Cholesterol

Overview

High blood cholesterol is a major women's health issue. One in three Americans has high cholesterol, according to the Centers for Disease Control and Prevention.

Overall, an estimated 78 million American adults (37 percent) have high low-density lipoprotein (LDL) or "bad" cholesterol. Of these, about half are taking the necessary measures to get the condition under control. It is important to keep LDL cholesterol in a healthy range because high LDL cholesterol levels are a contributing factor to heart disease, which develops over years.

But don't fool yourself into thinking that high blood cholesterol is a problem only for middle-aged or elderly men and women. High cholesterol is a problem for some children and teenagers, too. According to the American Heart Association, 7 percent of adolescents have high cholesterol.

The guidelines regarding the diagnosis and treatment of high cholesterol changed in 2013 and again in 2018 when the American College of Cardiology (ACC) and the American Heart Association (AHA) released new cholesterol guidelines.

The biggest difference in 2013 was that the new guidelines no longer contained "treatment targets"—cholesterol levels at which health care professionals are instructed to start treatment. The ACC/AHA guidelines also endorsed a specific risk assessment tool, which assesses your 10-year risk of heart disease or stroke.

The 2018 ACC/AHA Guidelines on the Management of Blood Cholesterol allow for more personalized care for patients, including more detailed risk assessments and new cholesterol-lowering drug options for people at the highest risk for heart disease.

Also, in addition to traditional risk factors for high cholesterol such as smoking, high blood pressure and high blood sugar, the 2018 guidelines add factors such as certain health conditions including metabolic syndrome, kidney disease, premature menopause, chronic inflammatory diseases and high lipid biomarkers. They also look at family history and ethnicity when determining risk and options for treatment.

The 2018 guidelines recommend that health care providers use coronary artery calcium scores as a secondary tool when deciding whether to prescribe statin drugs.

In addition, the 2018 ACC/AHA guidelines recommend the following:

• Looking at the effects of high cholesterol over the full lifespan and identifying and treating the condition as early as possible.
• Discussing options for people with newly defined very high risk of atherosclerotic cardiovascular disease (ASCVD) who still have LDL cholesterol levels higher than 70 mg/dL after maximizing statins.
• Considering other non-statin drugs, including ezetimibe and PCSK9 inhibitors.
• Creating a value statement that highlights the need for patients and health care providers to factor in the cost of drugs when determining treatment. Overall, there's a new emphasis on making sure the highest risk patients receive the treatment they need.
• Using clinician and patient tools to boost understanding of the new guidelines and to provide better treatment.

Going By the Numbers

Despite new ACC/AHA guidelines, some practitioners still prefer to follow the previous guidelines from the National Cholesterol Education Program (NCEP), a division of the National Heart, Lung and Blood Institute (NHLBI). The NHLBI/NCEP guidelines provide specific numbers for cholesterol goals and beginning treatment. To that end, here are the older guidelines:

Total blood cholesterol levels (calculated by taking your LDL cholesterol plus your high-density lipoprotein [HDL] cholesterol plus 20 percent of your triglycerides)
Normal: less than 200 mg/dL
Borderline high: 200 to 239 mg/dL
High: 240 mg/dL or above

HDL blood cholesterol levels
Optimal: above 60 mg/dL. Levels above 60 mg/dL are considered especially beneficial and can offset risk factors for heart disease, according to AHA. The higher the level, the healthier it is.
Average: 50 to 60 mg/dL for women; 40 to 50 mg/dL for men
Low: 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.

Non-HDL cholesterol levels
This is calculated by subtracting HDL cholesterol from total cholesterol.
Optimal: Less than 130 mg/dL. Higher numbers indicate a higher risk of heart disease.

Triglyceride levels
Normal: less than 150 mg/dL
Mildly increased: 150 to 499 mg/dL
Moderately increased: 500 to 886 mg/dL
Very high: Greater than 886 mg/dL

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.

Saturated fats, found primarily in whole-milk dairy products and meats, and trans fats from foods like coconut oil, cocoa butter, palm kernel oil, palm oil and partially hydrogenated oils—sometimes 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.

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. However, vLDL is not measured routinely.

You can think of all bad cholesterol put together as "non-HDL cholesterol." Non-HDL cholesterol is a good predictor of cardiovascular disease risk, and it is a better predictor of risk than LDL cholesterol in women, as well as in people with type 2 diabetes

Diagnosis

The American Heart Association (AHA) recommends checking cholesterol levels once between the ages of 9 and 11 years and again between the ages of 17 and 21 years for children and young adults without other risk factors or a family history of early heart disease. After age 20, your health care provider should recheck your cholesterol and other risk factors every four to six years as long as your risk remains low.

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 ages 2 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.

Your health care professional may also order "expanded" cholesterol testing. These tests identify the levels of certain types of LDL cholesterol, including the number of particles and their size, providing a more accurate reading of your overall risk of cardiovascular disease.

Additionally, other markers indirectly related to lipids but associated with cardiovascular risk, like homocysteine and 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 homocysteine 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.

Treatment

Therapeutic lifestyle changes (TLC) are generally considered the first line of treatment for high LDL cholesterol. They focus on limiting saturated fat and increasing soluble fiber in the diet, managing weight and increasing physical activity.

Guidelines issued by the ACC/AHA emphasize intensified use of nutrition, physical activity and weight control in the treatment of elevated blood cholesterol—specifically LDL cholesterol. The 2018 guidelines put an even greater emphasis on lifestyle factors, particularly in adults ages 20 to 39, who have more years to adopt healthy habits and prevent cardiovascular heart disease.

The guidelines emphasize creating a healthy balance between the calories you take in with food and the calories you burn with physical activity. If you are trying to lose weight, aim to burn more calories than you take in. They recommend getting at least 30 minutes of moderate physical activity on most—preferably all—days of the week. For those with high blood pressure or cholesterol, the AHA recommends 40 minutes of moderate to vigorous activity, three to four times a week.

In terms of diet, the guidelines suggest:

• Eat a variety of nutrient-dense, low-calorie foods from each of the food groups, with an emphasis on fruits and vegetables, whole grains, lean poultry, oily fish rich in omega-3 fatty acids (two times a week), and nuts.
• Limit processed sugary foods and beverages full of empty calories.
• Limit trans fats and saturated fats.
• Restrict consumption of saturated fats to no more than 5 percent to 6 percent of your daily calories (this amounts to about 13 grams in someone eating 2,000 calories per day). Limit your sodium (salt) intake to no more than 2,300 milligrams per day, and optimally, no more than 1,500 mg.
• If you drink alcohol, limit your intake to one drink per day if you are a woman and two drinks per day if you are a man.

For more information on lifestyle changes, check out the AHA's Diet and Lifestyle Recommendations.

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

Soluble fiber. According to the AHA, you should aim for 25 grams of soluble fiber per day. Good sources of soluble fiber include oats and oat bran, barley, beans, eggplant and okra.

Nuts. Nuts contain a lot of calories, but a small handful a day of any kind of nut can be a heart-healthy snack.

Lean protein. Aim for about 646 grams of protein a day. Opt for low-fat sources of protein, such as lean meats, low-fat dairy products, soy and legumes. You can find soy in soybeans (edamame), tofu, soy milk, soy bars, soy burgers, dried soy protein and more. Fish is another good protein source for heart health; try for two servings per week.

Comprehensive lifestyle changes—low-fat vegetarian diet, stopping smoking, stress management training and moderate exercise—have even been shown to decrease coronary atherosclerosis. Your health care provider will likely recommend lifestyle changes as a first step in treating high cholesterol.

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)
• Metabolic syndrome

The ACC/AHA guidelines include a risk assessment tool to help you determine your 10-year risk of having a heart attack or dying from heart disease. The tool assigns risk values based on age, total cholesterol levels, HDL cholesterol levels, blood pressure level and diabetes and smoking status. Click here to access the risk calculator.

If lifestyle changes alone don't improve your cholesterol levels, your health care provider 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.

Children over age 10 whose LDL cholesterol remains high even after they've changed their dietary habits may benefit from cholesterol-lowering medication.

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. Many statin drugs are available in the United States: atorvastatin (Lipitor), fluvastatin (Lescol), lovastatin (Mevacor, Altoprev), pravastatin (Pravachol), pitavastatin (Livalo), simvastatin (Zocor) and rosuvastatin (Crestor). These highly effective drugs help reduce 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.

According to the ACC/AHA guidelines, there are four groups that benefit from taking a statin to lower their blood cholesterol. These groups are:

1. People with a history of a cardiac event—a heart attack, stroke, stable or unstable angina, peripheral artery disease, transient ischemic attack or coronary or other arterial revascularization.
2. Individuals ages 21 and older with elevated LDL cholesterol greater than 190 mg/dL.
3. People ages 40 to 75 who have LDL cholesterol levels between 70 and 189 and a 7.5 percent higher risk of having a heart attack or stroke within 10 years.
4. Individuals with diabetes and an LDL cholesterol level of 70 to 189 mg/dL who are between 40 and 75 years old.

It takes about four to six weeks of taking a statin to achieve its 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 sometimes 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 main bile acid resins prescribed in the United States are cholestyramine (Questran, Prevalite), 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, you should only take it under the direction of a health care professional.

Niacin appears to have stronger effects on HDL cholesterol and triglycerides than it does on LDL cholesterol. It comes in capsule and tablet forms, both regular and time released.

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.

Fibrates. These drugs reduce triglycerides and usually raise HDL cholesterol. Fibrates are not recommended as the sole drug therapy for women with heart disease if the primary goal is reducing LDL cholesterol levels. Available fibrates are fenofibrate (Tricor, Antara, Lofibra and Triglide), clofibrate (Atromid-S) and gemfibrozil (Lopid).

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 for. Fibrates may also increase the risk of rhabdomyolysis when used in combination with statins.

Newer drugs. A relatively new class of drugs lowers cholesterol by preventing it from being absorbed in the intestine. More specifically, 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. Studies find it lowers LDL cholesterol, but there is no evidence yet that it reduces heart attack risk. Another class of non-statin drugs—PCSK9 inhibitors—also shows promise in the treatment of high cholesterol.

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.

Most medical professionals now advise against using menopausal hormone therapy to prevent heart disease. Studies to date have not shown that hormone therapy reduces the risk for major coronary events or deaths among postmenopausal women, particularly when compared to statins.

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 four to six 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). For those with high blood pressure or cholesterol, the AHA recommends 40 minutes of moderate to vigorous activity, three to four times a week.
• 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 5 percent to 6 percent and your intake of trans fat as much as possible.
• Increase your intake of fruits and vegetables high in antioxidants. Aim for at least 4.5 cups of fruits and vegetables per day.
• If you drink alcohol, consume only moderate amounts, 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 zero in on the amount of cholesterol in foods. But such an approach addresses only part of the problem—and the lesser part at that. 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 increases 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—coconut oil, 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 may 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.

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 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. Oily fish such as salmon, mackerel, albacore tuna, herring, lake trout and sardines are highest in heart-healthy omega-3s.

Psyllium, a fiber supplement, also provides cholesterol-lowering benefits when taken in conjunction with a low-fat, low-cholesterol diet. Studies have shown psyllium can lower LDL cholesterol levels, thus reducing risk of cardiovascular disease. When taken in combination with cholesterol-lowering drugs, psyllium provides added heart-healthy benefits.

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 saturated fats to no more than 6 percent of daily calories. 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. For those with high blood pressure or cholesterol, the AHA recommends 40 minutes of moderate to vigorous activity, three to four times a week.

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

Facts to Know

1. Today, more than one-third of American adults need to lower their blood cholesterol.
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. All women should begin blood cholesterol testing at age 20, with testing repeated every four to six years, earlier and more frequently if there are other risk factors for heart disease.
6. 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.
7. 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.
8. 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.
9. A normal 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.

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. How often should I have my cholesterol level tested?
3. Why do I keep hearing about "good" and "bad" cholesterol? What are they?
4. What are triglycerides? What do they have to do with my heart disease risk?
5. What type of test best measures my cholesterol levels?
6. Will you explain the results of my cholesterol test?
7. If I have high LDL cholesterol, what lifestyle and dietary changes can I make to lower it?
8. What types of food should I avoid or add to my diet?
9. When and how often should I have my cholesterol level checked?
10. 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?
11. Are there alternative medications I can take if I cannot or do not wish to use a statin?
12. If I have high blood cholesterol, are my children at risk for developing high blood cholesterol?
13. I have diabetes. How does it affect my risk for developing high cholesterol? Will it affect treatment?

Key Q&A

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. "Check" heart-healthy eating off your list
   Research has found people who follow the American Heart Association's Heart Check Food Certification program nutrition requirements are more likely to eat healthier and have fewer heart disease risk factors than those who do not. The Heart Check program assigns a heart-check mark icon to the front-of-packages of foods that meet the AHA's criteria for a heart-healthy diet.
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 (TFAs) can raise cholesterol. TFAs are 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. 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 are indeed faster than visiting your health care professional and may be a good way to get an idea of your cholesterol level, but they are no substitute for a cholesterol test ordered by your health care professional. The kits, which require the user to draw blood from a prick of the skin, measure cholesterol (some kits break numbers down into HDL and LDL cholesterol), but they don't provide other important information about your overall cardiovascular risk or address the impact of diet or exercise on your cholesterol. To get the most accurate measurement of your cholesterol and how it fits into your cardiovascular risk profile, see your health care professional.

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: https://www.acc.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: https://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: https://www.nhlbi.nih.gov
Address: Attention: Website
P.O. Box 30105
Bethesda, MD 20824
Phone: 301-592-8573
Email: nhlbiinfo@nhlbi.nih.gov

WomenHeart: National Coalition for Women with Heart Disease
Website: https://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: https://www.whi.org
Address:Clinical Coordinating Center
Fred Hutchinson Cancer Research Center
1100 Fairview Ave N, M3-A410
PO Box 19024
Seattle, WA 98109-1024
Phone: 800-218-8415
Email: nihinfo@od31tm1.od.nih.gov

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

Books

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

Spanish-language resources

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