Dyslipidemia is abnormal levels of lipids (cholesterol, triglycerides, or both) carried by lipoproteins in the blood. This term includes hyperlipoproteinemia (hyperlipidemia), which refers to abnormally high levels of total cholesterol, low density lipoprotein (LDL)—the bad—cholesterol, or triglycerides, as well as an abnormally low level of high density lipoprotein (HDL)—the good—cholesterol.

• Lifestyle, genetics, disorders, drugs, or a combination can contribute.
• Atherosclerosis can result, causing angina, heart attacks, strokes, and peripheral arterial disease.
• Doctors measure levels of triglycerides and the various types of cholesterol in blood.
• Exercise, dietary changes, and drugs can be effective.

Levels of lipoproteins and therefore lipids, particularly low density lipoprotein (LDL) cholesterol, increase slightly as people age. Levels are normally slightly higher in men than in women, but levels increase in women after menopause. The increase in levels of lipoproteins that occurs with age can result in dyslipidemia and increase the risk of atherosclerosis.

A high level of high density lipoprotein (HDL)—the good—cholesterol is beneficial and is not considered a disorder. A level that is too low is considered dyslipidemia and increases the risk of atherosclerosis (see Atherosclerosis).

Factors that increase the risk of dyslipidemia include the following:

• Having close relatives who have had dyslipidemia (having a family history of the disorder)
• Being overweight
• Consuming a diet high in saturated fats and cholesterol
• Being physically inactive
• Consuming large amounts of alcohol

Some people are more sensitive to the effects of diet than others, but most people are affected to some degree. One person can eat large amounts of animal fat, and the total cholesterol level does not rise above desirable levels. Another person can follow a strict low-fat diet, and the total cholesterol does not fall below a high level. This difference seems to be mostly genetically determined. A person's genetic makeup influences the rate at which the body makes, uses, and disposes of these fats. Also, body type does not always predict levels of cholesterol. Some overweight people have low cholesterol levels, and some thin people have high levels. Eating excess calories can result in high triglyceride levels, as can consuming large amounts of alcohol.

Some disorders, including some hereditary disorders (see Cholesterol Disorders: Hereditary Dyslipidemias), cause lipid levels to increase. Diabetes that is poorly controlled or kidney failure can cause total cholesterol levels or triglyceride levels to increase. Some liver disorders and an underactive thyroid gland (hypothyroidism) can cause the total cholesterol level to increase.

Use of drugs such as estrogens (taken by mouth), oral contraceptives, corticosteroids, retinoids, thiazide diuretics (to some extent), and possibly antiviral drugs used to treat human immunodeficiency virus (HIV) infection and AIDS can cause triglyceride levels to increase.

Cigarette smoking, poorly controlled diabetes, or kidney disorders (such as nephrotic syndrome) may contribute to a low HDL cholesterol level. Drugs such as beta-blockers and anabolic steroids can lower the HDL cholesterol level.

Symptoms

High lipid levels in the blood usually cause no symptoms. Occasionally, when levels are particularly high, fat is deposited in the skin and tendons and forms bumps called xanthomas. Very high triglyceride levels can cause the liver or spleen to enlarge and may increase the risk of developing pancreatitis. Pancreatitis can cause severe abdominal pain and is occasionally fatal.

The risk of developing atherosclerosis increases as the total cholesterol level increases, even if the level is not high enough to be considered dyslipidemia. Atherosclerosis can affect the arteries that supply blood to the heart (causing coronary artery disease), those that supply blood to the brain (causing cerebrovascular disease), and those that supply the rest of the body (causing peripheral arterial disease). Therefore, having a high total cholesterol level also increases the risk of having a heart attack or stroke. Having a low total cholesterol level is generally considered better than having a high one. However, having a very low cholesterol level may not be healthy either (see Cholesterol Disorders: Hypolipoproteinemia). For adults, a total cholesterol level of less than 200 mg/dL is desirable. In parts of the world (such as China and Japan) where the average cholesterol level is 150 mg/dL, coronary artery disease is less common than it is in countries such as the United States. The risk of a heart attack more than doubles when the total cholesterol level approaches 300 mg/dL.

The total cholesterol level is only a general guide to the risk of atherosclerosis. Levels of the components of total cholesterol—particularly LDL and HDL cholesterol—are more important. A high level of LDL (bad) cholesterol increases the risk. A high level of HDL (good) cholesterol decreases the risk, and a low level of HDL cholesterol (defined as less than 40 mg/dL) increases the risk. Experts consider an LDL cholesterol level of less than 100 mg/dL optimal.

Whether high triglyceride levels increase the risk of a heart attack or stroke is uncertain. Triglyceride levels higher than 150 mg/dL are considered abnormal, but high levels do not appear to increase risk for everyone. For people with high triglyceride levels, the risk of heart attack or stroke is increased if they also have a low HDL cholesterol level, diabetes, kidney disease, or many close relatives who have had atherosclerosis (family history).

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Desirable Lipid Levels in Adults Lipid Goal (mg/dL)* Total cholesterol Less than 200 mg/dL Low-density lipoprotein (LDL) cholesterol Less than 100 mg/dL High-density lipoprotein (HDL) cholesterol More than 40 mg/dL Triglycerides Less than 150 mg/dL *mg/dL = milligrams per deciliter of blood.

Diagnosis

Levels of total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides—the lipid profile—are measured in a blood sample. The lipid profile should be measured in all adults 20 years and older, and the measurement should be repeated every 5 years. Because consuming food or beverages may cause triglyceride levels to increase temporarily, people must fast at least 12 hours before the blood sample is taken.

When lipid levels in the blood are very high, special blood tests are done to identify the specific underlying disorder. Specific disorders include several hereditary disorders (hereditary dyslipidemias), which produce different lipid abnormalities and have different risks.

Did You Know... Margarines made primarily from liquid oil (squeeze or tub margarines) and those that contain plant stanols or sterols, unlike stick margarines, are healthier substitutes for butter.

Treatment

Usually, the best treatment for people is to lose weight if they are overweight, stop smoking if they smoke, decrease the total amount of fat and cholesterol in their diet, increase physical activity, and then, if necessary, take a lipid-lowering drug.

A diet low in fats and cholesterol can lower the LDL cholesterol level. Experts recommend limiting calories from fat to no more than 25 to 35% of the total calories consumed over several days.

The type of fat consumed is also important (see Coronary Artery Disease: Types of Fat). Fats may be saturated, polyunsaturated, or monounsaturated. Saturated fats increase cholesterol levels more than other forms of fat. Saturated fats should provide no more than 7 to 10% of total calories consumed each day. Polyunsaturated fats (which include omega-3 fats and omega-6 fats) and monounsaturated fats may help decrease levels of triglycerides and LDL cholesterol in the blood. The fat content of most foods is included on the label of the container.

Large amounts of saturated fats occur in meats, egg yolks, full-fat dairy products, some nuts (such as macadamia nuts), and coconut. Vegetable oils contain smaller amounts of saturated fat, but only some vegetable oils are truly low in saturated fats.

Margarine, which is produced from polyunsaturated vegetable oils, was once thought to be a healthier substitute for butter, which is high in saturated fat (about 60%). However, some margarines (and some processed foods) contain trans fats, which may increase LDL (bad) cholesterol levels and lower HDL (good) cholesterol levels. Margarines made primarily from liquid oil (squeeze or tub margarines) contain less saturated fat than butter, contain no cholesterol, and contain fewer trans fats than stick margarines. Margarines that contain plant stanols or sterols can slightly lower total and LDL cholesterol levels.

Did You Know... Eating oat bran, oatmeal, beans, peas, rice bran, barley, citrus fruits, strawberries, and apple pulp can help lower cholesterol.

Eating lots of fruits, vegetables, and grains, which are naturally low in fat and contain no cholesterol, is recommended. Also recommended are foods rich in soluble fiber, which binds fats in the intestine and helps lower the cholesterol level. Such foods include oat bran, oatmeal, beans, peas, rice bran, barley, citrus fruits, strawberries, and apple pulp. Psyllium, usually taken to relieve constipation, can also lower the cholesterol level.

Regular physical activity can help lower the LDL cholesterol level and increase the HDL cholesterol level. An example is walking briskly for 30 to 45 minutes 3 to 4 times a week.

Treatment with lipid-lowering drugs depends not only on the lipid levels but also on whether coronary artery disease, diabetes, or other major risk factors for coronary artery disease (see Coronary Artery Disease: Overview of Coronary Artery Disease) are present. For people who have coronary artery disease or diabetes, the goal for the LDL cholesterol level is 100 mg/dL or less. Consequently, such people usually require lipid-lowering drugs. For people who do not have coronary artery disease or diabetes but have two or more other risk factors for coronary artery disease, the goal is 130 mg/dL or less. For those with one or no risk factors, the goal is 160 mg/dL or less.

There are different types of lipid-lowering drugs: bile acid binders, fibric acid derivatives, niacin (a lipoprotein synthesis inhibitor), cholesterol absorption inhibitors, supplements of omega-3 fats, and statins. Each type lowers lipid levels by a different mechanism. Consequently, the different types of drugs have different side effects and may affect lipid levels differently. Following a low-fat diet when drugs are used is recommended.

Lipid-lowering drugs do more than lower lipid levels—they can also prevent coronary artery disease. In addition, niacin and statins have been shown to reduce the risk of early death.

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Limiting Fat and Cholesterol in the Diet Type of Fat Recommended Amounts Food Sources Saturated 7-10% of total calories Less than 7% for people who have high lipid levels or coronary artery disease Meats Nonskim dairy products, such as whole milk, cheese, and butter Artificially hydrogenated vegetable oils Polyunsaturated Up to 10% of total calories Monounsaturated Up to 20% of total calories Canola oil Olive oil Nuts Avocado Cholesterol Less than 0.3 grams (300 milligrams) a day Less than 0.2 grams (200 milligrams) a day for people with high lipid levels or coronary artery disease Egg yolks Organ meats, such as liver Meat Poultry Fish and other seafood Nonskim dairy products

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A Practical Approach to a Low-Cholesterol, Low-Saturated Fat Diet Foods to Reduce Foods to Choose Meats and meat products Fatty cuts of beef, lamb, and pork Spareribs Organ meats, such as liver Regular cold cuts Sausage Hot dogs Fish Chicken and turkey (without the skin) Lean cuts of beef, lamb, pork, and veal Dairy products and eggs Whole milk Evaporated or condensed whole milk Cream Half-and-half Most nondairy creamers Nonfat (skim) milk ½% fat milk 1% fat milk Buttermilk Whipped toppings Low or nonfat whipped toppings Whole-milk yogurt Whole-milk cottage cheese Cheeses (such as blue, Roquefort, Camembert, cheddar, and Swiss) Cream cheese Sour cream Ice cream Nonfat or low-fat yogurt Low-fat cottage cheese Low-fat cheeses Low or nonfat sour cream Sherbet, sorbet, and frozen low-fat yogurt Butter and butter-margarine mixtures Less solid forms of margarines made from liquid vegetable oils (packaged in a tub or squeeze bottle) Olive oil Canola oil Margarine products containing a plant sterol or stanol Egg yolks (to less than 3 a week) Cholesterol-free egg substitutes Egg whites (2 whole egg whites can be substituted for 1 egg in recipes) Commercial baked goods Pies Cakes Doughnuts Croissants Pastries Muffins Biscuits High-fat crackers High-fat cookies Egg noodles Breads made with several eggs Homemade baked goods made with unsaturated oils Angel food cake Low-fat cookies and crackers Whole-grain* (oatmeal, bran, rye, and multigrain) breads and cereals Saturated fats and oils Chocolate Cocoa powder Carob Nonfat chocolate syrup Coconut oil Palm oil Lard Bacon Unsaturated vegetable oils: canola, olive, corn, safflower, sesame, soybean, and sunflower Dressings Dressings made with egg yolk Low-fat mayonnaise and salad dressings made with liquid oils Fruits and vegetables Fruits and vegetables prepared in butter, saturated fats, cream, or sauces made with saturated fat Fresh, frozen, canned, and dried fruits or vegetables* Coconut Seeds and nuts* *Fruits, vegetables, grains, seeds, and nuts contain no cholesterol, and most contain little or no saturated fat. A Practical Approach to a Low-Cholesterol, Low-Saturated Fat Diet Foods to Reduce Foods to Choose Meats and meat products Fatty cuts of beef, lamb, and pork Spareribs Organ meats, such as liver Regular cold cuts Sausage Hot dogs Fish Chicken and turkey (without the skin) Lean cuts of beef, lamb, pork, and veal Dairy products and eggs Whole milk Evaporated or condensed whole milk Cream Half-and-half Most nondairy creamers Nonfat (skim) milk ½% fat milk 1% fat milk Buttermilk Whipped toppings Low or nonfat whipped toppings Whole-milk yogurt Whole-milk cottage cheese Cheeses (such as blue, Roquefort, Camembert, cheddar, and Swiss) Cream cheese Sour cream Ice cream Nonfat or low-fat yogurt Low-fat cottage cheese Low-fat cheeses Low or nonfat sour cream Sherbet, sorbet, and frozen low-fat yogurt Butter and butter-margarine mixtures Less solid forms of margarines made from liquid vegetable oils (packaged in a tub or squeeze bottle) Olive oil Canola oil Margarine products containing a plant sterol or stanol Egg yolks (to less than 3 a week) Cholesterol-free egg substitutes Egg whites (2 whole egg whites can be substituted for 1 egg in recipes) Commercial baked goods Pies Cakes Doughnuts Croissants Pastries Muffins Biscuits High-fat crackers High-fat cookies Egg noodles Breads made with several eggs Homemade baked goods made with unsaturated oils Angel food cake Low-fat cookies and crackers Whole-grain* (oatmeal, bran, rye, and multigrain) breads and cereals Saturated fats and oils Chocolate Cocoa powder Carob Nonfat chocolate syrup Coconut oil Palm oil Lard Bacon Unsaturated vegetable oils: canola, olive, corn, safflower, sesame, soybean, and sunflower Dressings Dressings made with egg yolk Low-fat mayonnaise and salad dressings made with liquid oils Fruits and vegetables Fruits and vegetables prepared in butter, saturated fats, cream, or sauces made with saturated fat Fresh, frozen, canned, and dried fruits or vegetables* Coconut Seeds and nuts* *Fruits, vegetables, grains, seeds, and nuts contain no cholesterol, and most contain little or no saturated fat.

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Lipid-Lowering Drugs Type Mechanism of Action Indications Some Side Effects Bile acid binders Cholestyramine Colesevelam Colestipol Bind bile acids in the intestine, causing the acids to be excreted rather than used to make bile and causing the liver to remove more LDL cholesterol from the bloodstream to make bile High LDL cholesterol Abdominal pain Binding of some other drugs (reducing their effectiveness) Bloating Constipation Nausea Increase in triglyceride level (slight) Cholesterol absorption inhibitor Ezetimibe Decreases cholesterol absorption in the small intestine High LDL cholesterol Few serious side effects Face and lip swelling (rare) Loose stools Muscle aches Fibric acid derivatives Bezafibrate* Ciprofibrate* Fenofibrate Gemfibrozil Increase the breakdown of lipids and speed the removal of VLDL from the bloodstream May decrease VLDL production by the liver High triglycerides Low HDL cholesterol Dysbetalipoproteinemia Possibly high VLDL cholesterol Abdominal pain Bloating Diarrhea Gallstones High liver enzyme levels Muscle aches due to inflammation (myositis) Nausea Rash Lipoprotein synthesis inhibitor Niacin Slows removal of HDL Lowers triglyceride levels At high doses, decreases production rate of VLDL, which is used to synthesize LDL High triglycerides Low HDL cholesterol High LDL and VLDL cholesterol Dysbetalipoproteinemia Digestive upset Flushing Gout High blood sugar level (hyperglycemia) High liver enzyme levels Itching Ulcers Statins (HMG-CoA reductase inhibitors) Atorvastatin Fluvastatin Lovastatin Pravastatin Rosuvastatin Simvastatin Block the synthesis of cholesterol, increasing the removal of LDL from the bloodstream High LDL cholesterol, triglycerides, or both Bloating Constipation (mild) Fatigue Headache Loose stools Rarely, high liver enzyme levels Rarely, muscle aches due to inflammation (myositis) or degeneration (rhabdomyolysis) Fat supplements Omega-3 fatty acids Lower levels of triglycerides May decrease production of VLDL High triglycerides Belching Diarrhea Weight gain if taken in addition to other fats (instead of as substitutes) HDL = high density lipoprotein; HMG-CoA = 3-hydroxy-3-methylglutaryl coenzyme A; LDL = low density lipoprotein. *Not available in the United States. Lipid-Lowering Drugs Type Mechanism of Action Indications Some Side Effects Bile acid binders Cholestyramine Colesevelam Colestipol Bind bile acids in the intestine, causing the acids to be excreted rather than used to make bile and causing the liver to remove more LDL cholesterol from the bloodstream to make bile High LDL cholesterol Abdominal pain Binding of some other drugs (reducing their effectiveness) Bloating Constipation Nausea Increase in triglyceride level (slight) Cholesterol absorption inhibitor Ezetimibe Decreases cholesterol absorption in the small intestine High LDL cholesterol Few serious side effects Face and lip swelling (rare) Loose stools Muscle aches Fibric acid derivatives Bezafibrate* Ciprofibrate* Fenofibrate Gemfibrozil Increase the breakdown of lipids and speed the removal of VLDL from the bloodstream May decrease VLDL production by the liver High triglycerides Low HDL cholesterol Dysbetalipoproteinemia Possibly high VLDL cholesterol Abdominal pain Bloating Diarrhea Gallstones High liver enzyme levels Muscle aches due to inflammation (myositis) Nausea Rash Lipoprotein synthesis inhibitor Niacin Slows removal of HDL Lowers triglyceride levels At high doses, decreases production rate of VLDL, which is used to synthesize LDL High triglycerides Low HDL cholesterol High LDL and VLDL cholesterol Dysbetalipoproteinemia Digestive upset Flushing Gout High blood sugar level (hyperglycemia) High liver enzyme levels Itching Ulcers Statins (HMG-CoA reductase inhibitors) Atorvastatin Fluvastatin Lovastatin Pravastatin Rosuvastatin Simvastatin Block the synthesis of cholesterol, increasing the removal of LDL from the bloodstream High LDL cholesterol, triglycerides, or both Bloating Constipation (mild) Fatigue Headache Loose stools Rarely, high liver enzyme levels Rarely, muscle aches due to inflammation (myositis) or degeneration (rhabdomyolysis) Fat supplements Omega-3 fatty acids Lower levels of triglycerides May decrease production of VLDL High triglycerides Belching Diarrhea Weight gain if taken in addition to other fats (instead of as substitutes) HDL = high density lipoprotein; HMG-CoA = 3-hydroxy-3-methylglutaryl coenzyme A; LDL = low density lipoprotein. *Not available in the United States.

Hereditary Dyslipidemias

Cholesterol and triglyceride levels are highest in people with hereditary dyslipidemias, which interfere with the body's metabolism and elimination of lipids. People can also inherit a tendency for HDL cholesterol to be unusually low. Consequences of hereditary dyslipidemias can include premature atherosclerosis, which can lead to angina or heart attacks. Peripheral arterial disease is also a consequence, often causing decreased blood flow to the legs, with pain during walking (claudication—see Peripheral Arterial Disease: Arteries of the Legs and Arms). Stroke is another possible consequence.

In lipoprotein lipase deficiency and apolipoprotein CII deficiency, rare disorders caused by the lack of certain proteins needed for the removal of triglyceride-containing particles, the body cannot remove chylomicrons from the bloodstream, resulting in very high triglyceride levels. Without treatment, levels are often considerably higher than 1,000 mg/dL. Symptoms appear during childhood and young adulthood. They include recurring bouts of abdominal pain, an enlarged liver and spleen, and pinkish yellow bumps in the skin on the elbows, knees, buttocks, back, front of the legs, and back of the arms. These bumps, called eruptive xanthomas, are deposits of fat. Eating fats worsens symptoms. Although this disorder does not lead to atherosclerosis, it can cause pancreatitis, which is occasionally fatal. People who have this disorder must avoid eating fats of all types—saturated, unsaturated, and polyunsaturated.

In familial hypercholesterolemia, the total cholesterol level is high. This severe disorder affects about 1 of 500 people. People may have inherited one abnormal gene or they may have inherited two abnormal genes, one from each parent. People who have two abnormal genes (homozygotes) are more severely affected than people who have only one abnormal gene (heterozygotes). Affected people may have fatty deposits (xanthomas) in the tendons at the heels, knees, elbows, and fingers. Rarely, xanthomas appear by age 10. Familial hypercholesterolemia can result in rapidly progressive atherosclerosis and early death due to coronary artery disease. Children with two abnormal genes may have a heart attack or angina by age 20, and men with one abnormal gene often develop coronary artery disease between ages 30 and 50. Women with one abnormal gene are also at increased risk, but the risk starts later.

Treatment begins with following a diet that is low in saturated fats and cholesterol. When applicable, losing weight, stopping smoking, and increasing physical activity are advised. One or more lipid-lowering drugs are usually needed. Some people benefit from a liver transplant.

In familial combined hyperlipidemia, the levels of cholesterol, triglycerides, or both may be high. This disorder affects about 1 to 2% of people. The lipid levels typically become abnormal after age 30 but sometimes at a younger age, especially in people who are overweight, who have a diet that is very high in fat, or who have metabolic syndrome (see Obesity and the Metabolic Syndrome: Metabolic Syndrome).

Treatment involves limiting intake of fat, cholesterol, and sugar as well as exercising and, when applicable, losing weight. Many people with this disorder need to take lipid-lowering drugs.

In familial dysbetalipoproteinemia, levels of VLDL and total cholesterol and triglycerides are high. These levels are high because an unusual form of VLDL accumulates in the blood. Fatty deposits (xanthomas) may form in the skin over the elbows and knees and in the palms, where they can cause yellow creases. This uncommon disorder results in the early development of severe atherosclerosis. By middle age, atherosclerosis often produces blockages in the coronary and peripheral arteries.

Treatment involves achieving and maintaining recommended body weight and limiting intake of cholesterol, saturated fats, and carbohydrates. A lipid-lowering drug is usually needed. With treatment, lipid levels can be improved, the progression of atherosclerosis may be slowed, and the fatty deposits in the skin may become smaller or disappear.

In familial hypertriglyceridemia, triglyceride levels are high. This disorder affects about 1% of people. In some families affected by this disorder, atherosclerosis tends to develop at a young age, but in others, it does not. When applicable, losing weight and limiting alcohol consumption often lower triglyceride levels to normal. If these measures are ineffective, use of a lipid-lowering drug can help. For people who also have diabetes, good control of the diabetes is important.

In hypoalphalipoproteinemia, the HDL cholesterol level is low. A low HDL cholesterol level is often inherited. Many different genetic abnormalities can cause the low HDL level.

In people who have a genetic disorder that causes high triglycerides (such as familial hypertriglyceridemia or familial combined hyperlipidemia), certain disorders and substances can increase triglycerides to extremely high levels. Examples of disorders include poorly controlled diabetes and kidney dysfunction. Examples of substances include excessive alcohol consumption and use of certain drugs that increase triglyceride levels. Symptoms can include fatty deposits (eruptive xanthomas) in the skin on the front of the legs and back of the arms, an enlarged spleen and liver, abdominal pain, and a decreased sensitivity to touch due to nerve damage. This disorder can cause pancreatitis, which is occasionally fatal. Limiting fat intake (to less than 50 grams a day) can help prevent nerve damage and pancreatitis. Losing weight and not drinking alcohol can also help. Lipid-lowering drugs may be effective.

Last full review/revision August 2008 by Anne Carol Goldberg, MD