Cholesterol is kind of like golf. The lower your total score, the better.

But for many of us, lowering your cholesterol score is as difficult as sinking a 45-foot downhill putt. The Centers for Disease Control and Prevention says almost 40% of adults in the United States have high total cholesterol, which can put you at risk for serious heart problems.

Dr. Marianthe Burns

Here to explain why you should care about cholesterol – and how to lower yours if it’s high – is Dr. Marianthe Burns, a family medicine physician at Novant Health Forsyth Family Medicine in Winston-Salem.

What is cholesterol, and more importantly, is it going to kill me?

In the right amount, cholesterol is helpful – it’s a waxy substance that circulates in your blood, makes vitamins and hormones, and helps you digest your food.

Your body naturally makes all the cholesterol it needs. But when you eat a lot of animal-based foods like meat, butter and dairy products – which are high in saturated fats – your liver makes more cholesterol than it should.

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Inactivity, smoking, obesity, Type 2 diabetes, genetics and ethnicity also affect your risk for high cholesterol. Your cholesterol levels may also rise as you get older.

What happens when my cholesterol is too high?

The excess cholesterol builds up on your arteries and can cause them to narrow and harden over time.

When your arteries narrow, your heart receives less blood, oxygen and nutrition, putting you at increased risk for heart disease, and death.

Narrowed arteries can also reduce blood flow to the brain, leading to a stroke, which can also be deadly or cause permanent disability.

So high cholesterol = heart attack?

It’s not just your cholesterol that determines your risk of heart disease.

To help patients understand this, I use a cardiac risk calculator. I input your age, gender, cholesterol scores, blood pressure, whether any high blood pressure or cholesterol is treated with medication or not, and whether you’re a smoker.

Then the calculator tells us your risk of developing heart disease in the next 10 years. For example, a 20% risk means that 2 in 10 people with your score will develop cardiovascular disease over the next 10 years.

The calculator doesn’t look at your family history of heart disease, or some of your medical conditions, so your individual risk may be even higher than what the calculator says. There are other tests we can look at to round out our understanding of your personal risk.

So no, high cholesterol isn’t a guarantee of heart disease – it’s just one risk factor. But it’s one of the factors we can really impact through lifestyle choices. And our lifestyle choices add up as we age.

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Let’s get more specific. What should I do (and not do) to lower my cholesterol score?

Regularly exercising directly affects your cholesterol score. We recommend 150 minutes of exercise per week, split up between cardio and strength training.

Avoid smoking, or make a plan to stop if you currently smoke.

Other than that, diet is hugely important.

So what should I eat to lower my cholesterol? And what about eggs – good or bad?

There were many years where “low fat” was ingrained into people, but we now know that it’s important to eat healthier fats, not no fat.

I talk with my patients about replacing saturated fats (the kind that can lead to high cholesterol) with healthier fats. So, for example, when you are cooking, replace butter – a saturated fat – with canola, olive or soybean oil instead. Replace red meats with leaner meats and especially fish. Replace full fat dairy products with nonfat or lower fat dairy products.

You can eat eggs. They have natural cholesterol in them, but we have learned that they don’t contain the kind of unhealthy fat we worry about. The egg itself is a good source of protein and healthier fats, as long as you aren’t loading them with butter.

You may have heard a push for the Mediterranean diet, and that’s because it’s high in lean protein, healthy fats, and the kinds of oils we want to replace the saturated fat with. I highly recommend this to my patients.

It’s difficult to change your lifestyle habits if you’re on the go and used to just grabbing foods. So, I try to encourage people to meal prep ahead of time. Have the healthy foods available and ready so you don't get home from work and think, “I'm exhausted. I don't want to cook. I'm just going to order something.” Cooking at home using these healthier ingredients can make a huge difference in your cholesterol level.

When do I need to consider medication, like a statin?

Any time the risk or the cholesterol number is elevated, we will talk about lifestyle modifications to see if there is anything you can change to improve your numbers. Some patients want a chance at that before they start medicine to lower their cholesterol.

However, if your cardiac risk score is greater than 10%, I still recommend a statin, even if you are able to bring your numbers down with diet and exercise. If you are at 10%, that means there is still an “intermediate” risk that you might have a heart attack – and you don’t want to take that risk.

A statin reduces the amount of cholesterol your liver makes, and helps your liver remove cholesterol from your blood. Taking a statin lowers the relative risk of cardiovascular disease by 30%, which is really huge.

What about side effects of statins?

Statins get a bad rap. Muscle pain is the No. 1 side effect people worry about. However, in multiple studies, muscle pain was no higher in people taking a statin than a placebo. Scientifically, there’s a good reason to take these drugs: You don’t want to have a heart attack.

I also hear people say, “I’m not going to take medication. If something's going to take me out, I'd rather have a massive heart attack and go." That might sound like an ideal way to die, but many people don't actually die.

They have heart attacks and survive and then have heart failure, or they have strokes that leave them with long-lasting debilitating issues. It's not something to aim for.

Be open-minded about statin treatment. Statins save lives, and they save quality of life.

Closing thoughts: Understand your risk, and make a healthy lifestyle a priority

Talk to your primary care doctor about your individual cardiac risk. Just because you have a good cholesterol number now doesn't mean that there aren't things you could be doing better to make sure it stays that way down the road. Or, maybe you’re a higher risk than you realize. Talking about your own risk and what you can do to improve it is extremely important.

Also, life doesn’t slow down, ever. Making those good habits has to be a priority. Even if you work a long day at a full-time job, it’s important to make a time to exercise that works for you – whether that's in the morning, after work, getting out and walking on a lunch break, or even going to the gym every weekend if your week is too busy. If you still haven't “found” the time, you probably won’t. You have to make the time.

Why do we hear about “good” cholesterol and “bad” cholesterol?

When you get your cholesterol measured (in a blood test called a “lipid panel”), there are a few numbers, each measured in milligrams per deciliter (mg/dL). Here’s what they mean. If you use the MyChart app you’ll probably see your numbers under Test Results.

LDL (“bad” cholesterol) – when you have too much of this form of cholesterol, it builds up on your arteries, increasing your risk for heart disease and stroke. You want this number to be low (preferably below 100 mg/dL, says the CDC).

HDL (“good” cholesterol) – this form of cholesterol is absorbed and then flushed from your body. Having high levels of this one is actually good and can lower your risk of heart disease and stroke. You want this number to be higher (at least 40 mg/dL in men and 50 mg/dL in women, says the CDC).

Triglycerides – this is measured alongside cholesterol and is a type of fat that will cause your arteries to harden. When you have too many triglycerides in your blood, you have a higher risk of heart disease. You want this to be below 150 mg/dL, says the CDC.

Total cholesterol – this is the total amount of cholesterol in your blood, which is calculated by adding your “bad” and “good" cholesterol levels, along with 20% of your triglyceride level. If your total cholesterol is under 180, your cholesterol does not put you at increased risk for cardiovascular disease.

If your score is 180 to 199, it’s “borderline” or “not optimal.” A score of 200 to 239 puts you at “elevated risk,” and 240 or higher puts you at “major risk” of cardiovascular disease.

Cholesterol is often checked beginning in childhood, depending on personal and family history. You should get it checked yearly beginning in your 20s so you can see how your lifestyle and choices are impacting it in real time.