Cholesterol

Overview

Cholesterol is a waxy, fatty substance that travels around your body in your blood. Your body needs some of it to build cells and make hormones, so it isn't all bad. The problem starts when there is too much of the 'bad' kind in your blood. Over time, extra cholesterol can stick to the inside walls of your arteries (the tubes that carry blood to your heart and brain), making them narrower and stiffer. This raises your chance of a heart attack or stroke. The good news is that high cholesterol can be found with a simple blood test, and it can be lowered.

Yes, it's very common. High cholesterol is one of the most widespread health issues in adults worldwide, and because it has no warning signs, many people don't know they have it until they have a routine check. It becomes more common as people get older.

Anyone can have high cholesterol, including children in some families. It is more likely if you are over 40, eat a lot of saturated fat, carry extra weight around your middle, smoke, drink heavily, or are not very active. It also runs in families — a condition called familial hypercholesterolaemia (inherited high cholesterol) can affect people from birth, so tell your doctor if a close relative had a heart attack or stroke young. Some ethnic groups, including people of South Asian background, have a higher risk of heart disease at lower cholesterol levels.

Symptoms

Common symptoms

• Usually none — high cholesterol is often called a 'silent' condition because you can feel completely well.
• Symptoms tend to appear only when arteries have already narrowed, which can take many years.
• Chest tightness or discomfort, especially with exercise (this is a sign of heart disease, not of cholesterol itself).
• Cramping pain in the calves when walking that eases with rest (a sign of narrowed leg arteries).
• Rarely, soft yellow patches around the eyes or knobbly lumps on tendons, which can happen with very high inherited cholesterol.

Symptoms in children

• Almost always no symptoms at all.
• Children with inherited high cholesterol (familial hypercholesterolaemia) usually feel perfectly well, which is why family testing matters so much.
• Rarely, yellow patches around the eyes or on the skin may be noticed.
• If a parent or sibling has very high cholesterol or had a heart attack young, ask your doctor whether your child should be tested.

Symptoms in older adults

• Still usually no direct symptoms, even when cholesterol has been high for years.
• Symptoms are more likely to come from related heart or blood vessel disease, such as breathlessness, chest discomfort or leg cramps when walking.
• Many older adults take other medicines, so any new treatment should be reviewed together with your doctor or pharmacist to avoid interactions.
• Regular checks are worthwhile, because risk of heart attack and stroke rises with age.

Causes

Main causes

• Eating a lot of saturated fat (found in fatty meats, butter, cheese, pastries, coconut and palm oil) raises LDL cholesterol.
• Not being physically active enough lowers 'good' HDL cholesterol.
• Carrying extra weight, especially around the waist, changes how your body handles cholesterol.
• Smoking damages blood vessels and lowers HDL cholesterol.
• Drinking more alcohol than the recommended limits can raise cholesterol and blood pressure.
• Genes — inherited high cholesterol (familial hypercholesterolaemia) affects about 1 in 250 people and is present from birth.
• Other conditions such as an underactive thyroid, kidney disease, liver disease and diabetes can push cholesterol up.
• Some medicines, including certain steroids and treatments for high blood pressure, can affect cholesterol levels.

Risk factors

• Being over 40
• A close relative who had a heart attack or stroke before age 60
• Family history of very high cholesterol
• Type 2 diabetes or prediabetes
• High blood pressure
• Smoking
• Being overweight, especially around the middle
• An inactive lifestyle
• An underactive thyroid, kidney or liver disease
• South Asian background, which carries higher heart risk
• Drinking a lot of alcohol

When to see a doctor

See a doctor urgently if:

• New chest discomfort or tightness, especially with effort — treat sudden or severe chest pain as an emergency.
• New breathlessness or swelling in the ankles.
• Leg pain that reliably comes on when you walk and goes away when you rest.
• A new irregular heartbeat or palpitations that don't settle.

Book a routine appointment if:

• You are over 40 and haven't had a cholesterol check or NHS Health Check in the last five years.
• A parent, brother or sister had a heart attack, stroke or very high cholesterol, especially before age 60.
• You have diabetes, high blood pressure, kidney disease or an underactive thyroid.
• You want advice on diet, weight, stopping smoking or getting more active.
• You've been told your cholesterol is borderline and you'd like to understand what it means.

Diagnosis

High cholesterol is found with a simple blood test called a lipid profile or lipid panel. It measures your total cholesterol, your LDL ('bad') cholesterol, your HDL ('good') cholesterol and your triglycerides (another type of blood fat). Your doctor puts these numbers together with your age, blood pressure, smoking status, weight and family history to work out your overall risk of heart attack or stroke over the next ten years. That overall risk, not one number on its own, is what guides decisions about treatment.

Tests that may be done

• A lipid profile blood test — a small sample of blood from your arm.
• Sometimes a 'non-HDL cholesterol' calculation, which your doctor may use instead of LDL alone.
• Blood pressure measurement and a check of your weight and waist.
• Blood tests for diabetes, kidney and liver function, and thyroid, which can affect cholesterol.
• A family history review, and testing of close relatives if inherited high cholesterol is suspected.
• A home cholesterol test kit is available in some places, but a GP test is more reliable and gives the full picture.

What to expect at your appointment

You may be asked whether to fast (not eat) for a few hours beforehand — many practices no longer ask this, so follow their instructions. The blood sample takes a minute or two. Results usually come back within a few days, and your doctor or nurse will talk them through with you. If your level is raised, you'll normally be offered a follow-up to agree on next steps, and a repeat test after a few months to see how changes are working.

Treatment

Treatment for high cholesterol has two parts: everyday changes to how you eat, move and live, and — for some people — medication. Which you need depends on how high your cholesterol is and, more importantly, on your overall risk of heart attack and stroke. Someone with a modest cholesterol level but several other risk factors may be advised to take medication, while someone with a slightly raised level and no other risks may do well with lifestyle changes alone and regular checks.

Self-care at home

• Cut down on saturated fat: swap butter for vegetable oils, choose lean meats, and trim visible fat.
• Eat more fibre — porridge oats, beans, lentils, fruit and vegetables all help lower LDL cholesterol.
• Try plant sterols and stanols, found in some fortified spreads and drinks, if your doctor or dietitian suggests them.
• Aim for at least 150 minutes of moderate activity a week — brisk walking, cycling, swimming, anything that raises your heart rate.
• If you smoke, stopping is one of the single biggest things you can do for your heart — ask your GP or pharmacist for support.
• Keep alcohol within recommended limits, and have several alcohol-free days a week.
• Losing a modest amount of weight, especially around the waist, can improve cholesterol and blood pressure.
• Take any prescribed medicine regularly, and don't stop it without talking to your doctor first.

Medical treatments

If lifestyle changes aren't enough, or if your overall risk of heart attack or stroke is high, your doctor may suggest medication. There are several types of cholesterol-lowering medicine; the most commonly used group works by helping the liver clear LDL cholesterol from the blood, and another group reduces how much cholesterol your body absorbs from food. Some injections are available for people with inherited high cholesterol. Your doctor will explain the benefits, possible side effects and how the medicine is monitored, usually with a blood test after a few weeks and then once a year. Medication is not a substitute for healthy habits — it works best alongside them.

When is surgery considered?

Surgery is not used to treat high cholesterol itself. Occasionally, people whose arteries have already narrowed may need procedures to restore blood flow — such as a stent (a small tube holding an artery open) or a bypass operation. These treat the heart or blood vessel problem, not the cholesterol, and good cholesterol control afterwards is still important.

Living with this condition

High cholesterol mostly lives in the background — it doesn't usually change how you feel day to day. What changes is your routine: reading food labels, planning meals, finding activity you actually enjoy, and remembering any medication. Many people find that after a few months the new habits feel normal and their energy and general health improve too. Keep a note of your test results so you can see your progress over time.

Lifestyle tips

• Build activity into your day — a brisk walk after dinner, stairs instead of the lift, or cycling to the shops.
• Cook more meals from scratch so you know what's in them.
• Choose wholegrain versions of bread, pasta and rice.
• Eat oily fish such as salmon, mackerel or sardines once or twice a week if you eat fish.
• Keep an eye on portion sizes and sugary drinks.
• Find a way to manage stress that works for you — walking, gardening, breathing exercises, or talking to someone.
• Have your cholesterol and blood pressure checked at the intervals your GP recommends.
• Ask your pharmacist to review all your medicines together if you take several.

Diet and exercise

Food and movement are the foundation of cholesterol control. Aim for a diet rich in vegetables, fruit, beans, lentils, oats, nuts and whole grains, with olive or rapeseed oil instead of butter, and fish, chicken or vegetarian proteins more often than fatty red meat. Cut back on processed meats, pastries, crisps, biscuits and hard cheeses. For exercise, the goal is 150 minutes a week of something that makes you slightly warm and out of breath — you don't need a gym, just steady, regular movement you'll keep up. Even small increases help, so start where you are and build up gradually.

Mental health and emotional wellbeing

Being told you have a risk factor for heart disease can bring up worry, and some people feel anxious or low about it. That's understandable, and it's common. Try to remember that high cholesterol is manageable and that taking action is a positive step, not a punishment. If worry is affecting your sleep, mood or appetite, please talk to your doctor — support is available, and looking after your mental health is part of looking after your heart. If you ever feel you cannot cope or have thoughts of harming yourself, contact your local emergency number or a crisis support service in your country straight away.

Prevention

Partly, yes. You can't change your genes, but you can strongly influence your cholesterol and your overall heart risk through food, activity, weight, not smoking and limiting alcohol. These steps help even if you already have high cholesterol or are taking medication — it's never too late to make a difference, and the benefits start within weeks.

Screening programmes

In the UK, adults aged 40 to 74 are offered an NHS Health Check every five years, which includes a cholesterol blood test. Your GP may also check your cholesterol sooner if you have diabetes, high blood pressure, kidney disease, a strong family history, or if you ask for it. If a close relative is found to have inherited high cholesterol, relatives should be offered testing — this is called cascade screening, and it can catch problems early in people who feel completely well.

Complications

If left untreated

• Atherosclerosis — fatty deposits (plaques) building up inside arteries and making them narrower and stiffer.
• Coronary heart disease, where the arteries feeding the heart are narrowed, which can cause angina (chest pain on effort).
• Heart attack, if a plaque ruptures and blocks blood flow to the heart.
• Stroke, if blood flow to part of the brain is blocked.
• Peripheral arterial disease, causing leg pain when walking and slower healing of wounds.
• Reduced kidney function over time, as the small blood vessels in the kidneys are damaged.

Long-term outlook

The outlook is genuinely encouraging. Most people can lower their cholesterol with changes to food and activity, and medication works well for those who need it. Lowering your cholesterol steadily reduces your chance of heart attack and stroke, and the benefit grows the longer you keep it under control. Many people find that a check-up and a plan give them a sense of control rather than worry — and small, steady steps really do add up.

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