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A Heart Doctor Explains Cholesterol Levels

by Kate Silver

You hear it all the time: know your numbers, watch your cholesterol, HDL is good, LDL is bad. But what does it all mean? Go Red For Women ( asked Suzanne Steinbaum, M.D., Director, Women and Heart Disease with the Heart and Vascular Institute at Lenox Hill Hospital in New York, to help us understand cholesterol, as well as cholesterol-lowering drugs called statins, based on the updated cholesterol guidelines.

These updated guidelines are the result of the latest medical research and rewrite best practices for the first time in a decade. 

Go Red for Women (GRFW): What is cholesterol? 

Dr. Suzanne Steinbaum (SS): Cholesterol itself isn’t bad. In fact, cholesterol is just one of the many substances created and used by our bodies to keep us healthy.

Cholesterol comes from two sources: your body and food. Your liver and other cells in your body make about 75 percent of blood cholesterol. The other 25 percent comes from the foods you eat. Cholesterol is only found in animal products.

There are two types of cholesterol: “good” and “bad.”  It’s important to understand the difference, and to know the levels of “good” and “bad” cholesterol in your blood. Too much of one type — or not enough of another — can put you at risk for coronary heart disease, heart attack or stroke. 

GRFW: What does cholesterol consist of? 

SS: There are several different parts of the cholesterol profile. One of them is the high-density lipoprotein (HDL), another one is the low-density lipoprotein (LDL) and triglycerides. 

GRFW: What is “bad” cholesterol? 

SS: We have called the LDL cholesterol the “bad” cholesterol. If there’s too much LDL cholesterol in the blood, it can lead to plaque formation in the arteries, so we don’t want that LDL cholesterol to be too high. 

GRFW: What is “good” cholesterol? 

SS: HDL is what we call the “good” cholesterol. When you have a high HDL, it is protective. It actually sort of shuttles the LDL out of the arteries and protects the lining of the arteries from developing plaque.

The female sex hormone estrogen tends to raise HDL cholesterol, and as a rule, women have higher HDL (good) cholesterol levels than men. Estrogen production is highest during the childbearing years. 

GRFW: What lowers HDL in women? 

SS: Smoking, being overweight and being sedentary can all result in lower HDL cholesterol. 

GRFW: How can people increase their HDL? 

SS: You may be able to raise your HDL (good) cholesterol levels through weight loss, dietary changes and physical activity. Your doctor may also prescribe medicine to help. 

GRFW: What should women know about triglycerides? 

SS: Triglycerides are the most common form of fat in the body. Many women who have heart disease or diabetes have high triglyceride levels. A high triglyceride level combined with low HDL cholesterol or high LDL cholesterol seems to speed up atherosclerosis (the buildup of fatty deposits in artery walls). Atherosclerosis increases the risk for heart attack and stroke.

Older women tend to have higher triglyceride levels. Triglycerides go up due to being overweight/obese, physical inactivity, cigarette smoking, excess alcohol consumption, other diseases such as type 2 diabetes, some drugs, genetic factors, and/or a diet very high in carbohydrates (60 percent or more of calories). 

GRFW: What can women do to treat high triglycerides? 

SS: Reducing saturated and trans fats in the diet is a great starting place to improve triglyceride and HDL levels. 

GRFW: What changed with the new cholesterol guidelines? 

SS: The guidelines advise doctors to consider a patient’s overall health in treatment decisions. And that’s why one of the biggest changes in the cholesterol guidelines could lead to more people taking cholesterol-lowering drugs called statins. Doctors have long prescribed statins based on a cholesterol number, particularly the level of LDL (bad) cholesterol.

But the guidelines advise assessing factors such as age, gender, race, whether a patient smokes, blood pressure and whether it’s being treated, whether a person has diabetes, as well as blood cholesterol levels in determining their overall risk for a heart attack or stroke. They also suggest that healthcare providers may want to consider other factors, including family history. Only after that very personalized assessment is a decision made on what treatment would work best.

The guidelines also advise doctors to no longer prescribe additional cholesterol-lowering drugs, such as fibrates and niacin, to patients who do not reach targets with statins alone because those drugs have not been shown to reduce heart attack or stroke risk. 

GRFW: Who should receive statin therapy? Is there a specific level of “bad” cholesterol at which a person should receive statin treatment? 

SS: The guideline recommends statin therapy for the following groups:

  • People without cardiovascular disease who are 40 to 75 years old and have a 7.5 percent or higher risk for having a heart attack or stroke within 10 years.
  • People of any age with a history of a cardiovascular event (heart attack, stroke, stable or unstable angina, peripheral artery disease, transient ischemic attack, or coronary or other arterial revascularization).
  • People 21 and older who have a very high level of “bad” cholesterol (190 mg/dL or higher).
  • People with Type 1 or Type 2 diabetes who are 40 to 75 years old.

Some patients who do not fall into the four categories may also benefit from statins, a decision that should be made on a case-by-case basis. 

GRFW: Is there a target number for LDL cholesterol in statin patients? 

SS: For patients taking statins, the guidelines say they no longer need to get LDL cholesterol levels down to a specific target number – a significant departure from how doctors have treated cholesterol for years. While research clearly shows that lowering LDL lowers the risk for heart attack and stroke, there is no evidence to prove that one target number is best.

Thus, the current guidelines focus instead on matching a patient’s heart attack and stroke risk level with the intensity of statin treatment. In addition to lowering cholesterol, statins have other biochemical effects that may also help reduce the risk for heart attack and stroke. Most, including high-intensity statins, are now available in generic versions for as little as $4 for a month’s supply. 

GRFW: What do the guidelines recommend in addition to statin therapy to help prevent heart disease? 

SS: A healthy lifestyle should always accompany statin therapy. That includes eating a heart-healthy diet, being physically active on a regular basis, not smoking and staying at a healthy weight. The guidelines encourage healthcare providers to help their patients accomplish the changes they need to make.

For more information, visit and the American Heart Association (

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