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- Herausgeber: John Wiley & Sons
- Kategorie: Ratgeber
- Sprache: Englisch
Take charge of your heart health with this guide to managing cholesterol
Managing Cholesterol For Dummies demystifies cholesterol and clearly offers effective solutions for prevention, management, and lowering it which have changed in recent years.
This approachable guide helps you understand why balancing overall cholesterol is important, and what you can do to improve your numbers and keep them in check. It also navigates the latest lifestyle tips, medical treatments, complementary therapies, and culinary nutrition research available to keep your heart in shape. You'll also learn what cholesterol really is, how it's formed and linked to inflammatory processes you can reverse, and why it's never too early to think about keeping cholesterol regulated. If you're managing an existing condition, this book will help you make sure you're on a treatment path that works for you. This Dummies guide lays it all out in a clear way, so you can get your cholesterol questions answered without feeling overwhelmed.
- Learn how to maintain good health and reduce the risk of diseases linked to high cholesterol
- Get the latest cholesterol insights, like oxidized LDL cholesterol and why it matters
- Make mouthwatering recipes packed with fiber, antioxidants, and healthful fats to fight inflammation
- Decide on a treatment plan, including medications and complementary therapies, that's right for you
For anyone dealing with elevated cholesterol or helping a loved one manage their numbers—and for people who want to avoid high cholesterol altogether—Managing Cholesterol For Dummies covers all the must-know information for staying healthy.
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Veröffentlichungsjahr: 2025
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Managing Cholesterol For Dummies®
To view this book's Cheat Sheet, simply go to www.dummies.com and search for “Managing Cholesterol For Dummies Cheat Sheet” in the Search box.
Table of Contents
Cover
Table of Contents
Title Page
Copyright
Introduction
About This Book
Foolish Assumptions
Icons Used in This Book
Beyond the Book
Where to Go from Here
Part 1: Understanding Cholesterol
Chapter 1: Why Cholesterol Matters for Health
What Cholesterol Means for You
What Causes Heart Disease
How Cardiovascular Diseases Harm the Body
Why an Integrated Approach Counts
Chapter 2: Defining Cholesterol
Recognizing the Importance of Cholesterol
Measuring Cholesterol
Beyond the Basics: Looking at Additional Tests
Chapter 3: Understanding High Cholesterol
Familial High Cholesterol: Blame It on Genetics
Other Causes of High Cholesterol
Chapter 4: Appreciating Oxidative Stress and Inflammation
Looking at the Lipid Theory of Cholesterol and Chronic Disease
Focusing on Oxidation and Inflammation
Identifying the Diseases Caused by High Cholesterol
Part 2: Changing Your Diet to Manage Cholesterol
Chapter 5: Understanding the Role of Cholesterol and the Diet
Identifying Foods That Raise Cholesterol
Focusing on Cholesterol-Friendly Foods
Chapter 6: Discovering the Best Diet for Cholesterol Management
Defining the Mediterranean Diet
Comparing the Mediterranean Diet to the Western Diet
Weighing the Evidence for the Mediterranean Diet
Making the Mediterranean Diet Work for You
Part 3: Assessing Risks
Chapter 7: Calculating the Risk of Cholesterol
Understanding the Difference between Primary Prevention and Secondary Prevention
Making Sense of Risk Assessment Tools
Chapter 8: Understanding Your Individual Risk
Interpreting the Risks
Working with Your Doctor to Treat (or Not Treat) Your Cholesterol
Chapter 9: Reducing Risk through Self-Care, Sleep, and Connection
Taking Time for Self-Care
Getting Good-Quality Sleep
Keeping Connected
Chapter 10: Reducing Risk through Exercise and Stress Management
Enjoying Exercise
Reducing Stress
Part 4: Incorporating Medicines and Holistic Approaches
Chapter 11: Evaluating Treatment Options for Cholesterol
Knowing When Medications Are Considered for High Cholesterol
Surveying the Medications Used to Treat High Cholesterol
Personalizing Therapy
Looking at Other Common Treatments for Cardiovascular Disease
Chapter 12: Choosing a Holistic Approach
Holistic Approaches
Complementary Therapies
Part 5: Heading into the Kitchen
Chapter 13: Cooking and Eating to Manage Cholesterol
Cooking to Manage Cholesterol
Making Whole Foods Taste Great
Preparing Base Recipes
Chapter 14: Organizing the Kitchen and Meals
Organizing Your Kitchen
Finding Time to Cook
Planning Meals
Eating Out with Pleasure and Health in Mind
Chapter 15: Recipes
Finding Cholesterol-Friendly Foods
Breakfast
Savory Appetizers and Small Plates
Hearty Main Courses
Satisfying Salads
Dazzling Desserts
Part 6: The Part of Tens
Chapter 16: Ten Easy Wins to Manage Cholesterol
Increasing Your Fiber Intake
Choosing Healthy Fats
Reading Food Labels
Focusing on a Sustainable Mediterranean Diet
Embracing Extra-Virgin Olive Oil
Planning Your Meals
Enjoying More Exercise
Sleeping Well
Taking Care of Yourself
Checking Out Other Risks for Cardiovascular Disease
Chapter 17: Ten Cholesterol-Friendly Foods to Incorporate into Your Diet
Herbs and Spices
Beans and Other Legumes
Nuts and Seeds
Extra-Virgin Olive Oil
Fish
Whole Grains
Greek Yogurt
Fruits and Vegetables
Chapter 18: Ten Misconceptions about Cholesterol
Myth: All Cholesterol Is Bad
Myth: Cholesterol Is the Most Important Risk Factor
Myth: Only Overweight People Have High Cholesterol
Myth: Cholesterol Simply Blocks Arteries
Myth: Everything That Matters Is Measured in Risk Calculator Tools
Myth: Success Is Measured by a Lipid Panel
Myth: You Can’t Lower Cholesterol Risk without Medications
Myth: I Can Eat Whatever I Want Because I Take a Statin
Myth: A Low-Fat Diet Is Best
Myth: Sugar Has No Effect on Cholesterol
Index
About the Authors
Connect with Dummies
End User License Agreement
List of Tables
Chapter 2
TABLE 2-1 Cholesterol Levels Categorized
TABLE 2-2 Summary of Variability Effects by Lipid Type
TABLE 2-3 Example TC/HDL Ratios
Chapter 5
TABLE 5-1 Saturated Fats and Their Effect on Cholesterol
Chapter 6
TABLE 6-1 The Western Diet versus the Mediterranean Diet: Macronutrient Composi...
TABLE 6-2 The Western Diet versus the Mediterranean Diet: Key Food Type Consump...
TABLE 6-3 The Western Diet versus the Mediterranean Diet: Health Impact
Chapter 10
TABLE 10-1 Increasing the Feel-Good Hormones
List of Illustrations
Chapter 1
FIGURE 1-1: A blood vessel showing signs of developing changes of atheroscleros...
Chapter 4
FIGURE 4-1: How antioxidants reduce free radicals.
FIGURE 4-2: The stages of blood vessel plaque formation.
FIGURE 4-3: Oxidative stress in a cell.
FIGURE 4-4: The difference between acute and chronic inflammation.
FIGURE 4-5: Blood vessels in a healthy heart.
Chapter 6
FIGURE 6-1: The Mediterranean Diet Pyramid.
Guide
Cover
Table of Contents
Title Page
Copyright
Begin Reading
Index
About the Authors
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Managing Cholesterol For Dummies®
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Library of Congress Control Number: 2025944155
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Introduction
You may be reading this book because you’ve had your cholesterol measured or perhaps because a friend or relative has been told that they have high cholesterol.
Maybe you’re confused about what cholesterol actually is, what causes it to rise, what the numbers mean, and how this may affect your health. You probably also want to know how you can have better conversations with your doctor about the implications of test results and, most important, how you can manage your cholesterol.
You’ll be delighted to hear that the advice contained in this book combines the most up-to-date, evidence-based medical knowledge with a truly holistic approach to achieve the best diet and lifestyle for your cholesterol and general health and well-being.
About This Book
This book demystifies cholesterol and provides effective solutions for preventing high cholesterol, managing existing cholesterol levels, and achieving a lower cholesterol overall. This new, holistic, and integrative approach to cholesterol management offers real hope for people looking not only to lower their cholesterol numbers, but also to avoid the complications that are associated with higher cholesterol in the first place. It explains the best way to manage the risks of cardiovascular disease (CVD), including heart attacks and strokes, which are associated with a high cholesterol.
You can find more information about specific conditions such as heart disease in Preventing & Reversing Heart Disease For Dummies by James Rippe (John Wiley & Sons). There is a deeper dive into the dietary and lifestyle approach introduced in this book in titles such as Mediterranean Lifestyle For Dummies by Amy Riolo and Olive Oil For Dummies by Amy Riolo and Simon Poole, MD (both published by John Wiley & Sons).
Managing Cholesterol For Dummies explains the evolution of the latest scientific knowledge and helps you understand the best ways to handle your cholesterol through lifestyle changes, medical treatments, and other therapies. The easy and mouthwatering recipes in Chapter 15 focus not only on the important ingredients known to reduce “bad” cholesterol but also on the delicious antioxidant-rich foods that decrease the oxidation of cholesterol and control inflammation for optimal cholesterol management.
Within this book, you may note that some web addresses break across two lines of text. If you’re reading this book in print and want to visit one of these web pages, simply key in the web address exactly as it’s noted in the text, pretending as though the line break doesn’t exist. If you’re reading this as an e-book, you’ve got it easy — just click the web address to be taken directly to the web page.
Foolish Assumptions
In writing this book, we made a few assumptions about you, our reader:
You don’t know very much about cholesterol, but you may have heard that a high cholesterol level can affect your health.
You aren’t already familiar with all the ingredients that can be used to raise “good” cholesterol and lower “bad” cholesterol, as well as those with anti-inflammatory effects.
You don’t know how to prepare the types of meals that someone managing cholesterol should prepare.
You’re curious and interested and willing to try new things — especially if it means improving your quality of life.
Icons Used in This Book
The icons in the margins of this book point out information we think is especially important. Here are the icons used in this book:
Remember icons mark the information that’s especially important to know. To siphon off the most important information in each chapter, just skim through these icons.
The Tip icon marks important information that can save you time and energy.
Watch for the Warning icon — it warns about potential problems (for example, the possible results if you don’t treat a condition).
The Technical Stuff icon marks information of a highly technical nature that you can normally skip over.
Beyond the Book
In addition to the material in the print or e-book you’re reading right now, this product also comes with some access-anywhere goodies on the web. Check out this book’s online Cheat Sheet. Just go to www.dummies.com and type Managing Cholesterol For Dummies Cheat Sheet in the Search box. You’ll find tips on quick and easy ways to achieve your cholesterol goals.
Where to Go from Here
Where you go from here depends on your immediate needs. If you’re looking for something to make for dinner tonight, head to Chapter 15. If you’ve just gotten your lipid panel results and you’re trying to make sense of all those numbers, head to Chapter 3. If you’re wanting to understand more about the best diet for cholesterol management, turn to Chapter 6, or if you need to learn more about medications, turn to Chapter 11. And if you’re not sure where to turn, you can start reading Chapter 1 — or use the Table of Contents or Index to find the information that most interests you.
Many of the changes we suggest can take some time to implement. The good news is that they involve positive, enjoyable, and sustainable transitions that have much broader beneficial effects than simply reducing your cholesterol.
Part 1
Understanding Cholesterol
IN THIS PART …
Make a whole-person approach to cholesterol management work.
Understand why cholesterol matters in health.
Witness how the story of cholesterol has changed.
Appreciate how oxidation and inflammation affect cholesterol and why tackling them is key to protecting your heart.
See how lifestyle and culinary medicine can help.
Chapter 1
Why Cholesterol Matters for Health
IN THIS CHAPTER
Understanding the basics of cholesterol and the new science of cholesterol and health
Recognizing the importance of risk
Exploring the benefits of lifestyle and culinary medicine
Odds are, you hear a lot about cholesterol. It’s one of the most common blood tests recommended by doctors and requested by patients — about two-thirds of U.S. adults say they’ve had their cholesterol checked within the last five years. According to the World Health Organization (WHO), approximately 40 percent of adults worldwide have high cholesterol. In 2024, the U.S. Centers for Disease Control and Prevention (CDC) estimated that 86 million adults in the United States have cholesterol levels that are considered borderline or high. In 2024, the value of cholesterol-lowering medications produced by the pharmaceutical industry was $34 billion and it’s predicted to rise to $50 billion by 2033.
But what does this mean for you? To answer that question, you need to know the role of cholesterol in the body, the risks associated with high cholesterol, the latest research that’s changing our understanding of the link between cholesterol and disease, and the role of lifestyle and medications in keeping our cholesterol levels and blood vessels healthy.
In this chapter, you begin to appreciate the importance of cholesterol and why it’s appropriate to ask questions and perhaps challenge some of the previous assumptions about how best to manage your results. Many people feel disempowered by a lack of understanding of the risks of high cholesterol and the pros and cons of taking medication. With the help of the different approach of this book, you can take back that control!
What Cholesterol Means for You
If you’ve had your cholesterol measured, it was probably done in the form of a full lipid panel or full lipid profile, which is a test of circulating fats that include different types of cholesterol. (We describe the elements that make up this complete result and their significance in Chapter 2.)
You may have requested a blood test because you heard it’s important to know your cholesterol level, or your doctor may have ordered the blood test as part of an annual checkup or possibly because you have symptoms of an illness, whether associated with cholesterol or not.
The importance of knowing your cholesterol level stems from the association of high levels of some types of circulating cholesterol with vascular pathology (a disease of the blood vessels that can lead to many different illnesses, including the most common causes of death and sickness in most countries — heart disease and stroke).
But there is much more to the story of cholesterol and the risk of heart disease and stroke than first meets the eye. There is certainly more than is known to many physicians and much more than can be explained in a brief consultation, which may result in a patient committing to lifelong medication. Many aspects of cholesterol remain poorly understood. Not everyone with high cholesterol will end up getting sick. Given that cholesterol levels can vary along a spectrum, the definition of a high cholesterol is inevitably somewhat arbitrary. Plus, there is debate about what causes high cholesterol for many people, as well as controversy about the extent to which highly effective cholesterol medications may cause significant side effects.
During 35 years of clinical practice as a physician in primary care, Simon has had countless consultations with patients about cholesterol — discussing blood tests, risk assessment, and possible treatment for high cholesterol. The challenge for all doctors is to provide enough accurate and up-to-date information within the constraints of the time available, so every patient is in a position to make a fully informed and individual decision about what’s best for them and how to consider if those judgments may change over time.
What Causes Heart Disease
All parts of the body — whether it’s the heart, brain, muscles, lungs, kidneys, or any other organ — depend on a healthy blood supply to fulfill their various functions. The blood vessels that supply oxygen, nutrients, immune support, and hormones to effectively sustain the cells that perform the tasks for life are called arteries. Together with veins, which take the blood back to the heart, they’re collectively described as the vascular system.
Larger blood vessels, which carry blood over longer distances, are part of the macrovascular system. Branches of blood vessels get smaller as they approach the cells they support; here, the arteries become arterioles and capillaries and are described as the microvascular system.
Arteriosclerosis is a condition in which the arteries are hardened and thickened, with fatty or calcified deposits known as plaques. A similar term, atherosclerosis, is more specifically used when describing plaques in larger arteries. (See the nearby sidebar for more on the coining of this term and the study of heart disease over the past couple hundred years.) The changes visible in blood vessels affected by atherosclerosis are shown in Figure 1-1.
© John Wiley & Sons, Inc.
FIGURE 1-1: A blood vessel showing signs of developing changes of atherosclerosis.
So, what does cholesterol have to do with it? Years ago, doctors believed that cholesterol (and saturated fat, which leads to cholesterol production) in the diet caused excess circulating fats, or lipids, and those excess lipids were deposited in blood vessel walls as plaques. The result was damage to and narrowing of the blood vessels, and ultimately blockage of blood supply to vital organs like the heart and brain. But today we know that the process by which cholesterol may be associated with heart disease, stroke, or other organ damage is complex. And the consequences of this understanding are significant.
The path to heart disease or any other vascular disease must be dependent on other factors. After all, not everyone with high cholesterol will develop problems. Plus, because of the complexity of the multiple risk factors for atherosclerosis and how they interact, people with identical cholesterol profiles may well have very different likelihoods of developing disease. It’s obvious that there must be something else (or many other things) going on.
But the story is even more complicated: Cholesterol in the diet doesn’t actually contribute most to blood cholesterol levels, and different fats can have adverse or beneficial effects. Other factors — including carbohydrate metabolism, diabetes, obesity, physical inactivity, some medications, and smoking — can affect cholesterol levels as well.
There have been numerous recent advances in research into the formation, structure and chemistry of blood vessel plaques and it is now possible to explain much more about their relationship with circulating cholesterol. We offer an up-to-date description of how plaques in blood vessels develop, become unstable, and lead to disease in more detail in Chapters 5, 9, and 10. When you understand this subject, you have the opportunity to make actionable changes in the management of your cholesterol.
Perhaps the greatest change in approach has come from the appreciation that plaque progression occurs as a result of chronic inflammation, and that a process called cholesterol oxidation contributes to this process — a phenomenon that has its own underlying causes and can vary significantly between individuals and over time.
Bottom line: The development of atherosclerosis is not just a matter of cholesterol. It relates to oxidation of cholesterol and inflammation of plaques, which can occur where there are excessive reactive oxygen atoms, described as oxidative stress and chronic inflammation. We explore this subject more extensively in Chapter 3. In addition, Chapters 4 and 10 focus on how you may be able to reduce that oxidation and inflammation with relatively easy changes to diet and lifestyle.
THE HISTORY OF THE STUDY OF HEART DISEASE: A CHANGING STORY
In the 17th and 18th centuries, anatomists began to explore the relationship between postmortem changes and diseases. In 1829, Jean Lobstein, a French pathologist, coined the term arteriosclerosis. Lobstein linked this condition to aging and disease, but the mechanism was unclear.
A few decades later, Rudolf Virchow, a German physician and scientist, proposed that plaques resulted from lipid accumulation and inflammation. He described how cholesterol deposits and cellular debris contributed to arterial blockage, forming the foundation for the modern understanding of atherosclerosis.
Early 20th-century researchers, including Nikolai Anichkov, demonstrated experimentally that dietary cholesterol could lead to arterial plaques in animals. This understanding solidified the connection between lipids, plaques, and vascular disease. By the mid-20th century, epidemiological studies, such as the Framingham Heart Study, connected high cholesterol levels and plaque buildup to cardiovascular events like heart attacks and strokes.
From the University of Washington, Seattle, Professor Russell Ross’s 1999 article “Atherosclerosis — An Inflammatory Disease” in the New England Journal of Medicine was a landmark publication that redefined atherosclerosis as a chronic inflammatory condition. It emphasized the role of blood vessel wall injury from smoking and pollution toxins, chemical changes of high glucose or cholesterol levels, and the physical stress from high blood pressure as the initiating event, triggering an immune response, which promotes inflammation, leading to plaque buildup and arterial narrowing. Cholesterol trapped in the arterial wall can undergo a process called oxidation (damage from circulating reactive oxygen atoms), which triggers an immune response and makes this a central player in plaque formation and inflammation.
How Cardiovascular Diseases Harm the Body
The supply of blood through blood vessels to the organs is essential for the organs’ proper functioning and the maintenance of health. It’s what keeps you alive. Disruption and compromise of the efficient passage of oxygen and nutrients carried by blood cells through those vessels is responsible for the illnesses that cause the most sickness and death in the majority of populations — cardiovascular diseases (CVDs), which include coronary heart disease and cerebrovascular disease, more familiarly referred to as heart disease and stroke, respectively.
When large blood vessels are affected, it may result in sudden events of critical loss of blood supply to a large area of an organ, such as a myocardial infarction (heart attack) or a cerebrovascular accident (stroke) affecting the brain. When the smaller blood vessels are more involved, more gradual and smaller incremental damage may occur and result in slower deterioration in functioning, such as in heart failure or vascular dementia.
CVDs are the leading cause of death globally. In 2019, an estimated 17.9 million people died from CVDs, representing 32 percent of all global deaths. Of these deaths, 85 percent were due to heart attack and stroke. CVDs are the leading cause of death and disability in the WHO European Region. An estimated 4.2 million people in Europe died from CVDs in 2019, representing 42.5 percent of all deaths. This is the highest proportion of all the WHO regions. According to the WHO, the majority of these deaths are preventable.
The CDC describes heart disease as the leading cause of death for men, women, and people of most racial and ethnic groups in the United States, with one person dying every 33 seconds from CVD. In 2022, 702,880 people died from heart disease. The cost of CVD was estimated to be about $252.2 billion from 2019 to 2020.
The heart and brain are the organs that are most vulnerable to vascular diseases, but deficiencies in blood supply to other parts of the body can result in damage to the following:
Kidneys:
Vascular diseases can impair blood flow to the kidneys, leading to kidney damage and chronic kidney disease.
Lungs:
Vascular diseases can affect the blood vessels in the lungs, leading to conditions like
pulmonary embolism
(blood clot in the lungs) and
pulmonary hypertension
(high blood pressure in the lungs).
Liver:
Vascular diseases can reduce blood flow to the liver, leading to liver damage and dysfunction.
Limbs:
Vascular diseases, particularly
peripheral artery disease,
can affect the blood vessels in the legs and arms, causing pain and numbness, and potentially leading to tissue damage and amputation.
Eyes:
Vascular diseases can affect the blood vessels in the eyes, leading to conditions like
diabetic retinopathy
(damage to the retina of the eye from diabetes) and
age-related macular degeneration
(age-related damage to central vision).
Optimum management of cholesterol is not just a numbers game. A low cholesterol number shouldn’t in itself be the target — the desired outcome is a healthy and fulfilled life, free from the burden of illness.
An article in the journal Life in 2016 that considered how physicians can influence lifestyle changes in patients at risk of heart disease noted a phenomenon referred to as statin complacency or risk compensation. This idea is based on the notion that people taking medications such as statins to lower cholesterol may feel a false sense of security, believing the medication is sufficient to manage their cardiovascular risk and, therefore, maintain a poor diet, feel no need to exercise, or even continue to smoke! Fortunately, there are also research papers that contradict this concern, showing that most people who receive adequate explanations about cholesterol, medication, and lifestyle tend to adopt more healthy behaviors. We look at medical treatments for high cholesterol in Chapter 11.
With any level of cholesterol, oxidation and inflammation, which are now known to be crucial to the development of CVD, are also critical factors. Measuring oxidation and inflammation isn’t as straightforward, though, and because doctors generally rely on simple numbers that only provide the proportions of lipids, virtually no attention is given to levels of oxidation and inflammation. As Albert Einstein said, “Not everything that counts can be counted, and not everything that can be counted counts.” Despite being a less measurable and tangible aspect of cholesterol, what is happening to the cholesterol circulating in the body must be central to any discussion about its management.
Why an Integrated Approach Counts
CVD and other vascular diseases are linked not just to high cholesterol, but to a number of other aspects of life: smoking, high blood pressure, poor diet, obesity, diabetes, and physical inactivity. Being male increases the risk, though following menopause the risk is similar if not higher in females, as well as having a family history of CVD. Risk further rises with age. Conditions of chronic inflammation and oxidative stress also increase rates of CVD. Having high cholesterol is just one of many factors, and it shouldn’t be looked at in isolation. That’s why it’s important to consider an integrated approach to managing cholesterol and reducing the risk of CVD.
Preventing or treating disease by managing risk
When you manage cholesterol, you’re managing a risk factor for vascular disease. The fact that CVD and other disorders of blood vessels are so common makes it an important consideration, but as a single risk factor, a high cholesterol level should not be thought of in isolation. Any gains in reducing cholesterol should be seen in the context of all other risk factors. On its own, raised cholesterol is a poor predictor of whether someone is likely to develop CVD, but where it exists among other risks, it becomes much more significant. (We explore the concept of risk in detail in Chapters 7 and 8.)
There is a big difference in the effects of reducing cholesterol levels depending on whether a person is known to have already established vascular disease. Primary prevention targets people without CVD to prevent its development, while secondary prevention focuses on individuals with CVD or risk factors to reduce the risk of future events.
The 4S Study was a landmark clinical trial published in the prestigious Lancet journal in November 1994 looking at people who had CVD. It demonstrated a 30 percent reduction in overall mortality and a 28 percent reduction in the risk of coronary heart disease events in patients with coronary heart disease who were treated with simvastatin, a cholesterol-lowering and oxidation-reducing medication in a class of drugs called statins. This study demonstrated the importance of cholesterol management in secondary prevention. Statins have become the cornerstone of medical prevention of further strokes, heart attacks, or other complications in people who have been diagnosed with vascular diseases or who are at high risk.
The reduction in risk of further events in the secondary prevention of CVD with statin treatment is very impressive. However, comparable risk reductions can be seen when people adopt a Mediterranean diet, exercise regularly, and stop smoking, showing that lifestyle changes in conjunction with medical treatments can be very effective and that one should not be a substitute for the other.
Primary prevention of CVD may also involve medications like statins; however, the reduced risks and lower potential gains mean that different considerations apply. The significance of modestly elevated cholesterol in a young person with no other risk factors is much less important than the implications of the same level in someone who is older or who has other risks of vascular disease.
Whether a person has their cholesterol checked at all may depend on where they live and what attitudes they and their doctor have about cholesterol and risk. In some countries, the approach to screening is much more proactive and there is a lower threshold for active management, surveillance, and treatment. In regions where this more anticipatory attitude is common, public health bodies issue guidelines encouraging doctors to screen. Sometimes there are financial incentives for health practitioners to identify and treat patients with high cholesterol. For example, in some countries pharmaceutical companies are allowed to advertise or even sell medications directly to the public; in other countries, legislation prohibits or limits this activity. How often you have your cholesterol checked, if at all, at what age, and whether this results in medication depends to some degree on where you live.
This reality makes understanding the implications of cholesterol even more important. It empowers you to know when to request a test, how to respond to an invitation for screening, and how to decide, in discussion with your doctor, on the best treatment for you.
Modifying lifestyle and drawing on culinary medicine
The majority of healthcare professionals receive most of their training applying the medical model of care (the traditional approach to healthcare focused on diagnosing and treating diseases primarily through clinical interventions such as medications, surgeries, and other acute care measures). Under the medical model of care, there is a tendency to emphasize identifying and addressing specific diseases or conditions and treating symptoms or managing crises rather than preventing illnesses. Although this model is often effective for acute illnesses and emergencies, it sometimes overlooks broader lifestyle and social determinants of health, such as diet, exercise, and mental well-being.
Increasingly, there is a drive to take a more holistic approach with the practice of complementary and aligned principles of lifestyle medicine, which takes a proactive, prevention-oriented approach to health by addressing the root causes of chronic diseases through lifestyle changes. Lifestyle medicine is built on principles of maintaining health and considering the whole person, engaging individuals as active participants in their health journey (including their physical, mental, and emotional well-being), and encouraging sustainable modifications in areas such as the following:
Nutrition
Physical activity
Sleep
Stress management
Substance avoidance
Social connectedness
Relaxation
Various components of lifestyle medicine — such as exercising, eating a healthful diet, losing weight if necessary, using healthful cooking methods, and reducing stress through yoga, tai chi, and meditation — may also help you to keep your cholesterol levels under control. Chapter 12 discusses various alternative therapies to consider as well.
Culinary medicine is a new field of medicine that combines the art of cooking with evidence-based nutritional science to help people achieve better health through food. It focuses on the role of dietary habits in preventing, managing, and even reversing chronic diseases while emphasizing the enjoyment and cultural significance of eating. Culinary medicine bridges the gap between knowing what to eat (nutrition) and making it practical and enjoyable (culinary skills), empowering individuals to take control of their health through food. This field recognizes that food is not only medicine but also a source of joy, culture, and connection.
The best way to optimize taking care of your cholesterol is through lifestyle and culinary medicine, with effective medical management explored if you and your healthcare professional agree that it’s necessary and appropriate.
Chapter 2
Defining Cholesterol
IN THIS CHAPTER
Understanding the role of cholesterol in the body
Making sense of “good” and “bad” cholesterol
Interpreting your blood work
Most people think of cholesterol as a number — a test result. That number may cause concern (because high levels of cholesterol carry an increased risk of the most common causes of sickness and death: heart disease and stroke). Maybe the number is a regular topic of conversation between you and your doctor. And perhaps the number results in disappointment when the figure seems to fluctuate beyond your control.
But there’s more to cholesterol than just a scary or apparently reassuring number. Cholesterol is made by the body and performs functions in cells throughout the body, but it has to be transported to and from those cells through blood vessels. Too much circulating cholesterol in certain forms is associated with damage to the blood vessels, which results in cardiovascular disease, but there some forms of cholesterol that counter this risk and are beneficial.
In this chapter, we explain the role of cholesterol, spell out which types of cholesterol are the “good” and “bad” types, how cholesterol is measured, and the meaning of those results.
Recognizing the Importance of Cholesterol
Cholesterol is an essential component of the human body. It is present in every cell and circulates in the bloodstream. Despite its reputation as something harmful, cholesterol is vital for numerous bodily functions.
Cholesterol is a sterol, a type of lipid (fat) molecule made up of carbon, hydrogen, and oxygen atoms. Its unique structure allows it to interact with fats and water, making it a crucial component in cells and other systems such as carrying messages essential for life.
Although we get some cholesterol directly from foods, 70 percent to 80 percent of the cholesterol in the bloodstream is manufactured by the body. The liver is the primary organ responsible for cholesterol production; it synthesizes cholesterol from fats, carbohydrates, and proteins. Even without dietary cholesterol, the liver can produce all the cholesterol needed to maintain health.
The body is a great regulator. Through feedback mechanisms, the body tries to keep cholesterol levels in a natural balance. When there is more cholesterol in the diet, the liver produces less; conversely when dietary intake decreases, the liver compensates by producing more cholesterol. Cholesterol levels can rise for a number of reasons, and it’s not always possible for the body to maintain healthy regulation of cholesterol, risking damage to blood vessels that supply vital organs. When there are high levels of cholesterol in the blood, this is sometimes referred to as hypercholesterolemia.
Appreciating the role of cholesterol in the body
Cholesterol fulfills several essential functions contributing to health, including the following:
Cholesterol is a building block for cell membranes.
Cholesterol is incorporated into the walls of cells to maintain the structure and permeability of cells. Cholesterol allows important nutrients and chemical messages to pass in and out of cells, while ensuring the cells’ integrity.
Cholesterol is a precursor for hormones.
Cholesterol is the starting material for the synthesis of steroid hormones, including sex hormones (such as estrogen and testosterone) and adrenal hormones (such as cortisol).
Hormones
are chemical messengers that stimulate specific cells to act in ways to support life.
Cholesterol helps in the production of bile acids.
Bile acids, derived from cholesterol, are substances produced in the liver and released into the gut to aid in breaking down dietary fats and absorbing fat-soluble vitamins (vitamins A, D, E, and K).
Cholesterol helps with the synthesis of vitamin D.
Sunlight converts cholesterol in the skin into vitamin D, a nutrient crucial for calcium absorption and immune health.
Cholesterol is especially important for the brain. In fact, the brain is the most cholesterol-rich organ in the body — it contains about 20 percent of the body’s total cholesterol. Cholesterol is critical in the formation and maintenance of synapses (the connections between neurons essential for learning, memory, and overall brain function). It also contributes to the selective permeability of the blood-brain barrier, protecting the brain from harmful substances in the blood, while allowing nutrients to pass through. Cholesterol is a component of myelin (the fatty sheath that insulates nerve fibers and ensures efficient signal transmission between nerve cells). It also helps regulate the release of neurotransmitters (chemicals that transmit signals between nerve cells).
Identifying the types of circulating cholesterol
Cholesterol can’t dissolve in blood, so it’s transported by lipoproteins, which are complexes of lipids and proteins designed to carry fats, including cholesterol, through the bloodstream. The protein component helps make the fat more soluble in blood and directs it to where it’s needed in the body. The main types of lipoproteins are:
Low-density lipoprotein (LDL): Often called “bad” cholesterol, LDL cholesterol carries cholesterol to tissues but can contribute to plaque buildup in arteries if levels are too high.
LDL has two subtypes:
Small, dense LDL particles
are smaller and denser than larger LDL particles. They’re more prone to oxidation, which makes them more likely to contribute to plaque buildup in the arteries. Studies have shown that having a high proportion of small, dense LDL particles is associated with an increased risk of heart disease, even if your total LDL cholesterol level is within a normal range.
Large, buoyant LDL particles
are larger and less dense than small, dense LDL particles. They’re generally considered less
atherogenic
(less likely to cause plaque buildup).
High-density lipoprotein (HDL): Known as “good” cholesterol, HDL cholesterol helps remove excess cholesterol from the bloodstream and transports it back to the liver for disposal or recycling. Moderately, but not excessively, high HDL cholesterol is considered to reduce the risk of heart disease.
HDL has two subtypes:
Large, mature HDL particles
are larger and contain more cholesterol.
Small, dense HDL particles are smaller and contain less cholesterol.
Some studies suggest the small HDL particles may have strong protective effects, but the overall function of HDL — including antioxidant and anti-inflammatory properties — and not just particle size, determines its cardiovascular benefit.
Intermediate-density lipoprotein (IDL):
Formed during the transition from VLDL to LDL, these lipoproteins are temporary carriers of cholesterol and triglycerides.
Chylomicrons:
These are the largest lipoprotein and carry mainly
triglycerides
(a type of fat used for energy storage and metabolism). After meals, triglycerides are absorbed from food in the gut and transported by these lipoproteins to tissues for immediate energy or storage in fat cells for future use.
Very low-density lipoprotein (VLDL):
These lipoproteins carry triglycerides and cholesterol from the liver to tissues. They’re considered a precursor to LDL because when they’ve delivered the triglycerides, they become denser and more like LDL.
Lipoproteins also carry the vitamins A, D, E and K, which are fat soluble, so they “hitch a ride” with lipoproteins, which can carry fats in the blood to where they’re needed.
When cholesterol is being transported by lipoproteins through the circulatory system, especially in excess amounts, it’s vulnerable to damaging chemical reactions, including oxidation (a process where unstable molecules called free radicals with unpaired electrons damage cells by stealing electrons from healthy molecules). Oxidized LDL can be retained in damaged blood vessel walls, forming plaques and triggering an immune response leading to the chronic inflammation that results in cardiovascular disease. We explain this process in more detail in Chapter 4.
The state of oxidation of LDL cholesterol is not measured, so it isn’t possible to precisely understand how damaging any level of circulating cholesterol may be in practice. We discuss the limitations of cholesterol test results in more detail in the next section.
Measuring Cholesterol
A cholesterol blood test measures circulating cholesterol in the lipoproteins. The LDL cholesterol (LDL-C) component is associated with cardiovascular diseases, whereas the HDL cholesterol (HDL-C) gives protection. For this reason, it’s difficult to interpret the meaning of a simple total cholesterol (TC) level. The TC may be made up of predominantly “bad” LDL-C or have a high level of “good” HDL-C. Without knowing the proportions of each component, it’s not possible to say if a high TC level is a significant risk factor for cardiovascular disease and whether you should try to lower your levels.
A more accurate measurement is the lipid panel test, which provides levels of TC, LDL-C, and HDL-C. It may also include a measure of non-HDL cholesterol, which combines the levels of the LDL cholesterol and VLDL cholesterol. Other fats that are commonly measured in a lipid panel are circulating triglycerides (TGs), which we cover later in this chapter.
Here’s a summary of the lipids most commonly measured in a lipid panel test:
TC:
Measures the overall cholesterol level in your blood.
LDL-C:
Often called “bad” cholesterol, high levels of LDL-C can increase the risk of plaque buildup in arteries, leading to heart disease or stroke.
HDL-C:
Known as “good” cholesterol, HDL-C helps remove excess cholesterol from the bloodstream and transports it to the liver for excretion.
TGs:
A type of fat in your blood. High levels are linked to an increased risk of heart disease, especially in combination with high LDL-C or low HDL-C.
Non-HDL cholesterol (optional):
Calculated as TC minus HDL-C, this includes all “bad” cholesterol types, such as LDL-C and VLDL cholesterol.
Ratio calculations:
The ratios of cholesterol components, such as TC to HDL-C or LDL-C to HDL-C, are reported to provide additional risk assessment.
TC and HDL-C are not significantly affected by food intake, so it’s usually possible to take a cholesterol screening blood test at any time of day without fasting. This is not the case for TGs, however, so if your healthcare provider wants to focus more particularly on issues of TG management as part of the lipid panel measurement, it’s recommended that the blood test be done when you’re fasting. This may also be important if a specialist medical professional is looking at LDL-C in greater detail because high levels of TGs can affect the accuracy of LDL-C measurement.
Blood tests are usually done using a syringe and needle in a healthcare setting with the analysis undertaken in a laboratory, but rapid testing in a doctor’s office or pharmacy can also be reasonably accurate. There are now commercial home finger-prick kits available, but be sure to get medical advice and to repeat more detailed analysis with more formal testing if you have any concerns about managing your cholesterol.
Get the best professional advice you can, and do the type and frequency of testing that are appropriate for you. Testing techniques provide different degrees of accuracy, and there may be some variability in results even from the same laboratory. Always remember to discuss and ask questions of your trusted, certified, and regulated healthcare provider.
Discuss the frequency and type of testing with your healthcare provider. These factors will depend on the reasons for assessing your cholesterol in the first place, your medical history, the lipid panel results, and the aims of any management strategies or treatment you may be receiving.
When you get your cholesterol or full lipid panel test, it’s always a good idea to understand what’s being tested and whether the result will give you and your healthcare provider the information needed to make the best assessment of the significance of the result.
Interpreting the results
If you’ve had a full lipid panel test at a healthcare clinic, you should be given an appointment to discuss the results with someone qualified to provide advice on the implications. You’ll feel much more empowered if you’re able to understand the numbers and come to a shared decision on the best management plan.
The lipid panel will provide a number of readings. The most important of these for most people is the cholesterol ratio (a calculation based on the levels of “good” and “bad” cholesterol). We consider this subject in more detail later in the “Paying attention to your cholesterol ratio” section, later in this chapter.
High lipid levels, including high levels of LDL-C and low levels of HDL-C, are risk factors for cardiovascular disease. As such, there is no absolute cutoff for what’s “normal” or “abnormal.” Results always need to be considered in the context of other risk factors and the degree to which lifestyle factors may mitigate the effects of a high “bad” cholesterol level. Age also needs to be taken into account. The significance of a high cholesterol level as a risk factor for cardiovascular disease may be reasonably viewed very differently in someone in their 40s than an individual in their 80s. (We explore this subject in more detail in Chapters 7 and 8.) For someone with existing cardiovascular disease or at a particularly high risk of developing vascular disease, there are much more stringent targets for cholesterol reduction (see Chapter 11), which for the vast majority of people are achieved through medication.
Several reliable authorities advise on how to interpret a lipid panel test, including the American Heart Association (AHA), the World Health Organization (WHO), and the National Cholesterol Education Program (NCEP). The European Society of Cardiology (ESC), in collaboration with the European Atherosclerosis Society (EAS), produces guidelines about normal lipid levels and cardiovascular risk management widely used in European countries. There can be small variations in the definitions of low, optimal, or high levels of lipids between different organizations.
The usual units of measurement in the United States (milligrams/deciliter, or mg/dL) are different from those used in Europe and many other parts of the world where the results are expressed as millimoles per liter, or mmol/L.
Table 2-1 lists commonly used guidelines for lipid panel results for an average adult without a diagnosis of cardiovascular disease.
TABLE 2-1 Cholesterol Levels Categorized
Total Cholesterol
Category
mg/dL
mmol/L
Optimal
Less than 200
Less than 5.2
Borderline high
200 to 239
5.2 to 6.2
High
240 or higher
≥ 6.3
LDL Cholesterol
Category
mg/dL
mmol/L
Optimal
Less than 100
Less than 2.6
Near optimal
100–129
2.6–3.3
Borderline high
130–159
3.4–4.0
High
160–189
4.1–4.9
Very high
190 or higher
5.0 or higher
HDL Cholesterol
Category
mg/dl
mmol/L
Undesirably low (a risk factor)
Less than 40 for men, less than 50 for women
Less than 1.0 for men, less than 1.3 for women
High (protective)
60 or higher
1.6 or higher
Triglycerides
Category
mg/dL
mmol/L
Normal
Less than150
Less than 1.7
Borderline high
150–199
1.7–2.2
High
200–499
2.3–5.6
Very high
500 or higher
5.7 or higher
Non-HDL Cholesterol (Total Cholesterol – HDL)
Category
mg/dL
mmol/L
Optimal
Less than 130
Less than 3.4
Borderline High
130–159
3.4–4.0
High
160–189
4.1–4.9
Very High
190 or higher
≥ 4.9
It’s important to remember that in some situations, there can be temporary changes to some of the components of a lipid panel test. If any of these situations apply, they may be reflected in the result, which is a good reason for tests to be repeated over time to make sure you have an accurate picture of your cholesterol levels in the long term.
The reasons for variability in lipid levels are quite logical. Following exercise, fats have been mobilized and consumed for energy. A temporary increase in TGs from the gut can be seen following a meal. A heart attack or other acute illness (for example, severe infection or surgery) typically causes a temporary reduction in total cholesterol, LDL, and HDL levels in what is known as the acute phase response, which occurs because the liver shifts focus to producing proteins that are involved in inflammation and tissue repair, instead of cholesterol. Lipid levels can remain artificially low for six to eight weeks post-illness, so retesting is recommended after recovery. Table 2-2 summarizes how various factors can affect the different lipid types.
TABLE 2-2 Summary of Variability Effects by Lipid Type
Factor
Total Cholesterol
LDL
HDL
Triglycerides
Recent meals
Minimal
Minimal
Minimal
Increased
Recent exercise
Minimal
Minimal
Increased
Decreased
Alcohol
Minimal
Minimal
Increased
Increased
Heart attack
Decreased
Decreased
Decreased
Decreased
