Cholesterol is probably something you have only vague knowledge about, picked up from yoghurt and margarine packaging which talks about how to lower your cholesterol – at least, lower “bad” cholesterol, as a lot of health products put it.
But bad cholesterol doesn’t exist. Neither does “good” cholesterol. “Cholesterol is cholesterol,” says Rupy Aujla, a doctor who produces podcasts and cookbooks as The Doctor’s Kitchen. Specifically, cholesterol is a fatty substance, which we produce ourselves but also absorb through our food, that’s essential to the human body. It helps build our cell membranes and hormones like testosterone, among other good stuff.
What people actually mean when they talk about good and bad cholesterol is how cholesterol is carried through the body, by particles called lipoproteins. High-density lipoproteins (HDLs), says GP Jeff Foster, take fat out of your blood “and puts it in your liver, where it can’t do damage”. Low-density lipoproteins (LDLs) take fat “out of your liver and puts it into your blood, where it can stick to stuff like arteries”. That’s why having too much LDL can lead to heart problems. (If you want to get really granular about all this, then Aujla has a couple of podcasts on the topic.)
You can get your cholesterol levels measured with a blood or finger-prick test – the NHS recommends having it done if you’re over 40, if you’re overweight, or if heart problems run in the family. It’s a useful exercise on its own, says Foster, but is best paired with a QRISK test, which uses your medical data to calculate your risk of developing cardiovascular disease. “Supposing you’re just somebody that has borderline cholesterol [levels],” he says, “then knowing your overall QRISK score will give you a better indicator of whether you need to do anything with that information.”
If you do need to lower your cholesterol, diet is one of the best places to start. Cut out foods high in saturated fat, like butter, cheese, and fatty cuts of poultry and beef; junk foods like cake and crisps are, unsurprisingly, also culprits. Instead, go big on unsaturated fats via oily fish like salmon and mackerel, and avocado, says Foster, because these up your HDL levels and “push down that LDL impact”. Aujla gives a “special shoutout to edamame; soy-based legumes, so soybeans, tofu, tempeh; nuts like walnuts and almonds”. The British Heart Foundation recommends eating high-fibre foods, like wholegrain bread, brown rice, lentils and chickpeas. Simply eating less food, says Aujla – about 5 to 10% fewer calories than you need – has also “been shown time and time again to reduce your LDL cholesterol”.
The usual broad guidelines regarding a healthy lifestyle apply here, says Foster – they often help your cholesterol situation indirectly rather than directly. Drinking too much alcohol, for example, damages your liver, meaning “you can’t look after your cholesterol as well”. Smoking affects your QRISK score, and so could turn a “marginal” cholesterol level into a genuine problem. Exercise helps move cholesterol to your liver, and if you’re sleeping badly, a healthy diet “tends to go out the window”.
But if you have a family history of high cholesterol, or if lifestyle fixes aren’t working, then medication might be the solution. Statins, a type of cholesterol-lowering drug, are now widely prescribed and, for the vast majority of people, come with no serious side effects beyond some occasional aches and pains. A newer drug, Inclisiran, is still tricky to get through GPs but is also effective, says Foster. There are others your doctor might recommend to you too, while cholesterol-lowering food ranges like Benecol can have a smaller but still significant effect.
Thinking about how to lower your cholesterol shouldn’t be done in isolation from how you approach your health overall. “We focus too much on specifics of cholesterol itself,” says Foster, “and not the fact that core health would improve if we spent our time just [eating] a generally good diet. The things that really do make a difference are the things that we’ve known about for 40 years.” Ultimately, he thinks it comes down to “just not being a douche and looking after yourself” – which is not a message you’re likely to find on a yoghurt pot, but is a useful one nonetheless.