Cholesterol: What You Need to Know to Protect Your Heart

Cholesterol has become a household word—often one that sparks fear. Although quite simple, it is more nuanced than “good” or “bad.” I find that once patients understand what cholesterol actually does in the body and how it can be managed, they feel more empowered to take charge of their heart health. Let’s break it down:

What is Cholesterol, Really?

Cholesterol is a waxy, fat-like substance your body needs to build cells, produce hormones, and digest food. It’s made in the liver and also found abundantly in animal-based foods. When the liver (and other cells) prepare cholesterol for transportation through the blood, it attaches them to molecules called lipoproteins. Think of cholesterol as the school children and the lipoprotein molecules as busses.

Good vs. Bad Cholesterol

• LDL (Low-Density Lipoprotein): Often called “bad” cholesterol. These "busses" take the cholesterol from the liver to the rest of the body. Due to their small size, LDL molecules can make their way into the walls of blood vessels and build up there. This is called plaque and causes narrowing your arteries and increasing your risk of heart attack and stroke.

• HDL (High-Density Lipoprotein): This is the “good” cholesterol. HDL helps remove cholesterol from the bloodstream, transporting it back to the liver to be broken down and removed. Higher HDL levels are generally protective against heart disease.

• A third number you’ll often see is Triglycerides, which are another type of fat in the blood. High triglycerides can also raise your risk for heart disease, especially when combined with low HDL or high LDL.

How to Lower LDL (Bad) Cholesterol?

Let me start by saying, for most people, lowering LDL is significantly more important than raising HLD (good cholesterol) or lowering triglycerides.

1) Improve Your Diet:

• Focus on soluble fiber (found in oats, beans, lentils, apples, and flaxseed).

• Avoid trans fats and limit saturated fats, often found in fried foods, baked goods, and fatty cuts of meat.

• Incorporate plant sterols and stanols, found in seeds, nuts and legumes.

2) Exercise Regularly:

• Aerobic activity (often referred to as "cardio") helps your body use LDL for energy, which reduces the amount in your bloodstream.

3) Quit Smoking & Limit Alcohol:

• These lifestyle changes not only help cholesterol but improve overall cardiovascular health.

4) Consider Medication if Needed:

• Statins are often prescribed when lifestyle changes aren't enough, especially if you’ve had a heart attack or stroke, or are at high risk for one.

How to Raise HDL (Good) Cholesterol?

• Exercise: One of the most reliable ways to raise HDL.

• Healthy Fats: Swap out saturated fats for unsaturated fats (like olive oil, avocado, and nuts).

• Lose Excess Weight: Even a modest reduction in weight can increase HDL levels.

• Quit Smoking: It can lead to a noticeable bump in your HDL over time.

Interestingly, while raising HDL is considered beneficial, recent studies (like the Copenhagen City Heart Study) have shown that simply raising HDL through medication doesn’t always reduce heart disease risk unless LDL is well controlled. That’s why we now focus on the overall lipid profile and risk rather than HDL alone.

Cholesterol Goals: One Size Does Not Fit All

• If you’re very young and healthy, with no significant medical history, your LDL goal may be under 130 mg/dL.

• There are certain conditions that automatically necessitate (with some exceptions) an LDL lowering medication. For example the The United States Preventive Services Task Force recommends starting a medium intensity statin medication in patients with diabetes.

• If you're above 45 years old, the American Heart Association recommends setting your LDL goal (and the strength of statin you should be on) based on your 10 year risk of having a cardiovascular event. Like everything else in medicine, there's an algorithm for that.

• If you have had a stroke or a heart attack, or if you have a diagnosis of peripheral artery disease or coronary artery disease, the American College of Cardiology (ACC) and the American Heart Association (AHA) recommend an LDL goal of 70.

Conclusion: Your Numbers Are Just the Start

Managing cholesterol isn’t just about hitting a number—it’s about reducing your risk of serious cardiovascular disease over time. That’s why I always encourage patients to work with their doctor to:

• Set cholesterol goals that are right for them

• Make lifestyle changes that feel sustainable

• Decide if and when medication makes sense

When approached with a plan tailored to you, cholesterol management can be life-extending and empowering.

By Ziya Aktig, MD