Cholesterol & Your Heart: Beyond the Numbers

Some health risks can be hard to pin down, challenging to manage or impossible to control. High cholesterol is just the opposite.

Although an estimated one in three Americans has it—and decades of experience and research show us that it harms the heart and blood vessels—the good news is that treating it is safe, effective and inexpensive.

Cholesterol’s Function

Cholesterol is a lipid, a waxy molecule in the fat family. It does not dissolve in water, making it an ideal component of the cell membrane—the envelope that keeps cells separate from one another.

But its insolubility can make it dangerous. Since blood is mostly water, it cannot dissolve a persistent build-up of cholesterol. At some point, that cholesterol penetrates the walls of the blood vessels, triggering an immune response and causing inflammation. That’s the recipe for plaque, the fatty deposit that narrows blood vessels, blocks blood flow and encourages clotting, putting you at risk for heart attack and stroke.

Over your lifetime, your body would make all the cholesterol it needs, even if you never consumed any. The liver makes it from raw materials in the fat and sugar we consume. High cholesterol isn’t a problem in cultures that eat a plant-based diet. Not so in cultures that crave sweet and fatty foods.

It’s a common misconception that only foods with cholesterol will increase your cholesterol. Even sugar alone can raise your triglycerides, a building block of cholesterol. So whether we eat cholesterol-rich foods, or foods like sugar that encourage the liver to make cholesterol, we may risk a potentially harmful build-up.

Cholesterol, Good and Bad

When you get a lipid panel blood test, it shows a combination of cholesterol and triglycerides. Cholesterol comes in two varieties: low density lipoprotein (LDL) and high density lipoprotein (HDL).

LDL is known as the “bad” cholesterol, a reputation well deserved. And although HDL is often labeled “good” cholesterol, its protective qualities are limited. Your HDL level is mainly a product of metabolism, lifestyle and genetic makeup. It’s difficult to boost, and, even if you could do so easily, it wouldn’t be enough to protect you against heart and blood vessel disease if the LDLs and triglycerides are also elevated.

The triglyceride is another type of fat molecule that stores calories to keep the body functioning between meals. It is tightly linked to inflammation and blood sugar, both of which can impact the health of the heart and blood vessels. When we consume too much food, all those stored calories cannot be burned, and the triglyceride level jumps.

The Numbers Game

LDL, however, is the main culprit; the higher it is, the greater the risk to your health. But rather than focus on that single number, I’m interested in the balance between a patient’s LDL and HDL. For example, I like to see the LDL at no more than twice HDL, but 1.5 times is even better. So, if your HDL is 40, an LDL of 80 is good, but an LDL of 60 is preferable.

Of course, in any internet search on the topic of cholesterol, you’ll quickly find guidelines on where your numbers “should” be. But it’s not that simple.

The guidelines were designed to assess the health of the general population, not of any one individual. In my opinion, the numbers most frequently recommended are too high. If your goal is merely to stay below them, you could still be at significant risk. It’s essential to talk with your healthcare provider and determine the best plan to keep your numbers where they need to be, based on your unique metabolism and risk factors.

Taking Action

It can take decades for the adverse health effects of high cholesterol to show up—one reason why the risk for heart and blood vessel disease increases with age. But most Americans have the beginning stages of cardiovascular disease even before the age of 40, and it is almost exclusively thanks to high cholesterol levels.

So begin early to reduce your risk. Prevention is the best medicine, and it’s critical to monitor and control it before you get to that point, even if you’re younger and your heart and blood vessels are in perfect shape.

Of course, due to genetics, some people are naturally prone to high cholesterol. But, since we can’t yet alter genetics, we focus on factors we can control. Lifestyle choices can be significant. In an ideal world, we would all be active enough and eat healthily enough to control cholesterol issues without medication. But, because many Americans can use additional help, we have a first line of defense—statins.

Statins are more effective and reliable than lifestyle modification alone. They’re safe and inexpensive. I believe we should be working to increase access, especially for all Americans over age 40. The health risks associated with cholesterol are significantly higher and more dangerous than any risks associated with statin medications. In my opinion, they’re very safe when used properly—significantly safer than aspirin—and should be reclassified as over the counter. To really decrease heart and blood vessel disease, I’d like to see patients empowered with better access to these useful medications.

This is supported by science. For instance, one well-known study—Heart Outcomes Prevention Evaluation, or HOPE-3—showed conclusively that low-dose statin therapy is superior to both placebo and blood pressure meds in reducing long-term cardiovascular events in a population with intermediate risk.

That’s not to say taking a statin gives you a free pass to smoke, avoid exercise, and eat and drink as much as you want. A healthy lifestyle is the foundation of cholesterol control. Even if you are taking a cholesterol-reducing drug, healthy living makes it more effective, since it doesn’t have to work as hard.

Exercise is a true wonder drug, with so many benefits overall, including lower weight and blood pressure, better regulation of blood sugar, and increased fitness of the heart and blood vessels.

Among controllable lifestyle choices, smoking merits special mention. Although research shows no direct link between blood cholesterol and tobacco, using it is like pouring gasoline on the fire. It worsens every other cardiovascular risk, complicates existing disease, and encourages a host of problems.

Other Medications

Certain patients may experience side effects from statin drugs, such as muscle pain, liver problems, elevated blood sugar and neurological effects. Gender, genetics and lifestyle might also complicate the side effects.

Recognizing the potential issue for some, the drug industry responded with non-statin agents, some in pill form, some injectable. My patients do well on both.

Like diabetics, patients can quickly adapt to injectables. And, unlike insulin for diabetes, injectable cholesterol drugs are taken much less frequently—once or twice a month, depending on the drug.

Also, for some patients, the first line of medication may not be enough. Perhaps they lower LDLs, but triglycerides remain high. In those cases, we may advise the addition of fish oil to the patient’s regimen—but not the capsules or supplements found in the vitamin aisle, which are not advised for cholesterol control. Rather, we’ll recommend highly refined, pharmaceutical-grade prescription fish oil.

The Bottom Line

• If you’re healthy, under 40 and have no other cardiovascular risk factors, we recommend that you get a lipid panel every three to five years.
• If you have any other risk factors—if you’re over 40, have a family history, or have hypertension, for example—request an annual cholesterol screening.
• Eat healthy foods. Being overweight can increase triglycerides. When choosing food and beverages, avoid fatty and sweet ones as much as possible. Moderate your alcohol intake, as that can increase your triglycerides, too.
• Get outside and move. This is especially important during the pandemic, when so many are working from home, moving less, and eating and drinking more.
• Be sure to trust and take your cholesterol medications. We rely on these medications as key components of a heart disease prevention plan.
• Most importantly, keep the lines of communication open with your healthcare provider.

By controlling high cholesterol, we can all make a measurable positive impact on the health of the nation. Plus, it might save your life.