is the best way of gathering evidence from cohort studies that have looked at the link between an exposure or risk factor and an outcome. However, the strength of a review’s findings is only as good as the studies they include. In cohort studies, it is often difficult to directly attribute an outcome to a specific cause, and there is always the potential that other factors are influencing the outcome.

What did the research involve?

The researchers searched one literature database (PubMed) in December 2015 to identify English-language cohort studies that had included a general population sample aged 60 and over. Studies had to have taken baseline measures of LDL cholesterol and then followed participants up over time, looking at the link with all-cause or cardiovascular mortality.

Three authors reviewed potential studies and extracted data. From an initial 2,894 hits, 19 publications, covering 30 cohorts and including 68,094 participants, were included. The majority of studies were excluded outright, as they didn’t seem to contain anything relevant in the study title or abstract (summary). The other reasons for exclusion were non-English language, participants not being representative of the general population, not measuring LDL cholesterol at baseline, and not giving separate data for older adults or looking at mortality outcomes.

What were the basic results?

The researchers did not pool the results of the individual cohorts in a meta-analysis, but gave a narrative summary of the findings.

Overall, they reported that 16 cohorts (representing 92% of individuals in the review) of 28 examining all-cause mortality found an inverse relationship between LDL cholesterol and all-cause mortality. That is, as LDL cholesterol went down, all-cause mortality went up – higher LDL was apparently linked to lower all-cause mortality. In 14 of these 16, this was said to be a statistically significant link. The remaining 12 cohorts found no link with all-cause mortality.

Only nine of the identified cohorts specifically reported cardiovascular mortality. Seven found no link between LDL cholesterol and cardiovascular mortality. The other two found that those in the lowest fourth (quartile) of LDL levels actually had the highest cardiovascular mortality.

How did the researchers interpret the results?

The researchers concluded that, “High LDL-C is inversely associated with mortality in most people over 60 years”. They said their finding contradicts the cholesterol hypothesis: that cholesterol, particularly LDL, causes fatty build-up in the arteries.

They consider that as they found older adults with high LDL live just as long as those with low LDL, this “provides the rationale for a re-evaluation of guidelines recommending pharmacological reduction of LDL-C in the elderly”.


This research suggests that – contrary to common belief – LDL cholesterol is not as “bad” as may be thought, and higher levels are not linked to all-cause or cardiovascular mortality.

However, before accepting this as fact, there are many important limitations to consider – both to the review and the included studies – many of which the review authors themselves acknowledge:

  • There is the potential that many studies relevant to this question may have been missed out. The review searched only a single literature database, excluded studies only available in non-English language, and excluded studies where the title and abstract did not appear to contain information on the link between LDL and mortality in older adults.
  • The study only looked at the link in older adults aged over 60. LDL-cholesterol levels may show different links with long-term mortality in younger adults. Though this was intended to represent the general older-age population, some studies had excluded people with specific conditions such as dementia, diabetes or terminal illness.
  • The studies varied widely in adjustment for confounding factors that could be having an influence on the link between LDL and mortality. Age, gender and body mass index (BMI) were common factors that studies took into account, but others variably accounted for lifestyle factors (e.g. smoking, alcohol), socioeconomic factors, presence of conditions, and use of medications.
  • Only LDL cholesterol was examined. Levels of total cholesterol, trigylcerides, and the ratio of LDL to HDL “good” cholesterol could be having an effect and mediating the link between LDL and mortality.
  • Most of the evidence for this review is for the link with all-cause mortality – not cardiovascular mortality. High LDL-cholesterol is believed to be linked with the development of atherosclerosis and cardiovascular disease. This review does not provide enough firm evidence to refute this link. The review cannot with certainty explain the reasons for the apparent link between LDL levels and death from any cause – with roughly half of studies finding a link and half not.
  • Importantly, the study does not provide evidence that statins are “a waste of time”. These are not trials examining mortality between people prescribed statins or not. The researchers openly acknowledge that the use of statins – which they haven’t directly examined – may be confounding the links in these studies. For example, the people found to have the highest LDL cholesterol levels at the study’s start may have then been started on statins, and this could have dramatically cut their reduced mortality risk.

The findings of this review and possible explanations will need to be explored further, but for now this review doesn’t provide solid evidence that high LDL cholesterol is good for you, or that statins are of no help. People given statins should continue to take them as prescribed.

“Fat is actually good for you” may be a great headline for a newspaper, and there are always researchers who are willing to make such a case, as we saw with the recent National Obesity Forum report.

These types of stories are often based on a selective view of evidence, rather than a comprehensive systematic review. There is currently no comprehensive body of evidence that contradicts current official advice on saturated fat consumption – which recommends no more than 30g of saturated fat a day for men and 20g for women.

Analysis by Bazian
Edited by NHS Website

Links to the headlines

Daily Mail, 13 June 2016

High cholesterol ‘does not cause heart disease’ new research finds, so treating with statins a ‘waste of time’

The Daily Telegraph, 13 June 2016

Health experts slam study that suggests over-60s live longer with ‘bad cholesterol’

Daily Mirror, 12 June 2016

Don’t throw away your statins yet – LDL cholesterol is probably still bad for you

The Guardian, 13 June 2016

Links to the science

Ravnskov U, Diamond DM, Hama R, et al.

Lack of an association or an inverse association between low-density-lipoprotein cholesterol and mortality in the elderly: a systematic review

BMJ Open. Published online June 12 2016

Cholesterol is a waxy material that is produced naturally by the liver. It protects the nerves, produces hormones and makes cell tissues, according to the American Academy of Family Physicians. However, too much cholesterol can be a bad thing — which is why it’s important to manage it and keep it at reasonable levels.

People can check their cholesterol levels by getting a simple blood test. The test measures total cholesterol, HDL (high density lipoprotein), LDL (low density lipoprotein) and triglycerides, another type of fat in the blood stream.

HDL is the “good” cholesterol that keeps LDL, the “bad” cholesterol, down, according to the American Heart Association. Too much LDL cholesterol can cause deposits known as plaque to build up in the blood vessels, which causes a decrease the amount of blood and oxygen going to the heart. This, in turn, can lead to heart disease and heart attack.

When people learn they have high cholesterol, the value often reflects their LDL cholesterol levels, said Dr. Kavita Sharma, the clinical director of The Ohio State University Wexner Medical Center Lipid Clinic.

Symptoms & causes

There are really no symptoms of high cholesterol. That’s why the National Heart, Lung and Blood Institute at the National Institutes of Health (NIH) recommends getting your cholesterol checked at age 20, and then every five years after that. The doctor will be able to tell if the cholesterol levels have risen too quickly and can help formulate a treatment plan.

Bad cholesterol levels that narrow and harden the arteries are exacerbated by a diet rich in saturated fat, being overweight or obese, and having little or no physical activity. Foods high in saturated fats include fatty beef, pork, fried foods, as well as high-fat dairy products, such as milk, butter and cheeses made of high fat, Sharma said.

Trans fats, which can also raise LDL cholesterol levels, can be difficult to calculate. Observant eaters can look at nutrition labels to see how many trans fats are in their diet, Sharma said.

High cholesterol is also caused, in part, by genetics. For instance, familial hypercholesterolemia, a genetic disorder, happens when the body is unable to remove LDL cholesterol from the blood, according to the NIH.

Age and gender are also risk factors. Women generally have lower LDL levels than men before menopause, but after menopause women’s cholesterol levels tend to rise, according to the American Heart Association. Smoking and diabetes are also risk factors for high cholesterol, according to the Mayo Clinic.

High triglycerides levels are also linked to an increased risk of blood vessel plaque formation and heart disease, Sharma said. They’re also linked to diabetes and metabolic syndrome, a condition related to high blood pressure, high blood sugar levels, excess body fat around the waist and high cholesterol levels, according to the Mayo Clinic.

Diagnosis & tests

A doctor may ask you to fast for 12 hours before taking a cholesterol test. After collecting a blood sample, doctors can measure the different concentrations of total cholesterol, HDL cholesterol, LDL cholesterol and triglycerides.

In 2013, the American College of Cardiology and the American Heart Association released new cholesterol guidelines. These new recommendations help doctors determine which people should receive statins. Statins are drugs that block cholesterol production, and may also help the body reabsorb cholesterol that built up in plaques within a person’s blood vessels, according to the Mayo Clinic.

People in four groups should receive statins, according to the guidelines. These include people who have:

  • A history of cardiovascular disease.
  • An LDL cholesterol level of 190 milligrams per deciliter (mg/dL) or higher.
  • Type 2 diabetes, and are between 40 and 75 years old.
  • A high risk of heart disease.

The last group can be determined using a formula that takes the person’s age, sex, race, smoking history and cholesterol levels into account. Healthy LDL cholesterol levels can range from below 100 to about 160 mg/dL, Sharma said.

Treatment & medication

Doctors will always recommend lifestyle changes first to treat high cholesterol, such as eating healthy foods, exercising and losing weight. However, there are medications that can help lower cholesterol, too. They include statins that are known under the brand names Lipitor, Lescol, Mevacor, Pravachol, Crestor, Zocor and Livalo, Sharma said.

Another type of medication is the bile-acid-binding resin, which includes the brand names Prevalite, Questran, Welchol and Colestid, according to the Mayo Clinic. This medication increases the liver’s production of bile acids, thereby reducing the amount of cholesterol in the blood.

Studies show that statins are highly effective at lowering cholesterol, but they can cause side effects, such as muscle pain, in some people, Sharma said. In these cases, people can use cholesterol absorption inhibitors, such as the brand name Zetia, which limit the amount of dietary cholesterol that your body absorbs. These inhibitors can also be combined with a statin, such as in the drug Vytorin, which decrease both absorption of and the production of cholesterol, according to the Mayo Clinic.

There are also some natural food and supplements that may help to lower cholesterol, according to the Mayo Clinic, including artichokes, barley, garlic, oat bran, beta-sitosterol, blond psyllium (found in Metamucil) and sitostanol. Even beans can help lower bad cholesterol levels, according to a 2014 study in the Canadian Medical Association Journal, as can foods with soluble fiber such as apples, brussel sprouts, pears and prunes, Live Science previously reported.

High-cholesterol prevention strategies

The best way to prevent high cholesterol is the same way to treat high cholesterol — living a healthy lifestyle. By losing weight, eating foods that are low in saturated fats, eliminating trans fats, eating whole grains, fruits, vegetables and fish and drinking alcohol in moderation, it’s possible to keep cholesterol and triglycerides levels down, according to Sharma and the American Heart Association. Regular exercise — 30 to 60 minutes a day — and leading a smoke-free lifestyle are also important methods to prevent high cholesterol.

Couples trying to conceive may also want to watch their cholesterol levels. According to a 2014 study of about 500 couples, researchers found a strong link between men and women with higher levels of cholesterol and the time it took them to become pregnant, Live Science previously reported.

However, it may be unwise to have your cholesterol levels bounce around dramatically like a yo-yo. According to a 2018 study in the journal Circulation that looked at 6.7 million people in South Korea, otherwise healthy people who had fluctuations in weight, blood pressure, cholesterol and/or blood sugar levels had an increased risk of heart attack, stroke and early death from any cause compared with people with more stable readings.

Even so, it’s important to strive for lower cholesterol and seek treatment if needed. A 2018 viewpoint in the journal JAMA stated that more than 39 million people in the United States are “eligible for but not taking a statin” for their cholesterol.

Additional resources

  • Cholesterol Fact Sheet, from the CDC.
  • Top 5 lifestyle changes to improve your cholesterol, from the Mayo Clinic.

Additional reporting by Amanda Chan. This article is for informational purposes only and is not meant to offer medical advice.

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