Navigating cholesterol

What works, from the tried-and-true to the new

An awful lot of us struggle with high cholesterol. In fact, according to the Centers for Disease Control, about one in every six adults has too much blood cholesterol, placing those individuals at an increased risk of heart disease, the number-one killer in the United States. Anyone can develop high cholesterol, even kids.

Cholesterol is considered a significant risk marker for cardiac events, says Steven L. Schwartz, MD, FACC, medical director of Foundation Cardiology, located at Southern New Hampshire Medical Center. “And it is likely not just a marker but also an active player in that risk,” Schwartz says. Excess cholesterol can settle in arteries and eventually clog them, impeding blood flow and possibly leading to a heart attack.

Make no mistake: too much cholesterol can significantly harm your heart. But even though cholesterol is usually framed as the bad guy, it is a substance our body needs and produces. “There are two sources of cholesterol,” says Richard A. Boss, MD, a cardiologist at Concord Hospital Cardiac Associates. “There’s the cholesterol you eat and the cholesterol you make.” Cholesterol is a waxy substance manufactured in the liver that contributes to body functions including hormone production and maintenance of cellular structure. “It’s in every cell in our body,” Boss says. “[But] it’s very important that we watch our diet and not add to the cholesterol production our bodies are already making.”

Further contributing to cholesterol’s somewhat contradictory nature are two of its main components, LDL and HDL. LDL, which stands for low-density lipoprotein, is considered a “bad” type of cholesterol because it transports cholesterol through the bloodstream and into arteries, contributing to the dangerous plaque build-up that leads to heart disease. “We know that plaques that have a lot of cholesterol in them are more likely to have plaque rupture, and the ones that rupture are more likely to cause heart attacks,” says Schwartz.

HDL, or high-density lipoprotein, on the other hand, protects against heart disease by removing cholesterol from the blood. HDL returns cholesterol to the liver, where it is broken down and passed from the body. Given the consequences of LDL and HDL, the goal for each of us should be to minimize our level of LDL, and maximize the amount of HDL in our body, Boss says.

We run into cholesterol trouble, however, when factors such as lifestyle, diet, and genetics skew cholesterol levels. Smoking and a sedentary lifestyle, for example, contribute to plaque build-up in the arteries, and poor dietary choices — such as eating saturated fat in animal products, trans fat in baked goods and processed foods, and certain oils — stimulate our liver to produce more cholesterol. Those who have a family history of cholesterol problems might find that even if they make all the right lifestyle and diet choices, their bodies continue to make too much cholesterol. “It’s almost like there’s a thermostat that’s set high in the house that puts cholesterol production at a high level,” Boss says. Doctors typically recommend medication for those patients, he says.

Statins, a class of cholesterol-lowering prescription drugs that work by inhibiting the natural production of cholesterol in the body, are a cornerstone of cholesterol management. “We use them in a lot of people, with tremendous impact,” Boss says. The number of people who can’t take statins because of side effects “is very small,” he says. And while any medication carries some risk, statins “have tremendous potential benefit for people who take them,” Boss says.

A new alternative to statins, PCSK9 inhibitors, works by inhibiting degradation of LDL receptors in the liver so that more receptors are available to “catch” LDL and aid its release from the body, Schwartz says. PCSK9 inhibitors are administered via injection every two to four weeks and are not as popular as statins given their short track record — doctors prefer to see long-term outcome results before prescribing a medication — and high expense, particularly when compared to statins.

But even given the effectiveness of drugs like statins, patients who take cholesterol medication should be careful not to rely solely on medication to keep cholesterol in check. “You want to use as little medicine as possible,” Boss says, and recognize that cholesterol poses an ongoing challenge. “I don’t want [patients] relying on medication and ignoring diet and exercise,” he says, because factors such as not smoking, eating heart-friendly foods, and consistently getting aerobic exercise play a key role in maintaining healthy cholesterol levels and a healthy heart.


Your total cholesterol score is calculated using the following equation: HDL + LDL + 20 percent of your triglyceride level.

HDL (good) cholesterol: With HDL cholesterol, higher levels are better. Low HDL cholesterol puts you at higher risk for heart disease. People with high blood triglycerides usually also have lower HDL cholesterol. Genetic factors, type 2 diabetes, smoking, being overweight and being sedentary can all result in lower HDL cholesterol.

LDL (bad) cholesterol: A low LDL cholesterol level is considered good for your heart health. However, your LDL number should no longer be the main factor in guiding treatment to prevent heart attack and stroke, according to new guidelines from the American Heart Association. For patients taking statins, the guidelines say they no longer need to get LDL cholesterol levels down to a specific target number. A diet high in saturated and trans fats raises LDL cholesterol.

Triglycerides: A high triglyceride level combined with low HDL cholesterol or high LDL cholesterol is associated with atherosclerosis, the buildup of fatty deposits in artery walls that increases the risk for heart attack and stroke. For more, visit

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