Decoding Your Numbers: Understanding Cholesterol and What to Do About It
You get your blood work back and see a list of cholesterol numbers. Total cholesterol, LDL, HDL, triglycerides—what does it all mean? Is higher better or worse? And what should you actually do about it?
Cholesterol is one of the most discussed—and most misunderstood—health topics. Let's clear up the confusion and give you the knowledge to take control of your heart health.
What Is Cholesterol?
Cholesterol is a waxy, fat-like substance found in every cell of your body. Despite its bad reputation, cholesterol is essential for life. Your body uses it to:
- Build cell membranes
- Produce hormones (including estrogen, testosterone, and cortisol)
- Make vitamin D
- Create bile acids for digestion
- Support brain function
Your liver produces all the cholesterol your body needs. Problems arise when there's too much cholesterol circulating in your blood—particularly the wrong types.
The Players: Understanding Your Lipid Panel
Cholesterol travels through your bloodstream attached to proteins called lipoproteins. Different types of lipoproteins have different effects on your health.
LDL Cholesterol ("Bad" Cholesterol)
Low-density lipoprotein (LDL) carries cholesterol from your liver to your cells. When there's too much, it deposits cholesterol in your artery walls, forming plaques. Over time, these plaques narrow arteries, restrict blood flow, and can rupture—causing heart attacks and strokes.
Goal: Lower is generally better
- Optimal: Below 100 mg/dL
- Near optimal: 100-129 mg/dL
- Borderline high: 130-159 mg/dL
- High: 160-189 mg/dL
- Very high: 190+ mg/dL
For people with heart disease or diabetes, targets are often below 70 mg/dL.
HDL Cholesterol ("Good" Cholesterol)
High-density lipoprotein (HDL) acts like a cleanup crew, picking up excess cholesterol from your arteries and returning it to your liver for disposal. Higher HDL levels are protective against heart disease.
Goal: Higher is better
- Low (increased risk): Below 40 mg/dL (men), below 50 mg/dL (women)
- Optimal: 60 mg/dL and above
Triglycerides
Triglycerides aren't cholesterol but are measured on the same panel. They're a type of fat your body uses for energy. Elevated triglycerides—often caused by excess sugar, refined carbs, and alcohol—contribute to artery disease and are associated with metabolic problems.
Goal: Lower is better
- Normal: Below 150 mg/dL
- Borderline high: 150-199 mg/dL
- High: 200-499 mg/dL
- Very high: 500+ mg/dL
Total Cholesterol
This is the sum of all cholesterol in your blood. While it's a useful screening number, it doesn't tell the whole story. You can have "normal" total cholesterol but unhealthy ratios of LDL to HDL.
General guidelines:
- Desirable: Below 200 mg/dL
- Borderline high: 200-239 mg/dL
- High: 240+ mg/dL
Beyond the Basic Numbers
Modern understanding of cholesterol has become more nuanced:
Non-HDL Cholesterol
Calculated by subtracting HDL from total cholesterol, this captures all the "bad" cholesterol particles—LDL plus other atherogenic particles. Many experts consider this a better predictor of risk than LDL alone.
LDL Particle Number and Size
Not all LDL is equal. Small, dense LDL particles are more dangerous than large, fluffy ones because they penetrate artery walls more easily. Advanced testing can measure particle number and size.
Ratios
- Total cholesterol/HDL ratio: Should be below 5; optimal is below 3.5
- Triglyceride/HDL ratio: Should be below 2; higher ratios suggest insulin resistance
Why Cholesterol Matters
High LDL cholesterol is a major risk factor for atherosclerosis—the buildup of plaque in artery walls. This process:
- Begins silently, often in young adulthood
- Progresses over decades without symptoms
- Can suddenly cause heart attacks or strokes when plaques rupture
Heart disease remains the leading cause of death in the United States. Managing cholesterol is one of the most effective ways to reduce your risk.
What Affects Cholesterol Levels?
Factors You Can't Control
- Genetics: Familial hypercholesterolemia and other genetic conditions can cause very high cholesterol regardless of lifestyle
- Age: Cholesterol tends to rise with age
- Sex: Before menopause, women typically have lower LDL than men; this changes after menopause
Factors You Can Control
- Diet: Saturated fat, trans fat, and dietary cholesterol raise LDL
- Weight: Excess weight raises LDL and triglycerides, lowers HDL
- Physical activity: Sedentary lifestyle worsens lipid profiles
- Smoking: Lowers HDL and damages arteries
- Alcohol: Excessive intake raises triglycerides
Lifestyle Strategies to Improve Cholesterol
Dietary Changes
Reduce:
- Saturated fat: Found in red meat, full-fat dairy, butter, coconut oil. Limit to less than 7% of daily calories.
- Trans fat: Found in some processed foods, fried foods, baked goods. Avoid completely.
- Refined carbohydrates and added sugars: Raise triglycerides and lower HDL.
Increase:
- Soluble fiber: Found in oats, barley, beans, lentils, apples, citrus. Binds cholesterol in the gut and removes it. Aim for 10-25 grams daily.
- Omega-3 fatty acids: Found in fatty fish (salmon, mackerel, sardines), walnuts, flaxseed. Lower triglycerides and may raise HDL.
- Plant sterols and stanols: Found in fortified foods or supplements. Block cholesterol absorption; can lower LDL by 6-15%.
- Nuts: Almonds and walnuts have been shown to improve cholesterol profiles.
Consider the Mediterranean diet: Emphasizes olive oil, fish, vegetables, whole grains, and legumes. Consistently shown to improve cardiovascular outcomes.
Exercise
Regular physical activity:
- Raises HDL cholesterol
- Lowers triglycerides
- May modestly lower LDL
- Improves the quality of LDL particles (larger, less dangerous)
Aim for at least 150 minutes of moderate-intensity exercise weekly. Both aerobic exercise and resistance training help.
Weight Management
Losing excess weight improves virtually every aspect of your lipid profile. Even modest weight loss (5-10% of body weight) produces significant improvements.
Quit Smoking
Smoking lowers HDL and damages artery walls. Quitting raises HDL and begins reversing arterial damage almost immediately.
Limit Alcohol
Moderate alcohol may raise HDL slightly, but the risks often outweigh benefits. Excessive alcohol significantly raises triglycerides.
When Medication Is Needed
Lifestyle changes are always the foundation, but many people also need medication—particularly those with:
- Established heart disease
- Very high LDL (190+ mg/dL)
- Diabetes
- High calculated cardiovascular risk
Statins
The most commonly prescribed cholesterol medications, statins work by:
- Blocking cholesterol production in the liver
- Lowering LDL by 30-50%
- Modestly raising HDL
- Reducing inflammation in arteries
- Stabilizing existing plaques
Common statins include atorvastatin (Lipitor), rosuvastatin (Crestor), simvastatin (Zocor), and pravastatin (Pravachol).
Side effects: Muscle aches occur in some patients; serious muscle damage is rare. Liver problems are uncommon with modern statins.
Other Medications
- Ezetimibe (Zetia): Blocks cholesterol absorption in the gut
- PCSK9 inhibitors: Injectable medications that dramatically lower LDL; typically for very high risk patients
- Fibrates: Primarily lower triglycerides
- Niacin: Raises HDL but side effects limit use
- Bempedoic acid (Nexletol): Newer option for statin-intolerant patients
- Icosapent ethyl (Vascepa): Prescription omega-3 for high triglycerides
How Often Should You Check Cholesterol?
General recommendations:
- Adults 20+: At least every 5 years
- Men 45-65, women 55-65: Every 1-2 years
- Over 65: Annually
- Those with risk factors or on treatment: As recommended by your doctor
Questions to Ask Your Doctor
- What are my specific risk factors for heart disease?
- What are my cholesterol goals based on my overall risk?
- Should I try lifestyle changes first, or do I need medication?
- If I'm prescribed a statin, what should I watch for?
- How often should I have my cholesterol rechecked?
The Bottom Line
Cholesterol management is not about a single number—it's about understanding your overall cardiovascular risk and taking appropriate action. For some people, lifestyle changes alone are sufficient. For others, medication is an important tool for reducing heart attack and stroke risk.
Don't ignore your cholesterol numbers, but don't panic about them either. Work with your doctor to understand what they mean for you specifically, and develop a plan that fits your situation.
If you haven't had your cholesterol checked recently, or if you have questions about your numbers, schedule an appointment. Understanding your cholesterol is one of the most important steps you can take for long-term heart health.
