Cholesterol is important in the formation of bile acids and steroid hormones, and is a component of cell membranes. It is synthesized by cells throughout the body, but particularly the liver. Some comes from dietary sources. While cholesterol is necessary for human life, high levels can cause gallstones and hardening of the arteries (atherosclerosis) — the cause of heart attacks, strokes, angina, vascular dementia, blockages in the arteries to the legs and intestines, and erectile dysfunction.

A “cholesterol test” includes the level of total cholesterol; HDL (good cholesterol — think “H” for healthy); LDL (bad cholesterol — think “L” for lousy) and triglycerides. Think of your LDL as garbage in your arteries, so if you have too much garbage you’ll have a problem with your arteries. Think of HDL as garbage trucks, so you’ll also have a problem with your arteries if you don’t have enough garbage trucks. Low HDL combined with high triglycerides signifies insulin resistance/pre-diabetes.

There are caveats with HDL, though, because some people have a low number of garbage trucks (low HDL), but the ones they have are super-charged, and these people have normal arteries. Other people have lots of garbage trucks (high HDL) but their garbage trucks are dysfunctional and cause rather than prevent problems.

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There are some caveats with LDL as well. LDL particle number is more meaningful than the usually measured level of LDL. Lp(a) is a particularly harmful type of LDL that is often present in families with lots of early heart disease. And it’s best if your LDL particles are large and fluffy rather than small and dense. Measuring these things is relatively inexpensive.

National cholesterol guidelines specify that ideal lipid levels are: total cholesterol less than 200; HDL greater than 40 in men and postmenopausal women, greater than 50 in premenopausal women; LDL less than 100, and in people with a history of heart attack, stroke, or diabetes LDL should be less than 70; triglycerides less than 150. However, half of people who have heart attacks and strokes meet these guidelines. Heart attack prevention doctors feel that — given that 20 percent of heart attacks victims die — if atherosclerosis can be demonstrated in a patient by studies such as a coronary calcium score (CT scan of the heart) or carotid IMT (ultrasound exam of the carotid arteries in the neck), LDL should be less than 70.

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Plant-based providers feel that normal lipid levels should be those seen in people who never develop atherosclerosis and who are therefore heart attack-proof — such as people in the Blue Zones. These people have total cholesterol levels of less than 150; LDLs in the 30s and 40s; and triglycerides less than 70.

All animal products, including seafood, contain cholesterol, so to achieve optimal cholesterol levels, these foods should be avoided. Furthermore, the saturated fat present in all animal products and in oils cause the liver to produce more LDL. Over 30 years ago Dr. Dean Ornish proved that heart disease can not only be prevented but can be reversed with a plant-based, whole food diet with no salt, sugar or added oil. This diet is also one of the few things that lowers Lp(a).

Plant foods that are especially good at lowering cholesterol include high-fiber fruits, vegetables, legumes and whole grains, ground flaxseed and certain herbs and spices including Amla (1/2 teaspoonful of powder daily, which also lowers Lp(a)) and black cumin. Red yeast rice contains a weak, natural statin that lowers cholesterol a little, but being a supplement is unregulated, so you don’t know for sure what it contains.

For genetic reasons, sometimes diet isn’t enough. For these people, and for people unwilling to change their diet, drug options are available: Statins prevent the liver from making so much cholesterol; ezetimibe prevents absorption of cholesterol; and for people who don’t tolerate statins, there are the newer but more expensive PCSK9 inhibitors, which are given by injection every two to four weeks.

Atherosclerosis can start in infancy, and the National Heart, Lung, and Blood Institute recommends that all children have a cholesterol screen between age 9 and 11, and again at 17-21. Obese children, children with a family history of very high cholesterol (called familial hyperlipidemia), and children with a family history of early heart disease are advised to be screened earlier than 9. Adults should have their cholesterol checked every five years starting at 20 — more often if their lipids are abnormal.

Greg Feinsinger, M.D., is a retired family physician with a special interest in heart disease and diabetes prevention and reversal, ideally through lifestyle changes. He’s available for free, one-hour consultations — call 970-379-5718.