How to Lower Your Cholesterol Levels
Experts are learning that no one plan fits everyone. This advice will help you determine what’s best for you.
With age, our “bad” cholesterol levels are more likely to rise and our “good” cholesterol tends to drop to lower than ideal. We’ve long known that this can hike the risks of cardiovascular disease (CVD). Lifestyle habits, such as exercising and following a heart-healthy diet, are important but can’t always lower cholesterol enough. So medication, notably a statin—the most common type of cholesterol drug—is often added. This group of drugs includes atorvastatin (Lipitor), fluvastatin (Lescol XL), lovastatin (Altoprev), pitavastatin (Livalo), pravastatin (Pravachol), rosuvastatin (Crestor, Ezallor), and simvastatin (Zocor, FloLipid).
Experts generally agree that adults with CVD should take a statin. There has been less consensus about people who don’t have CVD but are at risk for it, especially those older than 75. “For years, they were left out of the equation, since people over the age of 75 were not usually included in the original trials for cholesterol-lowering medications,” says Howard Weintraub, MD, clinical director of the Center for the Prevention of Cardiovascular Disease at NYU Langone Medical Center. As a result, he says, some in that age group who might benefit from statins were advised against taking them. Others shied away over concerns about side effects like muscle pain and damage, liver problems, and increased blood sugar. But studies in the past few years have included people 75 and older. A 2020 observational study published in JAMA found that adults 75 and older who began statin therapy were 20 percent less likely to die of heart disease compared with nonusers.
Still, questions remain. Older adults often take multiple medications, which may interact with statins. And for some people 75 and older, the potential for side effects may outweigh the benefits, especially when cholesterol levels are only slightly abnormal, says Michael Hochman, MD, MPH, an internal medicine physician at Keck Medicine of USC in Los Angeles. So many cardiologists and internists have moved toward more personalized cholesterol management, where they discuss their patients’ overall health and preferences. “There’s no one set of rules for all older adults,” Weintraub says. Here’s what to know about how to lower cholesterol, whatever your age.
Lifestyle Changes That Can Help
Whatever your cholesterol levels, you can benefit from the following tips. “You need to put all these steps together to improve cholesterol and reduce your overall risk for heart disease,” says Amit Khera, MD, director of the preventive cardiology program at the UT Southwestern Medical Center in Dallas.
What's Normal, What's Not
Ideal cholesterol levels are generally the same for all adults, Khera says. That means:
• Total cholesterol less than 200 mg/dL.
• LDL (bad) cholesterol below 100 mg/dL.
• HDL (good) cholesterol of at least 40 mg/dL for men and 50 mg/dL for women.
• Triglycerides less than 150 mg/dL.
Healthy adults should have their cholesterol screened every four to six years, the American Heart Association says. But if your results are borderline or you have CVD, it’s best to get checked much more frequently, Weintraub says. If you already take a statin, you should be screened every year.
When to Consider a Statin
Generally speaking, the American College of Cardiology (ACC) and the AHA advise statins for:
• Adults of any age with CVD with atherosclerosis (plaque buildup in artery walls) or a past heart attack or stroke. The goal is to get your LDL under 70, and even lower is better, says Steven Nissen, MD, chair of cardiovascular medicine at the Cleveland Clinic. “If you already have heart disease or had a heart attack or stroke, aim for at least under 70,” he says. “Under 55 is ideal.”
• Many adults with type 2 diabetes. For those between ages 40 and 75, the ACC and AHA advise moderate-intensity doses of statins like atorvastatin, pravastatin, rosuvastatin, or simvastatin, and high-intensity doses of statins like atorvastatin or rosuvastatin for those with multiple risk factors for CVD (such as high cholesterol and high blood pressure). Over age 75, the groups say that a statin might be reasonable if you’ve discussed the risks and benefits with your doctor.
• Adults ages 40 to 70 with an LDL level of 190 or above. In this case, the AHA-ACC recommends the highest-dose statin you can safely tolerate.
When It's Less Clear
The groups recommend that you consider a moderate-intensity statin if you’re under 75 and have an LDL above 70 mg/dL and some risk of CVD with atherosclerosis. But plenty of adults with LDL in that range and no other CVD risks may be able to bring their cholesterol in line with lifestyle changes alone, Hochman says.
A calculator that assesses your 10-year risk of a heart attack or stroke, such as the AHA’s risk calculator, may be a starting point for discussing options with your doctor. They’re essentially questionnaires that use your age, race, blood pressure and cholesterol levels, and health and smoking history to estimate your risk of a heart attack or stroke in the next decade. The results can help you and your doctor determine whether you should start taking cholesterol drugs.
The ideal result is below 7.5 percent. If yours is intermediate (7.5 to 19.9 percent), “weigh other factors, such as a family history of heart disease and personal preference,” says Adam Cifu, MD, a professor of medicine at UChicago Medicine.
But these calculators aren’t foolproof. A 2018 analysis found that they may overestimate risk by up to 20 percent, and even more for Black people. And research published recently in the journal Circulation suggests that the tools may underestimate the risk for people of South Asian background. Plus, they aren’t always accurate for people over the age of 75, Cifu says. That’s why he generally advises that his patients, especially those who are over age 75, use the results only as a guide.
Another option to gauge your risk is a coronary artery calcium scan, which can reveal how much calcified plaque has built up in your arteries. “If yours is very low for your age, you don’t need to be treated,” says Khera, co-author of the 2019 ACC-AHA guidelines on the primary prevention of cardiovascular disease. And if you start taking a statin and find it intolerable—you have muscle aches that make it tough to exercise, for instance—ask your doctor about a lower dose or taking the statin every other day or twice a week, says Nieca Goldberg, MD, a cardiologist at the NYU Grossman School of Medicine. “In these cases, we often combine statins with other cholesterol medications, such as ezetimibe [Zetia],” she says. And newer self-injectable drugs known as PCSK9 inhibitors may sometimes be more effective than statins. But they’re not always covered by insurance.
Finally, remember that you’re a key part of the decision-making, whether it’s to stick with lifestyle changes or add medication. “At the end of the day,” Hochman says, “it’s an individual decision.”
Correction: This article has been updated to address the effect of stopping smoking on cholesterol levels.
Editor’s Note: A version of this article also appeared in the November 2021 issue of Consumer Reports On Health.