Cholesterol

What is it?

Overview

What Is It?
Cholesterol is found in cells or membranes throughout the body and is used to produce hormones, vitamin D and the bile acids that help digest fat. The body is able to meet all these needs by producing cholesterol in the liver.

High blood cholesterol is a major women's health issue. According to the Centers for Disease Control and Prevention, one in every six adults—or 16.3 percent of the population—has high cholesterol, defined as 240 mg/dL or higher. The average cholesterol level among American adults is 200 mg/dL, which is borderline high risk.

More women than men have high cholesterol in the United States, which puts them at about twice the risk of coronary heart disease (CHD) as those without the condition.

But don't fool yourself into thinking that high blood cholesterol is a problem only for middle-aged or elderly men and women. As the obesity rates in children, teenagers and young adults are rising, so are the rates of high cholesterol in these populations.

Guidelines released by the National Cholesterol Education Program (NCEP), a division of the National Heart, Lung and Blood Institute (NHLBI), in May 2001 and in July 2004, substantially expanded the number of American women and men who need treatment for high cholesterol. The next update is due out soon.

Based on mounting evidence that deaths from heart disease could be cut with aggressive treatment of high cholesterol, the NCEP guidelines spotlight elevated low-density lipoprotein (LDL) or "bad" cholesterol. Elevated LDL cholesterol injures blood vessel walls and has been identified as a major cause of CHD.

NCEP recommendations include:

  • More aggressive cholesterol lowering treatment and better identification of those at risk for a heart attack
  • Use of a complete lipoprotein profile as the first test for high cholesterol
  • A revised level at which low HDL cholesterol becomes a major heart disease risk factor
  • A revised optimal level for LDL cholesterol for the population
  • More aggressive treatment of high cholesterol for those with diabetes
  • More intensive LDL cholesterol goals and treatment options for people at very high, high and moderately high risk for heart attack
  • Intensified use of nutrition, physical activity and weight control to treat elevated cholesterol levels. Medication may also be recommended for individuals at moderate to high or very high risk of developing heart disease, based on their cholesterol ranges. This integrated approach, called the Therapeutic Lifestyle Changes (TLC) treatment plan, is a primary recommendation.
  • A sharper focus on a cluster of heart disease risk factors linked to insulin resistance, known as the metabolic syndrome, which often occur together and dramatically increase the risk for coronary complications
  • Increased attention to the treatment of high triglycerides, complex lipoproteins that can also raise your risk for heart disease
  • Advisory against using menopausal hormone therapy (HT) to treat high cholesterol

Know Your Numbers

Here are guidelines for your cholesterol levels according to NHLBI/NCEP guidelines:

Total blood cholesterol levels
less than 200 mg/dL Desirable
200 to 239 mg/dL Borderline high
240 mg/dL or above High
LDL blood cholesterol levels
less than 70 mg/dL Optional goal for high-risk patients
less than 100 mg/dL Optimal
100 to 129 mg/dL Near optimal/above optimal
130 to 159 mg/dL Borderline high
160 to 189 mg/dL High
190 mg/dL and above Very High
HDL blood cholesterol levels
above 60 mg/dL. Levels above 60 mg/dL are considered especially beneficial and can offset risk factors for heart disease, according to NHLBI. The higher the level, the healthier it is. Optimal
50 to 60 mg/dL for women; 40 to 50 mg/dL for men Average
less than 50 mg/dL for women; less than 40 mg/dL for men. Below these levels is considered a major risk factor for heart disease. Low
Triglyceride levels
less than 150 mg/dL Normal
150 to 199 mg/dL Borderline High
200 to 499 mg/dL High
500 mg/dL or higher Very high

For more information on the updated NHLBI cholesterol guidelines, visit: www.nhlbi.nih.gov/guidelines/cholesterol/#guidelines.

Your Cholesterol Glossary—Terms to Know

While high levels of cholesterol—a waxy, fat-like substance—are dangerous, our bodies do need some cholesterol. Cholesterol belongs to a family of chemicals called lipids, which also includes fat and triglycerides. Cholesterol is found in cells or membranes throughout the body and is used to produce hormones, vitamin D and the bile acids that help digest fat. The body is able to meet all these needs by producing cholesterol in the liver.

Some types of saturated fats, found primarily in whole-milk dairy products and meats, and some trans fats from foods like palm kernel oil, palm oil and partially hydrogenated oils—most often found in processed foods—raise blood levels of cholesterol. Over the years, cholesterol and fat in the blood are deposited in the inner walls of the arteries that supply blood to the heart, called the coronary arteries. These deposits make the arteries narrower, a condition known as atherosclerosis. It is a major cause of coronary heart disease (CHD). Dietary cholesterol, such as is found in eggs, dairy products and some other foods, may also raise cholesterol in the blood slightly, but newer studies find that consumption of dietary cholesterol is unlikely to substantially increase risk of coronary heart disease or stroke among healthy men and women, and most studies have found no link between egg intake and coronary risk.

Research on various types of fat and their effects on cholesterol continues, with increasing emphasis put on substituting monounsaturated and polyunsaturated fats in place of saturated fats. Researchers recognize that not all fats have the same affects on cholesterol. Even among saturated fatty acids, there are different types, some of which are more harmful than others. For instance, studies have shown that stearic acid, which is a saturated fatty acid found in dark chocolate, does not raise LDL cholesterol.

If the coronary arteries become narrowed or blocked, then oxygen- and nutrient-supplying blood can't reach the heart. The result is coronary heart disease (CHD) or a heart attack. The part of the heart deprived of oxygen dies.

Types of blood cholesterol. Cholesterol travels in the blood in packages called lipoproteins, which consist of lipids (fats) and protein. Cholesterol packaged in low-density lipoprotein (LDL) is often called "bad" cholesterol because too much LDL in the blood can lead to cholesterol buildup and blockage in the arteries. LDL carries most of the cholesterol in the blood.

Another type of cholesterol package is high-density lipoprotein (HDL), often called "good" cholesterol. HDL helps transport cholesterol from other parts of the body to the liver, which helps remove it from the body, preventing it from piling up in the arteries.

A third type of lipoprotein is very low density (vLDL). This package transports triglycerides in the blood; high levels of vLDL and triglycerides have also been linked to an increased risk of heart disease. There is no direct way to measure vLDL cholesterol, so it's normally not mentioned during routine cholesterol screenings. The vLDL measurement is usually estimated as a percentage of your triglyceride value, with a normal value between 5 and 40 mg/dL.

Diagnosis

Diagnosis

Guidelines previously recommended that all women have their blood cholesterol checked beginning at age 20. But in 2011, the National Institutes of Health released guidelines recommending that children be routinely screened for high cholesterol between ages nine and 11 and again between 17 and 21. The test should then be repeated at least once every five years, more often depending on your risk range. Medicare beneficiaries can now get a free cardiovascular screening test for cholesterol, triglycerides and lipid levels. Ask your health care professional about this benefit.

Additionally, children age two or older with a family history of premature heart disease, at least one parent with high blood cholesterol or a condition commonly associated with increased risk of coronary heart disease, such as obesity or hypertension should have their cholesterol levels tested.

Blood cholesterol levels are measured with a small blood sample. You should have a complete lipoprotein panel, which measures total cholesterol (LDL + HDL), LDL (bad cholesterol), HDL (good cholesterol) and triglyceride levels. Ideally, it should be a fasting panel, completed after you've fasted for nine to 12 hours.

Additionally, other markers indirectly related to lipids but associated with cardiovascular risk, like C-reactive protein, may be measured.

It is possible to have a standard lipid profile with all your numbers in the target range, but still have an LDL particle number or C-reactive protein level that increases your risk for cardiovascular disease. Such expanded testing may help your health care provider better target your therapy to reduce your individual risk.

Cholesterol and Triglyceride Levels

Blood cholesterol is measured in milligrams per deciliter (mg/dL). A deciliter is one-tenth of a liter). NCEP defines a "desirable" total cholesterol level as less than 200 mg/dL, and levels for most women stay in the healthy or "desirable" range until middle-age. But between the ages of 45 and 55, women's average total cholesterol rises to almost 220 mg/dL. Between the ages of 55 and 64, those levels average 240 mg/dL.

Total cholesterol levels between 200 and 239 mg/dL are considered borderline high, meaning you have a "borderline-high" risk of developing heart disease. Levels of 240 mg/dL and above put you in the high-risk category for developing heart disease.

LDL cholesterol levels less than 100 mg/dL are considered "optimal," according to NCEP guidelines. As with total cholesterol, the higher the LDL number, the higher your risk for developing heart disease.

HDL-cholesterol levels are interpreted differently. The lower your HDL level, the higher your heart disease risk. In women, a level less than 50 mg/dL is a major risk factor for heart disease. An HDL level of 60 mg/dL or higher is considered protective.

The lipoprotein profile that determines your cholesterol levels also measures another fatty substance called triglycerides. Triglycerides are complex fat molecules that link together three molecules of fat from food. They tend to be short-term transporters of fat, and their levels rise right after a meal.

More research is needed to determine whether high triglycerides themselves cause narrowing of the arteries or are simply associated with other risk factors (such as low levels of HDL cholesterol and being overweight). It is known that people with high levels of the "packages" triglycerides usually travel in (vLDLs) are at increased risk. Most people with raised triglycerides are also overweight, and losing weight usually lowers the elevated levels.

Here are guidelines for your cholesterol and triglyceride levels according to NHLBI/NCEP guidelines:

Total blood cholesterol levels
less than 200 mg/dLDesirable
200 to 239 mg/dLBorderline high
240 mg/dL or aboveHigh
LDL blood cholesterol levels
less than 70 mg/dLOptional goal for high-risk patients
less than 100 mg/dLOptimal
100 to 129 mg/dLNear optimal/above optimal
130 to 159 mg/dLBorderline high
160 to 189 mg/dLHigh
190 mg/dL and aboveVery High
HDL blood cholesterol levels
above 60 mg/dL. Levels above 60 mg/dL are considered especially beneficial and can offset risk factors for heart disease, according to NHLBI. The higher the level, the healthier it is.Optimal
50 to 60 mg/dL for women; 40 to 50 mg/dL for menAverage
less than 50 mg/dL for women; less than 40 mg/dL for men. Below these levels is considered a major risk factor for heart disease.Low
Triglyceride levels
less than 150 mg/dLNormal
150 to 199 mg/dLBorderline High
200 to 499 mg/dLHigh
500 mg/dL or higherVery high

The American Heart Association suggests the following guidelines for cholesterol ranges in children, ages two to 19:

Total blood cholesterol levels
less than 170 mg/dLAcceptable
170 to 199 mg/dLBorderline high
200 mg/dL or greaterHigh
LDL blood cholesterol levels
less than 110 mg/dLAcceptable
110 to 129 mg/dLBorderline high
130 or greaterHigh

It is important to remember that these recommendations are for healthy individuals, not for women with existing risk factors for heart disease, such as diabetes, kidney disease, being overweight, smoking or having a family history of heart disease. If you are at risk for heart disease, your target goals likely will be lower.

For example, having diabetes means your risk of a heart attack in 10 years is as high as if you already had heart disease. That's why NCEP guidelines recommend that those with diabetes be treated as intensively as those with heart disease in terms of medication and lifestyle changes.

Discuss your target ranges with your health care professional, including which treatment and prevention options are best for you given your current health status. For additional information visit: www.nhlbi.nih.gov/guidelines/cholesterol/index.htm.

Treatment

Treatment

Guidelines issued by the National Cholesterol Education Program (NCEP) emphasize intensified use of nutrition, physical activity and weight control in the treatment of elevated blood cholesterol —specifically LDL cholesterol. Its "Therapeutic Lifestyle Changes (TLC) Treatment Plan" includes a cholesterol-lowering diet (the TLC diet), and guidelines for drug treatment with cholesterol-lowering drugs based on a risk assessment of LDL levels.

The TLC plan includes daily intakes of less than seven percent of calories from saturated fat and less than 200 mg of dietary cholesterol. It also allows up to 35 percent of daily calories from total fat, provided most of the fat is unsaturated fat, which doesn't raise cholesterol levels. In addition, the guidelines encourage the use of certain foods rich in soluble fiber to boost the diet's LDL-lowering power. They also include regular physical activity. It is widely accepted that the threshold for saturated fat should be applied to the combination of saturated and trans fat.

In children with elevated cholesterol, the American Heart Association recommends the first line of treatment be lifestyle changes to encourage healthier eating and more physical activity.

How Treatment is Determined

If you have high cholesterol, you and your health care professional will determine the type of treatment that is most appropriate for you and your lifestyle. There are several major risk factors that affect your LDL cholesterol goal and will be considered when recommending a treatment plan. These are:

  • Diabetes

  • Kidney disease

  • Coronary heart disease

  • Peripheral vascular disease

  • Presence of vascular disease

  • Age (in general, the older you are, the more likely your health care professional will decide drug therapy is appropriate if your LDL cholesterol level is too high; for women, 55 is often the threshold age)

  • Smoking (or daily exposure to secondhand smoke)

  • High blood pressure. The goal is less than 120/80 mm Hg for the general population, less than 140/90 mm Hg for people who have been diagnosed with high blood pressure and less than 130/80 mm Hg in people with kidney disease or diabetes.

  • Low levels of HDL cholesterol (below 50 mg/dL for women)

  • Family history of premature heart disease (heart disease in father or brother before age 55; heart disease in mother or sister before age 65)

The NHLBI guidelines include a risk assessment tool to help you determine your 10-year risk of having a heart attack or dying from heart disease. This can be used to establish goals for lowering your LDL cholesterol levels. The tool assigns risk values based on age, total cholesterol levels, HDL cholesterol levels, blood pressure level and smoking status. For more information, please see: www.nhlbi.nih.gov/guidelines/cholesterol/index.htm.

If lifestyle changes alone don't improve your cholesterol levels, your doctor may recommend drug treatment. When to begin drug therapy typically depends on your risk factors. Several classes of safe, effective medications for reducing cholesterol levels are available. You may have to be proactive in getting your health care professional to consider drug therapy.

Diet and exercise are also the first line of treatment in children. If diet and exercise alone are not effective in lowering cholesterol, medications, including statins, may be considered in children older than age 8.

Here are NCEP's guidelines (updated in July 2004) for when cholesterol-lowering medications should be used to help reach LDL-target goals.

  • Very high risk women have heart disease with multiple risk factors (especially diabetes) with severe or poorly controlled risk factors (especially persistent cigarette smoking), or metabolic syndrome (high triglycerides, low levels of "good" HDL cholesterol, obesity). If you have just had a heart attack, you're also considered at very high risk.

    Lipid-lowering medication is almost always indicated in the very high-risk group, with a goal of bringing LDL levels below 70.
  • High risk women have heart disease or diabetes or have multiple risk factors, such as smoking or high blood pressure, giving them a greater than 20 percent risk of having a heart attack within 10 years. They generally need cholesterol-lowering medication if their LDL level is 100 mg/dL or higher. The overall goal remains an LDL level of less than 100 mg/dL, with an optimal goal of less than 70 mg/dL.

    Therapeutic lifestyle changes (TLC), including intensive use of nutrition, physical activity and weight control, are also important for cholesterol management. These should definitely be discussed with your health care professional if you are high risk and your LDL is at or greater than 100 mg/dL.
  • Moderately high risk means you have two or more risk factors for heart disease and/or heart attack, with a 10 percent to 20 percent risk of having a heart attack or other cardiovascular event within the next 10 years. Your LDL goal should be 130 mg/dL or lower, but you may have a goal of under 100 mg/dL and use drug therapy at LDL levels of 100 to 129 mg/dL to reach this lower goal. If your LDL cholesterol level is higher than this target, the TLC dietary and other lifestyle changes will be recommended as a cholesterol-lowering strategy.
  • Moderate risk means you have two or more risk factors for heart disease and/or heart attack with a less than 10 percent risk of having a heart attack or other cardiovascular event in the next 10 years. Your LDL goal is less than 130 mg/dL. If your LDL is greater than or equal to 130 mg/dL, TLC dietary and other lifestyle changes will be recommended as a cholesterol-lowering strategy. If your LDL cholesterol level is 160 mg/dL or more, your health care professional may also recommend drug therapy.
  • Lower risk means you have one or no risk factors for heart disease or heart attack. Your LDL goal is less than 160 mg/dL.

    If your LDL is 160 mg/dL or above, you should start the TLC diet. If your LDL level is still 190 mg/dL or more, you may need to start drug therapy. You and your health care professional may also consider an LDL-lowering drug at LDL levels of 160 to 189 mg/dL.

Medication Options for Treating High Cholesterol

There are several medications that reduce cholesterol levels. Before taking these or any other medications, talk to your health care professional about other conditions you have and medications you are taking, including birth control pills (statins, for example, can raise blood levels of birth control hormones) and over-the-counter medications, including vitamins and nutritional supplements.

Statins. Six statin drugs are available in the United States: atorvastatin (Lipitor), fluvastatin (Lescol), lovastatin (Mevacor, Altoprev), pravastatin (Pravachol), simvastatin (Zocor) and rosuvastatin (Crestor). In most cases, statins are highly effective at lowering cholesterol levels and overall cardiovascular disease risk. They also provide the added benefits of increasing HDL cholesterol somewhat and reducing triglyceride levels.

Statins are also found in the combination medications Advicor (lovastatin + niacin), Caduet (atorvastatin + amlodipine) and Vytorin (simvastatin + ezetimibe).

Statins work by inhibiting an enzyme called HMG-CoA reductase, which controls the body's cholesterol production rate. They ramp down production of cholesterol and boost the liver's ability to remove LDL cholesterol from the blood. In several large clinical trials, they have proven their merit not only in lowering cholesterol levels, but also in achieving the ultimate goal: reducing heart attacks and deaths related to heart disease.

Most statins are usually taken once a day in the evening or before bed. The timing is important, since the body makes more cholesterol at night than during the day. It takes about four to six weeks to achieve the full effect. After six to eight weeks, your health care professional will probably check your LDL cholesterol and perhaps adjust your medication.

According to the U.S. Food and Drug Administration, all statin drugs have been associated with reports of a rare and potentially fatal muscle condition called rhabdomyolysis, which causes muscle cells to breakdown and enter the bloodstream.

A much more common side effect is benign muscle pain, which often responds to supplemental Coenzyme Q10.

The risk of rhabdomyolysis increases with higher doses of statins and when statins are used in combination with certain drugs, such as the fibrate gemfibozil (Lopid), and cyclosporine (Restasis), a drug used to suppress immunity in people who undergo organ transplants and for the treatment of rheumatoid arthritis.

The most common side effects associated with statins are upset stomach, gas, constipation, abdominal pain or cramps and muscle pain. The effects are usually mild to moderate and fade as your body adjusts to the drug. However, if you experience brown urine or muscle soreness, pain or weakness—possible symptoms of rhabdomyolysis—contact your health care professional immediately.

Bile acid sequestrants (resins). The three main bile acid resins prescribed in the United States are cholestyramine (Questran), colestipol (Colestid) and colesevelam (WelChol). These drugs work by binding with bile acids in the intestines that contain cholesterol. The cholesterol is then eliminated in the stool. A bile acid sequestrant may be prescribed in combination with another drug if you have high triglycerides or a history of severe constipation.

Bile acid sequestrants come in powders that are mixed with water or fruit juice and usually taken once or twice a day with meals. They are also available in pill form. They should be taken with plenty of water to avoid gastrointestinal side effects, such as constipation, bloating, nausea and gas.

If you take bile acid sequestrants, you should take any other medications at least one hour before or four to six hours after taking a bile acid resin because the bile acids can interfere with the absorption of other medications.

Niacin. This compound is more commonly known as nicotinic acid, a water-soluble B vitamin. Unfortunately, you can't lower your cholesterol by taking a vitamin supplement —to have such an effect it must be taken in doses well above the daily vitamin requirement. Although nicotinic acid is inexpensive and available over the counter, never take it for cholesterol reduction without a health care professional's oversight because of potential side effects. The extended-release form is available by prescription as Niaspan. It decreases triglycerides by limiting the liver's ability to produce LDL cholesterol.

Niacin appears to have stronger effects on HDL cholesterol and triglycerides than it does on LDL cholesterol. And at higher doses, nicotinic acid can also lower triglyceride levels. It comes in capsule and tablet forms, both regular and time released. An initial dose will probably be low, then gradually increased to between 1.5 grams and 6 grams a day.

Niacin also widens blood vessels, making flushing and hot flashes frequent side effects. These side effects may be reduced by taking the drug with meals or by taking aspirin or a similar medication with nicotinic acid. The extended release form, available by prescription as Niaspan, results in less flushing and liver toxicity than the immediate or sustained release forms.

Nicotinic acid can also intensify the effect of high blood pressure medication and produce various gastrointestinal problems—nausea, indigestion, gas, vomiting, diarrhea and activation of peptic ulcers. Serious side effects include liver problems, gout and high blood sugar, with risk rising in tandem with the dose.

This drug may not be prescribed if you have diabetes because it can raise blood sugar slightly. If you have diabetes, talk about the pros and cons with your health care professional.

Fibrates. These drugs lower triglycerides by reducing the liver's production of LDL cholesterol and assisting in the removal of triglycerides from the blood. The most widely used fibrate in the United States is gemfibrozil (Lopid). Fibrates are not recommended as the sole drug therapy for women with heart disease for whom LDL cholesterol reduction is the main goal.

Side effects are rare, with gastrointestinal problems the most common. Fibrates may also increase the risk of cholesterol gallstones and can boost the effects of blood thinners—a possibility your health care professional should watch out for. Fibrates may also increase the risk of rhabdomyolysis when used in combination with statins.

Selective cholesterol absorption inhibitors. This new class of drugs lowers cholesterol by preventing it from being absorbed in the intestine. More specifically, the one approved medication in this class—ezetimibe (Zetia)—acts in the small intestine to prevent cholesterol absorption so less cholesterol reaches the liver and more is cleared from the blood.

Combination drug therapy. If you haven't achieved your target LDL cholesterol level after a few months on a single medication, your health care professional may recommend adding another. Various combinations have been shown to be effective and safe. Lower doses of each individual drug can reduce the risk of side effects.

Update on Postmenopausal Hormone Therapy for Treating Elevated Cholesterol

Postmenopausal hormone therapy once was considered a medical option for treating elevated cholesterol in postmenopausal women because research suggested it might prevent the development of heart disease—the end result of high cholesterol levels for a long time.

The National Cholesterol Education Program at NHLBI now advises against using menopausal hormone therapy to prevent heart disease. Studies to date have not shown hormone therapy reduces the risk for major coronary events or deaths among postmenopausal women, particularly when compared to statins.

Prevention

Prevention

There are things you can do to try to keep your cholesterol levels within healthy ranges. In addition to getting your cholesterol screened regularly (every five years for individuals with no heart disease risk factors), take these steps:

  • Be physically active for at least 30 minutes, most days of the week (preferably every day, if possible).

  • Lose weight if you are overweight

  • Increase your intake of whole grains, with an emphasis on soluble fiber. Eat at least 25 to 30 grams of fiber a day, preferably from whole grains, fruits, vegetables and legumes.

  • Increase your intake of poly- and monounsaturated fatty acids and reduce your intake of saturated and trans fats. Limit your saturated fat consumption to less than 7 percent and your intake of trans fat to less than 1 percent of your total daily calories.

  • Increase your intake of fruits and vegetables high in antioxidants. Eat five or more servings of fruits and vegetables per day.

  • Consume moderate amounts of alcohol, defined as equal to or less than one drink a day for women (and two drinks a day for men).

You might think the key to lowering your blood cholesterol levels is to get dietary cholesterol levels to zero. But such an approach addresses only part of the problem. Reducing your cholesterol intake does indeed lower your risk of heart disease, but it has less impact on blood cholesterol levels than cutting back on saturated fat.

Saturated fat boosts your blood cholesterol level more than anything else in your diet. Saturated fat is found mainly in food that comes from animals, including whole-milk dairy products such as butter, cheese, milk, cream and ice cream, as well as the fat in meat and poultry skin.

A few vegetable fats—cocoa butter, palm kernel oil and palm oil—are also high in saturated fat. These fats may be found in cookies, crackers, coffee creamers, whipped toppings and snack foods, which also contain trans fatty acids, another form of fat that acts like saturated fat in the body. It is important to read food labels, which detail total fat, saturated and trans fat levels. Research is continuing to determine which of these fats are harmful; not all saturated fatty acids cause the same effects.

Monounsaturated fats (MUFAs), which are found in olive and canola oil, nuts, olives and avocados, help decrease cholesterol levels and are associated with reducing risk of cardiovascular disease. MUFAs are believed to be one reason why people who follow a Mediterranean style of eating have lower cholesterol and lower risk of heart disease. The Mediterranean eating pattern has a high ratio of monounsaturated to saturated fatty acid intake. It also emphasizes vegetables, fruits and nuts, olive oil and whole grains and includes limited amounts of meats and full-fat milk and milk products.

Polyunsaturated fats, such as safflower and corn oil, and monounsaturated fats, such as olive and canola oil, may lower LDL cholesterol levels slightly and raise HDL cholesterol levels. However, don't try to boost your intake of these fats. Instead, concentrate on cutting back fat from all sources but with an eye toward using these "healthier" fats in place of saturated fats.

Omega-3 fatty acids, which are found in oily fish such as salmon and soybean and canola oil, appear to lower blood levels of triglycerides. You may want to add fish to your diet at least twice a week and choose these oils over others. However, because of high levels of mercury and iodine found in fish these days, a daily fish-oil supplement (which is generally cleansed of these toxins) might be a better bet.

Psyllium, a fiber supplement, also provides cholesterol-lowering benefits when taken in conjunction with a low-fat, low-cholesterol diet. Research has shown that consuming 10 grams of psyllium a day combined with a low-fat diet can lower total cholesterol by 4 percent and LDL cholesterol by 7 percent in as little as eight weeks.

And margarine-like spreads approved as foods by the FDA are available that lower LDL cholesterol and may reduce the risk of heart disease when used as part of a low-fat, low-cholesterol diet. To get this effect, however, you have to consume up to three grams a day. These spreads include Benecol and Take Control. They both contain plant sterols (also called stanol esters), which work by blocking absorption of cholesterol in the digestive track. Recent studies find that plant sterols lower cholesterol even in patients already on statin medications.

If you don't have high cholesterol or heart disease, you're probably already on the right track when it comes to lifestyle. Be sure to stick with a program that keeps total fat to no more than 35 percent of daily calories, with saturated fat comprising no more than seven percent. You should also engage in regular physical activity (at least 30 minutes a day, most days of the week; every day if possible) to keep your weight in check and possibly lower high cholesterol levels.

If your cholesterol is elevated but you don't have heart disease, develop an action plan in consultation with a health care professional.

You can also check out the American Dietetic Association's website at www.eatright.org for more information on heart-healthy dietary strategies, or visit the websites produced by the American Heart Association and the National Cholesterol Education Program: www.americanheart.org/cholesterol and www.nhlbi.nih.gov/guidelines/cholesterol/index.htm.

Facts to Know

Facts to Know

  1. According to the Centers for Disease Control and Prevention, one in every six adults—or 16.3 percent of the population—has high cholesterol, defined as 240 mg/dL or higher. More women than men have high cholesterol in the United States.

  2. Cholesterol travels in the blood in packages called lipoproteins, which consist of cholesterol (fat) and protein. Cholesterol packaged in low-density lipoprotein (LDL) is often called "bad" cholesterol, because too much LDL in the blood can lead to cholesterol buildup and blockage in the arteries. LDL carries most of the cholesterol in the blood.

  3. Another type of cholesterol package is high-density lipoprotein (HDL), often called "good" cholesterol. That is because HDL cholesterol helps transport cholesterol to the liver, which removes it from the body, preventing buildup in the arteries.

  4. A third type of lipoprotein, very low-density lipoprotein (vLDL), transports triglycerides in the blood; high levels of vLDL and triglycerides have been linked to increased risk of heart disease.

  5. In 2011, the National Institutes of Health released new guidelines recommending that children be routinely screened for high cholesterol between ages nine and 11, and again between 17 and 21. The test should then be repeated at least once every five years, more often depending on your risk range.

  6. An LDL cholesterol level of less than 100 mg/dL is considered optimal. An optional goal for high-risk patients is less than 70 mg/dL.

  7. A healthy diet, healthy weight and regular exercise can all protect against heart disease and high cholesterol levels, while your age (over 55 for women) and family history may increase your risk of heart disease and high cholesterol.

  8. If there is too much cholesterol in your bloodstream, it builds up in the form of plaque on the walls of your arteries, narrowing them and eventually blocking them and reducing the blood flow to your heart. This process increases your risk of a heart attack.

  9. Reducing your intake of high-cholesterol food lowers your risk of heart disease, but it has less impact on blood cholesterol levels than cutting back on saturated and trans fats. Some people with high cholesterol levels do not respond to changes in diet, however. They will need medication.

  10. A desirable total cholesterol level for adults without heart disease is less than 200 mg/dL. An HDL cholesterol level of 60 mg/dL and above is considered protective against heart disease, while a level less than 50 mg/dL for women or 40 mg/dL for men is considered a major risk factor for heart disease.

  11. If you have heart disease, an LDL level (the "bad" cholesterol) above 100 mg/dL is considered high, and you and your health care professional should identify steps to bring your LDL-cholesterol level into a desirable range (less than 70 mg/dL), including exercise, diet changes and medication.

Questions to Ask

Questions to Ask

Review the following Questions to Ask about cholesterol so you're prepared to discuss this important health issue with your health care professional.

  1. What is my overall risk for heart disease? Can we review my risk factors?

  2. Why do I keep hearing about "good" and "bad" cholesterol? What are they?

  3. What are triglycerides? What do they have to do with cholesterol?

  4. What type of test best measures my cholesterol levels?

  5. Will you explain the results of my cholesterol test?

  6. If I have high LDL cholesterol, what lifestyle and dietary changes can I make to lower it?

  7. What types of food should I avoid or add to my diet?

  8. When and how often should I have my cholesterol level checked?

  9. Based on my cholesterol and other risk factors, am I a good candidate for a statin medication? What are the risks and benefits of using a statin?

  10. Are there alternative medications I can take if I cannot or do not wish to use a statin?

  11. If I have high blood cholesterol, are my children at risk for developing high blood cholesterol?

  12. I have diabetes. How does it affect my risk for developing high cholesterol? Will it affect treatment?

Key Q&A

Key Q&A

  1. What is cholesterol?

    Cholesterol is a waxy, fat-like substance found in whole-milk dairy products, eggs, animal fats and meat. It belongs to a family of chemicals called lipids, which also includes fat and triglycerides. It is found in cell walls or membranes throughout the human body and is used to produce hormones, vitamin D and the bile acids that aid the digestion of fat. Your body is able to meet all these needs by producing cholesterol in the liver.

  2. What is the connection between cholesterol and heart disease?

    Over the years, excess cholesterol and fat are deposited in the inner walls of the arteries that supply blood to the heart. These deposits make the arteries narrower, contributing to atherosclerosis and, if the process is unchecked, heart attack.

  3. Why should I worry about cholesterol? Aren't women protected from heart disease?

    No. Cardiovascular disease, which includes diseases of the heart and blood vessels such as stroke, is the leading cause of death in women, accounting for more than 300,000 deaths in females a year. Though women, in general, seem to develop heart disease later in life than men— typically after menopause—the time to worry about your heart's health is NOW. Talk to your health care professional for guidance.

  4. What is the difference between "good" cholesterol and "bad" cholesterol?

    "Bad" cholesterol comes in the form of low-density lipoprotein (LDL). This is the primary type of cholesterol in the blood and contributes to heart disease. High-density lipoprotein (HDL) is often called "good" cholesterol because it transports cholesterol from the body to the liver, which helps remove it from the body and prevents it from clogging arteries.

  5. How are cholesterol levels tested?

    A lipoprotein profile is a blood test usually administered after fasting for nine to 12 hours. It measures LDL cholesterol, total cholesterol, HDL cholesterol, and triglyceride levels. It is the preferred test for measuring cholesterol levels.

  6. What should my cholesterol levels be?

    If you do not have any risk factors for heart disease, the ranges below are important numbers to know. If you have heart disease or risk factors for heart disease (diabetes, previous heart attacks), your health care professional will recommend different ranges than those listed below and will likely choose a more aggressive approach to getting your cholesterol ranges under control:

    Total blood cholesterol levels

    less than 200 mg/dL

    Desirable
    200 to 239 mg/dLBorderline high

    240 mg/dL or above

    High
    LDL blood cholesterol levels
    less than 70 mg/dLOptional goal for high-risk patients
    less than 100 mg/dLOptimal
    100 to 129 mg/dLNear optimal/above optimal
    130 to 159 mg/dLBorderline high
    160 to 189 mg/dLHigh
    190 mg/dL and aboveVery High
    HDL blood cholesterol levels
    60 mg/dL or higher is ideal and helps to lower risk for heart diseaseOptimal
    50 to 60 mg/dL for women; 40 to 50 mg/dL for menAverage

    Less than 50 mg/dL is a major (high) risk for heart disease for women; less than 40 for men

    Low
    Triglyceride levels
    less than 150 mg/dLNormal
    150 to 199 mg/dLBorderline High
    200 to 499 mg/dLHigh
    500 mg/dL or higherVery high
  7. What can I do to reduce my cholesterol level without taking medications?

    Talk to your health care professional for the best strategy based on your personal and family health history. Lifestyle changes—including weight loss, exercise and a healthy diet—are just as effective as medication in lowering cholesterol for most people.

  8. What drugs are available to lower high cholesterol?

    Six medications in the statin class of drugs are available, including atorvastatin (Lipitor), fluvastatin (Lescol), lovastatin (Mevacor, Altoprev), pravastatin (Pravachol), rosuvastatin calcium (Crestor), and simvastatin (Zocor). Statins are most effective at lowering LDL cholesterol, but they may also have modest effects on raising HDL cholesterol and lowering triglycerides. Statins are the most frequently prescribed cholesterol-lowering drugs, but there are other types of cholesterol-lowering drugs available, including bile acid sequestrants (resins), fibrates and cholesterol absorption inhibitors.

  9. Isn't niacin just a vitamin I can take without a prescription?

    The amount of niacin, or nicotinic acid, needed to reduce cholesterol levels is higher than the recommended amount in vitamins. The extended-release form is available by prescription as Niaspan. You shouldn't attempt to take cholesterol-reducing quantities without a recommendation from your health care professional health care professional—the drug can have severe side effects, including liver problems, gout and high blood sugar. If you have diabetes, you should check with your doctor because niacin can have a modest impact on blood sugar.

  10. Is there any nutritional supplement or alternative medication that will do the trick?

    Omega-3 fatty acids have been publicized for cholesterol-lowering effects. Ask your health care professional for more information about fish oil supplements that may help to reduce cholesterol.

Lifestyle Tips

Lifestyle Tips

  1. Practice cholesterol-lowering cooking

    The definition of "low fat" is now more specific. Medical guidelines suggest you should reduce the amount of saturated fat you eat to keep your cholesterol in check. Saturated fat is found in animal products, including meat and whole-milk dairy foods. To cut back on saturated fats, try these cooking tips—they're a healthier way for the whole family to eat:

    • Rely on spices and other seasonings instead of fat for flavor.
    • Select poultry, fish and lean cuts of meat.
    • Remove the skin from chicken and trim the fat from meat.
    • Use low-fat cooking methods like poaching, baking and broiling instead of frying.
    • When sautéing or stir-frying, use monounsaturated fats such as olive oil, canola oil, peanut oil, sunflower oil and sesame oil or substitute bouillon.
    • Use low-fat or non-fat yogurt, sour cream and cream cheese instead of the high-fat varieties.
  2. Eat Your Oatmeal

    Research indicates that eating two servings of oats each day lowers cholesterol levels and reduces heart disease risk. A review of 10 studies on the effect of whole grains on heart disease risk found that people who ate whole-grain oatmeal experienced an average reduction in overall cholesterol of 7.7 mg/dL and an average reduction of LDL cholesterol of 7 mg/dL.

  3. Get Serious About Exercising

    Do you keep putting off exercising? You shouldn't. Not only can regular physical activity such as walking make you look and feel better, it may lower your LDL or "bad" cholesterol levels, raise HDL or "good" cholesterol levels, help you trim down if you're overweight, lower your blood pressure and make your heart and lungs more fit. Before starting any activity program, talk with your health care professional to make sure it's safe for you.

  4. Steer clear of trans fats

    Like saturated fat, trans fatty acids (TFA) can raise cholesterol. TFA is present in small amounts in various animal products such as beef, pork, lamb and the butterfat present in butter and milk. To avoid them, use canola or olive oil when possible. Some fast foods and commercial baked goods and snack foods may contain trans fatty acids, but that is rapidly changing. Increasingly, manufacturers are not using hydrogenated fats, and many packaged snacks are now labeled to show that they contain no trans fatty acids.

  5. Try a Cholesterol-lowering Spread

    Two margarine-like spreads approved as foods by the U.S. Food and Drug Administration can reduce cholesterol levels. Benecol contains hydrogenated sterols derived from pine tree wood pulp, while Take Control contains naturally occurring unsaturated sterols from soybean oil. Some margarines, orange juice and yogurt drinks also contain these added plant sterols, which can help reduce LDL cholesterol by more than 10 percent. Studies find that plant sterols effectively lower cholesterol even in patients already on statin medications. You should use two to three grams a day.

  6. Leave the cholesterol testing to your health care professional

    A word of caution concerning the new home cholesterol tests now available at local pharmacies and through the Internet: Home cholesterol tests, such as the CholesTrak and First Check Home Cholesterol Test, are indeed faster than visiting your health care provider, but may not be very useful. The kits, which require the user to draw blood from a prick of the skin, measure only total cholesterol (not HDL, LDL and triglycerides individually)—interesting information that doesn't provide accurate information about your cardiovascular risk or much about the impact of diet or exercise on your cholesterol.

Organizations and Support

Organizations and Support

For information and support on Cholesterol, please see the recommended organizations, books and Spanish-language resources listed below.

American College of Cardiology (ACC)
Website: http://www.cardiosource.org
Address: Heart House
2400 N Street, NW
Washington, DC 20037
Hotline: 1-800-253-4636
Phone: 202-375-6000
Email: resource@acc.org

American Heart Association (AHA)
Website: http://www.americanheart.org
Address: 7272 Greenville Avenue
Dallas, TX 75231
Hotline: 1-800-AHA-USA-1 (1-800-242-8721)
Email: Review.personal.info@heart.org

National Heart, Lung, and Blood Institute (NHLBI) - NHLBI Health Information Center
Website: http://www.nhlbi.nih.gov
Address: Attention: Website
P.O. Box 30105
Bethesda, MD 20824
Phone: 301-592-8573
Email: nhlbiinfo@nhlbi.nih.gov

Sister to Sister: The Women's Heart Health Foundation
Website: http://www.sistertosister.org
Address: 4701 Willard Avenue, Suite 223
Chevy Chase, MD 20815
Hotline: 1-888-718-8033
Phone: 301-718-8033
Email: webmaster@sistertosister.org

WomenHeart: National Coalition for Women with Heart Disease
Website: http://www.womenheart.org
Address: 818 18th Street, NW, Suite 930
Washington, DC 20006
Hotline: 1-877-771-0030
Phone: 202-728-7199
Email: mail@womenheart.org

Women's Health Initiative (WHI)
Website: http://www.nhlbi.nih.gov/whi
Address: 2 Rockledge Centre
Suite 10018, MS 7936 6701 Rockledge Drive
Bethesda, MD 20892
Phone: 301-402-2900
Email: nihinfo@od31tm1.od.nih.gov

Women's Heart Foundation
Website: http://www.womensheart.org
Address: P.O. Box 7827
West Trenton, NJ 08628
Phone: 609-771-9600

American Heart Association 365 Ways to Get Out the Fat: A Tip a Day to Trim the Fat Away
by American Heart Association

Good Cholesterol Bad Cholesterol
by Eli M. Roth M.D., Sandra Streicher-Lankin

Family Doctor
American Academy of Family Physicians
Website: http://familydoctor.org/online/famdoces/home/common/heartdisease/risk/029.html

Last date updated: 
Tue, 2012-01-24

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Last date updated: Tue 2012-01-24