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Does Cholesterol Cause Heart Disease? What does the Science Say?

Updated: Jul 11

cholesterol heart disease science evidence

Recently we have met or spoken with several members of the public who shared that they are not concerned about their cholesterol levels. Contrary to medical advice, they say that 'high cholesterol' is simply a measure of the body doing what needs to be done to protect itself.

Certainly high levels of cholesterol show that the body is doing something but unfortunately the science shows that too much cholesterol is a very real problem in the long-term. Has the scientific establishment or medical community got it wrong as some health influencers say? Where does the science lead us?

As ever, please talk to your doctor or medical practitioner most familiar with your medical history before implementing any changes in diet, exercise or lifestyle, especially if you are under treatment.


Cholesterol Basics

Cholesterol is essential in the body and the body makes all the cholesterol that it needs. When it comes to the cholesterol in our blood, what is happening?

  • Low-density lipoprotein (LDL) cholesterol, often referred to as "bad cholesterol," is a type of fat that circulates in the blood. LDL carries cholesterol to your arteries, where it can accumulate on the artery walls and form plaque. This plaque buildup can lead to atherosclerosis, a condition that narrows and hardens the arteries, potentially leading to heart disease, heart attacks, and strokes.

  • High-density lipoprotein (HDL) cholesterol, commonly known as "good cholesterol," helps to transport cholesterol away from the arteries. HDL carries cholesterol to the liver, where it can be processed and removed from the body. The latest research linked to studies on Apo B (another cholesterol carrier particle and better indicator of health), show that the HDL numbers are not as useful to understand one's health as once thought. More on this below.

  • Recent evidence suggests that high levels of HDL cholesterol may not be as protective as once thought, and in some cases, they may even be associated with adverse health outcomes. However, high LDL and triglyceride levels are consistently linked with an increased risk of cardiovascular disease. Therefore, managing and lowering LDL levels (or, more precisely, total non HDL levels) remains crucial for maintaining cardiovascular health.


The Evidence

A 2017 study and consensus statement from the European Atherosclerosis Society looked at the totality of evidence from multiple separate studies including:

  • Mendelian randomisation (genetic) studies

  • Randomised clinical trials

  • Meta-analyses of over 200 prospective cohort (epidemiologic) studies.

The studies included over 2 million participants with over 20 million person-years of follow-up and more than 150,000 cardiovascular events. This is a massive dataset of studies looking at not simpky at correlation but causation. (Note: the study citation and link is at bottom of page)

The result? That together these studies provide consistent and unequivocal evidence that LDL causes atherosclerotic heart disease.

Here is what the dataset shows, note the almost linear relationships between LDL exposure and risk of atherosclerosis across the multiple types of studies.

LDL cholesterol Singapore

The conclusion of the study states "Considered together, the strong and consistent evidence from the genetic studies, prospective epidemiologic cohort studies, Mendelian randomization studies, and randomized intervention trials discussed here, supported by mechanistic evidence to be presented in the second Consensus Statement on LDL causality, establishes that LDL is not merely a biomarker of increased risk but a causal factor in the pathophysiology of ASCVD."


What are typical causes of high cholesterol?

  • Diet, in particular saturated fat consumption.

  • While dietary cholesterol consumption is not considered a major factor, for some people it can be an issue. Confusingly, in recent years, the science has changed on this however the latest guidelines recommend caution. If you have high blood cholesterol, it is wise to reduce dietary cholesterol.

  • Alcohol

  • Smoking

  • Lack of exercise

  • Stress

  • Poor sleep

When it comes to the plate, recommendations suggest a focus on eating patterns rather than individual foods. The cholesterol lowering Portfiolio Diet or DASH Diet (a Mediterranean inspired diet, designed for reducing hypertension) are shown to be successful.


Cholesterol science can be confusing but for those who study and research it, the evidence is clear. Yes, cholesterol is essential (it is in every cell of our body) but too much over a long time period causes atherosclerosis.

Have you had your cholesterol levels tested recently? What are your numbers?

Recently a newer test for cholesterol has become more widely available: Apolipoprotein B (Apo B). This is a protein found in LDL and other non-HDL cholesterol (that is, atherogenic) particles. Apo B directly measures the number of particles that can cause plaque buildup, providing a more accurate assessment of cardiovascular risk compared to traditional tests.

Finding the path to health is not always easy, especially with our busy modern lifestyles. Becoming or being healthy does not have to be as difficult or restrictive as you might imagine. Health is not an all or nothing game. Small changes in diet, exercise, sleep work-life balance and beating stress can pay large dividends. Not only for heart health but all aspects of our health and longevity.

Stay Healthy,


Singapore cholesterol hyperlipidemia

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Related Studies and Resources

The major study highlighted in the article...

Ference BA, Ginsberg HN, Graham I, Ray KK, Packard CJ, Bruckert E, Hegele RA, Krauss RM, Raal FJ, Schunkert H, Watts GF, Borén J, Fazio S, Horton JD, Masana L, Nicholls SJ, Nordestgaard BG, van de Sluis B, Taskinen MR, Tokgözoglu L, Landmesser U, Laufs U, Wiklund O, Stock JK, Chapman MJ, Catapano AL. Low-density lipoproteins cause atherosclerotic cardiovascular disease. 1. Evidence from genetic, epidemiologic, and clinical studies. A consensus statement from the European Atherosclerosis Society Consensus Panel. Eur Heart J. 2017 Aug 21;38(32):2459-2472. doi: 10.1093/eurheartj/ehx144. PMID: 28444290; PMCID: PMC5837225.


Zakai NA, Minnier J, Safford MM, Koh I, Irvin MR, Fazio S, Cushman M, Howard VJ, Pamir N. Race-Dependent Association of High-Density Lipoprotein Cholesterol Levels With Incident Coronary Artery Disease. J Am Coll Cardiol. 2022 Nov 29;80(22):2104-2115. doi: 10.1016/j.jacc.2022.09.027. PMID: 36423994.

Lichtenstein AH, Appel LJ, Vadiveloo M, Hu FB, Kris-Etherton PM, Rebholz CM, Sacks FM, Thorndike AN, Van Horn L, Wylie-Rosett J. 2021 Dietary Guidance to Improve Cardiovascular Health: A Scientific Statement From the American Heart Association. Circulation. 2021 Dec 7;144(23):e472-e487. doi: 10.1161/CIR.0000000000001031. Epub 2021 Nov 2. PMID: 34724806.

Taheri H, Filion KB, Windle SB, Reynier P, Eisenberg MJ. Cholesteryl Ester Transfer Protein Inhibitors and Cardiovascular Outcomes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Cardiology. 2020;145(4):236-250. doi: 10.1159/000505365. Epub 2020 Mar 13. PMID: 32172237.

Carson JAS, Lichtenstein AH, Anderson CAM, Appel LJ, Kris-Etherton PM, Meyer KA, Petersen K, Polonsky T, Van Horn L; American Heart Association Nutrition Committee of the Council on Lifestyle and Cardiometabolic Health; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; Council on Peripheral Vascular Disease; and Stroke Council. Dietary Cholesterol and Cardiovascular Risk: A Science Advisory From the American Heart Association. Circulation. 2020 Jan 21;141(3):e39-e53. doi: 10.1161/CIR.0000000000000743. Epub 2019 Dec 16. PMID: 31838890.

Wang Q, Wang Y, Lehto K, Pedersen NL, Williams DM, Hägg S. Genetically-predicted life-long lowering of low-density lipoprotein cholesterol is associated with decreased frailty: A Mendelian randomization study in UK biobank. EBioMedicine. 2019 Jul;45:487-494. doi: 10.1016/j.ebiom.2019.07.007. Epub 2019 Jul 9. PMID: 31300347; PMCID: PMC6642403.



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