Beyond the Number: A Holistic Approach to Cholesterol and Cardiovascular Risk
A few days ago, I saw Robert in clinic - in his late 50s he had come to discuss his cholesterol after a routine blood test showed a level of 5 mmol/L (a level I would describe being in the 'complicated' range - not high enough that the decision to treat is pretty easy but equally not low enough that it can be safely ignored). His GP had suggested he consider taking a statin, but he wanted to understand more before making a decision.
Many people focus on cholesterol as a single number—if it’s high, it must be bad; if it’s low, it must be fine. But cholesterol is only one piece of the wider picture when it comes to cardiovascular risk. During our consultation, we looked beyond just that one figure and explored what it really meant for his long-term health.
The Full Cardiovascular Risk Picture
Rather than focusing on total cholesterol alone, we examined his overall cardiovascular risk. This includes factors such as:
Blood pressure
Family history of heart disease
Smoking history
Diabetes or prediabetes status
By looking at all these factors together, we get a clearer idea of whether cholesterol-lowering treatment might be beneficial.
Understanding the Cholesterol Profile
Total cholesterol on its own doesn’t tell the whole story. We looked at Robert’s cholesterol profile in more detail, including his Total Cholesterol:HDL ratio, which gives a better indication of cardiovascular risk. It looks at how much of the total cholesterol is made up of ‘good’ HDL cholesterol. A high ratio suggests a higher risk, while a lower ratio is more reassuring. This deeper analysis helps guide decisions beyond just a single cholesterol number.
The Influence of Others’ Experiences
One of the most important things to do when exploring medication options is to understand previous experiences and whilst Robert hadn’t personally taken statins before, he was hesitant about them. He knew someone who had been on a statin and described feeling “a bit rubbish and achey.” This is a common concern, and while muscle aches can happen with statins, they aren’t inevitable—indeed in my experience as well as in the wider medical literature—most people tolerate statins well, and for those who do experience side effects, there's a lot we can do to manage it like switching from hydrophilic (water-soluble) to lipophilic (fat-soluble) statins, adjusting the dose or timing.
Lifestyle Modifications: What Works and What Doesn’t
Just as importantly as looking at medication we looked at his lifestyle as a whole. He had already made efforts to improve his lifestyle, including changing his diet and increasing his physical activity. But he had struggled with weight loss in the past and hadn’t seen the results he hoped for. This is a frustration many people face—weight management is complex, and while lifestyle changes are important, they aren’t always enough to bring cholesterol and cardiovascular risk down to a safe level. Unfortunately genetics has a huge amount to answer for here.
We also discussed other non-statin options, such as ezetimibe, which lowers cholesterol in a different way. However, these alternatives are typically considered in specific situations, such as statin intolerance or when additional cholesterol-lowering is needed beyond what a statin alone can achieve.
Cholesterol Management: A Lifelong Perspective
One of the most important takeaways from our consultation was that cholesterol isn’t a short-term issue. Whether it’s through lifestyle changes, medication, or even an informed decision to do nothing at present, managing cardiovascular risk is a lifelong process. There’s no quick fix—what matters is making a choice that aligns with both the science and the individual’s personal circumstances, preferences, and risks.
In the end, he left with a clearer understanding of his options, feeling better equipped to make an informed decision.
If you’ve been told you have high cholesterol and are wondering what to do next, the most important thing is to look at the whole picture. Your cholesterol number is just one factor—understanding your overall cardiovascular risk and discussing all your options is key to making the best decision for your long-term health.