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Confused about cholesterol? You're not alone.

Facts change about which foods help keep your heart healthy and how much of each to eat. Reports about total cholesterol, HDL-cholesterol, LDL-cholesterol, triglycerides and the risk of heart disease has also been confusing.

The American Heart Association, for example, changes its dietary advice after scientific knowledge is confirmed. That way, everyone will be able to know and act upon the most recent and best information.

We prepared this information to dispel the confusion and help you learn:

what cholesterol is,
what your cholesterol and triglyceride (a blood fat) measurements mean, and
how the foods you eat can help you control your cholesterol.

Too much cholesterol in your blood increases your risk of heart attack. So the more you know about cholesterol and how to control it, the better your chances of avoiding a heart attack (which claims almost half a million American lives every year).

Understanding Cholesterol

Cholesterol is a soft, fat-like substance found in all your body's cells. It's a key part of a healthy body, because it's used to form cell membranes, some hormones and other needed tissues. But it can be a problem if you have too much of it in your body.

Cholesterol comes from two sources. It's made in your body, mostly in the liver. It's also found in foods from animals, such as meats, poultry, fish, seafood and dairy products. Egg yolks have lots of cholesterol; they're a key source of cholesterol in the diet..

Foods from plants (fruits, vegetables, grains, nuts and seeds) don't contain cholesterol.

Cholesterol and Your Arteries

Cholesterol travels to the body's cells through the bloodstream. But cholesterol and other fats can't dissolve in the blood, so they have to be transported to and from the cells by special carriers called lipoproteins

There are several kinds of lipoproteins, but the ones we're most concerned about are low density lipoprotein (LDL) and high density lipoprotein (HDL).

The Bad Guys: LDL-Cholesterol

Low density lipoprotein is the major cholesterol carrier in the blood. The liver and tissues that form cell membranes and other products use some LDL-cholesterol.

When a person has too much LDL-cholesterol circulating in the blood, it can slowly build up in the walls of arteries feeding the heart and brain. Together with other substances, it can form plaque, a thick, hard deposit that can clog those arteries. This condition is called atherosclerosis. If a clot (or thrombus) forms where this plaque is located, it can block blood flow to part of the heart muscle and cause a heart attack. If a clot blocks blood flow to part of the brain, a stroke ( brain attack) results.

A high level of LDL increases the risk of heart disease. That's why LDL is often called "bad" cholesterol.

The Good Guys: HDL-Cholesterol

About a third to one-fourth of blood cholesterol is carried by another kind of lipoprotein-high density lipoprotein or HDL. The liver makes most HDL and releases it into the bloodstream. Medical experts think HDL tends to carry cholesterol away from the arteries and back to the liver, where it's passed from the body. Some experts believe HDL removes excess cholesterol from atherosclerotic plaques, slowing their growth.

HDL is called "good" cholesterol because a high level of it seems to lower the risk of heart attack. The opposite is also true: a low HDL level increases the risk.

Your doctor can use a blood test to measure your total blood cholesterol, in milligrams per deciliter (mg/di). He or she can also measure your HDL and triglycerides to calculate the amount of LDL-cholesterol. Your HDL and LDL-cholesterol levels will help your doctor determine your risk of atherosclerosis.

The Triglyceride Connection

Triglyceride is the major form in which fat occurs in nature. It comes from food and is also made in your body.

Several clinical studies have shown that an unusually large number of people with heart disease also have high triglyceride levels. But some people with very high triglyceride levels are remarkably free of atherosclerosis, so high triglycerides may not directly cause atherosclerosis. However, a high triglyceride level often appears with a higher total cholesterol, a high LDL-cholesterol and a lower HDL-cholesterol level.

Cut Blood Cholesterol - and Heart Attack Risk

In 1984 the 10-year Coronary Primary Prevention Trial showed that owering blood cholesterol levels reduces the risk of heart disease.

This trial involved about 4,000 men with high cholesterol. It showed that the men who lowered their cholesterol levels with diet and drugs had fewer heart attacks and less heart disease. Other clinical trials have resulted in similar findings.

Recent studies have shown that further development of atherosclerosis may be stopped - or even reversed in some cases - if cholesterol is lowered a lot.

The results from all the trials show that, in general, reducing total cholesterol by 1 percent will reduce heart attack risk by 2 percent. That means that lowering blood cholesterol from 250 to 200 mg/dl, for example, reduces heart attack risk by 40 percent.

Two other recent clinical trials - the Scandinavian Simvastatin Survival Study Group and the West of Scotland Coronary Prevention Study Group - showed that cholesterol therapy will reduce heart disease morbidity and mortality.

Clearly, high blood cholesterol can be bad news. It's one of the factors that increase the risk of heart attack. Here's a chart that shows important risk factors.

Factors that increase your risk of heart attack:

Age: Male 45 years and older Female 55 years and older, or premature menopause without estrogen replacement therapy
Family history of premature coronary heart disease*
Smoking
High blood pressure
HDL-cholesterol less than 35 mg/dl
Diabetes

* A family history of premature CHD is defined as having first degree male relatives (grandfather, father or brother) who died from coronary heart disease before age 55 or first degree female relatives who died from CHD before age 65.

Information based on National Cholesterol Education Program guidelines set forth in the Second Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel, a.k.a. ATP 11).

What Do Your Cholesterol Numbers Mean?

Starting at age 20, have your total cholesterol and HDL-cholesterol checked, along with your other risk factors. It's a good idea to talk to your doctor about these levels. Your total cholesterol and HDL-cholesterol are probably the first numbers your doctor will discuss.

Your Total Blood Cholesterol Level

Your total blood cholesterol will fall into one of these categories:

Total Blood (Serum) Cholesterol	Classification
Less than 200 mg/dl	Desirable
200-239 mg/dl	Borderline high
240 mg/dl and over	High

If your total cholesterol is less than 200 mg/dl, that's good. Unless you have other risk factors listed in the table on page 9, your heart attack risk is relatively low. Even with a low risk, it's still smart to eat a cholesterol-lowering diet. Have your total cholesterol and HDL-cholesterol measured again within five years.

In general, people who have a total cholesterol in the 200 to 239 range have twice the risk of heart attack as people whose levels are well below 200. But don't feel alone: about 32 percent of American adults are in this group. Have your cholesterol and HDL rechecked in one to two years if:

your total cholesterol is in this range,
your HDL is more than 35 mg/dl, AND
you have fewer than two risk factors

You should also modify your diet to reduce your cholesterol level to below 200. If you have two or more risk factors, you'll need more tests.

Your doctor will probably suggest you have your triglycerides measured also. With this information, he or she can calculate your LDL-cholesterol. Ask your doctor to discuss your LDL-cholesterol with you.

Not every person whose cholesterol is between 200 and 239 mg/dl is at increased risk for developing atherosclerosis. For example, women before menopause and young, active men who have no other risk factors may have high levels of HDL-cholesterol. This increases their total cholesterol count. Trust your doctor to interpret your results; everyone's case is different.

If your cholesterol is over 240, it's definitely high. Your risk of heart attack is greater and you need more tests. Again, ask your doctor for advice.

Your HDL Level

In the average man, HDL-cholesterol levels range from 40 to 50 mg/dl; in the average woman, from 50 to 60. HDL-cholesterol that's less than 35 mg/dl is low.

Low HDL-cholesterol means you have less of the "good" cholesterol to remove cholesterol from your system. Smoking, being overweight and being sedentary can all result in lower HDL-cholesterol. The most common treatments for low HDL-cholesterol are avoiding cigarettes, losing weight (or maintaining ideal weight) and being physically active.

People with high blood triglycerides usually have lower HDL-cholesterol and thus an increased risk of heart attack. Progesterone, anabolic steroids and male sex hormones (testosterone) also lower HDL levels. Female sex hormones raise HDL levels.

Your LDL Cholesterol Level

Your LDL-cholesterol level greatly affects your risk of heart attack. In fact, LDL-cholesterol is a better predictor of heart attack risk than total blood cholesterol. Your LDL-cholesterol will fall into one of these categories:

LDL-Cholesterol	Classification
Less than 130 mg/dl	Desirable
130-159 mg/dl	Borderline high
160 mg/dl or higher	High

Most people with an LDL-cholesterol of 130 will have a total blood cholesterol of about 200. An LDL-cholesterol of 160 is comparable to total cholesterol of about 240. This is only a general estimate, though, so talk to your doctor about your numbers. The point to remember is, the lower your LDL-cholesterol, the lower your risk.

Your Triglyceride Level

Triglyceride level classifications are:

Triglyceride Levels	Classification
Less than 200 mg/dl	Normal
200-400 mg/dl	Borderline high
400-1000 mg/dl	High
Greater than 1,000 mg/dl	Very high

Most people with high triglycerides have underlying diseases or genetic disorders. The main therapy for them is to change their lifestyle. This means they should control their weight, eat a low-saturated-fat, low-cholesterol diet, exercise regularly, stop smoking and, in some cases, drink less alcohol. Drug therapy may be considered for people who need further treatment. The guidelines for those who qualify are:

LDL-Cholesterol	Level for Drug Consideration	Goal of Therapy
Without coronary heart disease and with fewer than two risk factors	(greater than or equal to) 190 mg/dL*	(less than)160 mg/dL
Without coronary heart disease and with two or more risk factors	(greater than or equal to)160 mg/dL	(less than)130 mg/dL
With coronary heart disease	(greater than or equal to)130 mg/dL**	(less than or equal to)100 mg/dL
*In men less than 35 years of age and premenopausal women with LDL cholesterol levels of 190 to 219 mg/dL, drug therapy should be delayed except in high-risk patients such as those with diabetes.
**in coronary heart disease patients with LDL cholesterol levels of 100 to 129 mg/dL, the doctor should exercise clinical judgment in deciding whether to initiate drug treatment.

Use an Experienced Laboratory

Cholesterol and triglycerides are hard to measure accurately. Your levels may vary greatly between labs or even within the same lab. They also may vary from time to time. Your diet, medicines and physical activity may cause changes in your results. Have your total cholesterol, HDL-cholesterol and triglyceride levels checked by a lab that your doctor chooses. Your doctor will calculate your LDL-cholesterol level from these values.

*A family history of premature CVD is defined as having first degree male relatives (grandfather, father or brother) who died from cardiovascular disease before age 55 or first degree female relatives who died from CVD before age 65.

Dietary Cholesterol

Dietary cholesterol is only in foods from animals, such as meat, fish, poultry and dairy products. These food are also sources of saturated fat. Egg yolks and organ meats - such as liver and kidney - are high in cholesterol. Foods from plants (fruits, vegetables, grains, nuts and seeds) don't contain cholesterol. Dietary cholesterol can raise your blood cholesterol level, increasing your risk of heart disease. The average American man consumes about 450 milligrams of cholesterol a day; the average woman, about 320 milligrams. The liver removes some dietary cholesterol from the body. Still, the American Heart Association recommends that you limit your cholesterol intake to an average of no more than 300 milligrams per day.

Getting a Fix on Fats

There are three kinds of fats in foods:saturated, polyunsaturated and monounsaturated fatty acids. Only saturated fatty acids and dietary cholesterol raise blood cholesterol. Let's take a closer look at these kinds of fats.

Saturated Fatty Acids

Saturated fatty acids are the main dietary culprit in raising blood cholesterol. They're found mostly in foods from animals and some plants.

Foods from animals that have lots of saturated fatty acids include beef, beef fat, veal, lamb, pork, lard, poultry fat, butter, cream, milk, cheeses, and other dairy products made from whole milk. These foods also contain dietary cholesterol.
Foods from plants with high amounts of saturated fatty acids include coconut oil,palm oil and palm kernel oil (often called tropical oils), and cocoa butter.

During food processing, fats may undergo a chemical process known as hydrogenation. In margarine, this process lets an oil be partly hardened and molded into tub or stick form. Fat for shortening can be hydrogenated to give it a creamy texture. Hydrogenation also helps oils stay fresh longer.

Recent studies suggest that these fats may raise blood cholesterol. Hydrogenated fats may be used if they contain no more than two grams of saturated fatty acids per tablespoon. The fatty acid content of most margarines and spreads is printed on the package or label.

The American Heart Association recommends that you limit your saturated fatty acid intake to less than 10 percent of total calories each day.

Polyunsaturated and Monounsaturated Fatty Acids

Polyunsaturated and monounsaturated fatty acids are the two unsaturated fatty acids. They're often found in liquid oils from plants.

Common sources of polyunsaturated fatty acids are safflower, sesame and sunflower seeds, corn and soybeans, many nuts and seeds, and their oils. Canola, olive and peanut oils, and avocados are sources of monounsaturated fatty acids.

Both polyunsaturated and monounsaturated fatty acids may help lower your blood cholesterol level when used in place of saturated fatty acids in your diet. But a moderate intake of all types of fat is best.

The American Heart Association recommends that you limit polyunsaturated fatty acids to no more than 10 percent of total calories. The rest of your unsaturated fatty acid intake, about 10 to 15 percent of total calories, is made up of monounsaturated fatty acids.

Use poly - or monounsaturated oils - and margarines and spreads made from them - in limited amounts. It's better than fats with a high saturated fatty acid content, such as butter, lard or hydrogenated shortenings.

Eating To Lower Your Cholesterol

It's fairly easy to reduce your blood cholesterol. Just eat more low-fat, low-cholesterol foods and cut down on high-fat ones, especially those high in saturated fatty acids. Here are some simple guidelines.

Eat more fruits, vegetables and whole grains instead of fatty meats and bakery goods.
Eat fish, poultry without skin and lean meats instead of fatty ones.
Consume low-fat or skim milk dairy products rather than whole milk dairy products.

Make reading food labels a habit. They will help you choose foods wisely to lower your blood cholesterol and risk of heart disease. Many foods may have substances such as saturated fat or hydrogenated fat that can raise blood cholesterol. Some may be high in sodium, which can increase blood pressure in some people.

Also, learn what descriptive terms like "light," "low" and "free" mean.

You can find many books and pamphlets with information on the fat, cholesterol, sodium and caloric content of commonly eaten foods. The American Heart Association Brand Name Cholesterol Counter lists this information for more than 4,000 brand name foods. The counter lists only those foods that meet AHA dietary guidelines for total fat, saturated fat and cholesterol. Sodium values and calorie counts are also included. This book is sold in bookstores and grocery stores.

Exploring Alternatives to High-Fat Foods

Whole Milk Dairy Products. Whole milk has more saturated fatty acids than low-fat or skim milk. About 45 percent of the calories in whole milk comes from saturated fat. Whole milk also has more cholesterol.Instead of whole milk, choose skim or 1 percent fat milk. Just 14 percent of the calories in 1 percent milk come from saturated fat. Skim milk has even less saturated fat. Low-fat milk or skim milk is rich in protein, calcium and other nutrients without being high in fat.

Butter, Cream and Ice Cream. Save these dairy products for special occasions-they have even more fat than whole milk. Watch out for butter and cream hidden in many casseroles and other dishes, bakery goods and desserts, too.

Cheese. Many people eat cheese instead of meat because it's high in protein. Unfortunately, many cheeses are also high in saturated fatty acids. About 60 to 70 percent of the calories in cheese comes from butter fat, about as much as in ice cream. Instead of regular cheese, choose low-fat cottage cheese, part-skim milk mozzarella, ricotta and other low-fat cheeses.

Eggs. One egg yolk contains about 213 milligrams of cholesterol. The American Heart Association recommends eating no more than three to four egg yolks per week, including those used in cooking. Egg whites, however, don't contain cholesterol and are good protein sources, so they're fine. In fact, you can substitute two egg whites for each egg yolk in many recipes that call for eggs. Be sure to eat only cooked - not raw-eggs and egg whites.

Meats. The American Heart Association recommends eating no more than six ounces of cooked lean meat, poultry,fish or seafood a day. Beef, Lamb, Pork and Veal.Look for lean cuts of these meats with minimal visible fat. Trim all outside fat before cooking. Most meats have about the same amount of cholesterol, roughly 70 milligrams in each three-ounce (cooked) serving. Eating lean red meat in moderation is okay.

Processed Meats. These include sausage, bologna, salami and hot dogs. About 70 to 80 percent of their calories come from fat. Many processed meats - even those with "reduced fat" labels - are high in calories and saturated fat. Read labels carefully and choose such meats only now and then. Recently some low - fat versions have begun appearing on the market; you may choose these more often.

Organ Meats. These include liver, sweet - breads, kidney, brain and heart. All of these - except the heart - are very high in cholesterol. If you're on a cholesterol - lowering diet, eat them only occasionally.

Poultry. Eat chicken and turkey rather than duck and goose, which are higher in fat. Chicken and turkey are also preferable to fatty red meat. Remove the skin before cooking poultry, except when roasting a whole bird. That's where a lot of the fat is stored.

Fish. Fish can be fatty or lean, but it's still among the best meats you can choose. That's because fatty fish usually come from the deep sea and have high amounts of omega-3 fatty acids. Some scientists think this kind of fatty acid may help protect against heart disease. Fish can come from either fresh or salt water and have little omega-3 fatty acids. Fish does have cholesterol, but it's very low in saturated fatty acids. For a cholesterol -lowering diet, fish is better than lean red meat and much better than fatty red meat.

People who've heard about the benefits of omega - 3 fatty acids often wonder whether to add fish oil to their diet. Because we don't yet know what the effect of large doses of omega-3 oils is, the AHA recommends getting your fish oil the natural way-by eating fish regularly.

Shellfish. Shrimp and crayfish have more cholesterol than most other types of fish and seafood. But they're lower in total fat and saturated fatty acids than most meats and poultry.

Bakery Goods. Store-baked goods are often made with egg yolks and saturated fats. Eating limited amounts is okay, but it's better to stick with homemade or store - baked goods made with poly - or monounsaturated oils and egg whites.

The Right Stuff

Fruits, Vegetables, Grains and Legumes. These foods are good sources of complex carbohydrate. They tend to be low in fat and have no cholesterol. Most are good sources of dietary fiber and vitamins, too. Dietary fiber is the term used for several materials that make up the parts of plants that your body can't digest. Fiber is either soluble or insoluble. The American Heart Association suggests that you eat foods high in complex carbohydrate, which tend to be high in both types of fiber. (Some kinds of soluble fiber, such as pectin and oat bran-when eaten in large amounts in a diet low in saturated fatty acids - may reduce total cholesterol and LDL.) The few exceptions are coconut, olives and avocados. Coconut is high in saturated fatty acids; olives and avocados are high in (monounsaturated) fat and calories. People who want to lose weight should eat these items sparingly.

When vegetable grains or legumes are cooked or processed into foods, saturated fats or cholesterol are often added. For instance, egg yolks may be added to breads or pastas.Processed and preserved vegetables also may contain added sodium. And in some people, too much sodium (salt) can lead to high blood pressure. Some food companies now are canning vegetables with no salt added. Look for these in the market or choose fresh or frozen vegetables.

Nuts and Seeds. These tend to be very high in fat and calories, but most of the fat is polyunsaturated or monounsaturated. Since they don't have cholesterol, they don't raise blood cholesterol. Nuts and seeds are good sources of protein.

Cooking with Fats and Oils

The major vegetable oils include canola, corn, olive, safflower, sesame, soybean and sunflower oils. They're low in saturated fatty acids and are good to use for cooking or dressings.

Peanut oil has slightly more saturated fatty acids. Don't use it as a major cooking oil, but you can use it now and then for flavoring. Vegetable oils are hydrogenated for use in margarines or shortenings. Hydrogenation may partly offset some of the benefits of using poly - or monounsaturated vegetable oils.

When Healthy Eating Isn't Enough

Sometimes when you switch to a cholesterol - lowering diet, your blood cholesterol level still won't drop enough. In this case, your doctor may have you take a cholesterol - lowering drug. Unless your cholesterol is dangerously high, it's best to try to reduce it by altering your diet. You and your doctor can work as a team to reach this goal.

There's More Than One Way To Fight Heart Attack

The four major risk factors for heart attack are:

high blood cholesterol;
cigarette/tobacco smoke;
high blood pressure; and
and physical inactivity.

Studies show that people who smoke cigarettes have more than twice the risk of heart attack as nonsmokers. Cigarette smoking is the most preventable cause of heart attack. It's also the biggest risk factor for sudden cardiac death. Even people who don't smoke, but are exposed to tobacco smoke in their daily environment, have a higher risk of heart disease. If you smoke, quit.

Blood pressure of 140/90 mm Hg (millimeters of mercury) and above increases your risk of stroke and heart attack. It should be controlled by diet or medication and diet. Have your blood pressure checked regularly. More than 40 separate studies show that heart disease is nearly twice as likely to develop in inactive people as in active ones. The best exercises condition your heart and lungs for 30-60 minutes three or four times a week. But even mild physical activities like walking for pleasure and gardening-if you do them daily - may help prevent heart disease.

Some risk factors can't be changed. They include: