How cholesterol became my latest health obsession

Cardiovascular disease remains the leading cause of death worldwide, and many heart attacks and strokes are linked to plaque buildup in the arteries. High levels of low-density lipoprotein (LDL) cholesterol—the “bad” cholesterol—are an important risk factor, but blood pressure, diabetes, smoking, and other factors matter, too.

This is a good time to understand cholesterol because this year, the American College of Cardiology (ACC) and the American Heart Association released their first major update since the 2018 cholesterol guideline—now broadened into a guideline on dyslipidemia, or unhealthy levels of cholesterol and other fats in the blood. It focuses more on lifelong exposure to cholesterol-related particles and markers such as Lp(a) and ApoB.

Don’t wait until something feels wrong

Exercise is one of the best things we can do for our health, but you can exercise regularly and still have high LDL because what you eat, genetics, and other risk factors matter.

You may feel healthy and think everything is fine, but high cholesterol can go unnoticed without obvious warning signs. Over time, LDL can contribute to plaque buildup in your arteries. If plaque ruptures, a blood clot can form and block blood flow.

That’s one reason a heart attack can seem to come out of nowhere, even in someone who looks fit and feels healthy. You may not know what’s been building in your arteries for years if you haven’t been checking your numbers.

Know your numbers, keep your old results, and see how they change over time. Talk to your doctor about how often you should get tested. Do it now, while you still feel well.

Your total cholesterol doesn’t tell the whole story

Know your LDL, high-density lipoprotein (HDL), and triglycerides—not just your total cholesterol. I used to think my high HDL and low triglycerides protected me from high LDL. They don’t cancel it out.

As I learned more, I asked my doctors about ApoB and Lp(a) and had both tested for the first time last June. LDL tells you how much cholesterol LDL particles carry, while ApoB gives you an idea of how many atherogenic particles are circulating.

Then there’s Lp(a), a mostly inherited particle linked to higher cardiovascular risk when elevated. Lifestyle changes don’t affect it much because it’s largely genetic. The new guideline recommends checking it at least once in adulthood. Mine wasn’t elevated, though it’s only one part of my overall risk.

Normal before might not mean normal now

“I’ve always had normal cholesterol.” I hear this often, especially from my midlife clients.

Our bodies change as we get older, and so can our cholesterol. You might eat the same, exercise regularly, and keep your weight steady, but your numbers can still change. Thyroid problems, insulin resistance, kidney or liver issues, and some medications can affect them. For women, declining estrogen during perimenopause and menopause can raise LDL and make us store more fat around the belly, adding to our cardiovascular risk.

Eat smarter, not stricter

After my June results, I didn’t become vegan or stop eating fat. I still ate foods I enjoyed and kept exercising as before, but I cut back on foods rich in saturated fat, such as fried foods, egg yolks, desserts, and some packaged foods.

Instead, I chose more unsaturated fats from avocado, olive oil, nuts, seeds, and fatty fish. I also increased soluble fiber from psyllium husk, oat bran, vegetables, legumes, and fruits.

My LDL improved more than when I went vegan for a year in 2017. My ApoB, which I only started testing last June, also improved substantially. Since my exercise routine hadn’t changed, I believe my diet changes played an important role.

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I’ve tracked my cholesterol for about 10 years and learned that being more restrictive doesn’t always mean better numbers. We also don’t all respond to food the same way. Some people see a bigger rise in LDL from saturated fat than others.

So don’t just look at the scale. Check your numbers and see how your body responds. Cut back on obvious sources of saturated fat like fatty meats, chicken skin, deep-fried foods, butter, cheese, and lard. Make smart swaps, get enough fiber, and eat better most of the time—not perfectly.

When lifestyle isn’t enough

I’ve seen people eat well, exercise regularly, and still have high LDL. Genetics can play a big role, so even their best efforts may not be enough. So I asked cardiologists: When is lifestyle enough? When do you need cholesterol-lowering medications, such as statins? And once you start, is it for life?

One high cholesterol result doesn’t automatically mean you need medication. Your doctor will look at your age, blood pressure, diabetes, smoking, family history, other health conditions, and how long your LDL may have been high. For some people, Lp(a) testing, a coronary calcium scan to check for calcified plaque, or both can help clarify risk.

Starting medication also doesn’t always mean taking it for life, although some may need it long-term. If your cholesterol improves, don’t assume you can stop because it may mean the medication is working. Talk to your doctor before making changes.

Take medication when you need it. It isn’t a failure. Healthy habits and medication can work together to protect your heart. Know your numbers and understand your risks. Accept what you can’t change, but do what you can.

Because the changes you make now can make a difference for years to come.