High cholesterol can cause heart problems and strokes – but levels can creep up without showing any symptoms. This is why, if you’re over 40, you should be getting your cholesterol checked every five years. It’s a simple enough concept, but, like alcohol and other things that could be slowly, invisibly damaging our bodies, cholesterol can feel a little abstract, hovering in the background less urgently than everything in the foreground of a busy life.
It doesn’t help when myths are flying about online, such as eggs being unhealthy because they contain cholesterol. Or when some fringe scientists and proponents of low-carb and high-fat diets dramatically downplay cholesterol’s significance in heart disease – arguing that sugar is a bigger risk to our health, despite all the evidence to the contrary. Nor does it help us laypeople that there are so many different ways to present – and therefore interpret – cholesterol levels.
And yet, says Manuel Mayr, a cardiologist and professor at Imperial College London, it’s important to act early to avoid levels creeping up: “Take prevention very seriously, because if your cholesterol is high, if it’s over decades, it builds up in your arteries.”
It might help to think of your circulatory system as a washing machine, he says. “If you have a lot of hard water, there’s a high risk of your washing machine getting a blockage.” When it comes to high levels of bad cholesterol, blockages can cause cardiovascular disease and could result in heart attacks and strokes. “The lifetime exposure is what damages the vessels over time,” Mayr adds.
So what is the truth about cholesterol? And how do you maintain healthy levels?
What is cholesterol?
Cholesterol, says Emily McGrath, a senior cardiac nurse at the British Heart Foundation (BHF), “is a fatty substance that is found naturally as part of your circulation”. We need a certain amount, says Tracy Parker, a senior dietitian at the same organisation, “for making things like hormones – like oestrogen and testosterone. And our cells need cholesterol to make them rigid and firm and solid. But when those levels go high, that’s a problem.” Our bodies make cholesterol, but levels are also affected by lifestyle and genetics.
There are two kinds of cholesterol in the blood. Low-density lipoprotein (LDL) is known as “bad cholesterol” because too much can cause plaque to build up in the arteries, increasing the risk of heart attack or stroke. High-density lipoprotein (HDL) is the good one. “HDL helps your liver to metabolise and reabsorb LDL into the bloodstream,” says McGrath, meaning HDL helps keep LDL levels in balance.
“What has been shown in numerous studies is that if you lower your bad cholesterol,” says Mayr, “you reduce cardiovascular events.”
When should you get your cholesterol checked?
The NHS advises five-yearly checks for those aged 40-74, with annual health checks for people 75 and over, says McGrath. “But if there are concerns over family history of heart disease, or if you’re suffering with angina-type chest pain, anyone is entitled to ask their GP for a check.”
What do the tests show?
Sometimes after an initial cholesterol test, you may be given a single number for the total LDL and HDL cholesterol in your blood. Ideally, the results would show a full lipid profile, says McGrath, “because that gives you the full breakdown of HDL and LDL and triglycerides, which is another type of fat we find in the blood.” All of these details together help paint a clearer picture.
Healthy HDL levels should be above 1mmol/L for men or 1.2mmol/L for women. “I don’t think I’ve ever heard of somebody saying they’ve got too high HDL,” says McGrath. LDL levels are considered healthy if below 3mmol/L. You should also get a cholesterol ratio number, which compares how much good (HDL) cholesterol you have within your total cholesterol levels. It is your total cholesterol divided by your HDL levels, and is considered healthy if below six – the lower the better.
What are triglycerides?
This other type of blood fat is significant because, says McGrath, “some people can have good cholesterol levels but high triglyceride, and it still puts them at risk.” Triglycerides are, essentially, “unused calories, a form of stored energy. Like the LDL, you still need some of it – if you use it for energy it will be taken out of your blood – you just don’t want too much of it.” Just enough is 2.3mmol/L or less, unless you’ve been asked to fast before your blood test, in which case the healthy limit is 1.7mmol/L.
Where do genetics come in?
While a healthy diet and active lifestyle are essential for all-round health, in many of us, says Mayr, “lipid levels are genetic, and if you have very high cholesterol, and you’re unfortunate to have inherited this from your parents, you need medication, because you can’t reach the target level just by making diet changes”.
The most common genetic lipid disorder, says McGrath, is familial hypercholesterolemia, which affects about one in 250 people: “If your father or your brother was under the age of 55 when they had a heart attack, or your mother or your sister were under 65, that’s an indication” that you might have it – and it’s worth getting your cholesterol tested. “Some people, unfortunately, might be the first person,” she adds. “So they don’t have any family history and find out by accident, or if, unfortunately, they have a heart attack.”
What else affects your risk of heart disease?
Cholesterol levels are usually given as part of a “key risk assessment”, which takes a range of factors into account. “Age, weight, family history, smoking status, alcohol intake, whether you have high blood pressure, ethnicity and gender. Men are at slightly increased risk of having high blood pressure, for example,” says McGrath. “If the key risk assessment is above 10%, you will be offered a statin.” Statins inhibit an enzyme the liver needs to make cholesterol, which reduces the amount of LDL cholesterol in the blood. They also reduce the risk of plaques breaking off from artery walls and causing blockages.
If you’re offered statins, can you try lifestyle changes instead?
If your high cholesterol isn’t down to genetics, you are entitled to say that you’d like to trial lifestyle changes before medication, says McGrath. “Most GPs will be willing to let that person have a try at reducing it themselves and then seeing how they get on. It’s a conversation for the doctor and you.” A doctor would consider how much your cholesterol level is above five, and your other risk factors.
Exercise works wonders for that all-important cholesterol ratio by decreasing LDL and increasing HDL. And a healthy diet (more of which below) not only affects how much fat is floating around your blood, but it also helps the liver clear more LDL cholesterol. “On the surface of the liver you have LDL receptors, which are responsible for the metabolism of cholesterol,” says McGrath. “And you want a lot of these, so there are more to receive the bad cholesterol.” This boost in LDL receptors also happens when you take statins.
After making positive lifestyle adjustments, McGrath says you could start seeing results after six to eight weeks. “It can be that quick. And then you’ll probably be set a new target.”
Parker says that generally, “when you’re asking people to make changes to their diet, we get them to come back in three months and see what the effect is on their cholesterol levels. It’s hard for a lot of people, but small, simple changes make a big difference. Those healthy swaps. You may not be changing everything, but changing from a full-fat milk to a low-fat milk, or butter to an unsaturated fat spread, or cutting down on processed meat – those little things make a big difference over time. If you do it right most of the time, five out of seven days, you’re probably doing all right.”
How does body weight affect cholesterol levels?
Not everybody who is overweight or obese will have high cholesterol, but, says McGrath, “it’s a contributing factor. Your risk of heart disease increases when you have high cholesterol, high blood pressure, you’re overweight or obese, you’re inactive or have a poor diet. But if you’ve got high cholesterol and you are overweight or obese, losing weight will bring your cholesterol levels down.”
What are the best foods for good cholesterol?
All dietary fibre helps to lower cholesterol, says Parker, but the soluble fibre you find in oats, beans and lentils has an added effect. “It’s a particular type of fibre called beta-glucans. It forms a gel in the gut that stops cholesterol being absorbed into the body, and then you excrete it. Around 3g a day can help to maintain or lower cholesterol levels.” A bowl of porridge with about 40g of oats will provide about 1.4g of beta-glucans.
Oatcakes, beans and pulses are high in both general fibre and soluble fibre, “and a great low-fat protein source as well”, Parker adds. “So when you’re replacing meat in the diet with beans and lentils, you get this dual action to help lower your cholesterol.” This is part of the reason why a largely plant-based diet is recommended: “more fibre, more vitamins and minerals”. Most of us are still only consuming three of the five recommended portions of fruit and veg a day. “That includes things like unsalted nuts and seeds as well, because they contain healthy unsaturated fats, as well as fibre and other vitamins and minerals. You might have heard all these foods classed as the ‘portfolio diet’, as a group of foods that work together to help lower your cholesterol.”
Unsaturated “good” fats mean, says Parker, “monounsaturated oils that we find in things like olive oil, rapeseed oil, avocados, olives and nuts such as almonds, hazelnuts, pistachios. And not forgetting things like oily fish and linseed oils – they’re all the healthy fats we need to be eating more of. So it’s not really about low fat. It is about eating the right type of fats.”
What are the worst foods for cholesterol levels?
“When we talk about lowering cholesterol, it’s about reducing saturated fat in the diet, as we know that that’s linked to raised LDL cholesterol,” says Parker.
Foods high in saturated fat include processed meats and high-fat dairy such as butter and cream. Parker also mentions “the tropical oils, such as coconut (which has about 85% saturated fat) and palm oil (which has about twice the saturated fat of butter). They’re the foods that tend to hike your cholesterol levels up, and we know that when you replace those with unsaturated fat, there’s a reduction in your cardiovascular disease risk.”
Sugary foods should be kept to a minimum. And opting for low-fat foods that have added sugar to make them more palatable should be avoided. “Back in the day, they were removing fat from products and replacing it with sugar because of palatability, and that wasn’t doing us any good.” Ultra-processed foods, too, are rich in saturated fat and should be minimised in your diet.
What about dietary cholesterol in eggs and other foods?
“You often get myths surrounding things like eggs, shellfish and offal, and dietary cholesterol,” says Parker. These foods contain cholesterol, but this, she says, “really has a small impact on our blood cholesterol levels, and it’s more important to reduce your intake of saturated fat, which we know increases cholesterol”. Most people can enjoy these items as part of a healthy diet. “The exclusion is those who have got familial hypercholesterolemia, where the body is making too much cholesterol, and part of their guidelines are to have lower intake of those sorts of foods.”
When do you need something more than statins?
If you have borderline high cholesterol levels, or moderately high cholesterol levels, says Mayr, “it’s very important to stress that statins are a super-safe drug. They are widely used and effective at reducing cholesterol. However, they typically lower cholesterol by around 50%. So, if you have very high cholesterol and a 50% reduction is not sufficient to achieve target levels, patients can now benefit from newer therapies, such as PCSK9 inhibitors.” These target a different protein in the liver to increase the LDL receptors and could be considered if you’ve already had a heart attack.
