Eight myths about cholesterol busted by a cardiologist

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There’s a good reason why high cholesterol is known as a “silent killer”. In most cases it has no symptoms but potentially fatal repercussions if left unchecked. And while some people are at risk due to questionable dietary and lifestyle choices, for others it may simply be a case of drawing the short straw in the genetic lottery.

Dr Oliver Guttmann is a consultant cardiologist at The Wellington Hospital (part of HCA Healthcare UK). When he tells people they have high cholesterol, he gets a range of reactions. “Sometimes patients know they live unhealthy lives,” he explains. “But often there will be a very fit, slim, healthy-looking person sitting in front of me, and when I tell them they’ve got massively elevated LDLs [‘bad’ cholesterol], they’re really shocked.”

Believing that being slim means you are not at risk is just one of many cholesterol-related misconceptions. Either through lack of information or misinformation, certain myths around the topic have taken root. However, given that cardiovascular disease is the leading cause of death and disability in the UK, killing about 170,000 people each year, it is vital to be armed with the facts.

Myth one: If your total cholesterol is fine, then you’re fine

Total cholesterol is the overall amount of cholesterol in your blood, both good and bad. High levels of “good” HDL cholesterol are protective, while high levels of “bad” LDL cholesterol increase your risk of heart attack and stroke.

When you have a cholesterol test, you should be given a range of results that include your total cholesterol (TC), HDL cholesterol, non-HDL cholesterol (the sum of all the “bad” cholesterol), LDL cholesterol, and triglycerides (another type of “bad” cholesterol).

“Total cholesterol is helpful,” says Dr Guttmann, “but what’s really important is the breakdown of the different types of cholesterol – especially LDLs, which are the main contributor to plaque in your coronary arteries.

“With all of these different types, we look first at how much of each you have but also at the ratio between them. For example, your total cholesterol might be normal but if your LDLs are really high and your HDLs are low, that’s a cause for concern.

“Another thing to consider is triglycerides.” The ratio between triglycerides and HDLs is also an indicator for heart health and underlying metabolic dysfunction.

Myth two: I’m slim so I won’t have high cholesterol

“Just because you’re slim or you go to the gym regularly, it doesn’t mean your cholesterol levels are good,” says Dr Guttmann. “Cholesterol is also influenced by how the liver works, the type of food you eat and your family history. It’s a combination of nature and nurture.”

As Dr Guttmann points out, you may stay slim by controlling your calorie intake, but if the food you’re eating is full of saturated fats, this will raise your LDL level. “Some people exercise every day,” he says, “but they eat unhealthy things like takeaways, fried foods, cheese, pastries, butter and processed meats. To begin with, when people have high cholesterol, there are no symptoms: they can look great but have very high ‘bad’ cholesterol for many years. That’s why it’s useful to have it checked regularly.”

Myth three: I had my cholesterol checked a few years ago, so I’m fine

Factors like menopause, changes in diet and lifestyle, and simply getting older can all affect your cholesterol levels, so it’s important not to be complacent.

“We learn more about cholesterol every day and that changes the way [doctors] react to it,” says Dr Guttmann. “In the past, we would start people on statins if their risk score was above 20 per cent. Now the guideline is 10 per cent, because we know how important it is to be more aggressive with treatment.”

For women, in particular, hormonal changes in middle age can affect cholesterol levels. LDL levels, for example, rise by 23 per cent post-menopause. “If you look at the statistics, women have heart attacks later in life than men,” says Dr Guttmann. “They’re protected, before that, by their hormones. But when your hormones start to change during menopause, a lot of things change, and one of them is your lipid profile and your risk of heart attack and stroke.”

Myth four: I’m healthy and in my 30s so I won’t have high cholesterol

Familial cholesterolemia, also known as familial hypercholesterolemia, is an inherited genetic disorder that causes extremely high levels of LDL cholesterol from birth. About one in 250 to one in 500 people has this condition, yet fewer than one in 10 of the people with familial hypercholesterolaemia in the UK is currently identified.

It is therefore crucial for anyone with a family history of heart disease to get their cholesterol checked early in life. “It doesn’t mean they’ll immediately be put on statins,” reassures Dr Guttmann. “But if an individual’s father had a heart attack when he was 45, and that individual is now 25 and their cholesterol is high, they need to exercise, monitor their diet, and generally make sure they look after themselves.”

Unfortunately, people with familial hypercholesterolaemia do sometimes have heart attacks early in life, as Dr Guttmann confirms. “Just this weekend I treated a 36-year-old woman who had suffered a heart attack,” he says. “Her mother had a heart bypass when she was 36. In cases like this, although there’s often an element of diet and lifestyle involved, family history is the key factor.”

Myth five: HDL is always ‘good’ cholesterol

You may have noticed that inverted commas are always used when describing LDLs and HDLs as “good” and “bad”. This is because, while these labels are a useful guide, the complete picture is more nuanced and the science is constantly being updated.

Research has revealed, for example, that other cholesterol types and related fats, such as VLDLs (very-low-density lipoprotein) and triglycerides are also important risk factors when it comes to heart disease, while very high levels of HDL cholesterol can be an indication of an underlying disorder. “This may be because the HDL has become dysfunctional and it’s not doing the job it’s supposed to do,” Dr Guttmann explains, adding that he “can’t remember the last time I said to someone in the clinic: ‘Your HDL is too high’.

“We know that getting your LDLs down will be beneficial, and in the majority of cases, higher HDL cholesterol is a good thing. Of course, as with everything in medicine, there are exceptions to the rule – and we’re learning more about it all the time – but for most people, it’s a useful way to approach this subject.”

Myth six: Eating eggs will raise your cholesterol

According to Dr Guttmann, a familiar refrain among patients who discover they have high cholesterol is: “But I don’t eat eggs.” The idea has become embedded that eating eggs is a fast track to elevated cholesterol, but it’s important to note the difference between blood cholesterol and dietary cholesterol (the type found in eggs). Our focus should be on limiting consumption of saturated fats, as these are more likely to elevate blood cholesterol levels.

“Ten years ago, doctors used to tell people to avoid eating eggs,” Dr Guttmann says, “but now we understand that they contain a lot of nutrients that are really beneficial. While egg yolks do contain some cholesterol, the research says that this cholesterol has a much smaller effect on blood cholesterol than we once believed.

“In fact, a recent study suggests that eating a moderate number of eggs [one to six per week] reduces the risk of cardiovascular disease-related death in later life – though of course this should always be in the context of a balanced and low-saturated-fat diet.”

Myth seven: If I take statins, I can eat what I want

“I have patients who say, ‘I’m on statins now – does that mean I can eat a lot of cheese?’” says Dr Guttmann. “The answer is definitely no. Statins are a powerful medication, but they cannot erase everything else you do in your life. The point of being on them is to change your lipid profile and lower your cholesterol, but you still have to look after yourself and make sure that you eat well. If you’re on statins and you continue to lead an unhealthy life, it defeats the whole purpose.”

Myth eight: Diet alone will fix my high cholesterol

When people are informed that they have elevated cholesterol, they are frequently reluctant to take medication, and vow instead to lower their levels through diet alone. “Obviously that’s a good thing to do,” Dr Guttmann says. “I give them between three and six months to turn things around, and then we reassess.”

He adds that while diet is important, there’s a limit to what it can achieve. “I’ve got patients who eat really healthily, they don’t smoke or drink alcohol, they exercise on a regular basis, and yet they still have very high cholesterol. These patients need to be on statins. Even after that it’s vital for them to do exercise, monitor their weight, avoid stress, get good sleep and so on. You can’t get away from your genetics, some people are just unlucky. In these cases, diet can help, but medication will do the rest.”

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Cholesterol explained

What is cholesterol, and when should you get yours checked?

Cholesterol is a fat found in the blood. Your body needs some of it to build healthy cells, but if your levels are too high, there’s an increased risk of developing cardiovascular disease. “Bad” LDLs (low-density Lipoproteins) can cause the build-up of plaque in the arteries, which can restrict blood flow and lead to a heart attack or stroke. “Good” HDLs (high-density Lipoproteins) help to remove LDLs from the bloodstream.

The NHS offers patients cholesterol checks from about the age of 40. Based on the results, and some other factors, your GP calculates your risk of having a heart attack in the next 10 years (your QRISK score). “However,” says Dr Guttmann, “if someone has diabetes or high blood pressure, or if they smoke or are very overweight, it makes sense to have a cholesterol check earlier.

“Some ethnicities [such as people with South Asian heritage] also have a greater risk of developing high cholesterol. And if any of your relatives has experienced heart problems at a young age, you should definitely be tested.”

What are the symptoms of high cholesterol?

In most cases a blood test is the only way to discover if you have dangerously high cholesterol. Yes, there are some physical signs, but these tend to occur at an advanced stage. They include xanthelasmas (fatty yellow deposits on the skin, especially around the eyelids), corneal arcus (a greyish-white ring in your eye, around your iris), and nodules or fatty lumps on your joints.

“These are things you would only see in somebody with extremely high cholesterol,” Dr Guttmann stresses. “In most cases, the first symptoms we see are things like chest pain, shortness of breath and intermittent claudication [leg pain when walking] – which indicate that there’s already some clogging up of the arteries.”

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