High Cholesterol

an evidence based guide

High cholesterol affects millions of people worldwide. Despite what you might have been told, weight loss isn’t required for effective treatment. This guide explains how to manage high cholesterol using evidence-based approaches that don’t involve dieting or weight loss.

What Is Cholesterol?

Cholesterol is an essential molecule produced primarily by your liver. Far from being harmful, cholesterol is vital for health and is found in every cell in your body. It’s not inherently “good” or “bad” – we literally need cholesterol to live.

Why Your Body Needs Cholesterol

Cholesterol serves several crucial functions in your body:

  • Cell membrane structure and fluidity: Cholesterol helps maintain the integrity of cell membranes
  • Hormone production: It’s essential for making estrogen, testosterone, cortisol, and other hormones
  • Vitamin D synthesis: When skin is exposed to sunlight, cholesterol is converted to vitamin D
  • Bile acid production: Cholesterol is used to make bile acids which help digest fats
  • Brain function and nerve insulation: The brain contains about 25% of all the cholesterol in your body despite being only 2% of body weight

Beyond “Good” and “Bad” Cholesterol

Cholesterol travels through your bloodstream in combination with proteins. Together these fat (lipid)/protein molecules re referred to as lipoproteins:

  • LDL (Low-Density Lipoprotein): Often called “bad” cholesterol, but its actual function is to deliver cholesterol to cells throughout your body
  • HDL (High-Density Lipoprotein): Commonly called “good” cholesterol because it helps remove excess cholesterol from tissues and carries it back to the liver
  • VLDL (Very Low-Density Lipoprotein): Carries triglycerides (another type of fat in the blood) and cholesterol in the bloodstream

 

About 80% of the cholesterol in your body is produced by your liver, regardless of what you eat. Only about 20% comes from dietary sources, which is why dietary restrictions often have limited impact on cholesterol levels.

What Is High Cholesterol?

High cholesterol refers to elevated levels of lipids (fats) in your blood. While cholesterol is essential for building healthy cells, having too much can increase your risk of heart disease. However, what’s considered “high” is based on arbitrary thresholds, not natural cutoff points. Normal readings vary by individual circumstances and risk factors.

Important Facts About High Cholesterol

What Actually Causes High Cholesterol?

Cholesterol levels are influenced by many factors:

  • Genetics
  • Age (levels naturally change throughout life)
  • Sex and hormonal factors
  • Medical conditions like hypothyroidism or kidney disease
  • Certain medications
  • Social and environmental factors
  • Chronic stress

 

The Truth About Weight Loss and Cholesterol

When it comes to preventative medicine, we need to look beyond the numbers on a screen and as whether an intervention actually prevents the long-term health outcomes of high cholesterol. While we know that reducing cholesterol can reduce cardiovascular risk, the evidence for weight loss as a treatment is woefully lacking:

  • Long-term studies show no clear link between weight loss and sustained cholesterol improvement
  • Even in studies showing some improvement, results are independent of whether weight loss was achieved
  • Weight cycling (losing and regaining weight) can worsen cardiovascular risk factors
  • The stress from pursuing weight loss can negatively impact overall health
  • There’s little evidence that weight loss has any impact on cardiovascular outcomes (such as heart attacks or strokes)

How Weight Stigma Affects Your Care

Weight stigma in healthcare can seriously impact cholesterol treatment and cardiovascular health:

  • Diagnosis of more advanced stages may be delayed while focusing unnecessarily on weight
  • You might be pressured into harmful restrictive diets with no long term benefits
  • The stress of forced weight loss attempts could worsen cardiovascular health
  • Important symptoms might be dismissed or blamed on weight
  • Medical conditions might progress while waiting for weight loss to “work”

How To Treat High Cholesterol Without Weight Loss

When Should High Cholesterol Be Treated?

Before discussing treatment options, it’s important to understand that not all elevated cholesterol requires treatment. Treatment decisions should be individualized based on your overall cardiovascular risk, not just your cholesterol numbers.

The Evolution of Cholesterol Guidelines

Cholesterol management guidelines have changed significantly over time:

  • 1980s-1990s: Focus was primarily on total cholesterol numbers
  • 2000s: Shifted to LDL targets and the ratio of LDL:HDL
  • 2010s: Moved toward a risk-based approach rather than target numbers
  • Current: Greater emphasis on individualized approach and shared decision-making

 

These frequent changes highlight the uncertainty that still exists in this field. What was considered “high” cholesterol requiring treatment a decade ago may not be considered concerning today, and threshold values have been repeatedly revised.

Evidence vs. Consensus

It’s important to understand that guidelines represent consensus among experts rather than purely evidence-based recommendations. Consider these factors:

  • Thresholds for “normal” cholesterol have consistently lowered over time, expanding the population recommended for statins
  • Many guideline authors have financial conflicts of interest with pharmaceutical companies
  • Different countries have different guidelines and recommendations
  • The potential benefits of treatment vary significantly based on individual risk factors

Making an Informed Decision

Treatment should be based on a comprehensive risk assessment, not just cholesterol numbers. Factors to consider include:

  • Your personal and family medical history
  • Age and other risk factors
  • Potential benefits vs. potential side effects of medication
  • Your preferences and values regarding medication use

 

A shared decision-making approach with a healthcare provider who respects your autonomy is essential. Remember that treating a number without considering the whole person doesn’t necessarily improve health outcomes.

Why Treat High Cholesterol?

High cholesterol itself rarely causes symptoms or immediate problems. Instead, treating high cholesterol is about managing long-term health risks. Research shows that:

  • Reducing LDL cholesterol can lower your risk of cardiovascular events
  • This benefit occurs regardless of your body size
  • Even modest reductions in cholesterol can help
  • Benefits accumulate over time

 

Understanding this can help reduce anxiety about cholesterol numbers. A single high reading isn’t an emergency, and you don’t need perfect numbers to benefit from treatment. The goal is to lower your long-term cardiovascular risk through consistent, sustainable treatment.

 

Primary vs. Secondary Prevention: Understanding the Difference

When discussing cholesterol treatment, it’s crucial to distinguish between primary prevention (treatment for people who have never had cardiovascular disease) and secondary prevention (treatment for people who have already had a cardiac event).

Lowering cholesterol reduces the risk of developing a major coronary event in the future. This applies equally to both groups. However, in primary prevention the baseline risk is low whereas once you’ve had one cardiac event, the chances of having another are much higher. That’s why guidelines typically recommend statins more strongly for people with established cardiovascular disease, and more selectively for those without it, depending on their overall risk profile.

For people without existing cardiovascular disease (primary prevention), the decision to start medication should involve a careful discussion of potential benefits versus risks, taking into account individual risk factors and preferences.

Weight Inclusive Treatment

Medications

Several effective medications exist that work regardless of body size:

  • Statins (like atorvastatin, rosuvastatin): These reduce the amount of cholesterol your liver makes and help remove cholesterol already in your blood. They’re the most commonly prescribed and well-studied cholesterol medications.
  • PCSK9 inhibitors (like alirocumab, evolocumab): These newer injectable medications help your liver absorb more LDL cholesterol, dramatically lowering levels. They’re typically used when statins aren’t enough or aren’t tolerated.
  • Ezetimibe: This reduces the amount of cholesterol your small intestine absorbs. It’s often used alongside statins for greater effect.
  • Bile acid sequestrants (like cholestyramine): These bind to bile acids in your intestines, indirectly lowering cholesterol. They’re sometimes used when other medications aren’t tolerated.
  • Fibrates (like fenofibrate): These primarily reduce triglycerides but may also modestly improve other lipid levels.
  • Omega-3 fatty acids: Prescription versions can help lower triglycerides in people with very high levels.

 

Lifestyle Approaches

It’s important to understand that while these approaches are commonly recommended, research shows they typically only produce modest changes in cholesterol levels – usually not enough to significantly reduce cardiovascular risk on their own:

  • Regular movement you enjoy (modest effects on HDL cholesterol)
  • Stress management techniques (effects vary widely between individuals)
  • Adequate rest and sleep (poor sleep is associated with worse lipid profiles)
  • Management of underlying conditions that could be affecting cholesterol levels

 

Dietary Changes

A review that analyzed various dietary approaches found that while most dietary patterns lead to modest improvements in cardiovascular risk factors over the first six months, these benefits largely disappear within the year. This is true regardless of which diet is followed.

Even recommendations like choosing foods low in saturated fat, high in mono-unsaturated fat, selecting wholegrain options, or reducing refined sugars lack solid evidence that they actually prevent cardiovascular disease in the long term.

Regarding commonly recommended dietary changes:

  • Increasing soluble fiber intake typically produces modest cholesterol reductions
  • Plant sterols (found in certain margarines and supplements) show small effects in long-term studies
  • The impact of dietary changes is often temporary and varies significantly between individuals
  • Research shows most dietary patterns lead to modest improvements in the first six months, but these benefits largely disappear within a year

These approaches are entirely optional and should be viewed as potential additions to medical treatment, not replacements for it. Choose the ones that fit your life and interests – there’s no evidence that forcing yourself to make lifestyle changes you don’t enjoy will improve your cholesterol long-term.

Remember: The most effective treatment for high cholesterol often includes appropriate medication, which can significantly reduce cardiovascular risk regardless of lifestyle factors.

 

Your Rights as a Patient

You deserve healthcare that:

  • Treats your health concerns effectively
  • Doesn’t delay proper treatment by focusing on weight loss
  • Considers all available treatment options
  • Respects you and takes your concerns seriously
  • Provides appropriate medication when needed
  • Includes regular monitoring without weight stigma

 

Getting Good Care

If your healthcare provider focuses primarily on weight loss:

  • You can refuse consent to discuss weight or weight loss during consultations
  • Ask “How would your recommendations change if weight wasn’t a factor?”
  • Request to focus on evidence-based treatments rather than weight loss
  • Ask about all available medication options
  • Seek a second opinion if needed
  • Remember that you deserve care that addresses your actual health needs

 

Try This Script

“I have researched the benefits and risks of intentional weight loss for high cholesterol. I do not wish to pursue this approach and do not consent to discussing my weight during consultations. I would like to discuss evidence-based treatments that work regardless of body size.”

This information is provided by Dr. Asher Larmie, The Fat Doctor. For more detailed information and resources, check out his masterclass. This information is provided for educational purposes and should not replace professional medical advice. Always consult with healthcare providers for personal medical decisions.