High total cholesterol: what it means and what to do

A high total cholesterol usually means your LDL is high, the cholesterol that can build up in your arteries. Sometimes, though, a high HDL is pushing it up, and then it is usually not a problem. The other lines of the same lab report tell you which.

What high total cholesterol means

It means there is more cholesterol in your blood than the limit on your report. But the total adds up different parts, and what matters is which one is high.

If your LDL is high, more cholesterol can build up in your arteries over the years. If your HDL is high and your LDL is fine, it is usually not a risk.

A high number is not a diagnosis: your doctor reads it with everything else, from blood pressure to family history.

What causes high total cholesterol

The first two are the most common.

• A lot of saturated fat: Butter, fatty cheese, fatty or processed meat and foods made with palm oil raise LDL, and with it the total.
• Your family’s genes: High cholesterol can run in families. In familial hypercholesterolaemia it is high from birth.
• Extra weight, little movement: Both tend to push it up. Even months of moving less than usual can show up in your blood.
• A high HDL: Good cholesterol counts in the total too. If it is doing the pushing and your LDL is fine, it is usually not a problem.
• Menopause: As hormones drop, cholesterol often rises.
• Pregnancy: It rises in pregnancy, and that is normal.
• A slow thyroid: A thyroid that works too little raises it. TSH, the thyroid test, shows it.
• Other, rarer causes: Some medicines, some kidney or liver diseases and a very low weight, as in anorexia. Bring your doctor the list of medicines you take.

Symptoms of high cholesterol

Usually none, even at very high levels. You cannot feel high cholesterol: a blood test is how you find out.

In the inherited form, after years of very high levels, small lumps can appear on tendons, for example at the heel or over the knuckles. The same goes for small yellowish patches on the eyelids: if you notice them, tell your doctor.

Tiredness and itching usually do not come from cholesterol. But if itching comes with yellow skin or eyes, see a doctor the same day: a liver problem can raise cholesterol too.

When the total is high because of HDL

HDL, the good cholesterol, counts in the total. If it is high, the total can go above the limit on your report even with a normal LDL. This happens more often in women, who usually have higher HDL.

In that case a high total is usually not a risk, as long as your LDL and ApoB are fine too. That is why each line of the report is read, not just the sum.

A very high HDL does not need lowering, but it does not protect you more: LDL and ApoB give the real picture.

Which tests to read alongside it

These tests help show where it comes from.

What your result means

The upper end of the scale, in mg/dL.

• 120 to 200: Normal. Inside the range on a typical lab report, though some print a lower desirable value. On its own it is not enough: check your LDL and HDL too. In the Rosa report you also see whether you are in your optimal range.
• Above 200, up to 240: Near the limit. Inside the range on a typical lab report, but above the desirable value some print next to it. What matters is whether LDL or HDL is pushing it up. In the Rosa report, from here your plan suggests what to change in your diet.
• Above 240, below 310: High. Above your report’s limit. LDL and diet are usually behind it, sometimes a high HDL. Check whether LDL or HDL is behind it, and talk to your doctor. If it is LDL, start with what you eat.
• 310 and above: Very high. It can be inherited high cholesterol, called familial hypercholesterolaemia. Talk to your doctor: the family is usually checked too.

High cholesterol: what to eat and how to lower it

First see what is pushing it up: if it is HDL, with LDL and ApoB fine, there is usually nothing more to do. If it is LDL, where to start:

• What to eat: extra virgin olive oil instead of butter, nuts, fish, vegetables and legumes. Less fatty cheese, processed meat and packaged sweets.
• More soluble fibre, the kind in oats, barley and legumes: at breakfast, in soups, most days.
• If you carry a few extra kilos, losing them helps. Move every day, even just a brisk walk.
• The effect of diet usually shows in about three months: repeat the test then.
• If that is not enough, or your risk is high, your doctor will consider medicines. If you already take them, do not stop them on your own.

When to worry

Talk to your doctor if:

• Your total cholesterol is 310 or more.
• It is high and your LDL or ApoB is high too.
• Someone in your family had a heart attack or stroke at a young age.
• It stays high after a few months of changes to what you eat.
• You have itching with yellow skin or eyes: see a doctor the same day.
• You have chest pain or pressure: call 112 or go to the emergency department.

With Rosa, a total cholesterol of 310 or more is always flagged to a doctor.

Frequently asked questions

Total cholesterol at 250: is it serious? It is not an emergency, but it is above the limit on your report. Check whether LDL or HDL is pushing it up and talk to your doctor, who weighs your risk. If it is LDL, change what you eat and repeat the test after about three months.

Cholesterol at 300: what symptoms does it cause? Usually none, not even at 300. A number that high should still be seen by your doctor, especially if your LDL is high: it can be inherited.

High total cholesterol but high HDL: is it a problem? Usually not, if your LDL and ApoB are fine: the total is up because your good cholesterol is high. Each line is read, not the sum.

High cholesterol in women: what changes? Before menopause women often have a higher HDL, which can raise the total: if LDL is fine, it is usually no worry. After menopause LDL often rises, and the total with it: it is worth watching more closely. As in men, it usually causes no symptoms.

Sources

• Nordestgaard and colleagues, familial hypercholesterolaemia is underdiagnosed and undertreated in the general population: guidance for clinicians. European Heart Journal, 2013. PMID 23956253
• Prospective Studies Collaboration (Lewington and colleagues), blood cholesterol and vascular mortality by age, sex and blood pressure: a meta-analysis of individual data from dozens of studies. Lancet, 2007. PMID 18061058
• Nordestgaard and colleagues, fasting is not routinely required for a lipid profile: a joint consensus statement from EAS and EFLM. European Heart Journal, 2016. PMID 27122601
• Friedewald and colleagues, estimating LDL cholesterol without measuring it directly. Clinical Chemistry, 1972. PMID 4337382
• Mach and colleagues, ESC/EAS guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. European Heart Journal, 2020. PMID 31504418