Cholesterol myths debunked: A cardiologist’s guide to protecting your heart health. Photo / Getty Images
An academic cardiologist, Prof Riyaz Patel is a practising consultant at St Bartholomew’s Hospital, one of the biggest specialist heart disease facilities in the UK, as well as running a research group at University College London which focuses on understanding the genetics underpinning cardiovascular risk.
Most people, even my own family, largely view cholesterol as just a number that needs to be managed if it is “red” on their blood test results. But what they don’t always realise is that a discussion about cholesterol is really about your risk for heart disease.
In my clinical practice, I see people with very high cholesterol or early heart disease on a daily basis, and from my experience, I can say without doubt that cholesterol is very misunderstood.
“When we talk about coronary artery disease, the commonest form of heart disease, what happens is that the small arteries which supply the heart with blood become steadily furred and clogged up with a build-up of fatty deposits (called plaques) made from cholesterol, a little like mini drainpipes building up ‘sludge’ over time. Eventually, this can culminate in a sudden blockage of the arteries which causes a heart attack.
Here are the top six things to know about your cholesterol, which could save your life.
Cholesterol is necessary for your body. It’s a fat-like substance which is needed by your body’s cells in small amounts to function, supporting their structure and to create hormones. However, your body is capable of making all the cholesterol you need, and you don’t require huge amounts of it.
To travel around the body in the bloodstream, cholesterol requires a special type of packaging, which is made up of a mixture of fat and proteins known as lipoproteins. Some cholesterol is transported in packages called high-density lipoproteins (HDLs), which is considered “good” cholesterol, as HDL takes cholesterol out of the bloodstream and back to the liver. However, very high HDL cholesterol may be problematic, as if it is consistently elevated, it can overwhelm your body’s ability to resist plaques forming.
Then there are low-density lipoproteins (LDLs), or “bad” cholesterol, which feeds the plaques building up in your arteries.
But heart attacks and furring of arteries isn’t just about cholesterol on its own. It’s one of many building blocks which contribute to disease. There are other triggers: damage caused by smoking, high blood pressure and genetic risk factors. These can make your arteries more disposed to letting in LDL cholesterol, which is why someone can have a heart attack even though their cholesterol readings may appear normal.
While heart disease is commonly perceived as a disease of old age, it can start surprisingly early in life, as young as the 30s, and because this process is completely silent, there are no symptoms.
High cholesterol can be caused by diet, or medical-related issues such as thyroid problems, but we also know that it can be influenced to varying degrees by genetics, my research area.
The main condition to be aware of is called familial hypercholesterolaemia, or FH, which is believed to affect one in 250 people in the UK. It’s caused by a gene mutation which impacts the liver’s ability to remove cholesterol from the bloodstream, leading to very high levels of LDL cholesterol. People who carry one copy of this mutation are vulnerable to experiencing heart disease as early as their 30s or 40s. One of the ongoing goals for the NHS is to identify more of the people who carry this hidden risk, and manage it by treating them from a young age.
If you have FH because of a single gene mutation, there’s a high risk that you will have heart disease and a 50% chance that you’ll pass this condition on to your children. Because of this, cardiologists urge people with a strong family history of heart disease to get their cholesterol checked as soon as they can, and if they have very high cholesterol (usually the total cholesterol is more than 7 or 8mmol/L) to discuss the possibility of FH with their doctor.
In England, anyone aged between 40 and 74 is eligible for an NHS Health Check, which is the easiest way to get your cholesterol tested. But if you’re younger and you’ve got a worrying family history, you can ask your GP for a test.
If your doctor thinks that FH is possible they will usually refer you to a specialist. If we find you carry a gene mutation for FH then something called cascade testing will be offered, to screen your family members to see who else is affected and also to treat them early so they can avoid heart disease. We can even test children, and if they are affected, we can start lowering their cholesterol from their early teenage years to protect them from heart disease later in life.
It’s key to try to identify this condition as early in life as possible, because we know that by lowering LDL cholesterol levels in these people through treatments such as statins, we can break this cycle of risk and prevent early tragic heart attacks occurring.
In addition to genetics, lifestyle plays a big role in driving your vulnerability to cardiovascular disease. The biggest culprit is smoking. It can damage the arteries in ways which can enable cholesterol and plaque build-up, and because of this, my message is: if your parents, grandparents or siblings have experienced early heart disease or stroke before the age of 60, think very carefully before you smoke, because you may be much more vulnerable than your peers. The age-old advice of don’t smoke, eat well and exercise really is the basis of good heart health.
Some of the saddest situations we see as cardiologists is when people have experienced a premature fatal or near-fatal heart attack, and it turns out that they had a really strong family history of the disease, but did not change their lifestyle.
Cholesterol actually exists in many foods, from eggs to full-fat dairy and organ meat such as liver. We used to think that this dietary cholesterol could increase your blood cholesterol levels, but we now know that this link doesn’t exist. Cholesterol in foods isn’t that relevant for your blood levels. Instead, it’s much more about how your body copes with the amount of saturated fat intake you’re consuming.
Switching to a more heart-healthy diet can make an impact on your cholesterol levels, but it depends on how bad your diet was in the first place. In my consultations with patients, I recommend the usual things as basics: eating your “five a day” of fruit and vegetables, less red meat and more white meat and oily fish, minimising sweet fruit juices and fizzy drinks, cutting down on takeaways and processed foods, and anything rich in saturated fat, and trying generally to eat in moderation. Nothing dramatic. I think the old saying that you dig your grave with a fork is quite apt.
On diet, cardiologists are concerned about the recent rise of keto and carnivore diets where people are loading up on saturated fats, because their LDL cholesterol levels go sky-high. In some cases, we see people with double-digit readings mimicking FH. I’m aware that some YouTubers and people promoting these diets, including doctors, often argue that these high levels of cholesterol aren’t relevant and that they’re safe, but people like me, who are on the front line, see people coming in with heart disease and are very wary of the risks from such high LDL levels.
Ultimately, I respect everyone’s autonomy, and of course you can eat what you want, but my advice is generally to stop and think twice about extreme diets, especially if you have a possible genetic risk also at play. What may be okay for one person may not be for you.
Statins are usually offered to people at high risk of heart disease or who have had heart disease, and they work and save lives. But they have a bad reputation, which is a shame, as we know that if more people used them, we could save thousands of heart attacks and strokes. Some of this is driven by a huge amount of misinformation about statins, which has very real effects on people’s lives. There was a study in Denmark a decade ago which showed that following negative headlines about statins, more people stopped taking them without seeking medical advice, and there was a subsequent increase in the numbers of heart attacks and strokes.
I know there are people who are vehemently against statins, because of what they’ve read, or heard about from friends, or social media, but what I would say is that the vast majority of people who take statins do so without any issues whatsoever.
When it comes to their safety, statins are not only arguably the most studied class of drugs in medicine, as we’ve been using them for more than 30 years, but no other drug has had such a significant benefit on cardiovascular health, because of their ability to reduce LDL cholesterol and arterial plaques. There are also no drug company interests or financial drivers to their use – as the drugs are generic, the market cost for a month of statins is barely £1.
A small number of people may report muscle aches and pains, but if you have concerns, I strongly urge you not just to stop them and risk your heart health. Talk to your doctor first. Because if someone really can’t tolerate a statin, we have multiple other options that can lower cholesterol just as well. These include inclisiran, which is given every six months, and evolocumab and alirocumab, which are self-administered every two weeks in a pen-like device.
There are many more exciting research developments and medications on the horizon, which we hope will lead to new breakthroughs in the coming years. But in the meantime, my main advice is simple: be aware of your disease risk, based on your family history, get your cholesterol tested when advised, and do your best to look after your “pipes”.
As told to David Cox