What Doctors Wish Patients Knew About High Cholesterol

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03/03/2022

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www.ama-assn.org

High cholesterol is a common health condition in the United States. In fact, nearly 94 million adults over the age of 20 have what could be considered borderline high cholesterol, according to the Centers for Disease Control and Prevention. Yet because this condition often presents without symptoms, many are not aware they have high cholesterol until they visit their doctor.

The AMA’s What Doctors Wish Patients Knew™ series provides physicians with a platform to share what they want patients to understand about today’s health care headlines.

In this installment, Kate Kirley, MD, a family doctor who is the director of chronic disease prevention at the AMA, shared what she and her physician colleagues wish patients knew about high cholesterol and how to lower levels.

“Overall, cholesterol is important for our bodies. We use cholesterol to do a variety of things,” said Dr. Kirley. “Our body creates cholesterol whether we eat it or not and it’s good to have for certain functions within our bodies.

“But there are some types of cholesterol that are potentially helpful and protective,” she added. “We usually think of HDL, or high-density lipoprotein, cholesterol as somewhat protective for our hearts and blood vessels because it absorbs cholesterol and carries it back to the liver.”

“We tend to think of LDL cholesterol, or low-density lipoprotein, as the main type of cholesterol that we focus on as a potentially harmful cholesterol for our hearts because it collects in the walls of your blood vessels,” said Dr. Kirley.

Another thing to keep in mind is triglycerides, which “are a type of fat or lipid that are most influenced by what we eat and they are closely related to cholesterol,” said Dr. Kirley. “Our triglyceride levels are changing throughout the day, and they can be a risk factor for heart attack and stroke.

“When visiting your doctor for blood tests, what you’re actually getting is a test of a few different forms of lipids or cholesterol,” she added. “We will also see what triglyceride levels look like when you get a cholesterol test done. That’s another thing a physician is looking at to decide whether they need to offer medications to manage those levels as well.”

“One of the biggest things we see is that people think their cholesterol levels are more tied to what they eat than they really are,” said Dr. Kirley, adding that people tend to think “if my cholesterol levels are high, that means I should eat less cholesterol.

“The amount of cholesterol that you eat, doesn't actually impact your own cholesterol very much,” she noted. “And that's because your body is making cholesterol. It makes cholesterol no matter what. Even if you eat no cholesterol, your body makes cholesterol.”

“What you eat matters, but it has less impact on cholesterol levels than a lot of people might realize,” Dr. Kirley said.

“We've actually gotten away from hard and fast levels of cholesterol for people,” said Dr. Kirley. “We look at their cholesterol numbers along with a number of other risk factors for heart disease and stroke.”

This includes “things like your blood pressure and whether you have diabetes, and we estimate your overall risk for heart attack and stroke and how much cholesterol plays into that,” she said. “Then we may recommend taking a medication that lowers cholesterol if we think it will help lower your risk for heart attack and stroke.”

“Oftentimes, one of the biggest factors that determines your cholesterol levels is your genes,” said Dr. Kirley. “How your genes affect your cholesterol is pretty complicated, but it’s safe to say that high cholesterol tends to run in families. 

“For most people, genetic testing isn’t necessary or helpful unless they have very high cholesterol levels,” she added. “And because genes are something we can’t change this is why medications are an important tool for treating high cholesterol.”

“Typically, there are not really warning signs for people with high cholesterol,” said Dr. Kirley, noting “there are some relatively uncommon disorders where people can get physical symptoms like lesions on their skin, but those are quite uncommon.

“For the most part, the only way you can get insight into your cholesterol levels and how they might play into your risk for heart attack and stroke is to be evaluated by your physician and have your levels tested with a blood test,” she added.

As for how often a person should have their cholesterol levels tested, “for many people, it does not need to be a yearly test,” said Dr. Kirley. “The guidelines have been evolving about this in terms of what age you need to start getting your cholesterol levels tested and how frequently.

“For most adults, it’s good to have them checked at least once so you have a general idea about where your levels may be and what your risk may be,” she added. “And then for people who have risk factors like high blood pressure or older age, we may start checking every few years or so.”

“People ask a lot about behavioral changes that they can make to impact their cholesterol levels,” said Dr. Kirley. This includes “changing what they eat and their physical activity levels.”

“We see that increasing physical activity and eating a generally more healthful diet can be helpful for cholesterol levels, but these changes tend to have a relatively small impact on cholesterol levels,” she said. “Eating more veggies, eating less saturated fat and getting more physical activity - those are wonderful things for your health and we totally recommend them—they reduce your risk for heart attacks and strokes overall,” Dr. Kirley added. “But they tend to not change your cholesterol levels very much.”

“For most people who have moderate to high risk for heart attacks and strokes, the best thing that we can do to both impact their cholesterol levels and impact their overall risk for stroke and heart attack is start a statin medication,” said Dr. Kirley. “A statin medication changes the way cholesterol is metabolized in your body so that you ultimately have lower levels of cholesterol circulating in your bloodstream, particularly that LDL cholesterol that we worry about.”

“We often hear a lot of fear around taking statin medications,” she said. “Perhaps the biggest misconceptions I see are that these medications are not safe or that they cause other diseases.

“Statin medications are among the most studied medications that we use in medicine. They have a wonderful safety profile and great evidence for effectiveness,” Dr. Kirley added.

“There are many factors that contribute to high cholesterol  like genetic family history and our environments,” said Dr. Kirley, noting that “we don’t necessarily understand very well how our environments contribute to our cholesterol levels yet.”

But “having other health conditions can definitely impact your cholesterol levels,” she said. For example, “having type 2 diabetes and other inflammatory conditions can impact your cholesterol levels.

“Other medications that you take can also impact your cholesterol levels,” she added.

It is important to note that “high cholesterol and high blood pressure tend to run together,” said Dr. Kirley. “One doesn’t necessarily cause the other, but it’s very common to see both in an individual.

“And certainly, both of them contribute to raising somebody’s risk for heart attack and stroke,” she added, noting that “the interventions to help—things like more physical activity and nutrition—can impact both your blood pressure and your cholesterol.”

“We’ve talked about nutrition and physical activity, but alcohol consumption can definitely impact your cholesterol levels,” said Dr. Kirley, adding that “alcohol can raise triglyceride and cholesterol levels in your blood.

“If triglyceride levels become too high, they can contribute to health problems like heart disease and fatty liver disease,” she added. “I find that many patients don’t realize that alcohol can affect cholesterol and triglycerides, and this is just another reason to minimize alcohol consumption.”

“The other thing we see is sometimes people look for supplements to help control their cholesterol levels,” said Dr. Kirley. “The most common one that people ask about is red yeast rice,” which is a supplement made by fermenting steamed rice with food fungus.

The Food and Drug Administration (FDA) “has said that certain levels of red yeast rice can’t even be marketed as supplements,” she said. “Red yeast rice is not well studied, so we don’t know a lot about its safety and effectiveness.

“We definitely don’t recommend using a supplement like red yeast rice to take care of your cholesterol,” said Dr. Kirley. “Instead, we recommend talking with your physician about FDA-approved, safe medications.”

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