Total cholesterol overview

What is a total cholesterol test? 

A total cholesterol test measures the amount of cholesterol found in your blood. Cholesterol is a waxy substance in the blood that is used to create new cells, hormones, and vitamin D. Although cholesterol serves several important functions, high cholesterol is a risk factor for heart disease. 

What does a total cholesterol test measure? 

Your total cholesterol is calculated by adding the levels of three different lipids (fats) in blood: low-density lipoprotein (LDL), high-density lipoprotein (HDL), and 20% of triglyceride levels.

• LDL is often referred to as “bad” cholesterol because it accumulates in your blood vessels and increases your risk for heart disease. Ideally, LDL levels should be less than 100 mg/dL, but lower is better. 

• HDL is considered “good” cholesterol because it protects against heart disease by scavenging cholesterol and returning it to the liver for excretion. The ideal HDL level is >60 mg/dL, though >40 mg/dL for men and >50 mg/dL for women are still considered good.

• Triglycerides are another type of fat that can build up in the bloodstream and increase your risk of heart disease. Ideally, triglycerides should be <150 mg/dL.  

What do your total cholesterol results mean?

Total cholesterol status is classified as follows:

• Optimal: <200 mg/dL

• Elevated: 200-240 mg/dL

• High: >240 mg/dL

Optimal total cholesterol results:

Optimal total cholesterol levels are below 200 mg/dL. Optimal cholesterol is associated with a lower risk of heart disease.

Elevated total cholesterol results:

You have elevated total cholesterol if your level is between 200-240 mg/dL. If your cholesterol is elevated, diet and lifestyle modifications may help reduce your levels back into the optimal range without the need for cholesterol-lowering medications. 

High cholesterol results:

Total cholesterol levels >240 mg/dL are considered high. High blood cholesterol can lead to a condition called atherosclerosis, the buildup of a sticky plaque in blood vessels throughout your body. Over time, uncontrolled high cholesterol can cause heart and blood vessel diseases, including coronary heart disease, carotid artery disease, heart attack, stroke, and sudden cardiac arrest [2]. The most common treatment for high cholesterol and its effects include a heart-healthy diet and lifestyle changes and cholesterol-lowering medicines.

While high cholesterol is typically tied to diet and lifestyle factors, familial hypercholesterolemia (FH) can also cause high cholesterol levels. FH is a common genetic disorder that causes LDL cholesterol to increase. If untreated, FH can lead to early heart attacks and heart disease in even young adults and children. Because FH is inherited, when one family member is diagnosed, it’s important all family members are also screened for this condition.

What factors impact total cholesterol levels?

A variety of factors can affect cholesterol levels, including your diet, weight, physical activity level, and smoking. Medications, certain diseases, as well as your age, sex, race, and genetics also affect total cholesterol levels.

• Diet: Diets that are high in saturated fats, trans fats, added sugar, and low in fiber can cause blood cholesterol to rise.

• Weight. Being overweight also tends to increase cholesterol levels. 

• Physical Activity. Being active can help lower LDL (bad) cholesterol and raise HDL (good) cholesterol levels. 

• Smoking: Smoking lowers your HDL (good) cholesterol, which can contribute to a higher level of bad cholesterol.

• Medications: Some medications can increase cholesterol levels. Some of the most common are corticosteroids, beta-blockers, thiazide diuretics, antivirals, retinoids, growth hormones.

• Diseases: Certain diseases like chronic kidney disease, diabetes, and HIV/AIDS can elevate total cholesterol.

• Age and sex: Premenopausal women tend to have lower total cholesterol levels than men of the same age. However, cholesterol levels tend to increase with age in both women and men. LDL (bad) cholesterol levels tend to rise in post-menopausal women.

• Genetics (heredity): High blood cholesterol can run in families. This is because your genes partly determine how much cholesterol is produced by your body. 

• Race: Certain races may have an increased risk of high blood cholesterol. For example, Blacks/African Americans typically have higher HDL and LDL cholesterol levels than Caucasians.

Groups at risk for high total cholesterol

• Older adults 

• People of Black/African American descent

• Overweight or obese individuals

• Physically inactive adults

• Those with a family history of high cholesterol, heart disease, heart attack, and stroke

• Certain health conditions like diabetes, hypothyroidism, chronic kidney disease, liver disease, and HIV/AIDs

Diet and lifestyle strategies shown to improve total cholesterol levels

To lower total cholesterol levels: 

• Eat fiber-rich foods such as veggies, fruit, whole grains, and legumes daily for a total of 30-40g fiber/ day. 

• Limit sources of refined carbs and added sugars such as soda, chips, candy, baked goods, sweetened yogurt, and ice cream. 

• Avoid trans fats (partially hydrogenated oils) and reduce saturated fat intake to < 10% total calories. 

• Eat small, fatty fish such as salmon, sardines, and trout, at least twice a week. 

• Be active every day: Aim for 30-60 minutes of physical activity 5x/week.

• Incorporate plant sterols and stanols daily (2g) in the form of food or a supplement. 

• Lose weight if you are overweight or obese.

• Quit smoking.

• If you have diabetes, achieve and maintain good blood sugar control (HbA1c).

Medications and supplements used to improve total cholesterol results

Medications

Medications are typically prescribed if diet and lifestyle changes aren’t enough to lower total cholesterol levels on their own. Some common cholesterol medications include:

• Statins: Statins (including atorvastatin, simvastatin, and rosuvastatin) reduce cholesterol production in your liver.  Statins are only prescribed if diet and lifestyle changes aren’t enough [3].

• Ezetimibe can be helpful for those with familial hypercholesterolemia and who have side effects with statins. 

• Bile acid sequestrants: These medications block cholesterol-rich bile acid from being absorbed into the bloodstream and can be prescribed in place of or in addition to a statin. 

• PCSK9 inhibitors: This medicine is injected under your skin every 2 or 4 weeks and may be prescribed alongside a statin if you are at high risk of heart attack or stroke, or have familial hypercholesterolemia.

• Lomitapide: Typically prescribed if you have familial hypercholesterolemia and requires liver enzyme monitoring as it can cause liver damage. Lomitapide is commonly also taken with vitamin E.

Supplements

• Plant sterols and stanols: Found in plant cell membranes, plant sterols and stanols (also called phytosterols) are similar in structure to cholesterol in the body and block dietary cholesterol from being absorbed. Phytosterols can be found in small quantities in vegetable oils, nuts, legumes, whole grains, fruits, and vegetables; however, the average daily intake (500 mg) is typically not enough to lower cholesterol. Studies show consuming 2000 mg (2g) of plant sterol and stanols daily from diet and supplements can help lower total cholesterol [4]. Taking plant sterol and stanol supplements before or with meals can help lower total cholesterol in parallel with other recommended diet and lifestyle changes [4].

• Omega-3 (EPA & DHA): Omega-3 fatty acids (specifically EPA & DHA) can significantly reduce blood triglyceride levels [6]. For cholesterol-lowering benefits, aim to consume 2,400-3,000 mg of omega-3 fats per day from your diet (salmon, mackerel, and trout are all good sources) and a quality fish oil supplement. 

• Beta-glucan: Beta-glucan is a form of soluble fiber that has been shown to help lower cholesterol levels. It’s found naturally in whole grains like barley, oats, rye, and wheat, mushrooms, and seaweed and is also available as a nutritional supplement. For cholesterol-lowering benefits, consume 3-7 g/day from your diet and a supplement.

• Psyllium: Another type of soluble fiber made from the husk of psyllium seeds, psyllium is good for digestive health and regularity and can also help lower cholesterol. Psyllium supplements are sold in powder form and can help reduce lipid levels when taken daily at a dose of 8-12 g/day. 

• Alpha-lipoic acid: A potent antioxidant made in the body, alpha-lipoic acid is also found in foods including carrots, beets, spinach, broccoli, potatoes, and red meat. Research indicates that 600 mg/day of alpha-lipoic acid from your diet and a supplement may help lower total cholesterol and LDL (bad) cholesterol [7]. 

• Turmeric: A spice commonly used to flavor and color curry dishes, turmeric may be helpful in lowering pro-inflammatory markers, blood cholesterol, and triglycerides [8]. More research needs to be done to determine optimal form and dosage but supplementing with 500 mg/day appears to be safe and potentially beneficial for lowering cholesterol.

• Bergamot extract: Bergamot is a citrus fruit that has long been used for medicinal purposes. Taking bergamot extract (made from the juice of the fruit) seems to lower cholesterol and triglyceride levels in adults with high cholesterol [9,10]. One study suggests taking bergamot extract daily for a month may be as effective as taking a low dose of the cholesterol-lowering drug called rosuvastatin (Crestor) [10]. A recent research review indicates that 1000 mg/day may be most effective for lowering cholesterol. 

• Green tea extract: Made from the leaves of the Camellia sinensis plant, green tea extract is a natural supplement that has been shown to help lower LDL (bad) and total cholesterol [11]. A daily dose of 400 mg may help lower your cholesterol but check with your doctor first as green tea extract can interact with certain medications, including beta-blockers and blood thinners. In addition, green tea extract may also have a stimulant effect.