For decades, cholesterol has been viewed as the real culprit of heart disease, heart attacks, atherosclerosis, and strokes. Many people have grown up hearing that high cholesterol means a high risk of heart disease, and that lowering cholesterol should be their main goal.
This way of thinking has been conditioned since the early 60s, when research by Ancel Keys and his hypothesis of the role of saturated fat on heart disease began to shape public health advice. The evidence from Keys’ research has been challenged, and his ideas debunked. I have written about this previously.
While cholesterol is an important marker of health, in many public health settings, it is still mainly associated with saturated fat and is looked at in isolation. In many cases, raised cholesterol might be a sign that changes have been occurring in the body already, rather than being the starting point of the problem.
Cholesterol has been viewed too simply
Most people think about cholesterol in a rather simple way: there is “good cholesterol” and “bad cholesterol”, and there is also total cholesterol, these three are to watch out for. If LDL (low-density lipoprotein) cholesterol, the so-called “bad cholesterol”, is high, the assumption is that the risk of heart disease has suddenly increased. But cholesterol isn’t just a harmful substance that floats around in our bloodstream.
A more clinically useful way to interpret cholesterol is to consider the metabolic processes that may have contributed to the numbers changing in the first place. For many people, altered cholesterol markers develop alongside raised blood sugar, insulin resistance, and inflammation. Diets consistently high in sugar and refined carbohydrates can place demands on the body’s metabolic systems, potentially contributing to changes in cholesterol over time.
Having elevated blood sugar levels regularly damages blood vessels, and the body has a coping mechanism to respond to this. Cholesterol-containing lipoproteins become involved in the repair process, serving as ‘patch-up work’ in places of damage. If the person does not do anything to change the factors that lead to the damage in the arteries and veins in the first place, then even taking cholesterol-lowering medications is not going to affect their risk of heart disease and stroke.
The conversation about saturated fat has changed
For many years, saturated fat was at the centre of the heart health conversation. People were encouraged to avoid butter, full-fat dairy products, red meat and other sources of saturated fat. More recent discussions have challenged this message. Several researchers, including Nina Teicholz, have questioned the strength of the original evidence behind the diet-heart hypothesis from the late 1950s and argued that saturated fat was blamed wrong.
It’s important to be clear. Current UK guidance still recommends limiting saturated fat to 20g per day for women and 30g per day for men, and many health organisations continue to advise replacing saturated fats with unsaturated fats. However, the conversation is no longer as simple as “fat is bad” and “low-fat is healthy”. A person eating nutrient-dense whole foods with good blood sugar control might have a very different metabolic profile from someone eating a diet high in refined carbohydrates, sugary snacks, and ultra-processed foods.
This is why you need to look at the full diet, not just one nutrient.
The role of blood sugar levels and heart disease
There is one marker in heart disease risk that needs to be given more focus - HbA1c or glycated haemoglobin. HbA1c shows average blood sugar levels over the previous two to three months. If this number is rising, it might suggest that the body is struggling to manage glucose effectively. This can be an early warning sign of insulin resistance, months and sometimes years before the person is diagnosed with type 2 diabetes.
Insulin resistance can develop quietly over years. During this time, the body has to produce more insulin to keep blood sugar levels under control. This can affect energy, weight, appetite, inflammation, and fat storage. By the time cholesterol numbers change, the underlying issue has been building for a long time. This is why, by focusing solely on cholesterol, we can miss the bigger picture. If blood sugar levels and insulin resistance aren’t addressed, your long-term risk can continue rising even if you are watching your cholesterol.
Cholesterol as part of metabolic syndrome
Cholesterol numbers should be viewed as part of broader metabolic health, not as a separate issue. Metabolic syndrome is a collection of interrelated conditions. These can include elevated blood sugar levels, high blood pressure, excess abdominal fat, weight gain, high triglycerides levels, and low HDL cholesterol.
This is important because heart disease risk is rarely about one factor.
Your HbA1c, triglycerides and HDL deserve more attention. Triglycerides are not commonly assessed in doctors’ offices, but they are among the most important markers to monitor, as they indicate how robust your metabolic health is. After food consumption, the digestive system breaks down fats from food into fatty acids, these are absorbed by the intestines and later assembled into triglycerides. In addition, triglycerides are formed when the liver converts excess energy (calories) consumed from sugars and refined carbohydrates.
HDL cholesterol, often called “good cholesterol” is protective for blood vessels, it helps transport cholesterol away from tissues and back to the liver.
The triglyceride-to-HDL ratio is a useful marker to know, because it gives you an insight into your individual metabolic health and risk for cardiovascular disease. If triglycerides are high and HDL is low, it might suggest the body isn’t handling glucose and fat efficiently. A healthy Tg-HDL ratio is 1.0 or below.
Management of cholesterol with lifestyle changes
Managing cholesterol to lower the risk of heart disease means improving the environment that affects cholesterol, blood sugar and inflammation. This starts with the diet.
The first step is reducing sugar and refined carbohydrates. This includes foods and drinks that have added sugars: sweets, biscuits, pastries, sweet drinks, as well as refined carbohydrates - such as white bread products, white rice, pasta, potatoes and highly processed foods. Regular consumption of these foods gives an increased risk of developing insulin resistance.
The next step is to reconsider fat as a macronutrient. Fat is an important macronutrient needed for cell membrane structure, for brain cells, as a building material for hormones, and as a transport mechanism for many fat-soluble vitamins. Thus, fat is not evil.
However, there is a range of foods where, due to manufacturing processes, the type of fat has changed form and become a health risk. These are trans fats (present in many ultra-processed foods), processed meats like salami, pepperoni, and deli meats, and also vegetable oils used in fried foods, take-aways, sauces, dressings, and packaged goods. Vegetable oils are shown to increase the risk of oxidised LDL, which is found in atherosclerotic plaques.
Good-quality protein, vegetables, whole-food fats (such as milk and cheese), fibre-rich foods are part of balanced and nutritionally supportive meals that could help manage cholesterol effectively.
Exercise supports healthier cholesterol levels
Exercise is important. Changes to lifestyle to support heart health need to include regular exercise. Exercise is a strong number one protector of blood sugar regulation, prevention against insulin resistance and lowered heart disease risk. Strength training is possibly one of the best ways to manage cholesterol.
Muscle is one of the most important tissues for metabolic health because it helps the body use glucose and fat for energy, which improves the function of HDL cholesterol in transporting excess cholesterol out of the body. The more active your muscles are, the better your body can manage blood sugar and energy regulation.
Strength training can also help improve HDL function and reduce triglycerides, especially when combined with dietary changes. This is one reason it can be so effective for people trying to improve cholesterol and long-term health.
However, strength training needs to be progressive. Very light weights might help with general movement and body conditioning, but they’re unlikely to create the same metabolic benefits as proper resistance training. You need to exert power for strength training to be effective, so start with a moderate weight and good technique, then gradually increase the challenge over time.
Look beyond cholesterol and focus on the full picture
Looking at cholesterol without also considering blood sugar, insulin resistance, triglycerides, diet, exercise, and broader lifestyle habits can lead to a very limited understanding of heart health.
For many people, cholesterol isn’t where the problem begins. It might be a sign that the body has been under metabolic stress for some time. At Boost My Energy, I look at health through a wider metabolic lens, helping clients understand how blood sugar, nutrition, movement, sleep, stress and lifestyle all work together.
With my health coaching programmes, including the Restore Metabolic Health programme, I support clients who are concerned about high cholesterol and long-term heart health. The focus is not on cholesterol numbers in isolation, but on the daily habits that can improve the overall picture. Get in touch with Boost My Energy to explore health coaching and learn how simple, consistent changes can help you take a more informed approach to your future health.