Womens Health Centre

Cholesterol Management


High Blood Cholesterol: What You need to know
Improving your blood cholesterol levels: What you need to do
Where you can go for help

So You Have High Blood Cholesterol...

A high blood cholesterol level means that you have more cholesterol in your bloodstream than your body needs. The higher your blood cholesterol level, the greater your risk or chance of developing coronary heart disease--the most common form of heart disease. Anyone can develop high blood cholesterol, no matter what his or her age, gender, race, or ethnic background. In fact, 52 million American adults now have a blood cholesterol level high enough to need medical advice to help lower it. High blood cholesterol has no warning signs. So, you may be surprised to know that you have it. Don't be alarmed, but do take it seriously. You can lower high blood cholesterol and bring down your risk of heart disease.

Blood Cholesterol and Lipoproteins: What They Are

Cholesterol is a waxy substance that occurs naturally in all parts of the body. Your body needs cholesterol to function normally (for example, to make certain hormones and vitamin D) hormones, vitamin D, and bile acids -- which are important the absorption of fat). Your body produces enough cholesterol to meet its needs.

How High Blood Cholesterol Leads to Heart Disease.

When there is too much cholesterol in your blood, the excess can become trapped in the walls of your arteries. By building up there, the cholesterol helps to cause "hardening of the arteries" or atherosclerosis. Atherosclerosis causes most heart attacks. How? The buildup narrows the arteries that supply blood to the heart, slowing or even blocking the flow of blood to the heart. So, the heart gets less oxygen than it needs. This weakens the heart muscle, and chest pain (angina) may occur. If a blood clot forms in the narrowed artery, a heart attack (myocardial infarction) or even death can result.

Cholesterol buildup happens very slowly--you are not even aware of it. If you lower your high blood cholesterol level, you can slow, stop, or even reverse the buildup--and lower your risk of illness or death from heart disease.

Cholesterol travels in the blood in packaged lipoproteins. Just like oil and water, cholesterol and blood do not mix. So in order to be able to travel in the bloodstream, the cholesterol made in the liver is coated with a layer of protein, making it a "lipoprotein." This lipoprotein then carries the cholesterol through the bloodstream.

Two types of lipoprotein affect your risk of heart disease.

Low-density lipoproteins (LDL): the "bad" cholesterol. LDL's carry most of the cholesterol in the blood, and the cholesterol and fat from LDLs are the main source of dangerous buildup and blockage in the arteries. Thus, the more LDL-cholesterol you have in your blood, the greater risk you have for heart disease.

High-density lipoproteins (HDL): the "good" cholesterol. HDL's carry some of the cholesterol in the blood but this cholesterol goes back to the liver, which leads to its removal from the body. So HDLs help keep cholesterol from building up in the walls of the arteries. If your level of good cholesterol is low, your risk of heart disease is greater.

How are LDL and HDL Levels Determined?

What Makes Blood Cholesterol High or Low?

Why do some people have too much cholesterol in their blood? Many factors determine whether your blood cholesterol level is high or low. The following factors are the most important:

Heredity. Your genes partly determine the amount of cholesterol your body makes, and high blood cholesterol can run in families.

Diet. Among the factors you can do something about, diet has the largest effect on your blood cholesterol. Two nutrients in the foods you eat make your blood cholesterol level go up: saturated fat, a type of fat found primarily in food that comes from animals, and cholesterol which comes only from animal products. Saturated fat raises your blood cholesterol level more than anything else you eat. Dietary cholesterol also increases your blood cholesterol level. Reducing the amounts of saturated fat and cholesterol you eat is an important step toward reducing your blood cholesterol levels.

Weight. Excess weight tends to increase your blood cholesterol level. If you are overweight and have high blood cholesterol, losing weight can help to reduce your cholesterol levels.

Age and sex. Before menopause, women have total cholesterol levels that are lower than those of men the same age. Pregnancy raises blood cholesterol levels in many women, but blood cholesterol levels should return to normal about 20 weeks after delivery. As women and men get older, their blood cholesterol levels rise. In women, menopause often causes an increase in their LDL-cholesterol level. Some women may benefit from taking estrogen after menopause because estrogen lowers LDL's and raises HDL's.

Alcohol. Moderate alcohol intake increases HDL-cholesterol. However, doctors do not know whether it also reduces the risk of heart disease. Drinking too much can damage the liver and heart muscle and cause other health problems. Because of these risks, you should not drink alcoholic beverages to prevent heart disease.

Stress. Long-term stress has not been shown to raise blood cholesterol levels. The real problem with stress may be how it affects your habits. For example, when some people are under stress, they console themselves by eating fatty foods. The saturated fat and cholesterol in these foods probably cause higher blood cholesterol, not the stress itself.

Other Risk Factors for Heart Disease

In addition to a high LDL-cholesterol level and a low HDL-cholesterol level, other factors also increase your chance of heart disease. The chart below lists these risk factors. The more of them you have, the higher your chance of developing heart disease. If you have any of these risk factors in addition to your high blood cholesterol, your risk of heart disease is even greater.

In addition to the risk factors on the chart, another factor that influences your risk of heart disease is where your body stores excess fat. If you have an "apple-shaped" body with most of your fat around the stomach, you are at a greater risk of heart disease.

Risk Factors for Heart Disease

Factors You Can Do Something About Factors You Cannot Control
Cigarette smoking Age:
45 years or older for men
55 years or older for women
High blood cholesterol (high total cholesterol and high LDL-cholesterol)
Low HDL-cholesterol Family history of early heart disease
(heart attack or sudden death):
Father or brother
stricken before the age of 55
Mother or sister
stricken before the age of 65
High blood pressure
Physical inactivity

Talk to your doctor about all of your risk factors and what you can do to reduce your chance of heart disease. Often, the actions you take to control one risk factor help reduce others as well. For example, losing weight helps to reduce blood cholesterol levels and high blood pressure, and helps to control diabetes. Regular physical activity can help you lose weight as well as improve the fitness of your heart and lungs, which can also help lower your risk of heart disease.

What Your Blood Cholesterol levels Mean

Now that you know the basics, let's take a closer look at blood cholesterol levels and their relationship to heart disease risk.

Note: The information in the following sections is appropriate only for people who do not currently have heart disease. If you have ever had a heart attack or have ever been told by a doctor that you have heart disease, please click here.

Your Blood Cholesterol Tests

Blood cholesterol levels are measured in a small blood sample taken from your fingers or your arm. The blood is tested for total cholesterol and, if accurate results can be obtained, HDL-cholesterol levels. You do not have to fast or do anything special before having this blood test. Depending on the results, you may also need a second blood test, a lipoprotein profile, to determine your LDL-cholesterol level; you do have to fast for this test. An LDL-cholesterol level gives the doctor more information about your risk of heart disease and helps to guide any necessary treatment.

After the test, compare your results with the levels listed in the chart below

Classification: Total and HDL-Cholesterol
Total Cholesterol
Desirable Blood Cholesterol Borderline-High Blood Cholesterol High Blood Cholesterol
less than 200 mg/dL 200-239 mg/dL 240 mg/dL and above
Low HDL-Cholesterol
Less than 35 mg/dL

Your Next Steps If You Do Not Have Heart Disease
If Your Total and HDL Levels are... Then...
Total Cholesterol HDL-Cholesterol
less than 200 mg/dL 35 mg/dL or greater You are doing well and should have your total and HDL-cholesterol levels checked again in about 5 years. In the meantime, take steps to keep your total cholesterol level down: eat foods low in saturated fat and cholesterol, maintain a healthy weight, and be physically active. The last two steps, along with not smoking, will also help keep your HDL level up.
less than 200 mg/dL or 200-239mg/dL less than 35 mg/dL You will need a lipoprotein profile to find out your LDL-cholesterol level. For this test you need to fast for 9-12 hours before the test. Have nothing but water, or coffee or tea with no cream or sugar.
200-239 mg/dL 35 mg/dL or greater Your doctor will see if you have other risk factors for heart disease and determine whether more tests (including a lipoprotein profile to find out your LDL-cholesterol) need to be done. No matter what your risk is, it is important to eat foods low in saturated fat and cholesterol, to maintain a healthy lifestyle.
240 mg/dL and above any level You will need a lipoprotein profile to find out your LDL-cholesterol level. Again, you need to fast for 9-12 hours before the test, having nothing but water, or coffee or tea with no cream or sugar.

What your LDL-Cholesterol Levels Mean

A high LDL-Cholesterol level increases your risk for heart disease. Use the chart below to find out about your risks and your next steps.

Classification: LDL-Cholesterol
Desirable Borderline-High Risk High Risk
less than 130 mg/dL 130-159 mg/dL 160 mg/dL and above

Your Next Steps If You Do Not Have Heart Disease
If your LDL Level is... Then...
less than 130 mg/dL You have a desirable LDL-cholesterol level. You will need to have your total and HDL -cholesterol levels tested again in 5 years. You should follow an eating plan low in saturated fat and cholesterol, maintain a healthy weight, be physically active, and not smoke.
130 mg/dL or above Your doctor will look at your other heart disease risk factors and decide what you need to do to lower your LDL-cholesterol level. The higher your level and the more other risk factors you have, the more you need to follow a diet low in saturated fat and cholesterol. For example, if your LDL is 160 mg/dL or greater and you have fewer than two other risk factors, your LDL goal is a level below 160 mg/dL. If your LDL is 130 mg/dL or greater and you have two or more other risk factors, your goal is to reduce your LDL level to below 130 mg/dL. It is also important to lose weight if you are overweight, to be physically active, and to not smoke. Discuss your treatment plan with your doctor

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What Your Blood Cholesterol Levels Mean If You Do Have Heart Disease

Your Blood Cholesterol Tests

Since you have heart disease, finding out about your blood cholesterol levels is a little different. you will need to have a blood test called a lipoprotein profile. This test will determine not only your total and HDL-cholesterol levels, but also your LDL-cholesterol levels--and levels of another fatty substance called triglyceride. Before you have the blood test, you must fast. You can have nothing to eat or drink but water, or coffee or tea with no cream or sugar, for 9 - 12 hours before the test.

Check Your Levels

Since you have heart disease, your doctor will use your LDL-cholesterol level to decide on the best treatment. Your aim should be to have an LDL-cholesterol level lower than that of people who do not have heart disease. Compare your levels to those in the chart below to find out what your next steps should be.

Your Next Steps If You Do Have Heart Disease
If your LDL Level is... Then...
100 mg/dl or less You do not need to take specific steps to lower your LDL, but you will need to have your level tested again in 1 year. In the meantime, you should closely follow a diet low in saturated fat and cholesterol, maintain a healthy weight, be physically active, and not smoke.
greater than 100 mg/dL You need to have a complete physical examination done to see if you have a disease or a health condition that is raising your cholesterol levels. You will probably need a diet that is lower in saturated fat and cholesterol, i.e., the Step II diet (see page 21). Since this diet will be more effective, your doctor will likely encourage you to start there, as well as to be physically active, to lose weight if you are overweight, and to not smoke. If your LDL level does not come down, you may need to take medicine.

Questions You May Have About Your High Blood Cholesterol

Since I'm a Woman, Why Should I Worry About Having a Heart Attack?

It's true that before menopause, women are unlikely to die from heart disease. But as they get older, especially after menopause, their chance of developing heart disease goes up. Women and men in their seventies have an equal likelihood of dying from heart disease. That's why at any age it is important for women as well as men to take steps to prevent high blood cholesterol.

At 69, I'm Feeling Fine. Why Do I Need to Make Changes Now?

You have three very good reasons to change some of your health habits. First, the risk of heart disease increases as you get older. Although you are feeling well, you may already have some buildup of fat and cholesterol in your arteries. Unless you try to stop or reverse the buildup, you may have a heart attack later on.

Second, adopting a healthy lifestyle helps reduce the risk of heart disease-even for people your age. People in their seventies can lower their blood cholesterol levels, and therefore deposit less fat in their arteries. Being more physically active is another important step that helps to protect older people against heart disease. A heart-healthy diet should also be a balanced diet. Most people will not have to make extreme changes to make their eating and activity habits healthy. These changes can fit in with your overall lifestyle.

Reason number three: You've got a lot of living yet to do. A man at 69 can expect on average to live another 15 years; a woman at 69 can expect to live another 19 years. The changes you make now can help make those years more healthy and enjoyable.

Will Lowering My Blood Cholesterol Help Me Live Longer?

Many studies show that lowering cholesterol levels reduces the risk of illness or death from heart disease, which kills more men and women each year than any other illness. If you have heart disease, lowering your cholesterol level will probably help you to live longer. If you don't have heart disease, the studies so far do not show that you will live longer, but you will definitely reduce your risk of illness and death from heart attack.

Since Heredity Can Cause High Blood Cholesterol, Do My High Levels Mean That My Family Is At Risk?

If you have high blood cholesterol, your family may also have high levels. This includes your children, parents, brothers, and sisters. They should all have their cholesterol levels tested to help protect them from heart disease.

How Much Does My Cholesterol Level Change From Day to Day?

Your cholesterol level varies somewhat from day to day, sometimes by more than 15-20 mg/dL. Different laboratories also may use different methods of analyzing blood cholesterol levels which can give different results. This is why you need more than one cholesterol test before starting any treatment.

What Is a Cholesterol Ratio?

Some laboratories may calculate a cholesterol ratio. The ratio is obtained by dividing either total cholesterol or LDL-cholesterol by the HDL-cholesterol. The ratio is not recommended since it is more important to know each value separately. Be sure to get separate total cholesterol, LDL, and HDL values.

My Blood Test Showed I Also Have High Triglycerides. How Does That Affect My Risk of Heart Disease?

Triglycerides are a form of fat that is carried through the bloodstream. Most of your body's fat tissue is in the form of triglycerides. High blood triglyceride levels alone usually do not raise your risk of heart disease. But many people have a high triglyceride level along with high LDL- and low HDL-cholesterol levels. In these cases, the three are often treated together.

Here's how to judge your triglyceride level:
Normal Borderline-High High Very High
less than 200 mg/dL 200-400 mg/dL 400-1,000 mg/dL Greater than 1,000 mg/dL

Borderline-high and high triglyceride levels are first treated with the same diet and lifestyle changes used for high blood cholesterol levels. These changes include:

Usually "very high" levels are due to heredity. They may be lowered with the changes above, along with medicines.

Does Eating Foods High in Salt and Sodium Increase My Blood Cholesterol Level?

No. The amount of sodium in your diet has no effect on your cholesterol level. However, sodium can cause blood pressure to rise in some people. Further, many people with high blood cholesterol also have high blood pressure. If you have both, it's a good idea to reduce your sodium intake. The National High Blood Pressure Education Program recommends no more than 2,400 mg per day (the amount in about 1 teaspoon of table salt). On average, Americans take in 4,000 to 6,000 milligrams of sodium each day. This sodium comes from many different foods. Foods high in sodium include some canned soups, vegetables, and meats; instant soups and cereals; ready-to-eat cereals; salty snacks and crackers; pickles and olives; and many frozen meals. For more help on reducing sodium as part of a cholesterol-lowering diet, write for Step by Step: Eating To Lower Your High Blood Cholesterol (See page 30.)


Take Action: Here's How

Now that you understand why you should lower your high blood cholesterol, this sections details how to do it. It covers:

This section also describes medicines for lowering high blood cholesterol. Medicines may become necessary for those who cannot lower their blood cholesterol through diet and exercise.

Three Steps to Reducing High Blood Cholesterol Levels

  1. Follow the Step I or Step II diet. Your doctor will first recommend one or the other. The diets contain all the daily nutrients you need and emphasize eating foods that are low in saturated fat, total fat, and cholesterol, and high in starch and fiber. You will probably be asked to follow a Step I diet first to see if it brings your blood cholesterol levels down sufficiently. If not, you may have to move to the Step II diet. If you already have coronary heart disease or a very high LDL level, your doctor may recommend starting with the Step II diet,

  2. Be more physically active.

  3. Lose weight if you are overweight.

Fortunately, these three steps work together, for example:

For a simple and effective way to implement these guidelines for reducing cholesterol, try the DietMate program. Click here for information on DietMate.

How Low Will You Go?

By closely following your diet, being more physically active, and watching your progress with regular checkups, you can lower your blood cholesterol level. How much your cholesterol levels change depends on:

Usually the higher your blood cholesterol is to begin with, the larger the changes you will see. However, sometimes due to heredity, levels will not change enough no matter how well you change your habits.

Learn about the Step I and Step II Diets

Step I Diet

On the Step I diet, you should eat:


On the Step II diet, you should eat:

Practical ways to change your diet

Here are some tips on how to choose foods for the Step I and Step II diets

1. To cut back on saturated fats choose:

To include more foods high in starch and fiber, choose:

2. Make Physical Activity Work for You

Regular physical activity by itself may help reduce deaths from heart disease by:

If you have been inactive for a long time, start with low-to-moderate level activities such as walking, taking the stairs instead of the elevator, gardening, housework, dancing, or exercising at home. Begin by doing the activity for a few minutes most days, then work up to a longer program-at least 30 minutes per day, 3 or 4 days a week. This can include regular aerobic activities such as brisk walking, jogging, swimming, bicycling, or playing tennis.

If you have heart disease or have had a heart attack, talk with your doctor before starting an activity to be sure you are following a safe program that works for you. Otherwise you may experience chest pain or further heart damage. if you have chest pain, feel faint or light-headed, or become extremely out of breath while exercising, stop the activity at once and tell your doctor as soon as possible.

3. Lose Weight If You Are Overweight

Two action steps are key

You May Need To Take Medicine

If you have successfully changed your eating habits for at least 6-12 months, and your LDL-cholesterol level is still too high, you may need to take medicine. Some people will need to take medicine from the start of their treatment because of a very high LDL level or the presence of heart disease.

If your doctor prescribes medicine, you also will need to:

Taking all these steps together may lessen the amount of medicine you need, or make the medicine work better. And that reduces your risk of heart disease.

Medicines Your Doctor May Prescribe

Several types of medicine can help lower blood cholesterol levels. These include:

Major Drugs

Other Drugs

In addition, if you are a woman going through or past menopause, your doctor may talk with you about estrogens. Sometimes called Estrogen Replacement Therapy, this can lower blood cholesterol levels, and may make it unnecessary to take a cholesterol-lowering drug.

Drugs that lower blood cholesterol work in different ways. Some may work for you while others may not. Before the doctor prescribes any medicine, be sure to state what other medicines you are taking. And once a medicine is prescribed, take it exactly the way your doctor tells you to. If you have any side effects from a medicine, tell your doctor right away The amount or type of drug can be changed to reduce or stop unwanted side effects. Whatever medicine you take, continue to follow the Step I or Step II diet and to be more physically active. This will help keep the dose of medicine as low as possible.

Get More Information

The National Cholesterol Education Program (NCEP), coordinated by the National Heart, Lung, and Blood Institute (NHLBI), has a pamphlet called Step by Step: Eating To Lower Your High Blood Cholesterol. This pamphlet gives details on how to change your eating habits in order to lower your blood cholesterol levels. The NCEP also has booklets for children with high blood cholesterol levels and their parents. In addition, the NHLBI has a booklet, Exercise and Your Heart, and a resource list of agencies and organizations able to answer questions on cholesterol and the other risk factors for heart disease. For these and other materials, write:

National Cholesterol Education Program
NHLBI Information Center
PO. Box 30105
Bethesda, Maryland 20824-0105

The American Heart Association can also provide you with additional information. Contact your local American Heart Association or call 1-800-AHA-USAI (1-800-242-8721).

PICS, Inc.
provides information on the Step I diet, weight reduction, cholesterol and hypertension control and exercise programs.
12007 Sunrise Valley Drive
Reston, VA 22091


Atherosclerosis: A type of "hardening of the arteries" in which cholesterol, fat, and other substances in the blood build up in the walls of arteries. As the process continues, the arteries to the heart may narrow, cutting down the flow of oxygen-rich blood and nutrients to the heart.

Bile Acid Sequestrants: One type of cholesterol-lowering medication, including cholestyramine and colestipol. The sequestrants bind with cholesterol-containing bile acids in the intestines and remove them in bowel movements.

Calories: Units of measurement that represent the amount of energy the body is able to get from foods. Different nutrients in foods provide different amounts of calories. Carbohydrates and protein provide about 4 calories per gram, while fat (both saturated and unsaturated) yields about 9 calories per gram.

Carbohydrate: One of the nutrients that supply calories to the body. Carbohydrates may be simple or complex. Complex carbohydrates also are called starch and fiber, which come from plants and can be found in whole-grain breads, cereals, pasta, rice, dried peas and beans, corn, lima beans, fruits, and vegetables.

Cholesterol: A soft, waxy substance. The body makes enough cholesterol to meet its needs. Cholesterol is used in the manufacture of hormones, bile acid, and vitamin D. It is present in all parts of the body, including the nervous system, muscle, skin, liver, intestines, and heart.

Estrogen Replacement Therapy (ERT): Treatment with the hormone estrogen, which has many effects, one of which is cholesterol lowering. It includes different amounts of estrogen and progestin, two hormones produced normally by women who have menstrual periods. ERT is given only to women who have gone through menopause. ERT may help prevent heart disease by lowering blood cholesterol levels, especially LDL.

Fat: One of the nutrients that supply calories to the body. The body needs only small amounts of fat. Foods contain different types of fat, which have different effects on blood cholesterol levels. These include:

Fibric Acid Derivatives: One type of cholesterol-lowering drug. It includes gemfibrozil. The fibric acids lower triglycerides and raise HDLS.

HMG CoA Reductase Inhibitors: See "Statins."

Lipids: Fatty substances, including cholesterol and triglycerides, that are present in blood and body tissues.

Lipoproteins: Protein-coated packages that carry fat and cholesterol through the bloodstream. Lipoproteins are classified according to their density.

Lipoprotein Profile: A test that uses blood from the arm to measure your total, HDL-, and LDL-cholesterol, and triglyceride levels. The test requires a fast for 9-12 hours beforehand. Nothing can be consumed but water, or coffee or tea with no cream or sugar.

Milligram (mg): A unit of weight equal to one-thousandth of a gram. There are about 28,350 mg in 1 ounce. Dietary cholesterol is measured in milligrams.

Milligrams/Deciliter (mg/dL): The measure used to express cholesterol and triglyceride levels in the blood. It stands for the weight of cholesterol in milligrams in a decaliter of blood. A decaliter is one-tenth of a liter or about one-tenth of a quart.

Nicotinic Acid: A cholesterol-lowering medicine that reduces total and LDL-cholesterol and triglyceride levels and also raises HDL-cholesterol levels. This is the same substance as Niacin or vitamin B1, but in doses that lower cholesterol. It should only be used with your doctor's supervision.

Risk Factor: A habit, trait, or condition in a person that is associated with an increased chance (or risk) for a disease.

Statins: One type of cholesterol-lowering drug that includes lovastatin, pravastatin, and simvastatin. These drugs lower LDL levels by limiting the amount of cholesterol the body can make.

Triglycerides: Lipids carried through the bloodstream to tissues. Most of the body's fat tissue is in the form of triglycerides, stored for use as energy. Triglycerides are obtained primarily from fat in foods.

Information in this section is adapted from "So You Have High Blood Cholesterol" published by the U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, Public Health Service, National Institutes of Health, National Heart, Lung, and Blood Institute, NIH Publication No. 93-2922.

For sale by the U.S. Govemment Printing Office
Superintendent of Documents, Mail Stop: SSOP, Washington, DC 20402-9328
ISBN 0-16-042916-1


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