Cholesterol levels can change as we age, but what do the numbers mean, when should we worry and what can we do to keep them under control?
Cholesterol might not be something you give much thought to until your GP flags a high reading, but as we get older it becomes increasingly important to pay attention. That’s because the effects of high cholesterol can build up over decades, increasing the risk of fatty deposits forming in our arteries and eventually triggering a heart attack or stroke.
If you’ve had that call from your GP, you’re far from alone. According to the latest Health Survey for England, almost two-thirds of men aged 45 to 54 and almost three-quarters of women aged 55 to 64 have raised cholesterol.
So what does a high reading actually mean, when should we worry and what can we do to keep our levels in check? We asked leading experts to cut through the confusion and explain what really matters.
If your cholesterol was perfectly healthy in your forties, there’s no guarantee it will still be the same in your fifties or sixties. Our cholesterol levels can change as we age, influenced by everything from hormones and genetics to changes in our weight and activity levels.
“LDL (‘bad’) cholesterol tends to creep up through adulthood, because the liver gradually becomes less efficient at clearing it,” explains consultant cardiologist Dr Jun Cheong. “Weight gain around the middle, less muscle and a less active lifestyle add to the effect.”
And it’s not just about the number on your latest blood test. The longer your arteries are exposed to high levels of LDL cholesterol, the greater the opportunity for fatty deposits, known as plaque, to build up. This process, called atherosclerosis, can narrow the arteries and increase the risk of a heart attack or stroke.
“As we get older, the cumulative biological impact of ageing changes the equation,” says Regina Giblin, senior cardiac nurse at the British Heart Foundation. “If your LDL cholesterol remains high for a long period, this increases the risk of plaque building up in the arteries.”
For women, there’s another important factor to consider, the menopause.
“Menopause is a key moment,” says Dr Cheong. “Oestrogen helps the liver clear LDL, so when it falls, total and LDL cholesterol typically rise, often by 10 to 15%.”
This change also affects women’s longer-term heart health. Before menopause, women’s cardiovascular risk is generally lower than men’s, but this advantage reduces afterwards.
“For women, the post-menopausal drop in oestrogen removes a natural cardiovascular shield,” says Giblin. “This causes a sharp, rapid rise in LDL and cardiac risk, quickly catching up to men.”
It’s also worth telling your GP if you’ve experienced an early menopause or complications during pregnancy.
“An early menopause (before 45) and pregnancy complications such as pre-eclampsia also raise long-term risk, and these are often forgotten decades later,” says Dr Cheong.
His advice is to have your cholesterol rechecked around and after menopause, and to make sure your doctor knows about any early menopause or pregnancy complications.
The message is that cholesterol isn’t something to check once and then forget about. As Giblin points out, it is also important to consider other factors, including blood pressure, family history, genetics, type 2 diabetes and kidney disease.
“A cholesterol number never exists in a vacuum,” she says.
If you eat well, exercise regularly and are a healthy weight, you might assume your cholesterol levels will be perfectly healthy, too. Unfortunately, it’s not quite that simple. Genetics can play a significant role in determining your cholesterol levels, meaning even the fittest among us aren’t necessarily in the clear.
“It catches many people out,” says Dr Cheong. “Genes account for a large share of your cholesterol level, probably around half.”
One of the best-known inherited conditions is familial hypercholesterolaemia (FH), which affects around one in 250 people. Many don’t even know they have it.
“Because LDL is high from birth, arteries are exposed for decades, and untreated FH can cause heart attacks in the 40s,” explains Dr Cheong.
Clues include very high LDL cholesterol (above about 4.9mmol/L), close relatives who have experienced heart disease at a relatively young age, or yellowish deposits around the eyes or on the tendons. If several members of your family have high cholesterol or have had heart attacks at a younger age than expected, it’s worth discussing this with your GP.
Another inherited risk factor that you might not have heard of is lipoprotein(a), usually shortened to Lp(a). This is a type of particle in the blood that carries cholesterol, and levels are largely determined by your genes.
“It needs only one blood test in your lifetime, as the level is genetically fixed, and it is raised in about one in five people,” says Dr Cheong. “It isn’t yet part of routine NHS testing, so it’s worth asking about if heart disease runs in your family.”
Giblin agrees that we shouldn’t assume someone is healthy simply because they look fit.
“You can run marathons, have a perfect body mass index (BMI), eat a healthy diet, and still have dangerously high cholesterol,” she says.
The liver makes around 80% of the cholesterol in our bodies, with the rest coming from our diet, so while eating well and exercising regularly are important, they aren’t the whole story.
“Exercise strengthens the heart and lowers blood pressure, but it cannot physically remove or prevent sticky LDL plaque from building up inside the arteries over time,” Giblin explains.
Being active and maintaining a healthy weight are undoubtedly good for your cardiovascular health, but they don’t guarantee that your cholesterol is under control.
“High cholesterol is not a moral failing,” says Dr Cheong. “Being fit and slim protects you, but it doesn’t make you immune.”
If you’ve ever looked at the results of a cholesterol blood test and wondered what all those different numbers mean, you’re not alone. Total cholesterol, LDL, HDL and non-HDL can look like a bit of a maths lesson, but understanding what they measure can help you make sense of your heart health.
The first thing to know is that not all cholesterol is the same. LDL (low-density lipoprotein) is often called “bad” cholesterol because it can contribute to fatty deposits building up in your arteries. HDL (high-density lipoprotein), meanwhile, is known as “good” cholesterol because it helps carry cholesterol away from the arteries and back to the liver. Non-HDL is a measure of all the cholesterol in your blood apart from HDL, so it includes LDL and other potentially harmful particles.
But what numbers should you actually be aiming for?
“There’s no single ‘pass mark’, but these are useful general guides for healthy adults,” says Dr Cheong.
| Cholesterol | Amount |
|---|---|
|
Total cholesterol |
Below 5.0 mmol/L |
|
Non-HDL cholesterol |
Below 4.0 mmol/L |
|
HDL (“good”) cholesterol |
Above 1.0 mmol/L for men; 1.2 mmol/L for women |
|
LDL (“bad”) cholesterol |
Lower is better. Your target depends on your individual risk |
Your ideal cholesterol levels depend on your wider health and whether you’ve already experienced a cardiovascular event.
“If you’ve already had a heart attack or stroke, the target is much lower: LDL of 1.8 or below, or non-HDL of 2.6 or below,” explains Dr Cheong.
This is why it’s important not to focus on one number in isolation. Your doctor will also consider factors such as your age, blood pressure, whether you smoke, diabetes and family history when assessing your chances of developing cardiovascular disease.
One way of bringing all these factors together is through a calculation called QRISK3. This estimates your risk of having a heart attack or stroke over the next ten years.
“Your cholesterol matters most in the context of your overall 10-year risk of a heart attack or stroke,” says Dr Cheong. “Doctors estimate this with a tool called QRISK3, which also takes in age, blood pressure, smoking, diabetes and family history.”
A score of 10%, for example, means that around 10 in every 100 people with a similar risk profile would be expected to have a heart attack or stroke within ten years.
Giblin says that people shouldn’t simply be reassured that their cholesterol is “fine for their age”.
“Never settle for a doctor or a lab report telling you your cholesterol is ‘fine for your age’,” she advises. “Ask for your specific numbers, find out your overall 10-year cardiovascular risk score, and aim for personalised targets rather than population averages.”
It’s a particularly important distinction as we get older, when other health conditions and risk factors can start to have a greater influence on our heart health.
Lifestyle changes can help lower cholesterol, but for some people medication will also be recommended.
Statins lower LDL cholesterol and reduce the risk of heart attacks and strokes, but whether you need to take them depends on your overall cardiovascular risk rather than your cholesterol reading alone.
“Statins are among the most studied medicines in history,” says Dr Cheong. “Under NICE guidance [National Institute for Health and Care Excellence], a statin is usually offered if your 10-year risk is 10% or higher, and more strongly if you’ve already had a heart attack or stroke or have familial hypercholesterolaemia.”
This doesn’t mean everyone with raised cholesterol automatically needs medication. Doctors look at your overall cardiovascular risk, considering factors such as age, blood pressure, smoking, diabetes and family history.
“To put the benefit in plain numbers, if 100 people at 10% risk take a statin for 10 years, around two or three will avoid a heart attack or stroke,” explains Dr Cheong. “For people who have already had one, the benefit is considerably greater.”
Diet can help lower cholesterol, but you don’t necessarily need to ban foods such as eggs. For most people, saturated fat has a much greater effect on blood cholesterol than the cholesterol found naturally in food.
“Eating too much saturated fat from foods like fatty meats, meat products, butter and pastries can raise blood cholesterol,” says Dell Stanford, senior dietitian at the British Heart Foundation. Instead, she recommends eating more plant-based foods, including peas, beans, lentils and wholegrains.
Stanford also cautions against supplements marketed as natural cholesterol-lowering alternatives, such as red yeast rice, which contains a compound chemically identical to the statin lovastatin.
“Supplements are not regulated in the same way as medicines, so there are concerns about variable strength, potential side effects and limited long-term safety data,” she says. “Red yeast rice supplements are not recommended for cholesterol lowering.” Evidence for garlic supplements is also too inconsistent to make firm recommendations.
Stanford’s advice? Focus on your overall diet rather than looking for a quick fix. And remember, diet isn’t always enough on its own. Genetics can play a significant role, so some people will need medication alongside lifestyle changes.
You may have spotted spreads, yogurt drinks and other products containing plant sterols and stanols in the supermarket but are they worth buying?
There’s good scientific evidence that these ingredients can help lower cholesterol by reducing how much is absorbed in the gut.
“When taken in the right amounts (between 1.5g to 3g) every day, these fortified foods can reduce cholesterol levels by 7 to 12%,” explains Stanford.
However, they need to be consumed daily to maintain the effect. They can also be used alongside statins to help lower cholesterol further but shouldn’t be seen as a replacement for prescribed medication.
If you’ve been told you have high cholesterol, you might assume you need to start pounding the pavements or spending hours in the gym. The good news is that you don’t need to become a fitness fanatic to make a difference.
“Exercise is very important, but I think we have to be careful not to sell it as some kind of magic cholesterol-lowering treatment,” says Ian Northcott, an exercise specialist who works with over-50s.
Regular physical activity can improve your cholesterol profile, reducing LDL and triglycerides while increasing HDL. However, the changes are generally modest. Where exercise really comes into its own is in improving your overall cardiovascular health.
“It can also improve blood pressure, glucose control, insulin sensitivity, body composition, cardiovascular fitness and physical function,” says Northcott. “I wouldn’t look at exercise purely as a way of lowering a cholesterol number.”
And you don’t have to choose between aerobic exercise and strength training. They all have an important role to play, particularly as we get older and naturally lose muscle mass.
“Aerobic exercise such as brisk walking, cycling, rowing or swimming is excellent for developing cardiovascular fitness,” Northcott explains. “But strength training becomes increasingly important as we get older because we naturally lose muscle mass and strength.”
Northcott recommends doing both ideally. UK guidelines suggest aiming for at least 150 minutes of moderate-intensity activity each week, or 75 minutes of vigorous activity, alongside strength exercises on at least two days.
If that sounds daunting, don’t let it put you off. Walking absolutely counts, and you don’t have to start with an ambitious exercise programme.
“If somebody has been inactive for several years, I am not going to tell them that they suddenly have to start exercising for 150 minutes next week,” says Northcott. “I would rather get them moving.”
His advice? Start small. “Walk for ten minutes. Take the stairs. Garden. Cycle to the shops. Get out of the chair more often. Find something you enjoy and start building it into your life.”
For moderate exercise, you should feel warmer and breathe more heavily but still be able to hold a conversation. As Northcott puts it: “The biggest mistake is convincing people that exercise only counts if it is hard. It doesn’t.”
Of course, exercise isn’t a licence to ignore what you eat. “You can’t really exercise your way out of a consistently poor diet,” he says. Reducing saturated fat, eating more fibre and making sensible food choices remain important for managing cholesterol.
His final message is reassuring: “The person who has done virtually nothing for five years and starts walking regularly has made a very meaningful change to their health.”
The important thing to remember is it’s never too late to make a difference. Whether you’re in your fifties, sixties or seventies, improving your diet, becoming more active, managing blood pressure and taking medication when recommended can all help protect your heart.
As Northcott puts it: “Medication and lifestyle are not opposing choices.”
Sometimes you need both, and there’s no shame in that.
Dr Mark Porter and his guests talk about how to stay fit, healthy and happy as you get older in Saga’s health podcast. From creaky knees to statins, they’ve got your health issues covered.
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