What it means if you have borderline high cholesterol – and what you can do about it

By | April 3, 2024

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aNearly 25 million adults in the U.S. have high cholesterol, putting them at greater risk for a heart attack or stroke in the next decade. But a much larger proportion have what’s called high cholesterol, an intermediate spot that’s not quite high, but not quite within a normal range.

Here’s what you need to know about borderline cholesterol.

What is borderline cholesterol?

High cholesterol is defined as a total cholesterol number of 240 mg/dl or higher. Meanwhile, someone has borderline cholesterol when their total cholesterol is between 200 and 239.

“We create these thresholds – which are admittedly somewhat artificial – to classify people so that we can understand whether we need to do further analysis or assessment to understand their risk of cardiovascular disease,” said Dr. Donald Lloyd-Jones, former president of the American Heart Association and professor of cardiology and chairman of preventive medicine at Northwestern University Feinberg School of Medicine. There is some flexibility: Some people can be completely healthy with a total cholesterol level of 235, while others are at risk for 205. It depends on a person’s other risk factors. But overall, these thresholds help physicians make patient care decisions.

People with total cholesterol levels under 200 tend to have a lower risk of developing heart disease, while people over 240 have a higher risk. Those who land between 200 and 239 are somewhere in the middle, Lloyd-Jones says.

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Cholesterol levels in this middle range aren’t automatically dangerous, but they do put you at greater risk of developing high cholesterol, says Dr. Daron Gersch, a family physician at CentraCare Hospital in Long Prairie, Minnesota. And if you spend enough time on it in the borderline category, the effects can add up. According to research published in 2015 in Circulation.

“The analogy I use is that we marinate our arteries in these cholesterol particles for our entire lifespan,” says Lloyd-Jones. “The more we marinate, the more likely we are to form plaques. People who have very high levels for a short period of time are at risk of forming plaques, but even people who have modest levels for a longer period of time can form plaques.” These plaques build up and become inflamed over time, leading to heart attacks and strokes.

The type of cholesterol is important

Total cholesterol levels do not show the whole picture. What’s most concerning are your levels of low-density lipoprotein or LDL cholesterol, also called “bad” cholesterol, says Dr. Ann Marie Navar, associate professor of cardiology at UT Southwestern Medical School and co-author of the Circulation study. That’s because LDL is the type of cholesterol that builds up in the arteries. A healthy LDL level is less than 100.

High-density lipoprotein or HDL cholesterol, on the other hand, is sometimes called “good” cholesterol because it removes fats from your blood, says Gersch. A healthy HDL level is 60 or higher.

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“If your total cholesterol levels are elevated because of HDL, you may not be at higher risk and you may be somewhat protected,” says Gersch. split into good and bad cholesterol.”

Therefore, it may be more appropriate to look only at borderline-high LDL cholesterol, Navar says. LDL cholesterol of 160 or higher is considered high, while LDL cholesterol of 130 to 159 is borderline, according to the American Academy of Family Physicians.

This is a rough classification and no guarantee for future heart problems. “LDL-related cholesterol risk is on a continuum: there is no magic number above which you are at risk and below which you are not,” says Navar. “The higher your LDL is and the longer your LDL is elevated, the more risk you accrue over time.”

How to Lower High Cholesterol

After reviewing your blood test results in the context of your medical history, your doctor will advise you on the best course of action to get your cholesterol levels within a healthy range for you.

If you have borderline high cholesterol but are otherwise healthy and under age 60, your doctor may recommend lifestyle adjustments that can help lower your overall risk of developing heart disease. These may include achieving and maintaining a healthy weight, eating a balanced diet (and cutting back on starches, alcohol and high-fat foods), quitting smoking and exercising regularly.

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But if you have high cholesterol — and two or more other risk factors for heart disease — your doctor will likely recommend cholesterol-lowering medications to keep your heart safe for as long as possible, Gersch says. Those risk factors include high blood pressure, diabetes, smoking or exposure to secondhand smoke, being 60 years or older, having a family history of heart disease, being sedentary or carrying extra weight.

When should you have your cholesterol tested?

If these risk factors sound familiar, you should have your cholesterol tested around age 20. Men without risk factors for cardiovascular disease can generally wait until age 35, and women without these risk factors can wait until age 45 before regularly testing their cholesterol, Gersch says.

You will be retested every four to six years if your test results show that your cholesterol is within the healthy range. But you can expect to have blood tests done more regularly, and as often as annually, if your levels put you in the borderline or high categories or if you have other risk factors for cardiovascular disease.

Having high cholesterol may mean it’s time to take some preventative measures, but that doesn’t mean a heart attack or stroke is inevitable — and that your overall health and risk factors for future heart disease are more important than one specific number in your cholesterol panel.

“Is there really a difference between 199 and 201? No, there is not,” says Lloyd-Jones. Rather, this is a general, population-wide relationship between cholesterol and cardiovascular disease risk, which is only one piece of the puzzle at the individual level. “These are kind of arbitrary barriers, but they initially help determine how aggressive and intense you want to be.”

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