What doctors wish patients knew about high cholesterol

High cholesterol is a common health condition in the U.S. Nearly 94 million adults 20 or older 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, two physicians shared what they wish patients knew about high cholesterol and how to lower levels. They are:

• Kate Kirley, MD, a family physician who is the vice president of prevention solutions at the AMA.
• Chase Noel, DO, a family physician at Baptist Health Medical Group, which is a member of the AMA Health System Program provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.

“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.”

“Triglycerides are really indicative of a bigger problem. Elevated triglycerides shouldn't just be considered to be an increased risk of cardiovascular disease,” Dr. Noel said. “High triglycerides are usually an indicative problem of metabolic syndrome, uncontrolled type 2 diabetes, other things like that. 

“Usually addressing those problems outside of your cholesterol is where you would put your focus if somebody had elevated triglycerides,” he added.

“Cholesterol is made in your liver. It's made in the hormone pathway, and your body can consistently produce cholesterol based on a genetic profile,” Dr. Noel explained.

“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.”

“When you look at a cholesterol panel, there is no way to really interpret it without something we call ASCVD [atherosclerotic cardiovascular disease] risk stratification. It’s recommended by the American Academy of Cardiology,” Dr. Noel said. “When you look at the cholesterol panel, we’re not trying to say you have good cholesterol or you have bad cholesterol. We’re trying to determine what your cardiovascular risk is and whether you need treatment.”

This takes into account various patient-specific factors, “whether the patient has hypertension, how well their hypertension is controlled, what their cholesterol levels are, smoking history, diabetes history, things of that nature to determine what their risk is and then to determine treatment,” he explained, noting physicians also look at “family history, psoriatic arthritis, rheumatoid arthritis and inflammatory disorders that predispose you to early cardiovascular events.”

“Primarily, your cholesterol profile is genetic. Diet and lifestyle modifications may be able to change your LDL between 10 and 20, and lifestyle modifications can significantly reduce your cardiovascular risk,” said Dr. Noel. “It cannot significantly change your cholesterol profile. Cholesterol profile is really genetically controlled.”

“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.”

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“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. 

“There are some rare, outwardly skin findings where you can have some cholesterol deposits under your eyelids and things like that,” Dr. Noel said. “Those don't necessarily correlate to a cholesterol panel. So, somebody may have those and also not have elevated cholesterol. It's one of those things like hypertension that we consider a silent killer. 

“Usually, we check a cholesterol profile on somebody in their 30s and we don't really need to check one again until they're 40 because we understand their cholesterol profile in their risk profile and it's going to be consistent because of their genetics,” he 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.”

“You need a cholesterol panel sometime between your ages of 20 and 30 to understand your risk profile,” Dr. Noel explained. “If you have a family history, maybe a little bit earlier than that. Then I wouldn’t recommend checking another one until you’re 40. Once you’re 40, we usually—from a screening standpoint—should do it every three to five years.

“Now, if we’re treating or we’re looking for specific goals, we may repeat it sooner,” he added. 

“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. But they tend to not change your cholesterol levels very much.”

“If you're talking to your doctor, you're wondering whether or not you should treat your cholesterol, you really should look at it from a cardiovascular risk standpoint,” Dr. Noel said. “If you have high cholesterol with a low cardiovascular risk, you don't necessarily need to reduce your cholesterol. 

“Now, if you have high cholesterol and your cardiovascular risk is low, that's when you really need to focus on diet and exercise modifications to reduce your overall cardiovascular risk,” he added.

“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.”

“For some reason, statins have gotten a bad rep in the community. I’m not really sure where that came from,” Dr. Noel said, emphasizing that “statins are one of the most well studied, most well tolerated medications that exist.”

“The big benefits we get is it reduces your inflammation in your coronary and your cerebral arteries,” he said. “Think of statins as an ibuprofen for your coronary arteries, reducing that inflammation or reducing your coronary artery disease as well as reducing your cholesterol. But the big, main effect is prevention of cardiovascular disease.”

“When we’re talking about primary prevention, there is not a recommended goal for how low we want your cholesterol to go based on your determined risk,” Dr. Noel said. “You’ll get a percentage risk—5% to 20% risk. Less than 5% doesn’t get any medicine. Then 5% to 7.5% is borderline risk and we talk to the patient about what their risks are and whether we recommend medicine or not.”

For a risk of “7.5% to 19%, we really think they need a medicine, and we’ll try to recommend that. And a 20% risk is they really need to go on a statin medication,” he said, noting that for 20% risk, “we consider moderate to high moderate intensity statins. We recommend a 40% reduction in LDL. High intensity statins, we’re looking for a 50% reduction in LDL.”

“Then a secondary prevention goal, we’re always looking for your LDL to be less than 70, so you may need some medications in addition to a statin to reduce your cholesterol further,” Dr. Noel said. With medication, “there has been some evidence that shows that starting low and going slow is the way to go.

“I usually start a statin at a specific dose. If a patient develops statin induced myopathies, the first thing I’ll do is try to reduce the dose to the lowest dose of the statin that I have and then titrate them up,” he added. “Studies show that about 70% of patients who get medication that way, do well and can tolerate the statin after that.” 

“Switching up a statin is an option as well. Again, starting at a low dose and titrating up in somebody who has a history of statin induced myopathies,” Dr. Noel said. 

“Primary prevention is not having a heart attack and trying to prevent your first event—whether a heart attack, stroke or peripheral vascular disease,” Dr. Noel said. “There is an entire other category that we look at, which is secondary prevention and that is after a person has had such a event, statins already have been prescribed to prevent secondary events.”

“Aspirin, Plavix, Brilinta—those medicines are recommended for secondary prevention,” he said, noting “for a long time, baby aspirin was recommended for men 55 to 65 years old for primary prevention. Recent evidence has shown that that is not as effective as we once thought it was.

“So, aspirin for primary prevention is not recommended, but aspirin and Plavix and those can be recommended for secondary prevention,” Dr. Noel 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.” 

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.”

“In recent years, we’ve noticed that alcohol really increases your risk for almost every type of cancer,” Dr. Noel said. “Does it maybe have some cardiovascular benefits? Possibly. But the increased risk of cancer and liver disease, the benefits don’t outweigh the risk in that case.”

“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.”