Hypercholesterolemia, or hyperlipidemia—abnormally high levels of fats (cholesterol, triglycerides, or both) in the blood—may be present without symptoms and yet put the patient at risk for generalized atherosclerosis, coronary artery disease or carotid artery disease. The risk of having a heart attack or stroke increases as a person's total cholesterol level increases. Total cholesterol level is ideally about 140 to 200 milligrams of cholesterol per deciliter of blood (mg/dL) or less. Moderate risk is 200 to 240 mg/dL; high risk is 240 mg/dL or higher.

Cholesterol and triglyceride levels are highest in people with hereditary hyperlipidemia, sometimes regardless of their diet and exercise level. Hereditary hyperlipidemia, or hyperlipoproteinemia, is a condition that interferes with the body's ability to metabolize and eliminate fats. Each of the five main types of hyperlipoproteinemia produces a different profile and risks.

• Type I hyperlipoproteinemia (familial hyperchylomicronemia) is a rare disorder, present at birth. Patients have recurrent bouts of abdominal pain and an enlarged liver and spleen, and develop xanthomas on their skin.
• Type II hyperlipoproteinemia (familial hypercholesterolemia) results in accelerated atherosclerosis and early death, usually from a heart attack. Patients have a high level of LDL cholesterol, and xanthomas grow in the tendons and skin.
• Type III hyperlipoproteinemia leads to high levels of VLDL cholesterol and triglycerides. Atherosclerosis often blocks arteries and reduces blood flow to the legs by middle age.
• Type IV hyperlipoproteinemia is common and affects several members of a family. A high level of triglycerides may increase a person's risk of developing atherosclerosis.
• Type V hyperlipoproteinemia is uncommon. The body can't metabolize and eliminate excess triglycerides. Although hereditary, it can result from alcohol abuse, poorly controlled diabetes, kidney failure, or eating after a period of starvation.

High fat levels:

• A diet high in saturated fat and cholesterol
• Cirrhosis of the liver
• Poorly controlled diabetes
• Underactive thyroid gland
• Overactive pituitary gland
• Kidney failure
• Porphyria
• Heredity

High triglyceride levels:

• Excess calories in diet
• Acute and chronic alcohol abuse
• Severe uncontrolled diabetes
• Kidney failure
• Certain drugs (estrogens, oral contraceptives, corticosteroids, and to some extent thiazide diuretics)
• Elevated serum insulin

• Obesity
• Diet rich in saturated fat
• Sedentary lifestyle
• Stress
• Hereditary hyperlipidemia
• Hyperhomocysteinemia

High fat levels may cause few, if any, symptoms. Diagnosis is usually made through blood tests. Severe symptoms may include:

• Fat deposits that form growths, or xanthomas, in the tendons and skin
• Extremely high levels of triglycerides (800 mg/dL and higher), which may cause enlargement of the liver and spleen and symptoms of pancreatitis, such as severe abdominal pain

• Hypothyroidism
• Obstructed liver disease
• Nephrotic syndrome
• Diabetes

See "Signs and Symptoms" above.

A blood sample determines total cholesterol. A sample used to measure HDL cholesterol, LDL cholesterol, and triglycerides is most effective after 12 hours of fasting. The following results represent the ideal range:

• Total cholesterol: 120 to 200 mg/dL
• Chylomicrons: None (after 12 hours of fasting)
• Very-low-density lipoproteins (VLDL): 1 to 30 mg/dL
• Low-density lipoproteins (LDL): 60 to 160 mg/dL
• High-density lipoproteins (HDL): 35 to 65 mg/dL
• LDL to HDL ratio: less than 3.5
• Triglycerides: 10 to 160 mg/dL

• Clinical observation of suspected hypercholesterolemia or a routine health screening will provide laboratory confirmation of elevated cholesterol triglycerides.
• Serum or urinary homocysteine levels

• Diet should be low in cholesterol and saturated fat to reduce LDL cholesterol level.
• Exercise to reduce LDL cholesterol level and increase HDL cholesterol level.
• Drinking a small amount of alcohol on a regular basis may raise HDL cholesterol level and lower LDL cholesterol level, but more than two drinks daily could have the opposite effect.
• Maintain an appropriate weight.
• Stop smoking.
• Avoid caffeine (may increase cholesterol levels).
• Consider a lipid-lowering drug for high cholesterol levels if behavioral intervention trial is unsuccessful.
• When cholesterol levels are very high and don't respond to usual treatments, specific blood tests are in order to identify the exact cause of the condition and to treat it appropriately.

• Bile acid sequestrants: cholestyramine/cholestipol—used to treat elevated LDL by promoting bile acid excretion and increasing LDL receptors in liver. One to six packets per day. Common side effects include bloating, constipation, and elevated triglycerides.
• Nicotinic acid—used to treat elevated LDL and VLDL by decreasing VLDL synthesis. 500 mg to 3 g/day to tid can cause cutaneous flushing, GI upset (which usually resolve over a few weeks), and elevated glucose, uric acid, and liver function tests
• HMG-CoA reductase inhibitors (statins): pravastatin, simvastatin, atorvastatin, fluvastatin, and lovastatin treat elevated LDL. 20 to 80 mg/day, single or divided dose. These drugs inhibit cholesterol synthesis and upregulate LDL receptors in the liver. Side effects include myositis (muscle inflammation), arthralgias (joint pains), GI upset, and elevated liver function tests.
• Fibric acid derivatives: gemfibrozil—used to treat elevated triglycerides and elevated remnants by stimulating lipoprotein lipase (an enzyme that breaks down lipids in lipoproteins). May decrease VLDL synthesis. Side effects include myositis (muscle inflammation), GI upset, gallstones, and elevated liver function tests.

The digestion, metabolism, and utilization of fats, as well as minimizing the effects of hypercholesterolemia, are areas in which alternative therapies can be very effective. Begin with dietary suggestions and nutritional support, as needed. Herbs can be used to facilitate the metabolism of cholesterol.

• Avoid saturated fats which contribute to cholesterol synthesis and contribute to oxidative stress.
• Vegetable proteins have been shown to lower cholesterol levels, while animal and milk proteins have been shown to raise them. Thus a vegetarian or semi-vegetarian diet has been shown to be efficacious in lowering cholesterol.
• Increase foods high in omega-3 oils which can help decrease cholesterol (cold water fish, nuts, and seeds).
• Reduce consumption of sugar and simple carbohydrates. The digestion of these foods causes a rise in serum insulin which can lead to an increase in lipid production.
• Include foods that help reduce cholesterol, such as those high in water-soluble fiber—legumes, grains, and fruits containing pectin.
• Increase foods that support the liver, such as beets, carrots, yams, artichokes, dark bitter greens, and lemons.
• Consider digestive enzymes in cases where poor fat digestion is a factor.
• Omega-3 fatty acids (1,000 to 1,500 mg bid to tid) decrease synthesis, increase breakdown of triglycerides, and lower total cholesterol levels. Found in fish oil capsules (EPA's eicosapentaenoic acid) and flaxseed.
• Niacin reduces total cholesterol while increasing the levels of the protective lipoprotein HDL. The amount of niacin needed to achieve these results is very high. Inositol hexaniacinate (IHN) 500 mg tid causes no short-term reactions, and is safe for the liver.
• Selenium (200 mcg/day) is needed for normal lipid metabolism.
• l-Taurine (200 mg/day) conjugates cholesterol and facilitates its excretion.
• Vitamin C (1,000 mg tid) and vitamin E (400 to 800 IU/day) decrease oxidative stress and are needed for cholesterol metabolism.
• B complex, especially vitamin B12 (1,000 mcg/day), folic acid (400 to 800 mcg/day), betaine (1,000 mg/day), and vitamin B6 (50 to 100 mg/day), are essential to methionine metabolism. The addition of these vitamins will reduce high levels of homocysteine.
• Coenzyme Q10 (50 to 100 mg/day) is an antioxidant and reduces oxidative damage to the circulatory system.
• Chromium (200 mcg one to three times a day) helps to stabilize glucose levels and reduce lipid oxidation secondary to diabetes.
• Magnesium (200 mg bid to tid) is needed for many metabolic pathways and has blood pressure lowering effects.
• Panthenine (500 mg tid) is a form of pantothenic acid that has shown effectiveness in reducing serum cholesterol.

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, it is important to ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites, or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 10 to 20 minutes and drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted.

• Garlic (Allium sativum) has the effect of reducing cholesterol. It is most effective when included in the diet in the raw form, or taken in capsules.
• Herbs that support the liver, and promote bile production and excretion may be taken singly or in combination. Herbs to consider include milk thistle (Silybum marianum), dandelion root (Taraxacum officinale), burdock root (Arctium lappa), blue flag (Iris versicolor), greater celandine (Chelidonium majus), and blue vervain (Verbena hastata). Greater celandine should be taken with caution (no more than 2 ml/day) as it can lead to bilary colic. Tinctures (15 to 20 drops/dose), or infusions (1 heaping tsp./dose), are best taken 10 to 20 minutes before meals.
• Hawthorn berries (Crataegus laevigata) help to lower high blood pressure, promote cholesterol metabolism, and suppress cholesterol synthesis, as well as strengthen connective tissue and cardiac muscle. Dried extracts are taken 200 mg bid to tid, or tincture 30 drops tid.
• Ginger (Zingiber officinale) has been shown to lower cholesterol levels.
• Alfalfa (Medicago sativa) has been shown to lower cholesterol levels.

An experienced homeopath should assess individual constitutional types and severity of disease to select the correct remedy and potency. For acute prescribing use 3 to 5 pellets of a 12X to 30C remedy every 1 to 4 hours until acute symptoms resolve. Constitutional homeopathy is useful as a supportive therapy.

Acupuncture can assist with improving liver/gallbladder function, and in strengthening the cardiovascular system.

Avoiding high-fat foods can help reduce cholesterol, and some foods actually have a cholesterol-lowering effect (see "Nutrition").

Lifestyle changes (quitting smoking, eating a low-fat diet, exercising, and reducing stress) are recommended first. If these actions aren't adequate, then lipid-lowering drugs can be prescribed.

• Atherosclerosis
• Coronary heart disease

Maintaining an appropriate weight, eating a low-fat diet, and exercising can have a significant impact on the patient's cholesterol level and long-term prognosis.

Auer W, Eiber A, Hertkorn E, et al. Hypertension and hyperlipidaemia: garlic helps in mild cases. Br J Clin Pract. 1990;44:3-9.

Barrie SA, Wright JV, Pizzorno JE. Effects of garlic on platelet aggregation, serum lipids and blood pressure in humans. J Orthomelec Med. 1987;2:15-21.

Bordia A. Effect of garlic on blood lipids in patients with coronary heart disease. Am J Clin Nutr. 1981;34:2100-2103.

Bordia A, Bansal HC, Arora SK, et al. Effect of the essential oils of garlic and onion on alimentary hyperlipemia. Atherosclerosis. 1975;21:15-19.

Jain AK, Vargas R, et al. Can garlic reduce levels of serum lipids? A controlled clinical study. Am J Med. 1993;94:632-635.

Johns Hopkins Health Information. Accessed at http://www.intelihealth.com on January 25, 1999.

Murray MT, Pizzorno JE. The Encyclopedia of Natural Medicine. 2nd ed. Rocklin, Calif: Prima Publishing; 1998.

Silagy C, Neil A. Garlic as a lipid lowering agent—a meta-analysis. JR Coll Physicians Lond. 1994;28:39-45.

Steiner M, Khan AH, Holbert D, Lin RI. A double-blind crossover study in moderately hypercholesterolemic men that compared the effect of aged garlic extract and placebo administration on blood lipids. Am J Clin Nutr. 1996;64:866-870.

Vorberg G, Scneider B. Therapy with garlic: results of a placebo-controlled, double-blind study. Br J Clin Pract. 1990;7-11.

Warshafsky S, Kramer RS, Sivak SL. Effect of garlic on total serum cholesterol: a meta-analysis. Ann Intern Med. 1993;119:599-605.

Werbach M. Nutritional Influences on Illness. New Canaan, Conn: Keats Publishing; 1988.

Yamamoto M. Serum HDL-cholesterol increasing and fatty liver improving actions of Panax ginseng in high cholesterol diet-fed rats with clinical affect on hyperlipidemia in man. Am J Chin Med. 1983;1:96-101.