Fact or Fiction: What Do You Really Know About Cholesterol?

Updated February 16, 2022.

Clinical Editors: Spencer Blackman, MD and Meg Scott, FNP

If you’re confused about cholesterol, you’re not alone. As the science changes, so does our approach to interpreting cholesterol levels and other health health numbers, including tests beyond cholesterol and blood pressure that better help you stay healthy. Now’s a great time to catch up — and separate fact from fiction.

Fact: Your overall heart health determines whether you should take cholesterol medication.

If this myth sounds familiar, it’s because that was the old-school way of managing cholesterol. Before, if your cholesterol was high, your provider would recommend a medication to lower it and then check your blood regularly to make sure that your LDL (“bad”) cholesterol stayed under a certain target level.

What’s wrong with that? This approach led patients and health care providers alike to over-focus on cholesterol target numbers that were actually pretty arbitrary. We don’t really know how much LDL-cholesterol levels change your risk of heart attack and stroke (i.e. your cardiovascular risk) — and after all, that’s what matters, not blood test results. Your cholesterol is just one indicator among many. Smoking cigarettes or just getting older, for example, are even bigger factors in your overall heart health.

We also now know (from good research) that many people who take cholesterol medication don’t need to have their cholesterol levels monitored frequently. It all depends on your personal heart health picture and goals (and fewer blood tests is a good thing!)

Fact: The higher your cardiovascular risk, the more you’ll benefit from taking a statin. For people with good heart health, the side effects of statins usually outweigh the benefits.

Statin medications lower the likelihood of heart attack, stroke and death for people with high cardiovascular risk, regardless of their cholesterol levels.

Given the side effects of statins, such as muscle pain (more common) and a higher risk of diabetes and liver damage (less common), it’s important that providers recommend cholesterol-lowering medication only for people who benefit from it the most, for whom the benefits outweigh the harms.

If you’re someone who has low cardiovascular risk, statins won’t do you much good; they won’t significantly reduce your already-low risk of heart attack and stroke — even if they bring your “bad” cholesterol level down to normal range. On the other hand, you might have “good numbers” when you get your cholesterol checked, but if you’re high risk for other reasons (smoking, or a strong family history of heart attacks) taking a statin could literally be a lifesaver. If you're at moderate risk, you should weigh the pros and cons of statin medications with your primary care provider and make a decision together about what’s right for you. For many people in this situation, exploring additional testing, such as a coronary artery calcium score, can give you more information to help you make a decision that is best for you.

Fact: Eating healthy fat is better for your heart than eating less fat.

A heart-healthy diet means eating real food and less processed, packaged, and fast food.

What does “real” mean? It’s eating food that’s close to its original form, whether that’s spinach sautéed in olive oil or a green apple with natural peanut butter. A good rule of thumb is to shop the perimeter of the grocery store, where you find fresh fruits, veggies, dairy and meats. The inner aisles are more likely to have packaged, processed foods with fewer nutrients your body needs (like fiber), and more of what you don’t need (like added sugar). And when it comes to fat, it turns out that the kinds of fats in your diet are much more important than the amount.

Here’s how to eat a heart-healthy diet with real food:

• Fruits and vegetables should take up half of your plate at every single meal.
• Eat whole grains like brown rice and quinoa.
• Avoid added sugar. It’s bad for your heart, whether it’s called high fructose corn syrup, maltodextrin, evaporated cane juice, or agave nectar.
• Eat healthy fats. Olive oil, fatty fish, nuts, and seeds are good for your heart. Avoid hydrogenated fat, also known as trans fat, such as margarine and non-dairy whipped topping.

Consider working with a nutrition expert to create a healthy diet that fits your lifestyle. To go along with your nutritious diet, make sure to get 20 to 30 minutes of moderate-to-intense aerobic exercise three times a week to keep your heart in good shape. If you smoke, quitting is one of the best things you can do for your heart. (Get help with smoking cessation: Talk to your primary care provider or check out the Quit Guide from the Centers for Disease Control.)

Schedule a Live Well visit with your primary care provider. She can walk you through a personalized cardiovascular risk assessment, asking about things like your age and family history of heart disease, plus other health conditions you might have, like diabetes. Then she’ll plug it all into a risk calculator for ASCVD (atherosclerotic cardiovascular disease), which tells you the percent-likelihood that you might have a heart attack or stroke in the next 10 years and in your lifetime. Finally, she’ll personalize all these numbers to help you create a sustainable plan to keep your heart healthy for as long as possible.