Is High Cholesterol Really as Bad as You've Been Told?

You’ve probably heard that you should be paying attention to your cholesterol levels. But why?

Cholesterol is a substance similar to fat. It circulates in your bloodstream and is used by cells throughout your body for key bodily processes.  

Too much of a certain type of cholesterol can pose a health risk and cause heart disease. But is it really that simple?

“Initially, doctors thought that high cholesterol was the primary reason for heart disease developing, but we’ve since realized that it’s not,” says Natalia Usoltseva, MD, a physician at UW Medicine Primary & Urgent Care at Ballard.

Instead, your risk for heart disease is determined by many factors that interact with high cholesterol — and there are different ways (not just meds) to treat it accordingly.  

Is high cholesterol really such a bad thing?  

High cholesterol usually refers to having high amounts of LDL (low-density lipoproteins) or “bad” cholesterol in the blood. When too many of these particles build up, it's called atherosclerosis. The buildup narrows and stiffens the arteries, disrupting blood flow. If the built-up plaque bursts, it can trigger a blood clot, which can lead to a heart attack or stroke.  

Alternately, it’s a good thing to have high levels of HDL (high-density lipoproteins) particles or “good” cholesterol because they help remove excess LDL from the bloodstream.  

Generally speaking, doctors recommend having LDL below 100 and HDL above 60 milligrams of cholesterol per deciliter of blood (mg/dL).    

But it isn’t just high LDL that clogs arteries: genetics, lifestyle factors, levels of inflammation (like in some autoimmune conditions) and conditions like high blood pressure can all contribute.

While having high cholesterol isn’t great, it isn’t something to panic about if your numbers come back less than ideal after a blood test. If, say, your LDL is 120 and your HDL is 55, it does not mean a stroke is imminent or you have to start taking statins, the most commonly prescribed cholesterol medication. (More on them in a minute.)  

And if you don’t know your numbers, ask your doctor for a lipid blood test. High cholesterol doesn’t cause symptoms until the arteries have already narrowed significantly, so the only way to catch it early is by testing. 

Does having high cholesterol mean I need to take statins?

Because so many different things can influence your cholesterol levels and heart disease risk, doctors don’t prescribe statins for everyone. A more nuanced calculation is often in order.

“For patients who have existing conditions like diabetes or peripheral vascular disease, and for patients whose LDL is above 180, medication is warranted right away,” Usoltseva says. “But for the rest of the population, we first need to take into account things like their age, blood pressure numbers and smoking history. A large proportion of patients don’t need medication right away.”  

There are lots of lifestyle changes you can make to significantly help your cholesterol — and no, it isn’t just about avoiding fatty foods, though that’s part of it.

Yes, it’s helpful to reduce your intake of saturated fats (most often found in red and processed meats, butter, ice cream and baked goods) and trans fats (from ultra-processed and fried foods). But it’s also helpful to increase how much fiber you’re eating, limit your alcohol intake, quit smoking and get 150 minutes of aerobic exercise each week. Eating more foods with healthy fats — like fish, lean meats, avocado and nuts — can be beneficial, too.

“In fact, of all these lifestyle modifications, only exercise has been shown to significantly increase HDL,” says Usoltseva.

These are the things Usoltseva works on first with patients with LDL above 100 but below 180. They may seem like small changes, but they can make a big difference.  

Losing weight can be helpful for some people, too, but not everyone in a larger body will need to lose weight to lower their cholesterol or will even have high cholesterol to begin with, despite assumptions that are often made, Usoltseva says.

What’s the deal with statins?  

Statins are medications used to treat high cholesterol. They work by blocking an enzyme the liver uses to produce cholesterol, lowering your LDL and upping your HDL.  

Statins are sometimes given a bad rap. They can cause side effects like muscle pain, confusion or memory loss that, while temporary, can still be alarming. Around 10% of patients who try statins will have some side effects, Usoltseva says.

“But the side effects depend on the dose and type of statin, so if I prescribe you 40 mg of one statin, and you develop muscle pain, you might not develop it on a 20 mg dose or with a different statin,” she says.  

Often, this means finding the right dose or type of statin requires some back-and-forth experimentation that your doctor will guide you through.  

The bottom line

If you’re concerned about cholesterol, ask your doctor for a blood test. And if your results aren’t optimal, try not to panic. High cholesterol alone doesn’t always mean you’re at risk for heart disease, and even if it does in your case, catching the issue early will help take steps today that will reduce your risk in the future.