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High Cholesterol: Prevention, Treatment and Research

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Cholesterol is a natural component in everyone’s blood. However, when you have too much of this fatty substance, it’s considered hyperlipidemia, hypercholesterolemia or high blood cholesterol—a major risk factor for heart attack, heart disease and stroke. About 71 million Americans have high cholesterol.


Here’s what happens in your body when you have high cholesterol: The waxy cholesterol builds up in artery walls and contributes to plaque, a hard deposit that narrows and clogs the arteries. (You may hear this referred to as atherosclerosis, or “hardening of the arteries.”) When plaque builds up, it becomes harder for the heart to circulate blood and oxygen, which can cause chest pain or shortness of breath with increased exertion (angina). If a blood clot forms at the site of a disrupted plaque in a narrowed artery, it can block blood flow to the brain (a stroke) or to the heart (a heart attack).

There are actually several different types of cholesterol. High-density lipoprotein (HDL cholesterol) provides a good, protective effect on your body. The other kinds of cholesterol, however, are considered harmful. Low-density lipoprotein, cholesterol or LDL cholesterol, is the most common of these, but there are others. Your total cholesterol reading minus your HDL cholesterol yields a number known as non-HDL cholesterol, which is becoming an increasingly important marker to help doctors assess heart health, says Johns Hopkins Ciccarone Center cardiologist Michael Blaha, M.D., M.P.H.

“Everyone should know their non-HDL cholesterol number,” says Blaha. “It’s the best cholesterol number to know for predicting cardiovascular risk.” 


To keep blood cholesterol numbers in a desirable range, it helps to follow these practices:

  • Know your numbers. Adults over age 20 should have their cholesterol measured at least every five years. That gives you and your doctor a chance to intervene early if your numbers start to rise.

  • Stick to a healthy diet. Saturated fats, trans fats and dietary cholesterol can all raise cholesterol levels. Foods thought to keep cholesterol low include monounsaturated fats (such as nuts and olive oil), polyunsaturated fats (such as fish and canola oil) and water-soluble fiber (such as oats, beans and lentils). Get practical ideas to eat for heart health in Eat Smart .

  • Exercise and manage your weight. Along with a healthy diet, staying fit and maintaining a normal weight for your height lower your heart risks by minimizing the odds of other contributing health problems like obesity and diabetes. If you’re overweight, losing as little as 5 to 10 percent of your weight can significantly lower your risk of heart disease. Learn how implementing an exercise routine helps your heart in Move More .


Only one in three people who have high LDL cholesterol have the condition under control. The main goal of treatment is to lower, or control, your LDL level to minimize your personal risk for heart attack or heart disease, based on your cholesterol numbers and other risk factors, such as a history of heart disease.

Lifestyle changes are recommended for anyone with high cholesterol. These include:

Diet upgrades . First on the treatment menu is a heart-healthy diet. “I find that my patients generally love the Mediterranean diet,” says Blaha. “It tastes great, it’s satiating, and there’s excellent evidence that it reduces cholesterol and cardiovascular risk.” Highlights of the Mediterranean diet include: reduced saturated fat (found in animal products, butter, whole and 2 percent dairy products, coconut oil and palm oil) and trans fats (found in fried foods and baked goods). Eat mostly polyunsaturated or monounsaturated fats (found in fish, avocadoes, olive oil, nuts, and canola and soybean oil). Alcohol can raise triglycerides, so you may be advised to cut back.

Regular exercise. Aim for 30 minutes of exercise a day, most days. The American Heart Association recommends 40 minutes of moderate to vigorous exercise three to four times per week.

Weight management. This step is especially important for those who are overweight and who have high triglyceride levels or too-big waistlines (above 40 inches for men or 35 inches for women).

Medications. In addition to lifestyle changes, some people are prescribed drugs designed to lower cholesterol. Here are some of those medications:

  • Statin medications slow the liver’s production of cholesterol and can help remove cholesterol circulating in the blood.
  • Selective cholesterol absorption inhibitors (like ezetimibe) prevent the absorption of cholesterol from the intestine.
  • Resins (bile acid sequestrants) bind to bile, a digestive acid, which causes the liver to produce more bile and thus use up more cholesterol.
  • Fibrates lower triglycerides (rather than LDL levels).
  • Niacin (nicotinic acid) is a B vitamin that affects the production of fats in the liver.
  • Omega-3 fatty acid medications derived from fish oils also work to lower high triglyceride levels.

Living With...

Working to lower your cholesterol can be a long-term effort, and changing your health habits is key, Blaha says. To increase your odds of success:

  • Don’t count on medications alone. You have to make lifestyle changes as well, according to Blaha.

  • Start small. Modifying your diet and lifestyle in minor ways will make it easier to incorporate those changes into your life over the long haul. For example, rather than embarking on a drastic calorie-cutting diet, start by swapping out high-cholesterol and high-fat foods you love for healthier choices. For instance, buy skim milk instead of whole. Substitute olive oil for butter when you cook. Purchase foods with “no trans fats” on the labels.

  • Know your cholesterol-lowering drugs. Some of these medications interact with grapefruit and pomegranate (and their juices). Pay close attention to your doctor’s guidelines about cholesterol drugs, and never stop taking them without consulting your physician. Be sure to report medication side effects to your doctor.


As Johns Hopkins researchers strive to uncover the causes and treatment of heart disease, they’ve made some helpful discoveries:

Statin benefits far outpace any risks. A Johns Hopkins review of more than 20 years of studies on more than 150,000 subjects showed that the drugs’ risks (such as memory problems and diabetes) are very low, while their potential cardiovascular benefit is very high.

Low cholesterol is linked to a lower risk of aggressive prostate cancer. In a Johns Hopkins study of more than 5,000 men, those whose cholesterol levels were normal or low had a lower risk of aggressive prostate cancer by nearly 60 percent compared with men who had high cholesterol.

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