Cholesterol: The good, the bad and staying healthy

| Posted On Apr 14, 2016 | By:

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Cholesterol. It’s a word frequently associated with health issues like heart disease, stroke, and even diabetes. Although cholesterol gets a pretty bad rap, our bodies produce it naturally. Of course, when it comes to something as delicate as the human body, too much or too little of anything can be cause for concern.

Let’s break down the basics:

What is cholesterol?

Simply put, cholesterol is a waxy, fat-like substance found in all cells of the body. It is also found in many of the foods you eat, especially meat, poultry, and full-fat dairy products. When you eat a diet high in saturated and trans-fats, your liver produces more cholesterol. While your body needs some cholesterol to make hormones, vitamin D, and substances that help you digest foods, excess cholesterol doesn’t dissolve in the blood and can lead to buildup on the walls of a person’s arteries. Over time, this buildup causes the arteries to narrow.

It’s not all bad.

You’ve probably heard mention of “good” cholesterol and “bad” cholesterol. Low-density lipoprotein (LDL) cholesterol is considered “bad” because it contributes to plaque, a thick, hard deposit that can clog arteries and make them less flexible, while high-density lipoprotein (HDL) cholesterol is considered “good” because it helps remove LDL from the arteries. Experts believe HDL acts as a “scavenger,” carrying LDL cholesterol away from the arteries and back to the liver, where it is broken down and removed from the body.

Getting tested

Screening for high cholesterol involves having blood drawn to be analyzed in a lab. It measures your level of total cholesterol, HDL cholesterol, and triglycerides. Triglycerides are a type of fat found in your blood.  When you eat, your body converts any calories it doesn’t need to use right away into triglycerides, which are stored in your fat cells. Your LDL cholesterol score is calculated from this data using the following equation: total cholesterol – HDL – 20 percent of your triglyceride level = LDL.

Do I need to fast (not eat) before the test?

Historically, we advised people to fast for 8 to 12 hours prior to a cholesterol profile. In the fasting state, triglycerides are as low as can be expected and allow more a more accurate calculation of your LDL cholesterol.  However, in 2016, these recommendations changed; a non-fasting cholesterol profile is a more accurate reflection of our cholesterol levels the majority of the time. (If you have profoundly high triglyceride levels, your medical team may still request a fasting lipid profile.)

What’s a normal cholesterol level?

There is significant disagreement about this, as many experts now focus on cardiovascular risk (which incorporates age, gender, smoking status, blood pressure, absence or presence of diabetes, and cholesterol levels).  Data has even emerged to suggest that high levels of HDL cholesterol (previously thought to be “good”) may, in some circumstances, increase cardiovascular risk.

Normal total cholesterol and LDL (bad) cholesterol are more difficult. Some have defined high total cholesterol as above 240 mg/dL; our labs use 200 mg/dL as their threshold for normal, and the cardiovascular risk estimator says 170 or below is “optimal.”  For several decades, LDL was the focus of cholesterol management, with a goal of 160 or less for people at low risk for heart disease, 130 or less for intermediate-risk people, and 100 or less for high-risk people.  In the recent past, some began advocating for more aggressive “optional” goals of 130, 100, and 70.

In November of 2013, however, the American College of Cardiology and the American Heart Association presented new guidelines, focusing on projected cardiovascular disease risk (which is influenced in part by cholesterol), and suggesting medications to lower LDLs above 190.

More recently (November 2018), these groups further refined their guidelines regarding cholesterol management and primary prevention of atherosclerotic cardiovascular disease.  Currently, for people whose 10-year risk (which can be calculated here) is under 5%, they do not recommend statins (unless other risk factors are present).  They strongly recommend statins for people with a 10-year risk above 20% (which reduces risk by 1/5 to 1/4).  For those in between 5% and 20%, it’s worth discussing with your medical team to determine if statins make sense for you.

Diet, exercise, and lowering your cholesterol

There are a range of factors that impact an individual’s cholesterol levels, but the major influences include diet, weight, physical activity, gender, and genetics. While there are drug treatment options for individuals with very high cholesterol, almost everyone would recommend healthy lifestyle habits to help lower cholesterol.  Researchers say that 30-40 minutes of aerobic exercise like brisk walking, swimming, or biking, three to four times a week, is enough to lower both cholesterol and high blood pressure. Changes in diet can also be highly effective. Many doctors state that a couple of servings a day of heart-healthy, fiber-rich foods such as oatmeal, Brussels sprouts, beans, or sweet potatoes can have a positive effect on your HDL. Fiber can help bump up your HDL while reducing LDL. Other cholesterol-friendly foods include avocado, oranges, pears, grapefruit, apples, soy nuts, and okra.

While you should always consult your physician before drastically changing the way you eat, the American Heart Association provides a great list of good vs. bad fats to help you determine a better dietary plan.

If you are age 20 or older and have not been diagnosed with cardiovascular disease, the American Heart Association recommends having your cholesterol checked every four to six years. Work with your doctor or healthcare provider to determine your total cholesterol and your risk for cardiovascular disease and stroke. When you can find a system that works with your lifestyle, whether it be medication, diet, exercise, or a combination of all three, you are on your way to healthy cholesterol and improved heart health.

Updated February 2021

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About Dr. David Rubin

Dr. David Rubin joined Atrius Health in 2005. He practices adult internal medicine at our Wellesley office. Prior to his career in medicine, he worked with an interactive advertising and marketing agency designing web sites for companies such as AT&T and John Hancock. His interests include preventive medicine, medical informatics, and clinical process improvement.


  1. I enjoyed Dr. Rubin’s article. It is written in simple, understandable language.

    I am a cardiac patient at Dedham Medical. I’ve had bypass surgery and take cholesterol medication. I have to avoid grapefruit. My late husband was on coumadin and cholesterol medication. He had to avoid his favorite veggy, brussels sprouts.

    The article very truthfully states that grapefruit and brussels sprouts are good choices for folks looking to maintain healthy cholesterol levels. Dr. Rubin stressed the importance of checking with one’s doctor prior to drastically changing eating habits. Perhaps an additional caviat would be helpful to people who aren’t up on food conflicts with medications? Something along the lines of: “Believe it or not, some foods negatively impact current medications. Be sure to check with your doctor or pharmacist before enjoying these foods”

    Thank you.

    Comment by Pamela Fraites on July 29, 2016 at 4:50 am

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