So You Have
High Blood Cholesterol
NATIONAL INSTITUTES OF HEALTH
National Heart, Lung, and Blood Institute
_______
Know Your Cholesterol Level
Lowering your high blood cholesterol is an important step for
reducing your chance of developing heart disease. Remember to
ask your doctor for your total cholesterol, LDL-cholesterol
levels each  time they are measured. Write the levels down on
the chart below to keep track of your progress.
Date _________________________     Date _________________________
Total Cholesterol _______________  Total Cholesterol_____________
HDL-Cholesterol _______________    HDL-Cholesterol_______________
LDL-Cholesterol _______________    LDL-Cholesterol_______________
Date _________________________     Date _________________________
Total Cholesterol ______________   Total Cholesterol_____________
HDL-Cholesterol _______________    HDL-Cholesterol_______________
LDL-Cholesterol _______________    LDL-Cholesterol_______________
Date _________________________     Date _________________________
Total Cholesterol _______________  Total Cholesterol_____________
HDL-Cholesterol _______________    HDL-Cholesterol_______________
LDL-Cholesterol _______________    LDL-Cholesterol_______________
Developed and produced by:
National Cholesterol Education Program
NHLBI Obesity Education Initiative
Endorsed by:
American Heart Association
___
Table of Contents
So You Have High Blood Cholesterol1
How This Booklet Can Help
High Blood Cholesterol: What You Need to Know3
Cholesterol and Your Risk of Heart Disease
How High Blood Cholesterol Leads to Heart Disease
Good and Bad Cholesterol: The Lipoproteins
What Makes Blood Cholesterol High or Low
Other Risk Factors for Heart Disease
What Your Blood Cholesterol Levels mean
...If You Do Not Have Heart Disease
...If You Do Have Heart Disease
Questions You May Have About Your High Blood Cholesterol
Improving Your Blood Cholesterol Levels:
What You Need to Do18
Take Action: Heres How
Three Steps to Reducing High Blood Cholesterol Levels
     LearnAbout the Step I and Step II Diets
     Make Physical Activity Work for You
     Lose Weight If You Are Overweight
You May Need To Take Medicine
Where You Can Go for Help28
Ask Your Health Professionals
Get More Information
Glossary
So You Have High Blood Cholesterol...
How This Booklet Can Help
A high blood cholesterol level means that you have more
cholesterol in your bloodstream than your body needs. The higher
your blood cholesterol level, the greater your risk or chance of
developing coronary heart diseasethe most common form of heart
disease. Anyone can develop high blood cholesterol, no matter
what his or her age, gender, race, or ethnic background. In
fact, 52 million American adults now have a blood cholesterol
level high enough to need medical advice to help lower it. High
blood cholesterol has no warning signs. So, you may be surprised
to learn that you have it.  dont be alarmed, but do take it
seriously. You can lower high blood cholesterol and bring down
your risk of heart disease.
This booklet can help. The first section, High Blood
Cholesterol: What You Need To Know, will give you facts about
cholesterol and heart disease. It will help you understand what
your blood cholesterol levels mean. It also will explain heart
diseases other risk factors and explain how these risk factors
combine with high blood cholesterol to put you at even greater
risk.
The second section, Improving Your Blood Cholesterol Levels:
What You Need To Do, will show you how to change your diet,
become more physically active, and lose weight (if you are
overweight). These steps are the best way for most people to
lower their high blood cholesterol. This section also will tell
you about an added step some people need: taking medicines.
At the end of the booklet, you will find two other useful
resources:
          Where You Can Go for Help, a list of people and
organizations
that can give you more information and support; and
          A glossary, which explains key medical and technical
terms
talking about high blood cholesterol.
Lowering your high blood cholesterol is very important: If you
already have heart disease, you can reduce your risk of future
problems; if you dont have heart disease, you can cut your risk
of ever developing it.
The advice in this booklet is for adults. The booklet is part of
a series on cholesterol from the National Cholesterol Education
Program (NCEP). Another booklet, Step by Step: Eating To Lower
Your High Blood Cholesterol, gives more detailed information
about how to change your diet. The NCEP also has booklets for
both children and adolescents with high blood cholesterol and
their parents. Page 30 tells you where to write in order to
obtain these booklets.
1
HIGH BLOOD CHOLESTEROL:  WHAT YOU NEED TO KNOW
Cholesterol and Your Risk of Heart Disease
Cholesterol is a waxy substance that occurs naturally in all
parts of the body. Your body needs cholesterol, which it uses to
make many hormones and vitamin D. Cholesterol is also involved
in producing bile acids, which help the body process the fats
you eat. Your body produces enough cholesterol to meet its
needs.
How High Blood Cholesterol Leads to Heart Disease
When there is too much cholesterol in your blood, the excess can
become trapped in the walls of your arteries.  By building up
there, the cholesterol helps to cause hardening of the arteries
or atherosclerosis. And atherosclerosis causes most heart
attacks. How? The cholesterol buildup narrows the arteries that
supply blood to the heart, slowing or even blocking the flow of
blood to the heart. So, the heart gets less oxygen than it
needs. This weakens the heart muscle, and chest pain (angina)
may occur. If a blood clot forms in the narrowed artery, a heart
attack (myocardial infarction) or even death can result.
Cholesterol buildup happens very slowlyyou are not even aware of
it. If you lower your high blood cholesterol level, you can
slow, stop, or even reverse the buildupand lower your risk of
illness or death from heart disease.
"Good" and "Bad" Cholesterol: The Lipoproteins
Cholesterol travels in the blood in packages called
lipoproteins. Just like oil and water, cholesterol and blood do
not mix. So, in order to be able to travel in the bloodstream,
the cholesterol made in the liver is also coated with a layer of
protein making a lipoprotein. This lipoprotein then carries the
cholesterol through the bloodstream.
Two types of lipoprotein affect your risk of heart disease.
     Low-density lipoproteins (LDLs): the bad cholesterol. LDLs
carry most of the cholesterol in the blood, and the cholesterol
and fat from LDLs are the main source of dangerous buildup and
blockage in the arteries. Thus, the more LDL-cholesterol you
have in your blood, the greater your risk of heart disease.
     High-density lipoproteins (HDLs): the good cholesterol.
HDLs carry some of the cholesterol in the blood, but this
cholesterol goes back to the liver, which leads to its removal
from the body. So HDLs help keep cholesterol from building up in
the walls of the arteries. If your level of good cholesterol is
low, your risk of heart disease is greater.
What Makes Blood Cholesterol High or Low
Why do some people have too much cholesterol in their blood?
Many factors help determine whether your blood cholesterol level
is high or low.  The following factors are the most important:
 Heredity: Your genes partly determine the amount of cholesterol
your body makes, and high blood cholesterol can run in families.
Diet: Two nutrients in the foods you eat make your blood
cholesterol level go up: saturated fat, a type of fat found
mostly in foods that come from animals; and cholesterol, which
comes only from animal products. Saturated fat raises your
cholesterol level more than anything else in the diet. Reducing
the amounts of saturated fat and cholesterol you at is an
important step in reducing your blood cholesterol levels.
Weight. Excess weight tens to increase your blood cholesterol
level. If you are overweight and have a high blood cholesterol,
losing weight may help you lower it.
Physical activity/exercise. Regular physical  activity may help
to lower LDL-cholesterol and raise HDL-cholesterol levels.
Age and sex. Before menopause, women have total cholesterol
levels that are lower than those of men the same age. Pregnancy
raises blood cholesterol levels in many women, but blood
cholesterol levels should return to normal about 20 weeks after
delivery.  As women and men get older, their blood cholesterol
levels rise. In women, menopause often causes an increase in
their LDL-cholesterol level. Some women may benefit from taking
estrogen after menopause, because estrogen lowers LDLs and
raises HDLs.
Alcohol. Alcohol intake increases HDL-cholesterol. However,
doctors dont know whether it also reduces the risk of heart
disease. Drinking too much alcohol can certainly damage and
liver and heart muscle and cause other health problems. Because
of these risks, you should not drink alcoholic beverages to
prevent heart disease.
Stress. Stress over the long term has not been shown to raise
blood cholesterol levels. The real problem with stress may be
how it affects your habits. For example, when some people are
under stress, they console themselves by eating fatty foods. The
saturated fat and cholesterol in these foods probably cause
higher blood cholesterol, not the stress itself.
Other Risk Factors for Heart Disease
In addition to a high LDL-cholesterol level and a low HDL-
cholesterol level, other factors also increase your chance of
heart disease. The chart below lists these risk factors. The
more of them you have, the higher your chance of developing
heart disease. If you have any of these risk factors in addition
to your high blood cholesterol, your risk of heart disease is
even greater.
In addition to the risk factors on the chart, another factor
that influences your risk of heart disease is where your body
stores excess fat. If you have an apple-shaped body with most of
your fat around the stomach, you are at a greater risk of heart
_____
Risk Factors for Heart Disease
Factors You Can Do Something About
          Cigarette smoking
          High blood cholesterol (high total cholesterol and high
              LDL-cholesterol)
          Low HDL-cholesterol
          High blood pressure
          Diabetes
          Obesity
          Physical inactivity
Factors You Cannot Control
     Age:
     45 years or older for men
     55 years or older for women
     Family history of early heart disease (heart attack or
sudden death):
     Father or brother stricken before the age of 55
     Mother or sister stricken before the age of 65
______
disease than if your body is pear-shaped, with most of your fat
around your hips. Generally, men carry their fat around the
stomach, while women carry it on the hips and thighs.
Talk to your doctor about all of your risk factors and what you
can do to reduce your chance of heart disease. Often, the
actions you take to control one risk factor help reduce others
as well. For example, losing weight helps to reduce your blood
cholesterol levels and high blood pressure, and helps to control
diabetes. Regular physical activity can help you lose weight as
well as improve the fitness of your heart and lungs, which also
can help lower your risk of heart disease.
What Your Blood Cholesterol Levels Mean
Now that you know the basics, lets take a closer look at blood
cholesterol levels and their relationship to heart disease risk.
Since the risks are greater for people who already have heart
disease, this section is divided into two parts:
          The first part deals with people who dont have heart
disease now.  This means if you have never had any of the problems
listed under Signs of Coronary Heart Disease. Go to page 9.
          If you have ever had any of the problems listed under
Signs of Coronary Heart Disease, the second part of the booklet
will help. Go to page 13.
Signs of Coronary Heart Disease
          Have ever had a heart attack.
          Suffer from chest pain which has been diagnosed as angina.
          Have had heart surgery such as a bypass operation,
balloon, or angioplasty procedure.
          Have ever been told by your doctor that you have a
buildup or blockage in any of your arteries.
What Your Blood Cholesterol Levels Mean...
If You Do Not Have Heart Disease
"Why Should I Worry?
Ive never been sick a day in my life."
Even if you dont now have any signs of heart disease, it doesn't
mean you never will. Now is the best time for prevention.
Otherwise, a high blood cholesterol level, as well as other risk
factors, can lead to problems in the future.
Your Blood Cholesterol Tests
Blood cholesterol levels are measured in a small blood sample
taken from your finger or your arm. The blood is tested for
total cholesterol and, if accurate results can be obtained, HDL-
cholesterol levels. You do not have to fast or do anything
special before having this blood test. Depending on the results,
you may also need a second blood test, a lipoprotein profile, to
determine your LDL-cholesterol level; you do have to fast for
this test. An LDL-cholesterol level gives the doctor more
information about your risk of heart disease and helps to guide
any necessary treatment.
Check Your Level
After the test, compare your results with the levels listed in
the chart below. Refer to page 10 to see what you next steps
should be.
Classification: Total and HDL-Cholesterol*
Total Cholesterol
Desirable Blood         Borderline-High Blood    High Blood
Cholesterol             Cholesterol              Cholesterol
less than 220 mg/dL     200-239 mg/dL            240 mg/dL and above
HDL-Cholesterol
     Low HDL-Cholesterol
     Less than 35 mg/dL
*For anyone 20 years of age or older
Your Next Steps     If you Do Not Have Heart Disease
If Your Total and HDL Levels are...     Then...
Total Cholesterol        HDL-Cholesterol
less than 200 mg/dL      35 mg/dL or greater
You are doing well and should
have your total and HDL-
cholesterol levels checked again
in about 5 years. In the
meantime, take steps to keep
your total cholesterol level
down: eat foods low in saturated
fat and cholesterol, maintain a
healthy weight, and be
physically active. The last two
steps, along with not smoking,
will also help keep your HDL
level up.
less than 200 mg/dL 200-239 mg/dL       less than 35 mg/dL
You will need lipoprotein
profile to find out your LDL-
cholesterol level. For this test
you need to fast for 9-12 hours
before the test. have nothing
but water, or coffee or tea with
no cream or sugar.
200-239 mg/dL            35 mg/dL or greater
Your doctor will see if you have
other risk factors for heart
disease and determine whether
more tests (including a
lipoprotein profile to find out
your LDL-cholesterol) need to be
done. No matter what your sick
is, it is important to eat foods
low in saturated fat and
cholesterol, to maintain a
healthy
240 mg/dL and above           any level
You will need a lipoprotein
profile to find out your LDL-
cholesterol level. Again, you
need to fast for 9-12 hours
before the test, having nothing
but water, or coffee or tea with
no cream or sugar.
What Your LDL-Cholesterol Levels Mean
A high LDL-cholesterol level increases your risk for heart
disease. use the chart below to find out about your risks and
your next steps.
Classification: LDL-Cholesterol
Desirable           Borderline-High Risk     High Risk
less than 130 mg/dL 130-159 mg/dL            160 mg/dL and above
Your Next Steps     If You Do Not Have Heart Disease
If Your LDL Level is     Then...
less than 130 mg/dL
You have a desirable LDL-cholesterol
level. You will need to have your total
and HDL-cholesterol levels tested again in
5 years. You should follow an eating plan
low in saturated fat and cholesterol,
maintain a healthy weight, be physically
active, and not smoke.
130 mg/dL or above
Your doctor will look at your other heart
disease risk factors and decide what you
need to do to lower your LDL-cholesterol
level. The higher your level and the more
other risk factors you have, the more you
need to follow a diet low in saturated fat
and cholesterol. For example, if your LDL
is 160 mg/dL or greater and you have fewer
than two other risk factors, your LDL goal
is a level below 160 mg/dL. If your LDL is
130 mg/dL or greater and you have two or
more other risk factors, your goal is to
reduce your LDL level to below 130 mg/dL.
It is also important to lose weight if you
are overweight, to be physically active,
and to not smoke. discuss your treatment
plan with your doctor.
PROFILE
Jack Williams Story
Risk Factors
Jack is 35 years old, and his father died from a heart attack at
the age of 50.  Jack smokes about half a pack of cigarettes a
day.  His diet is high in saturated fat, cholesterol and
calories.  He is not physically active.  His doctor ordered a
lipoprotein analysis, and the results are shown below:
Lab Report
Total cholesterol   260 mg/dL
HDL-cholesterol     40 mg/dL
LDL                 190 mg/dL
Evaluation
Jack is at a high risk for heart disease. Heres why:
     He has a family history of early death from heart disease.
     He smokes.
     His total cholesterol and LDL-cholesterol levels are high.
     He is physically inactive.
What Your Blood Cholesterol Levels Mean...
If You Do Have heart Disease
"I already have heart diseaseisnt the damage already done?"
Its not too late to help your heart. In fact, if you already
have heart disease, you should pay even more attention to your
cholesterol level. You have even more to gain. A person with
coronary heart disease has a much greater risk of having a
future heart attack than a person without heart disease. If you
lower your blood cholesterol level, you can definitely reduce
your risk of future heart attacks and may, in fact, prolong your
life.
Your Blood Cholesterol Tests
Since you have heart disease, finding  out your blood
cholesterol level is a little different. You will need to have a
blood test called a lipoprotein profile. This test will
determine not only your total and HDL-cholesterol levels, but
also your LDL-cholesterol leveland levels of another fatty
substance called triglyceride described on page 16. In order to
take the test you must fast. That means you can have nothing to
eat or drink but water, or coffee or tea with no cream or sugar
for 9-12 hours beforehand.
Check Your Levels
Since you have heart disease, your doctor will use your LDL-
cholesterol level to decide on the best treatment. Your aim
should be to have a LDL-cholesterol level lower than that of
people who do not have heart disease. Compare your levels to
those in the chart on page 14 to find out what your next steps
should be.
Your Next Steps          If You Do Have Heart Disease
If Your LDL Level is...  Then...
100 mg/dL or less        You do not need to take specific steps
to lower your LDL, but you will need to have
your level tested again in 1 year. In the
meantime, you should closely follow a diet
low in saturated fat and cholesterol,
maintain a healthy weight, be physically
active, and not smoke.
greater than 100 mg/dL     You need to have a complete physical
examination done to see if you have a
disease or a health condition that is
raising your cholesterol levels. You will
probably need a diet that is lower in
saturated fat and cholesterol, i.e., the
Step II diet (see page 21). Since this
diet will be more effective, your doctor
will likely encourage you to start there,
as well as to be physically active, to
lose weight if you are overweight, and to
not smoke. If your LDL level does not come
down, you may need to take medicine.
PROFILE
Betty Johnsons Story
Risk Factors
Betty is 60 years old and his a history of chest pain for which
she has had tests and which her doctor diagnosed as angina. She
is about 35 pounds overweight. She is not physically active. She
has no family history of heart disease.
Lab Report
Total cholesterol   240 mg/dL
HDL-cholesterol     30 mg/dL
LDL-cholesterol     174 mg/dL
Triglycerides       180 mg/dL
Evaluation
Betty has a high risk for having a heart attack. Heres why
     She already has coronary heart disease
     Her total blood cholesterol and LDL-cholesterol are high
     Her HDL-cholesterol is low
     She is overweight
     She is physically inactive
Since Betty has established coronary heart disease and high
total and LDL-cholesterol levels, the doctor decided to try the
Step II diet. he asked her what she usually eats and found that
her diet is high in saturated fat, cholesterol, and calories.
She eats out often and likes to cook and eat big meals with her
family. The doctor told her how to gradually change what she
eats in order to follow a Step II diet that is also low in
calories (see page 21) and how it could help her to lose weight.
After talking to the doctor, Betty tried making changes in what
she ate for a few days, but then she stopped, not wanting to
bother with it. She did not make any changes that would reduce
the saturated fat, cholesterol, and calories in her diet. Three
months later Betty had a heart attack.  (Betty Johnsons story
continues on page 25.)
Questions You May Have About Your High Blood Cholesterol
Since Im a Woman, Why Should I Worry About Having a Heart
Attack?
Its true that before menopause, women are unlikely to die from
heart disease. But as they get older, especially after
menopause, their chance of developing  heart disease goes up.
Women and men in their seventies have an equal likelihood of
dying from heart disease. Thats why at any age it is important
for women as well as men to the steps to prevent high blood
cholesterol.
At 69, Im Feeling Fine. Why Do I Need to Make Changes Now?
You have three very good reasons to change some of your health
habits.  First, the risk of heart disease increases as you get
older. Although you are feeling well, you may already have some
buildup of fat and cholesterol in your arteries. Unless you try
to stop or reverse the buildup, you may have a heart attack
later on.
Second, adopting a healthy lifestyle helps reduce the risk of
heart diseaseeven for people your age. People in their seventies
can lower their blood cholesterol levels, and therefore deposit
less fat in their arteries. Being more physically active is
another important step that helps to protect older people
against heart disease. A heart-healthy diet should also be a
balanced diet. Most people will not have to make extreme changes
to make their eating and activity habits healthy. These changes
can fit in with your overall lifestyle.
Reason number three: Youve got a lot of living yet to do. A man
at 69 can expect on average to live another 15 years; a woman at
69 can expect to live another 19 years. The changes you make now
can help make those years more healthy and enjoyable.
Will Lowering My Blood Cholesterol Help Me Live Longer ?
Many studies show that lowering cholesterol levels reduces the
risk of illness or death from heart disease, which kills more
men and women each year than any other illness. If you have
heart disease, lowering your cholesterol level will probably
help you to live longer, but you will definitely reduce your
risk of illness and death from heart attack.
Since Heredity Can Cause High Blood Cholesterol, Do My High
Levels Mean That My Family Is At Risk?
If you have high blood cholesterol, your family may also have
high levels. This includes your children, parents, brothers, and
sisters. They should all have their cholesterol levels tested to
help protect them from heart disease.
 How Much Does My Cholesterol Level Change From Day To Day?
Your cholesterol level varies somewhat from day to day ,
sometimes by more than 15-20 mg/dL. Different laboratories also
may use different methods of analyzing blood cholesterol levels
which can give different results. This is why you need more than
one cholesterol test before starting any treatment.
What Is a Cholesterol Ratio?
Some laboratories may calculate a cholesterol ratio. The ratio
is obtained by dividing either total cholesterol or LDL-
cholesterol by the HDL-cholesterol.  The ratio is not
recommended since it is more important to know each value
separately.  Be sure to get separate  total cholesterol, LDL,and
HDL values.
My Blood Test Showed I Also Have High Triglycerides How Does
That Affect My Risk of Heart Disease?
Triglycerides are a form of fat that is carried through the
bloodstream. Most of your body's fat tissue is in the form of
triglycerides. High blood triglyceride levels aline usually do
not raise your risk of heart disease. But many people have a
high triglyceride level along with high LDL- and low HDL-
cholesterol levels. In these cases,the three are often treated
together.
NormalBorderline-HighHighVery Highless 200 mg/dL200-400
mg/dL4000-1000 mg/dLgreater than
1,000 mg/dL
Borderline-high and high triglyceride levels are first treated
with the same diet and lifestyle changes used for high blood
cholesterol levels. These changes include :
          Weight loss (if you are overweight)
          A diet low in saturated fat and cholesterol (Step I and
Step II see page 21.)
          Increased physical activity
          No smoking
          No alcoholic beverages (for some people)
Usually "very high" levels are due to heredity. They may be
lowered with the changes above with medicines.
Does Eating Foods High in Salt and Sodium Increase My Blood
Cholesterol Level?
No. The amount of sodium in your diet has no effect on your
cholesterol level.  However, sodium can cause blood pressure to
rise in some people.  Further, many people with high  blood
cholesterol also have high blood pressure.  If you have both,
it's a good idea to reduce your sodium intake.  The National
High Blood Pressure Education Program recommends no more than
2,400 mg per day (the amount in about 1 teaspoon of table salt).
On average, Americans take in 4,000 to 6,000 milligrams of
sodium each day. This sodium comes from many different foods.
Foods high in sodium include some canned soups, vegetables, and
meats; instant soups and cereals; ready-to-eat cereals; salty
snacks and crackers; pickles and olives; and many frozen meals.
For more help on reducing sodium as part of a cholesterol-
lowering diet, write for Step by Step Eating To Lower Your High
Cholesterol (See page 30.)
2
Improving Your Blood Cholesterol Levels: What You Need To Do.
Take Action: Here's How
Now that you understand why you should lower your high blood
cholesterol, this section details how to do it.  It covers:
          Action steps to take and the benefits to expect
          Specific guidelines for diets to lower high blood
cholesterol
          Practical ways to change eating habits
          Tips to increase your physical activity
The section also describes medicines for lowering high blood
cholesterol. Medicines may become necessary for those who cannot
lower their blood cholesterol through diet and exercise.
Three Steps to Reducing High Blood Cholesterol Levels
Three steps can help you reduce your high blood cholesterol:
1.   Follow the Step I or Step II diet. These diets are described
in the boxes on page 21.  Your doctor will first recommend
one or the other.  The diets contain all the daily nutrients
you need and emphasize eating foods that are low in saturated
fat, total fat , and cholesterol, and high in starch and
fiber. You  will probably be asked to follow the Step I diet
first to see if it brings your blood cholesterol levels down
sufficiently. If not, you may have to move to the Step II
diet.  If you already have coronary heart disease or a very
high LDL level, your doctor may recommend starting with the
Step II diet.
2.   Be more physically active.
3.   Lose weight if you are overweight
Fortunately, these three steps work together. For example:
          Eating less fat, especially saturated fat, also may
help you decrease the amount of cholesterol and calories you eat.
Why? Foods high in fat and saturated fat are high in calories
and often high in cholesterol.  In fact, all fats both
saturated and unsaturated fat have more than twice as many
calories as either carbohydrate or protein. They provide 9
calories per gram and the other two provide 4 calories per
gram.
          Being more physically active helps burn more calories
which helps in weight loss. It may also help you lower your LDL-
cholesterol and raise your HDL-cholesterol, as well as
improve the health of your heart and lungs.
          Losing excess weight if you are overweight can help
lower your LDL-cholesterol and increase your HDL-cholesterol.
How Low Will You Go?
By closely following your diet , being more physically active,
and watching your progress with regular checkups,you can lower
your blood cholesterol level. How much your cholesterol levels
change depends on:
          How much fat, especially saturated fat, and how much
cholesterol you ate before you changed your diet;
          How closely you follow the changes; and
          How your body responds to these changes. Usually the
higher your blood cholesterol is to begin with, the more the
levels go down. However, sometimes due to heredity, levels will
not change enough no matter how well you change your habits.
For example: Your total blood cholesterol level is 240 mg/dL,
and you are eating a diet high in saturated fat and cholesterol.
By going on the Step I diet, you could reduce your cholesterol
level by 5-35 mg/dL; and 5-15 mg/dL more, if you then go on Step
II. Over time, you may reduce your cholesterol level by 10-50
mg/dL or even more. This drop will slow the fatty buildup in
your arteries and reduce your risk of illness and death from
heart attack. In fact, studies have shown that, in adults with
high blood cholesterol levels, for each 1 percent reduction in
total cholesterol levels, there is a 2 percent reduction in the
risk of heart attack. So if you reduce your cholesterol level by
10 percent (for example, from 240 mg/dL to 216 mg/dL), your risk
of heart disease could drop by 20 percent. And many people will
get even more of a drop in their cholesterol level.
1.   Learn About the Step I and Step II Diets
Step I Diet
On the Step I diet, you should eat:
          8-10 percent of the day's total calories from saturated
fat.
          30 percent or less of the day's total calories from
fat.
          Less than 300 milligrams of dietary cholesterol a day.
          Just enough calories to achieve and maintain a healthy
weight. (You may want to ask your doctor or registered
dietitian what is a reasonable calorie level for you.)
Step II Diet
On the Step II diet, you should eat:
          Less than 7 percent of the day's total calories from
saturated fat.
          30 percent or less of the day's total calories from
fat.
          Less than 200 milligrams of dietary cholesterol a day.
          Just enough calories to achieve and maintain a healthy
weight. (You may want to ask your doctor or registered
dietitian what is a reasonable calorie level for you.)
Practical ways to change your diet
Here are some tips on how to choose foods for the Step I and
Step II diets. For more help, write for Step by Step: Eating To
Lower Your High Blood Cholesterol (see page 30).
To cut back on saturated fats, choose:
          Poultry, fish, and lean cuts of meat more often. Remove
the skin from chicken and trim the fat from meat.
          Skim or 1 percent milk, instead of 2 percent or whole
milk.
          Cheeses with no more than 3 grams of fat per ounce
(these include low-fat cottage cheese or other low-fat cheeses). Cut
down on full-fat processed, natural, and hard cheeses(like
American, brie, and cheddar).
          Liquid  vegetable oils that are high in unsaturated fat
(these include canola, corn, olive, and safflower oil). Use
tub or liquid margarines that list liquid vegetable oil as
the first ingredient (instead of lard and hydrogenated
vegetable shortening which are high in saturated fat). Choose
products that are lowest in saturated fat on the label.
          Fewer commercially prepared and processed foods made
with saturated or hydrogenated fats or oils (like cakes, cookies,
and crackers). Read food labels to choose products low in
saturated fats.
          Foods high in starch and fiber, instead of foods high
in saturated fats.
Cutting back on saturated fat helps you to control dietary
cholesterol as well. Two additional points to remember when
cutting back on dietary cholesterol are:
          Eating less organ meat (such as liver, brain, and
kidney).
          Eat fewer egg yolks as whole eggs or in prepared foods
(try substituting two eggs whites for each whole egg in recipes,
or using an egg substitute).
To included more foods high in starch and fiber, choose:
          More whole grain breads and  cereals, pasta, rice, and
dry peas and beans.
          More vegetables and fruits.
2.   Make Physical Activity Work for You
Regular physical activity by itself may help reduce deaths from
heart disease by:
          lowering LDL levels
          raising HDL levels
          lowering high blood pressure
          lowering triglyceride levels
          reducing excess weight
          improving the fitness of your heart and lungs
If you have been inactive for a long time, start with low-to-
moderate level activities such as walking, taking the stairs
instead of the elevator, gardening, housework, dancing, or
exercising at home. Begin by doing the activity for a few
minutes most days, then work up to a longer programat least 30
minutes per day, 3 or 4 days a week This can include regular
aerobic activities such as brisk walking, jogging, swimming,
bicycling, or playing tennis.
If you have heart disease or have had a heart attack, talk with
your doctor before starting an activity to be sure you are
following a safe program that works for you.  Otherwise you may
experience chest pain or further heart damage.  If you have
chest  pain, feel faint or light-headed, or become extremely out
of breath while exercising, stop the activity at once and tell
your doctor as soon as possible.
PROFILE
Jack Williams' Story  continued from page 12
Remember- Jack is 35 years old; his father died from a heart
attack at the age  of 50; Jack smokes ; his diet is high in
saturated fat,  cholesterol , and calories; and he is not
physically  active.
Reducing Risk
The doctor identified Jack as being at a high risk for heart
disease. She advised him to stop smoking. Jack had tried to stop
on his own, but never quit for more than a few weeks. This time,
he enrolled in a program at work that charges him for each
class. But if he stops smoking, he will get his money back. His
health insurance premium also will go down.
The doctor wanted Jack to focus on giving up smoking.  She said
that changes in his eating and activity could wait. However, she
told him to eat fewer fried foods and more breads, fruits, and
vegetables. She said he should get at least some physical
activity and suggested that he part further away when shopping
at the store, work in his garden, and use the stairs more often.
Two months later, Jack had quit smoking.  But he still attended
the smoking classes so that he wouldn't start again. The doctor
said he was ready to start a Step I diet to improve his blood
cholesterol levels, and she told him how to follow it.  If Jack
had high blood pressure, he would have been advised to follow a
low-sodium Step I diet. The doctor also suggested he try to walk
about 5-10 minutes in the evening after work, a few days a week.
3 months later his blood cholesterol levels were:
Lab Report          3 months ago   Today
Total Cholesterol   260 mg/dL      224 mg/dL
HDL-Cholesterol     40 mg/dL       45 mg/dL
Jack's progress pleased his doctor, but his levels were still
not low enough. The doctor told him to walk briskly for 10-15
minutes three times a week and to add more  time each week until
he reached a 30 minute walk. She also put him on a Step II diet
and referred him to a registered dietitian (R.D.) to help him
follow it. After 1 month on the diet, he could follow it at home
but not when eating out. He went back to the dietitian to get
more tips to help him follow the diet when eating out.
After 3 months on the diet, Jack's blood cholesterol levels had
fallen to the desirable range. His wife also liked the diet and
has modified family recipes, as well as tried new ones for the
whole family to enjoy. Now when Jack eats out, he asks about how
a food is cooked to be sure it fits into the diet. His new food
habits have become a part of his way of eating and his family's.
Jack also walks 30 minutes, three or four times a week. He
hasn't smoked a cigarette since joining the class at work, and
he still attends the class once a month. He feels great and has
lots of energy. He plans to stick to his new habits and keep his
cholesterol levels down and reduce his risk of heart disease.
PROFILE
Betty Johnson's Story  continued from page 14
Remember- Betty is 60 years old and has a history of chest pain
diagnosed as angina; she is 35 pounds overweight and is not
physically active; and she has no family history of heart
disease.
Reducing Risk
After her heart attack, the doctor asked Betty whether she would
follow the Step II diet or preferred to try taking medicine.
Betty promised herself and the doctor to follow the Step II
diet. She began to eat smaller portions; choose items lower in
saturated fat and cholesterol such skim milk and low-fat dairy
products instead of the full-fat varieties; and baked her foods
more often using herbs and spices. Because she has heart
disease, she started with a low-calorie, Step II diet.  When she
returned to the doctor,s office 2 months later, she had lost
about 8 pounds. But her total and LDL-cholesterol levels were
still too high.
Lab Reports         2 months ago   Today
Total Cholesterol   240 mg/dL      216 mg/dL
LDL-Cholesterol     30 mg/dL       37 mg/dL
LDL-Cholesterol     174 mg/dL      149 mg/dL
Triglycerides       180 mg/dL      150 mg/dL
The doctor felt that she needed more help on her diet, so he
referred her to a registered dietitian for help. He also told
her to begin a morning walking program at the local mall and
build up to walking 20-30 minutes, three or four times per week.
In 3 months, Betty lost another 10 pounds and felt better. She
was walking three times per week and following the Step II diet
most of the time. She ate out less often and used the Step II
guidelines in cooking for her family.
(Betty Johnson's story is continued on page 26.)
3.  Lose Weight If You Are Overweight
Two action steps are key.
          Eat fewer calories (cutting back on the fat you eat
will really help).
          Burn more calories by becoming more physically active.
PROFILE
Betty Johnson . . . Reaching the Goal
Betty followed the Step II diet and was more physically active.
Her blood values were getting close to her goals.
Lab Report          5 months ago   3 months ago   Today
Total Cholesterol   240 mg/dL      216 mg/dL      205 mg/dL
HDL-Cholesterol     30 mg/dL       37 mg/dL       40 mg/dL
LDL-Cholesterol     174 mg/dL      149 mg/dL      135 mg/dL
Triglycerides       180 mg/dL      150 mg/dL      150 mg/dL
But, since her LDL level was still too high (greater than 130
mg/dL), the doctor decided to put her on a low dose of medicine.
He explained how important it was for her to continue her new
eating, exercising, and weight loss habits, even while taking
the medicine.  That way she could take a lower dose.  Betty took
the medicine, continued following the Step II diet, and
exercised four times a week.  Two months later, her blood
cholesterol levels reached their goals.  Betty is determined to
keep up her good work and not to have another heart attack.
You May Need To Take Medicine
If you have successfully changed your eating habits for at least
6-12 months, and your LDL-cholesterol level is still too high,
you may need to take medicine.  Some people will need to take
medicine from the start of their treatment because of a very
high LDL level or the presence of heart disease.
If you doctor prescribes medicine, you also will need to:
          Follow your cholesterol-lowering diet.
          Lose weight if overweight.
          Be more physically active.
          Stop smoking.
Taking all these steps together may lessen the amount of
medicine you need, or make the medicine work better.  And that
reduces your risk of heart disease.
Medicines Your Doctor May Prescribe
Sever types of medicine help lower blood cholesterol levels.
These include:
Major Drugs
Bile acid sequestrants (cholestyramine and colestipol) Nicotinic
acid HMG CoA reduces inhibitors ar "statins" (e.g., lovastatin,
pravastatin, and simvastatin)
Other Drugs
Fibric acid derivatives (gemfibrozil)
Probucol
 In addition, if you are a woman going through or past
menopause, your doctor may talk with you about estrogens.
Sometimes called Estrogen Replacement Therapy, this can lower
blood cholesterol levels, and may make it unnecessary to take a
cholesterol-lowering drug.
Drugs that lower blood cholesterol work in different ways.  Some
may work for you while others may not.  Before the doctor
prescribes any medicine, be sure to state what other medicines
you are taking.  And once a medicine is prescribed, take it
exactly the way our doctor tells you so.  If you have any side
effects from a medicine, tell you doctor right away.  The amount
or type of drug can be changed to reduce or stop unwanted side
effects.  Whatever medicine you take, continue to follow the
Step I or Step II diet and to be more physically active.  This
will help keep the dose of medicine as low as possible.
3
WHERE YOU CAN GO FOR HELP
As Your Health Professionals
In addition to your doctor, other health professionals can help
you control your blood cholesterol levels.  These persons
include:
          Registered dietitians (R.D.) or qualified
nutritionists, who can explain food plans and show you how to
make changes in what you eat.  They can give you advice on
shopping for and preparing foods, and eating out. They also
can help you set goals for changing the way you eat, so you
can successfully lower your high blood cholesterol without
making big changes all at once in you eating habits or in
your lifestyle
     To find a Registered Dietitian contact:
          The National Center for Nutrition and Dietetics'
Consumer Nutrition Hotline 1-800-366-1655,
          Your local hospital or health department, or
          Your doctor.
          The nurse in you doctor's office, who also may be able
to answer questions about hour high blood cholesterol or your
diet.
          Lipid specialists, who are doctors with an expertise in
treating high blood cholesterol and similar conditions.  In
special cases, you may be referred to lipid specialist if the
treatment your doctor is prescribing does not successfully
lower you blood cholesterol levels.
          Your doctor, who can answer questions about the
medicines you are taking.  Be sure to tell your doctor about
everything you are taking and if you feel different after you
take any of them.
          Pharmacists, who are aware of the best ways to take
medicines to lessen side effects and of the latest research on
drugs.
Get More Information
The National Cholesterol Education Program (NCEP), coordinated
by the National Heart, Lung, and Blood Institute (NHLBI), has a
pamphlet called Step by Step:  Eating to Lower Your High Blood
Cholesterol.  This pamphlet gives details on how to change your
eating habits in order to lower your blood cholesterol levels.
The NCEP also has booklets for children with high blood
cholesterol levels and their parents.  In addition, the NHLBI
has a booklet, Exercise and Your Heart, and a resource list of
agencies and organizations able to answer questions on
cholesterol and the other risk factor for hear disease.  For
these and other materials, write:
National Cholesterol Education Program
NHLBI Information Center
P.O. Box 30105
Bethesda, Maryland 20824-0105
The American Heart Association can also provide you with
additional information.  Contact your local American Heart
Association or call 1-800-AHA-USA1 (1-800-242-8721)
Glossary
Atherosclerosis:  A type of "hardening of the arteries" in which
cholesterol, fat, and other substances in the blood build up in
the walls of arteries.  As the process continues, the arteries
to the heart may narrow, cutting down the flow of oxygen-rich
blood and nutrients to the heart.
Bile Acid Sequestrants:  One type of cholesterol-lowering
medication, including cholestyramine and colestipol.  The
sequestrants bind with cholesterol-containing bile acids in the
intestines and remove them in bowel movements.
Calories:  Units of measurement that represent the amount of
energy the body is able to get from foods.  Different nutrients
in foods provide different amounts of calories.  Carbohydrates
and protein provide about 4 calories per gram, while fat (bother
saturated and unsaturated) yields about 9 calories per gram.
Carbohydrate:  One of the nutrients that supply calories to the
body.  Carbohydrates may be simple or complex.  Complex
carbohydrates also are called starch and fiber, which come from
plants and can be found in whole-grain breads, cereals, pasta,
rice, dried peas, and beans, corn, lima beans, fruits, and
vegetables.
Cholesterol:  A soft, waxy substance.  The body makes enough
cholesterol to meet its needs.  Cholesterol is used in the
manufacture of hormones, bile acid, and vitamin D.  It is
present in all parts of the body, including the nervous system,
muscle, skin, liver, intestines, and heart.
          Blood cholesterolCholesterol circulating in the
bloodstream. It is made in the liver and absorbed from the food
you eat. The blood carries it for use by all parts of the body.
A high level of blood cholesterol leads to atherosclerosis and
an increased risk of heart disease.
          Dietary cholesterolCholesterol in the food you eat.  It
is present only in foods of animal origin, not those of plant
origin.  Dietary cholesterol, like dietary saturated fat,
raises blood cholesterol, which increases the risk for heart
disease.
Estrogen Replacement Therapy (ERT):  Treatment with he hormone
estrogen, which has many effects, one of which is cholesterol
lowering.  It includes different amounts of estrogen and
progestin, two hormones produced normally by women who have
menstrual periods.  ERT is given only to women who have gone
through menopause.  ERT may help prevent heart disease by
lowering blood cholesterol levels, especially LDL.
Fat:  One of the nutrients that supply calories to the body.
The body needs only small amount of fat.  Foods contain
different types of fat, which have different effect on blood
cholesterol levels.  These include:
          Total fatThe sum of the saturated, monounsaturated, and
polyunsaturated fats present in food.  All foods have a
varying  mix of these three types.
          Saturated fatA type of fat found in greatest amounts in
the skin, whole-milk dairy products, lard, and in some vegetable
oils, including coconut, palm kernel, and palm oils.
Saturated fat raises blood cholesterol more than anything
else eaten.
          Unsaturated fatA type of fat that is usually liquid at
refrigerator temperature.  Monounsaturate fat and
polyunsaturated fat are two kinds of unsaturated fat.  When
used in place of saturated fat, monunsaturated and
polyunsaturated fats help to lower blood cholesterol levels.
          Monounsaturated fatAn unsaturated fat that is found in
greatest amount in food from plants, including olive and
canola oil.
          Polyunsaturated fatAn unsaturated fat found in greatest
amounts in foods from plants, including safflower, sunflower,
corn, and soybean oils.
Fibric Acid Derivatives:  One type of cholesterol-lowering drug.
It includes gemfibrozil.  The fibric acids lower triglycerides
and raise HDLs.
HMG CoA Reductase Inhibitors:  See "Statins."
Lipids:  Fatty substances, including cholesterol and
triglycerides, that are present in blood and body tissues.
Lipoproteins:  Protein-coated packages that carry fat and
cholesterol through the bloodstream.  Lipoproteins are
classified according to their density.
          High-density lipoprotein (HDL)Lipoproteins that contain
a small amount of cholesterol and carry cholesterol away from
body cells and tissues to the liver for the excretion from
the body.  A low level of HDL increases the risk of heart
disease, so the higher the HDL level, the better.  HDL is
sometimes called the "good" cholesterol.
          Low-density lipoprotein (LDL)Lipoproteins that contain
most of the cholesterol in the blood.  LDL, the "bad"
cholesterol, carries cholesterol to the tissues of the body
including the arteries.  For this reason, a high level of LDL
increases the risk of heart disease.
Lipoprotein Profile:  A test that uses blood from the arm to
measure your total, HDL-, and LDL-cholesterol, and triglyceride
levels.  The test requires a fast for 9-12 hours beforehand.
Nothing can be consumed but water, or coffee or tea with no
cream or sugar.
Milligram (mg):  A unit of weight equal to one-thousandth of a
gram.  There are about 28,350 mg in 1 ounce.  Dietary
cholesterol is measured in milligrams.
Milligrams/Deciliter (mg/dL):  The measure used to express
cholesterol and triglyceride levels in the blood.  It stands for
the weight of cholesterol in milligrams in a deciliter of blood.
A deciliter is one-tenth of a liter or about one-tenth of a
quart.
Nicontinic Acid:  A cholesterol-lowering medicine that reduces
total and LDL-cholesterol and triglyceride levels and also
raises HDL-cholesterol levels.  This is the same substance as
Niacin or vitamin B1, but in doses that lower cholesterol, it
should only be used with your doctor's supervision.
Risk Factor:  A habit, trait, or condition in a person that is
associated with an increased chance (or risk) for a disease.
Statins:  One type of cholesterol-lowering drug that includes
lovastatin, pravastatin, and simvastatin.  These drugs lower LDL
levels by limiting the amount of cholesterol the body can make.
Triglycerides:  Lipids carried through the bloodstream to
tissues.  Most of the body's fat tissue is in the form of
triglycerides, stored for use as energy.  Triglycerides are
obtained primarily from fat in foods.
DISCRIMINATION PROHIBITED:  Under provisions of applicable
public laws enacted by Congress since 1964, no person shall, on
the grounds of race, color, national origin, handicap or age, be
excluded from participation in, be denied the benefits of, or be
subjected to discrimination under any program or activity (or on
the basis of sex, with respect to any education program or
activity) receiving Federal financial assistance.  In addition,
Executive Order 11141 prohibits discrimination on the basis of
age by contractors and subcontractors in the performance of
Federal contracts and Executive Order 11246 states that no
federally funded contractor may discriminate against any
employee or applicant for employment because of race, color,
religion, sex, or national origin.  Programs of the National
Heart, Lung, and Blood Institute are operated in compliance with
these laws and Executive Orders.
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service
National Institutes of Health
National Heart, Lung, and Blood Institute
NIH Publication No. 93-2922
Revised December 1993