What does a total cholesterol level of 231 mean? Are there any symptoms associated with this level?

A total cholesterol level of 231 mg/dL is considered elevated. Although cholesterol serves several essential functions in the body, elevated cholesterol may put you at greater risk for heart disease. 

Your total cholesterol is calculated by adding your LDL (bad) cholesterol, HDL (good) cholesterol, 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 scavenges “bad” blood cholesterol and returns it to the liver for excretion. A HDL level >60 mg/dL is considered optimal and protective against heart disease, though levels >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.  

Elevated total cholesterol doesn’t have symptoms, which is why it’s important to know your levels. Lowering your cholesterol will reduce your risk of developing heart disease and other health issues. If you already have heart disease, lowering your total cholesterol can reduce your odds of serious complications, like a heart attack or stroke. 

Factors that could contribute to a total cholesterol level of 231: 

• Diet: Diets low in fiber and high in saturated fats, trans fats, added sugar, and other refined carbohydrates can cause blood cholesterol to go up.

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

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

• Smoking: Smoking lowers your HDL (good) cholesterol, contributing to higher LDL (bad) cholesterol.

• Medications: Certain medications can increase total cholesterol levels, including corticosteroids, beta-blockers, thiazide diuretics, retinoids, growth hormones, and antivirals.

• 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. After the age of menopause, women's LDL (bad) cholesterol levels tend to rise.

• Genetics (heredity): Genes partly determine how much cholesterol your body makes; thus, high blood cholesterol can run in families. 

• 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.

• Elevated HDL (good) cholesterol: A HDL level above 70 mg/dL may contribute to an elevated total cholesterol level. Higher HDL levels (>60 mg/dL) are considered protective against heart disease and are typically not a concern if your LDL and triglycerides levels are normal.

What to do if your total cholesterol level is 231?

Making changes to your diet and adopting healthy habits can help lower your total cholesterol level. To reduce your cholesterol:

• Eat plenty of fiber-rich foods, including vegetables, fruits, whole grains, and legumes. Gradually increase your fiber intake to 30-40 g/ day. 

• Limit refined carbohydrates and added sugars commonly found in chips, candy, baked goods, processed foods, sweetened yogurt, ice cream, and soda. 

• Avoid trans fats like partially hydrogenated oils and reduce your saturated fat intake to < 10% of total calories. 

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

• Be active every day: Aim for 30-60 minutes of exercise 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 currently smoke.

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

Medications and supplements used to improve total cholesterol results

If diet and lifestyle changes are not enough to lower your cholesterol, some drugs and supplements can be helpful to get them into a safer range. Some common ones include: 

Medications

Your doctor may prescribe cholesterol-lowering medication(s) if diet and lifestyle changes do not lower your levels enough on their own. Some common cholesterol-reducing medications include:

• Statins: Statins (including atorvastatin, simvastatin, and rosuvastatin) reduce cholesterol production in your liver. Because they typically need to be taken for life, 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: 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: Plant sterols and stanols (also called phytosterols) are found in plant cell membranes. They are similar in structure to cholesterol in the body and block dietary cholesterol from being absorbed. Phytosterols occur naturally 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 is effective for lowering total cholesterol [4]. Plant sterol and stanol supplements taken 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 [7]. 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, as well as 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 obtained 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: Alpha-lipoic acid is a potent antioxidant made in the body and found in foods like 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 [8]. 

• Turmeric: A spice commonly used to flavor and color curry dishes, turmeric may be helpful in lowering pro-inflammatory markers, blood cholesterol, and triglycerides [9]. 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 [10,11]. 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) [11]. 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 [12]. 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.