A total cholesterol of 220 mg/dL falls into the “borderline high” category, which covers readings between 200 and 239 mg/dL. It’s not in the “high” range (240 and above), but it’s above the desirable level of under 200. Whether 220 is something to worry about depends heavily on what’s driving that number, specifically the balance between your “good” and “bad” cholesterol.
Where 220 Falls on the Scale
Medical guidelines break total cholesterol into three tiers: below 200 mg/dL is desirable, 200 to 239 is borderline high, and 240 or above is high. At 220, you’re squarely in the middle zone. That means your cholesterol isn’t at a crisis point, but it’s elevated enough that your body is carrying more cholesterol than ideal through your bloodstream.
Over time, excess cholesterol can combine with other substances to form plaque deposits on the inner walls of your arteries. This gradually narrows blood vessels and makes them stiffer, a process called atherosclerosis. Narrowed arteries raise the risk of blood clots, which can lead to heart attacks, strokes, and other cardiovascular problems. The process is slow, which is why borderline numbers often get ignored, but the damage accumulates over years.
Total Cholesterol Doesn’t Tell the Full Story
A total cholesterol reading is the sum of several components, and two people with the same 220 can have very different risk profiles. The number that matters most is LDL cholesterol, often called “bad” cholesterol, because it’s the type that builds up in artery walls. Current guidelines from the American Heart Association and American College of Cardiology set optimal LDL below 100 mg/dL for the general population. Levels of 100 to 159 are considered elevated, and 160 or above is considered dangerous. People with existing heart disease should aim for LDL below 70 mg/dL.
HDL cholesterol, the “good” kind, works in the opposite direction. HDL particles pick up excess cholesterol from your blood and deliver it to your liver, which breaks it down and sends it out of your body. Higher HDL levels are linked to lower heart disease risk. So if your total cholesterol is 220 but a significant portion of that comes from high HDL (say, 70 or 80 mg/dL), your actual cardiovascular risk is lower than someone whose 220 is mostly driven by high LDL.
This is why doctors order a full lipid panel rather than relying on the total number alone. The breakdown between LDL, HDL, and triglycerides is what determines whether a reading of 220 needs aggressive treatment or just some lifestyle adjustments.
Your Other Risk Factors Matter Too
Cholesterol doesn’t exist in a vacuum. Doctors use a risk calculator that combines your cholesterol numbers with several other factors to estimate your 10-year risk of a cardiovascular event. Those factors include your age, sex, race, blood pressure, diabetes status, smoking history, and family history of heart disease (especially heart attacks before age 60). A 35-year-old nonsmoker with a total cholesterol of 220, normal blood pressure, and no family history is in a very different situation than a 58-year-old smoker with the same cholesterol reading and borderline high blood pressure.
This risk calculation also helps determine whether medication is warranted. Providers can model how treatments like cholesterol-lowering drugs might shift someone from intermediate risk down to low risk. For many people at 220 with few other risk factors, lifestyle changes alone are the first recommendation.
A Note on Test Accuracy
If you’re wondering whether your 220 reading might be off because you didn’t fast before the blood draw, the short answer is: it’s probably fine. A joint statement from the European Atherosclerosis Society and the European Federation of Clinical Chemistry and Laboratory Medicine concluded that fasting is not routinely required for a lipid profile. Non-fasting samples are reliable for total cholesterol, LDL, and HDL. Fasting only becomes necessary when triglycerides come back very high (above 440 mg/dL), at which point a repeat fasting test is recommended.
Lifestyle Changes That Lower Cholesterol
For a borderline reading like 220, dietary and lifestyle shifts can often bring the number down without medication. The changes that have the most evidence behind them target specific types of fat and fiber in your diet.
Reduce saturated fat. Saturated fat, found mostly in red meat and full-fat dairy, directly raises LDL cholesterol. Cutting back is one of the most effective single dietary changes you can make.
Check for trans fats. Although partially hydrogenated vegetable oils were banned in the U.S. in 2021, some older or imported products may still contain them. Look for “partially hydrogenated oil” on ingredient lists, even when the label says “0 grams” of trans fat (small amounts can be rounded down to zero).
Eat more soluble fiber. Soluble fiber physically blocks some cholesterol from being absorbed into your bloodstream. Good sources include oatmeal, kidney beans, Brussels sprouts, apples, and pears. Adding a daily serving or two of these foods can meaningfully nudge your numbers.
Add omega-3 fatty acids. Salmon, mackerel, herring, walnuts, and flaxseeds are all rich in omega-3s, which support heart health and can help improve your lipid profile.
Exercise also plays a direct role. Regular physical activity raises HDL cholesterol, which helps clear excess cholesterol from your blood. Even moderate activity like brisk walking, done consistently, makes a measurable difference over a few months.
When Medication Enters the Picture
For some people, lifestyle changes alone won’t be enough, particularly if LDL is significantly elevated or if other risk factors stack up. In those cases, cholesterol-lowering medication is the standard next step. The decision isn’t based on total cholesterol alone. It’s based on that combination of LDL levels, your overall cardiovascular risk score, and how you respond to lifestyle changes over a period of months. Many people with a total cholesterol of 220 never need medication, but those with high LDL, a family history of early heart disease, or other compounding factors may benefit from starting sooner rather than later.