High Cholesterol (Dyslipidemia)
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Overview
High cholesterol, or dyslipidemia, refers to unhealthy levels of fats in the blood: high LDL ("bad") cholesterol, high triglycerides, low HDL ("good") cholesterol, or a combination. Elevated LDL cholesterol is a direct cause of atherosclerosis, the buildup of plaque in the arteries that leads to heart attacks and strokes (Ference et al., European Atherosclerosis Society Consensus, European Heart Journal, 2017).
Obesity is strongly associated with a particular pattern called atherogenic dyslipidemia: high triglycerides, low HDL and small, dense LDL particles that are especially likely to enter artery walls. This pattern is driven by insulin resistance and excess visceral and liver fat, and it improves substantially with weight loss.
Lowering LDL cholesterol saves lives: across large statin trials, each 1 mmol/L (about 39 mg/dL) reduction in LDL lowered major cardiovascular events by about 22% (Cholesterol Treatment Trialists' Collaboration, Lancet, 2010). Weight loss, through lifestyle, medication or bariatric surgery, adds further benefit, particularly for triglycerides and HDL (Courcoulas et al., JAMA, 2013).
Understanding Your Numbers
- LDL cholesterol: lower is better; targets depend on overall risk, often below 100 mg/dL and below 70 or 55 mg/dL for people with heart disease or diabetes (Grundy et al., AHA/ACC Cholesterol Guideline, Circulation, 2019).
- HDL cholesterol: below 40 mg/dL in men or 50 mg/dL in women is considered low.
- Triglycerides: 150 mg/dL or higher is elevated; above 500 to 1,000 mg/dL raises the risk of pancreatitis.
- Lipoprotein(a): a genetically determined particle that increases risk independently of LDL.
Causes
- Genetics, including familial hypercholesterolemia and elevated lipoprotein(a)
- Obesity and insulin resistance, which raise triglycerides and lower HDL
- Diets high in saturated and trans fats, refined carbohydrates and sugar
- Physical inactivity
- Type 2 diabetes
- Excess alcohol, which raises triglycerides
- Hypothyroidism, kidney disease and certain medications
Risk Factors
- Family history of high cholesterol or early heart disease
- Obesity, especially abdominal obesity
- Type 2 diabetes and metabolic syndrome
- Sedentary lifestyle
- Smoking, which lowers HDL
- Age and menopause
Who It Affects
Abnormal cholesterol affects a large share of adults and is especially common among people with obesity, diabetes and metabolic syndrome. Familial hypercholesterolemia affects about 1 in 250 people and can cause very high LDL from childhood.
Complications
- Coronary artery disease and heart attack; see heart disease
- Stroke
- Peripheral artery disease
- Pancreatitis from very high triglycerides
- Fatty liver disease
Symptoms
High cholesterol usually causes no symptoms until a heart attack or stroke occurs. Very high levels can cause yellowish fatty deposits in the skin or tendons (xanthomas) or around the eyes.
Diagnosis
- Lipid panel: total cholesterol, LDL, HDL and triglycerides; fasting is not always required (Grundy et al., AHA/ACC Cholesterol Guideline, Circulation, 2019)
- Non-HDL cholesterol and apolipoprotein B, which better reflect risk in people with high triglycerides
- Lipoprotein(a) at least once in adulthood
- Cardiovascular risk calculation to guide treatment
- Coronary artery calcium scoring when treatment decisions are uncertain (Grundy et al., AHA/ACC Cholesterol Guideline, Circulation, 2019)
Differential Diagnosis
- Familial hypercholesterolemia
- Hypothyroidism
- Kidney disease (nephrotic syndrome)
- Medication effects
- Uncontrolled diabetes causing high triglycerides
Lifestyle Modifications
- Lose weight, which lowers triglycerides and raises HDL.
- Replace saturated fats with unsaturated fats such as olive oil, nuts and fish.
- Cut refined carbohydrates, sugar and alcohol to lower triglycerides.
- Increase soluble fiber from oats, beans and vegetables.
- Exercise regularly.
- Stop smoking.
Treatment Options
- Statins: the foundation of LDL-lowering therapy (Cholesterol Treatment Trialists' Collaboration, Lancet, 2010)
- Ezetimibe and PCSK9 inhibitors for additional LDL lowering (Grundy et al., AHA/ACC Cholesterol Guideline, Circulation, 2019)
- Bempedoic acid for statin-intolerant patients
- Omega-3 (icosapent ethyl) and fibrates in selected patients with high triglycerides
- GLP-1 medications: in the SELECT trial, semaglutide reduced major cardiovascular events by 20% in people with overweight or obesity and heart disease (Lincoff et al., SELECT trial, New England Journal of Medicine, 2023); see medical weight loss
- Bariatric surgery: in LABS-2, dyslipidemia resolved in a majority of gastric bypass patients at three years (Courcoulas et al., JAMA, 2013); see bariatric surgery
Weight Loss and Lipids
Weight loss has its largest effects on triglycerides and HDL. LDL changes are more variable, which is why many patients still need statins after losing weight, particularly when they have diabetes, heart disease or a strong family history.
When to See a Doctor
Adults should have cholesterol checked at least every four to six years, and more often with obesity, diabetes or a family history of early heart disease.
When to Seek Treatment
Seek emergency care for chest pain, shortness of breath, sudden weakness or numbness, or difficulty speaking. Seek prompt care for severe abdominal pain if your triglycerides are very high.
Long-Term Outlook
Lifelong healthy habits, appropriate medication and weight management keep cholesterol at target and protect the heart and brain.
Related Reading and Videos
Read more in our articles The Real Results After Bariatric Surgery: A Complete Patient Guide and GLP-1 Medications Explained: Benefits, Risks, and How to Choose a Treatment. Watch Ozempic, Wegovy, Mounjaro & Zepbound Don’t Just Help You Lose Weight. They Protect Your Heart and What GLP-1s Are Really Doing to YOUR Body. Obesity Medicine Specialist spills the Truth on our video library. Related conditions include Chronic Kidney Disease (CKD), Prediabetes, Back Pain and Mobility Limitations. Treatments that may be involved include Sleeve Gastrectomy, SADI-S (Single-Anastomosis DuodenoIleal Bypass With Sleeve) and Duodenal Switch (DS).
Prognosis
Lowering LDL and treating related risk factors substantially reduces heart attack and stroke risk (Cholesterol Treatment Trialists' Collaboration, Lancet, 2010).
Why Choose Dr. de la Cruz-Muñoz
Dr. de la Cruz-Muñoz is a board-certified metabolic and bariatric surgeon whose medical and surgical weight-loss programs address the obesity-driven lipid abnormalities that raise cardiovascular risk, in coordination with patients' primary care physicians and cardiologists.
Dr. de la Cruz-Muñoz has been performing bariatric surgery for over 25 years and has completed more than 9,000 bariatric operations — a volume few surgeons reach.
Featured Procedures
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FAQ
Many patients can reduce or stop these medications as they lose weight, but only under medical supervision. Blood pressure can drop quickly in the first weeks after surgery, so your doctors will adjust doses based on home readings, and some medications are reduced right after surgery. Cholesterol medications are adjusted based on lab results and your overall heart risk — some patients should continue statins even after weight loss. Never stop a medication on your own.
Yes. Weight loss lowers triglycerides and raises HDL ("good") cholesterol, and it often modestly lowers LDL. These changes are larger with greater weight loss, and bariatric surgery produces substantial improvements in triglycerides and HDL, with many patients able to reduce lipid-lowering medications. Exercise, limiting refined carbohydrates and alcohol, and choosing unsaturated fats add to the benefit. Some people have genetic forms of high cholesterol that need medication regardless of weight.
Treatment starts with lifestyle changes: a diet low in saturated fat, refined carbohydrates and added sugar; regular exercise; limiting alcohol; and weight loss. Statins are the first-line medication for lowering LDL cholesterol and cardiovascular risk, and other medications such as ezetimibe or PCSK9 inhibitors are added when needed. For patients with obesity, weight-loss medications and metabolic surgery can substantially improve triglycerides and HDL and reduce the need for medication.
Dyslipidemia — abnormal levels of cholesterol and triglycerides — results from a mix of genetics and lifestyle. Common contributors include obesity (especially abdominal fat), insulin resistance and type 2 diabetes, diets high in saturated fat and refined carbohydrates, physical inactivity, heavy alcohol use, an underactive thyroid, kidney disease and certain medications. Inherited conditions such as familial hypercholesterolemia cause very high LDL from a young age and require medication.
The 2022 ASMBS/IFSO guidelines recommend metabolic and bariatric surgery for people with a BMI of 35 or higher, regardless of whether they have obesity-related conditions. They also recommend considering surgery for people with a BMI of 30–34.9 who have metabolic disease, particularly when nonsurgical treatment has not led to adequate improvement. Individual evaluation is essential, and guidelines do not guarantee insurance coverage.
Patients should consider medical or surgical treatment when obesity is causing health problems (diabetes, hypertension, sleep apnea, fatty liver disease), when weight is affecting quality of life, or when repeated dieting has failed. Metabolic surgery is the most effective option for patients with severe obesity or obesity‑related diseases, offering durable weight loss and powerful metabolic improvements.
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