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Improve your cholesterol

A healthy diet, exercise, weight loss, and inexpensive drugs can help

Last updated: February 2013

High cholesterol levels contribute to about 420,000 heart attacks and strokes each year. Yet most people don't know their level of LDL (bad) cholesterol, the kind that contributes to heart disease by dumping cholesterol in the artery walls. Of those who do, only a third lower their level to recommended targets, in part because many fail to make the lifestyle changes that have been found to help or, when necessary, take the right medication. And probably even fewer know their HDL (good) cholesterol level, which helps protect the heart by sweeping up cholesterol and clearing it from arteries.

Get screened

Men 35 and older should get a complete lipid profile—which measures LDL (low-density lipoprotein) and HDL (high-density lipoprotein) cholesterol levels, as well as triglycerides, an artery clogging fat—at least every five years. Women 45 and older should, too, if they're at high risk of heart disease because of other risk factors like being a smoker or having a diabetes. (To determine your risk, use our calculator.) People younger than that should also consider testing, though the benefits for them are less certain, especially if they are female or are otherwise healthy and at low-risk of heart disease.

For the most accurate results, avoid nonessential drugs and all food and drink, except water, for 9 to 12 hours before testing. And don't exercise strenuously 12 to 24 hours before the test, since that might falsely elevate your HDL. Don't bother with home cholesterol tests. Our analysis found that they were rarely worthwhile because cholesterol levels don't change much from day to day, and because some tests measure only total cholesterol, not the breakdown of LDL, HDL, and triglycerides. Getting your cholesterol checked by your doctor is a better bet because the test is likely to be simpler, neater, and less painful than those designed for home use—and more likely to be covered by insurance.

Know your risk

Treatment usually focuses on LDL. But whether and how much you need to lower your LDL depends not just on that level but also on your overall coronary risk, which is determined by a number of additional factors. They include your HDL, since a high level protects your heart, and factors that increase the risk of heart attack, such as whether you smoke, have high blood pressure, or have diagnosed heart disease.

So use our calculator to determine your risk. Then talk with your doctor and use the table below to see whether you need to lower your LDL. If the table recommends reducing it and your coronary risk is high or moderately high, you'll probably need both drug therapy and lifestyle changes. If you're at low or moderate risk, you'll probably need medication if about three months of lifestyle changes fail to achieve the desired LDL reduction.

If your coronary-risk level is... Consider lowering your LDL if it is... Definitely lower your LDL if it is...
HIGH
1. 10-year heart-attack risk of about 20 percent or higher

OR

2. A personal history of diabetes or cardiovascular disease, including coronary heart disease, peripheralartery disease, carotidartery disease, or an aortic aneurysm
70 mg/dL or higher. 100 mg/dL or higher.
MODERATELY HIGH
1. 10-year heart-attack risk of 10 percent to 20 percent

AND

2. Two or more risk factors1
100 mg/dL or higher.2 130 mg/dL or higher.
MODERATE
1. 10-year heart-attack risk less than 10 percent

AND

2. Two or more risk factors1
130 mg/dL or higher.3 160 mg/dL or higher.
LOW
1. No risk factors, or one risk factor1
160 mg/dL or higher. 190 mg/dL or higher.4
1. Risk factors are cigarette smoking; a father or brother with coronary disease before 50, or a mother or sister before 55; systolic (upper) blood pressure of 140 mmHg or higher, diastolic (lower) pressure of 90 mmHg or higher, or use of drugs to treat high blood pressure; and HDL levels less than 40 mg/dL. If your HDL is 60 mg/dL or more, subtract one risk factor. (High LDL is also a risk factor, but it's already factored into the table.)
2. People in this risk category might want to check their level of C-reactive protein (CRP), a marker of inflamed coronary arteries, because for them, a high CRP (3 mg/L or higher) might make aggressive treatment of LDL worthwhile.
3. People in this risk category might want to check their level of C-reactive protein (CRP), a marker of inflamed coronary arteries, because for them, a high CRP (3 mg/L or higher) can make aggressive treatment of LDL more worthwhile.
4. This may not apply to some women or older people.
Adapted from the National Cholesterol Education Program, National Institutes of Health, July 2004; Circulation, July 13, 2004, pages 227-239.

Start with lifestyle changes

The battle against high LDL cholesterol levels should always start, and can often end, with lifestyle changes. Even people who take cholesterol-lowering drugs should make these changes, too, since they might allow them to take a lower and thus safer dose, and because the steps protect the heart in many other ways as well. Here's what has been found to work

Eat a heart-healthy diet. Focus especially on:

  • Reducing your intake of saturated fats, found mainly in red meat and full-fat dairy products, to less than 7 percent of total calories.
  • Eliminating trans fats or partially-hydrogenated oils, found in margarine, many fast foods, and store-bought pastries and other baked sweets.
  • Limiting dietary cholesterol to less than 200 milligrams per day. That's about the amount in one egg yolk, 10 ounces of lean sirloin, or 8 ounces of skinless chicken breast.
  • Getting plenty of fiber, mainly from whole grains, fruit, vegetables, and beans. Oat bran, psyllium, and barley might be particularly effective, cutting LDL by 5 to 10 percent.
  • Drinking moderately—if at all. One drink a day for women and two for men can raise a low HDL, but too much can be harmful or addictive.
  • Consider fish oil. A prescription fish-oil capsule boosted HDL by 8 percent over eight weeks in one study. Aim for a weekly intake of about 2 grams of the omega-3 fatty acids in fish oil, which you can generally accomplish by eating two to three servings per week of wild or canned salmon, sardines, pollock, tilapia, or other fish that tend to be low in mercury. If you're not a fish eater—or to get more omega-3s—consider a supplement, preferably one labeled "USP Verified," which means it meets standards for purity and potency set by the U.S. Pharmacopeia, a nongovernmental authority.

Control your weight by cutting calories and exercising. You can lower your risk of heart disease by losing as little as 5 percent of your weight. And for about every 10 pounds of sustained weight loss, HDL climbs by 2 mg/dL.

Stay active even if you don't have to lose weight, since exercise can raise your HDL level by almost 25 percent and might help lower LDL as well.

Quit smoking. HDL levels are about 7 mg/dL lower in smokers than in nonsmokers. And kicking the habit protects your heart in other ways, too, making it probably the single most important thing you can do to protect your hear.

Get the right drugs

To reach your target LDL, especially if it's below 100, most patients have to take a "statin" medication.

Our Best Buy Drugs report on statins generally recommend generic lovastatin or pravastatin if you need to lower your LDL by less than 30 percent, and generic simvastatin if you need a 30 percent or greater reduction or have a history of heart disease or diabetes. They are cheaper and just as safe and effective as the brand-name versions of those drugs (Altoprev and Pravachol, respectively). Atorvastatin (Lipitor) makes sense if you've had a heart attack or acute coronary syndrome and your LDL is highly elevated.

If taking lovastatin or pravastatin for a few months fails to lower LDL sufficiently, switching to simvastatin might help. Another alternative is to add a nonstatin drug, such as niacin, which can also boost HDL by 35 percent. People who also have high triglycerides might need to add a different class of drug, called fibrates, which include gemfibrozil (Lopid and generic) and fenofibrate (Lofibra, TriCor, and generic).

Our medical consultants see little value in using Vytorin, a pill that combines simvastatin and ezetimibe (Zetia), a drug that blocks absorption of dietary cholesterol. Research suggests that Vytorin is no more effective than simvastatin alone.

Heart attack calculator

Click on the image at right to use our heart-attack risk calculator. It can help you determine your risk of developing cardiovascular disease in the next 10 years. Based on your answers, we've also included recommendations to help keep you healthy.

Ratings of heart tests

Click on the image at right to see our Ratings of tests used to screen for heart disease. It can help find the tests that are best for you, based on your your age, gender, and risk level.

   

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