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Cholesterol

Key points

Blood cholesterol is a waxy, fat-like substance made by your liver.

Millions of people in the United States have high cholesterol.

High cholesterol is having a total cholesterol above 200 mg/dL.

What is Blood Cholesterol?

Cholesterol is a waxy, fat-like substance that's found in your blood and every cell of your body. Your body needs some cholesterol to make hormones, vitamin D, and substances that help you digest foods.

Your liver makes all the cholesterol your body needs and removes excess amounts. Cholesterol is also found in foods from animal sources, such as meat, egg yolks, poultry, and dairy products. Foods high in dietary fat can increase the cholesterol in your blood. If there's too much cholesterol in your blood, your liver can't remove it all.
Two types of lipoproteins include:
Low-density lipoprotein (LDL), This is sometimes called "bad" cholesterol. It makes up most of your body's cholesterol. High levels of LDL cholesterol raise your risk for heart disease and stroke.
High-density lipoprotein (HDL), This is sometimes called "good" cholesterol. It absorbs cholesterol in the blood and carries it back to the liver. The liver then flushes it from the body. High levels of HDL cholesterol can lower your risk for heart disease and stroke.
High levels of “bad” LDL cholesterol may create a buildup of plaque (fatty deposits) in your arteries. This buildup can lead to a heart attack, stroke, or other health problems. High levels of “good” HDL cholesterol may lower your risk for health problems. HDL cholesterol carries cholesterol and plaque to the liver to be flushed out of the body.
The genes you inherit and your lifestyle habits play a major role in your cholesterol levels.
Routine blood tests can show whether your cholesterol levels are healthy or unhealthy. To help get your cholesterol levels into the healthy range, you may need heart-healthy lifestyle changes or medicines.

What are triglycerides?

Triglycerides are a type of fat in your blood that your body uses for energy.

The combination of high levels of triglycerides with low HDL and/or high LDL cholesterol levels can increase your risk for health problems, such as heart attack.

Symptoms

High levels of low-density lipoprotein (LDL) cholesterol usually do not cause symptoms. Most people do not know they have high blood cholesterol until they have a blood test during a routine healthcare visit.
If your levels are very high, you may notice the following signs:
Fatty bumps (xanthomas) on your skin, especially on the elbows, joints, knees, hands, ankles, or buttocks
Grayish-white rings (corneal arcus) that appear around the cornea in your eye
These signs develop mostly in people who have very high cholesterol that runs in families (familial hypercholesterolemia).
Undiagnosed or untreated high blood cholesterol can lead to serious problems, such as heart attack and stroke. Talk to your healthcare provider about your risk and steps you can take to keep your cholesterol levels in a healthy range.
High cholesterol also increases your risk for heart disease and stroke, two leading causes of death in the United States.

Diagnosis

Your healthcare provider will diagnose you with high blood cholesterol based on your medical and family history, a physical exam, and a blood test of your cholesterol levels.

Medical history and physical exam

Your healthcare provider will ask about your eating habits, physical activity, family history, medicines you are taking, and other risk factors for heart or blood vessel diseases.

During your physical exam, your provider will check for signs of very high blood cholesterol, such as xanthomas, or signs of other health conditions that can cause high blood cholesterol.

Screening for high cholesterol

Your healthcare provider may order a blood test called a lipid panel to screen for unhealthy cholesterol levels.

Your healthcare provider may ask you to fast for 8 to 12 hours before a lipoprotein panel.

Lipoprotein (lipid) panel

A lipoprotein panel, also called a lipid panel or lipid profile, measures the levels of LDL and HDL cholesterol and triglycerides in your blood. Cholesterol and triglyceride levels that are higher than normal may be signs of higher risk of coronary heart disease.

A lipoprotein panel gives the following types of information:

Total cholesterol, This is a measure of the total amount of cholesterol in your blood. It includes HDL and LDL cholesterol.

Low-density lipoprotein (LDL) cholesterol, This is called the "bad" cholesterol. Too much of it in the blood causes the buildup of plaque in arteries. Plaque limits blood flow. Sometimes, plaque also breaks apart. That can lead to a heart attack or stroke.

High-density lipoprotein (HDL) cholesterol, This is called the "good" cholesterol. It helps carry away LDL cholesterol, the bad cholesterol. That keeps arteries open and blood flowing more freely.

Triglycerides, Triglycerides are a type of fat in the blood. When you eat, your body converts calories it doesn't need into triglycerides. Then triglycerides are stored in fat cells. High triglyceride levels are linked with many risk factors. These include being overweight, eating too many sweets or drinking too much alcohol. Smoking, being inactive or having diabetes also may raise the risk of high triglycerides.

Non-HDL cholesterol, non-HDL cholesterol is basically your HDL, or “good,” cholesterol number subtracted from your total cholesterol number. In other words, it’s a measure of all the “bad” types of cholesterol. Ideally, you want this number to be lower rather than higher.

Your lipoprotein panel may also provide other potentially useful numbers, such as your non-HDL cholesterol (total cholesterol minus HDL cholesterol) and remnant LDL (total cholesterol minus LDL and HDL cholesterol).

The goal for a healthy lipid profile is to have non-HDL levels below 130 milligrams (mg) per deciliter (dL) with an HDL of at least 40 mg/dL for men and 50 mg/dL for women. Check with your provider on the lipid levels that are best for you.

For healthy persons, how often you get a lipid panel done depends on your age, risk factors, and family history of high blood cholesterol or cardiovascular diseases, such as atherosclerosis, heart attack, or stroke.

Here is a general guide:

Ages 19 or younger: Screening begins at ages 9 to 11 and should be repeated every 5 years. Screening may be performed as early as age 2 if there is a family history of high blood cholesterol, heart attack, or stroke.

Ages 20 to 65: Younger adults should be screened every 5 years. Men ages 45 to 65 and women ages 55 to 65 should be screened every 1 to 2 years.

Older than 65: Older adults should be screened every year.

Lipoprotein-a

A lipoprotein-a, or Lp(a), test is not usually part of a routine lipid panel. High levels of Lp(a) may mean you are at higher risk of heart or blood vessel diseases, even if your other cholesterol levels are healthy. The genes you inherit from your parents determine how much Lp(a) you have. Your Lp(a) level is unlikely to change much from childhood to old age.

Your healthcare provider may order an Lp(a) test if you have a family history of stroke, early heart disease, such as a heart attack, or do not know your family medical history. If you have a high Lp(a) level, your provider may prescribe statins, a medicine to help lower your heart disease risk, even if your other cholesterol levels are in the healthy range.

What are normal cholesterol levels?

Normal cholesterol levels vary based on your age, ethnicity and sex.
Normal cholesterol levels by age chart
The chart below shows normal cholesterol levels. Healthcare providers consider these good cholesterol numbers for most people. If you have heart disease or many risk factors, your LDL target may be different. Your healthcare provider may want your LDL level to be below 70 mg/dL. So, it’s important to talk with your provider about your test results and what they mean for you.
All units in the chart below are mg/dL.

Age	Total cholesterol	Non-HDL cholesterol	Triglycerides	LDL cholesterol	HDL cholesterol
19 and younger	Below 170	Below 120	Below 150	Below 110	Above 45
20 and older; males	Below 200	Below 130	Below 150	Below 100	40 or higher
20 and older; females	Below 200	Below 130	Below 150	Below 100	50 or higher

As you review your results, remember that you want your LDL to be low and your HDL to be high. Ideally, your HDL should be above 60 to offer you protection against heart disease.
Sex-based differences
Most normal cholesterol levels are the same regardless of your sex. But there’s one key difference among adults. That’s your HDL number. As the chart above shows, females need a higher HDL level (at least 50) compared to males (at least 40).

What’s considered high cholesterol?

High cholesterol generally means your total cholesterol is 200 mg/dL or higher. But providers use additional categories like “borderline high” and “near optimal” to break down your results. If your numbers are close to normal levels, they may be easier to manage through lifestyle and dietary changes.

High cholesterol levels by age chart

The chart below shows cholesterol levels that are higher than normal. All units are mg/dL.

Age

Total
cholesterol

Non-HDL
cholesterol

LDL
cholesterol

19 and younger

Borderline high: 170-199

High: 200 or higher

Borderline high: 120-144

High: 145 or higher

Borderline high: 110-129

High: 130 or higher

20 and older

Borderline high: 200-239

High: 240 or higher

High: 130 or higher

Near-optimal: 100-129

Borderline high: 130-159

High: 160-189;

Very high: 190 or higher

Triglycerides are usually measured in milligrams (mg) of triglycerides per deciliter (dL) of blood. The commonly used guidelines for normal and higher levels of triglycerides in adults are:

Category	Triglyceride levels in adults
Healthy	less than 150mg/dL
Borderline high	150 to 199 mg/dL
High	200 to 499 mg/dL
Very high	500 mg/dL and higher

Causes and Risk Factors

An unhealthy lifestyle is the most common cause of high “bad” LDL cholesterol or low “good” HDL cholesterol. However, genes that you inherit from your parents, other medical conditions, and some medicines may also raise LDL cholesterol levels or lower “good” HDL cholesterol levels.

What raises the risk for unhealthy blood cholesterol levels?
Unhealthy lifestyle habits
Eating a lot of foods high in saturated fats raises “bad” LDL cholesterol levels. Saturated fats are found in fatty cuts of red meat and dairy products. No more than 10% of your daily calories should come from saturated fats.
Lack of physical activity is linked to a higher risk of having unhealthy blood cholesterol levels.
Smoking lowers HDL cholesterol, particularly in women, and raises LDL cholesterol.
Stress may raise levels of certain hormones, such as corticosteroids. These can cause your body to make more cholesterol.
Drinking too much alcohol (more than two drinks a day for men or one drink a day for women) can raise your total cholesterol level.
Getting little or low-quality sleep has been linked to lower cardiovascular health.
Learn about heart-healthy lifestyle changes you can make to lower your risk for high blood cholesterol.
Family history
Family members usually have similar cholesterol levels. This suggests that your genes can raise your risk of having unhealthy cholesterol levels.
Mutations, or changes, in your genes can be passed from parent to child. These changes in genes that control cholesterol levels can cause familial hypercholesterolemia. If you have a family history of high blood cholesterol, it may be more difficult for your body to remove LDL cholesterol from your blood or break it down in the liver.
Other medical conditions
Many health problems that raise your risk of high blood cholesterol are caused by unhealthy lifestyle habits. For example, a lack of physical activity and poor eating habits can lead to overweight and obesity, which are linked to diabetes and sleep apnea. For people with conditions such as lupus and HIV, the condition itself and the medicine used to treat it may lead to unhealthy cholesterol levels.
Talk to your healthcare provider about your risk of high cholesterol if you have any of the following:
Chronic kidney disease
Diabetes
HIV/AIDS
Hypothyroidism
Lupus erythematosus
Overweight and obesity
Polycystic ovary syndrome (PCOS)
Sleep apnea
Medicines
Some medicines that you take for other health problems can raise your level of “bad” LDL cholesterol or lower your level of “good” HDL cholesterol, including:
Arrhythmia medicines, such as amiodarone
Beta-blockers, for relieving angina chest pain or treating high blood pressure
Chemotherapy medicines, used to treat cancer
Diuretics, such as thiazide, to treat high blood pressure
Immunosuppressive medicines, such as cyclosporine, to treat inflammatory diseases or to prevent rejection after organ transplant
Retinoids, to treat acne
Steroids, such as prednisone, to treat inflammatory diseases such as lupus, rheumatoid arthritis, and psoriasis
Age
Unhealthy levels of cholesterol can affect people of all ages, even young children. However, high cholesterol is most commonly diagnosed in people between ages 40 and 59. As you get older, your body’s metabolism changes. Your liver does not remove “bad” LDL cholesterol as well as it did when you were young. These normal changes may increase your risk for developing high blood cholesterol as you age.
Race or ethnicity
Your race or ethnicity may affect your risk of high blood cholesterol:
Overall, non-Hispanic White people are more likely than other groups to have high levels of total cholesterol.
Asian Americans, including those of Indian, Filipino, Japanese, and Vietnamese descent, are more likely to have high levels of “bad” LDL cholesterol than other groups.
Hispanic Americans are more likely to have lower levels of “good” HDL cholesterol than other groups.
African Americans are more likely than other groups to have high levels of “good” HDL cholesterol.
A study found that higher levels of HDL may not be as beneficial in some Black and White adults as was once believed. Having other risk factors, such as high blood pressure, obesity, or diabetes may outweigh the health benefits of higher HDL levels.
Sex
Between ages 20 and 39, men have a greater risk for high total cholesterol than women.
A woman’s risk goes up after menopause. Menopause lowers levels of female hormones that may protect against high blood cholesterol. After menopause, women’s levels of total and “bad” LDL cholesterol usually go up, while their levels of “good” HDL cholesterol go down.

Can high blood cholesterol be prevented?
Even if you have a family history of high blood cholesterol, you can still help prevent unhealthy blood cholesterol levels with a heart-healthy lifestyle. Heart-healthy habits that start in childhood and continue throughout your life can help prevent unhealthy blood cholesterol and heart and blood vessel diseases such as heart attack and stroke.

Treatment

To treat unhealthy blood cholesterol levels, your healthcare provider may recommend heart- healthy lifestyle changes and prescribe medicines. If a medical condition or medicine is causing your blood cholesterol problem, your provider may treat that condition or change your medicine or its dose.
Talk with your provider about your cholesterol levels, your risk of developing heart disease, other medical conditions you have, and your lifestyle. You can learn about the benefits and side effects of medicines for lowering your blood cholesterol. Together, you can set up a treatment plan that will work for you.

Healthy lifestyle changes
To help you lower your LDL cholesterol level, your healthcare provider may talk to you about adopting a healthy lifestyle:
Choose heart-healthy foods. The Therapeutic Lifestyle Changes and DASH eating plans can help you lower your “bad” LDL cholesterol.
These plans encourage:
Limiting saturated fats found in fatty cuts of meats, dairy products, and desserts
Eating whole grains, fruits, and vegetables rather than refined carbohydrates such as sweets and other high-sugar foods
Eating a variety of nuts
Preparing foods with little or no salt
Get regular physical activity. Studies have shown that physical activity can lower LDL cholesterol and triglycerides and raise your “good” HDL cholesterol. For example, resistance training among postmenopausal women may decrease total cholesterol, LDL cholesterol, and triglycerides. Before starting any exercise program, ask your provider what level of physical activity is right for you.
Aim for a healthy weight. Research has shown that adults with overweight and obesity can lower “bad” LDL cholesterol and raise “good” HDL cholesterol by losing only 3% to 5% of their weight.
Manage stress. Research has shown that chronic stress can sometimes increase LDL cholesterol levels and decrease HDL cholesterol levels.
Quit smoking. For free help and support to quit smoking, you may call the National Cancer Institute’s Smoking Quitline at 1-877-44U-QUIT.
Get enough good quality sleep. Getting 7 to 9 hours of sleep a day lowers your risk for high “bad” cholesterol (LDL) and total cholesterol.
Limit alcohol. Visit the National Institute on Alcohol Abuse and Alcoholism for resources on support and treatment to stop drinking.
Medicines
Your healthcare provider may prescribe one of these medicines to help lower high blood cholesterol:
Statins are the most common medicine used to treat high blood cholesterol. They reduce the amount of cholesterol made in the liver. Studies have shown that statins lower the risk of heart attack and stroke in people with high LDL cholesterol. Statins usually don't cause side effects, but they may raise the risk of diabetes. However, this mainly happens in people already at high risk of diabetes, such as those who have prediabetes, overweight or obesity, or metabolic syndrome. Statins may also cause abnormal results on liver enzymes tests, but actual liver damage is extremely rare. Other rare side effects include muscle damage and cognitive impairment. Learn more about how you can stay safe while taking statins.
Medicine to treat familial hypercholesterolemia, which includes mipomersen, ezetimibe, bempedoic acid, and lomitapide. Ezetimibe or bempedoic acid may be used if statins cause side effects, or if statin treatment and lifestyle changes do not lower your “bad” LDL level enough. Ezetimibe works by blocking how cholesterol is absorbed into the body. In rare cases, these medicines can cause liver injury. Your provider will check your liver enzymes regularly and may recommend that you take vitamin E.
Bile acid sequestrants may be prescribed if you cannot take statins or if statins alone are not lowering your cholesterol enough. Bile acid sequestrants help lower LDL cholesterol. They keep bile acids, which digest fats and oils, from being absorbed into the body. These medicines may cause diarrhea, make some other medicines less effective, or raise your blood triglyceride level.
PCSK9 inhibitors are a type of medicine that you inject under your skin. The liver makes the protein, PCSK9. PCSK9 destroys parts of cells in the liver that allow LDL cholesterol to be absorbed. By stopping the PCSK9 protein, these inhibitors can reduce LDL cholesterol levels. Your provider may prescribe a PCSK9 inhibitor and a statin if you are at high risk of complications like heart attack or stroke, or if you have familial hypercholesterolemia. In 2021, the United States Food and Drug Administration approved the PCSK9 inhibitor, inclisiran, joining the already approved alirocumab, for patients with familial hypercholesterolemia. The most common side effects are itching, pain, or swelling at the place where you injected it.
If your provider prescribes medicines as part of your treatment plan, be sure to continue your healthy lifestyle changes. The combination of the medicines and heart-healthy lifestyle changes can help lower and control your blood cholesterol levels.
Lipoprotein apheresis
Some people with familial hypercholesterolemia may benefit from lipoprotein apheresis to lower their blood cholesterol levels. Lipoprotein apheresis uses a filtering machine to remove unwanted substances from the body. The machine removes “bad” LDL cholesterol from the blood, then returns the remainder of the blood to your body.

How often should I get my cholesterol checked?

Your provider will tell you how often you need your cholesterol checked.
It depends on your:
Age: The older you get, the more often you need to have your numbers checked.
Family history: If you have a close biological family member with a history of heart disease, you face a higher risk of heart problems, too. You may need cholesterol tests more often if your family member has high cholesterol or a history of heart attack or stroke.
Risk factors for heart disease: If you have a heart disease diagnosis or risk factors, you’ll need cholesterol tests more often.
Sex: Males need more frequent tests starting at a younger age.
Children should get their first test between ages 9 and 11. Then, they should receive a test every five years. Your child’s provider may recommend starting at a younger age based on family history.

Here are general guidelines for adults based on sex and age.

Males	Age	How often to get your cholesterol checked
	20 to 44	Every five years.
	45 to 65	Every one to two years.
	65+	Every year.

Females	Age	How often to get your cholesterol checked
	20 to 54	Every five years.
	55 to 65	Every one to two years.
	65+	Every year.

Living With High Cholesterol

Managing high cholesterol at home
Follow up with your healthcare provider regularly to see how well your treatment is working, whether you need to add or change medicines, and whether your health condition has changed:
Take all medicines regularly, as prescribed. Do not change the amount of your medicine or skip a dose unless your provider tells you to do so.
Schedule a follow up. Talk with your provider about how often you should schedule office visits and blood tests. If you start taking a statin or another cholesterol medicine, your provider may order a lipid panel 1 to 3 months later to see whether the drug is working. Repeat tests may be done every 3 to 12 months after that to make sure your cholesterol levels remain healthy.
Call your healthcare provider if you have any symptoms of complications or if you have problems with your blood pressure or blood sugar.
How high blood cholesterol may affect your health
Undiagnosed or untreated high blood cholesterol can lead to serious problems, such as heart attack and stroke.
High blood cholesterol can lead to a condition called atherosclerosis, in which plaque builds up in the arteries throughout your body. Over time, uncontrolled high blood cholesterol can lead to one of the following health problems:
Carotid artery disease
Coronary heart disease. You may feel chest pain (called angina).
Heart attack
Peripheral artery disease
Stroke
Your healthcare provider may use a risk calculator to estimate the chances of having one of these health problems in the next 10 years or over your lifetime. For example, the Atherosclerotic Cardiovascular Disease Estimator considers your cholesterol levels, age, sex, race, and blood pressure. It also factors in whether you smoke or take medicines to manage your high blood pressure or cholesterol.
Talk with your provider about your cholesterol levels and your risk of developing heart and blood vessel disease. Knowing your level of risk helps your provider decide whether you need medicine to treat high cholesterol and what healthy lifestyle changes to make to lower your risk. If your provider recommends lifestyle changes, focus on a balanced overall diet and ask if any dietary supplements may help.
High blood cholesterol can lead to serious cardiovascular complications, such as heart attack or stroke. If you think that you are or someone else is having symptoms, call 9-1-1 immediately. Every minute matters.
Learn how to stay safe while taking statins
Statins are the most common medicine used to treat high blood cholesterol. Learn some tips to stay safe if your healthcare provider gives you statins:
Take your statin medicine as prescribed. You should not stop taking this medicine on your own since that can lead to a serious problem or even cause death. Ask your provider if you have any concerns about your medicine or if you would like to stop or change to a different treatment.
Ask your provider what medicines, nutritional supplements, or foods you should avoid. Some of these can interact with statins and cause serious side effects or make statins less effective. For example, grapefruit (fresh or as juice) affects how your liver breaks down some statins.
Tell your provider about any symptoms or side effects. Sometimes, people report muscle problems while taking statins. If you start having muscle pain, your provider may order a blood test to look for muscle damage. The pain may go away if you switch to a different statin. Muscle damage with statins is rare, and your muscles may heal when you switch to a different medicine.
Adults living with HIV may benefit from daily statin use. If you have high cholesterol and live with HIV, ask your provider whether you would benefit from taking statins.
If you are planning to become pregnant, talk to your provider about your options. You should stop taking statins about 3 months before getting pregnant. Also, you should not take statins if you are breastfeeding.

FAQ's

Here are some questions people often ask about cholesterol levels.
What is a healthy cholesterol level by age?

For children and teens, borderline high total cholesterol levels are 170–199 mg/dl and borderline high LDL levels are 100–129 mg/dl. For adults aged 20 and over, borderline high total cholesterol levels are 200–239 mg/dl and borderline high LDL levels are 130–159 mg/dl. Over this is very high.
What cholesterol level is considered high?

If total cholesterol levels are 240 mg/dl or above, a doctor will consider this very high, while 200–239 mg/dl is borderline high. Very high levels of LDL are 190 mg/dl and above. HDL cholesterol levels of 40 mg/dl or less are very low and a major risk factor for heart disease.

What reduces cholesterol quickly?

Dietary measures, weight management, and exercise can all help lower cholesterol levels. A doctor may prescribe medication if the person has other cardiovascular risk factors or if their levels are very high or do not respond to lifestyle measures.

Summary

Knowing your cholesterol numbers can help you learn your risk for heart disease. But keep in mind that your cholesterol numbers are just part of the story. Your provider will also look at other aspects of your health to learn more about your risks. So, if your numbers fall outside the normal range, don’t panic.

Talk with your provider about what your cholesterol levels mean in the context of your overall health. And work with your provider to get your numbers back to a healthier place.

Cholesterol levels increase with age, and having high cholesterol at any age increases the risk of a heart attack or stroke.
Reaching or maintaining healthy levels may involve lifestyle changes and, if these are not enough, prescription medication.
A doctor should check cholesterol levels in adults, starting at the age of 20, every 4–6 years.

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