High Cholesterol: What the Numbers Mean
Cholesterol is a fat the body makes and needs, and the problem is not its presence but its balance. LDL cholesterol carries fat into the artery walls and drives the gradual furring that causes heart attacks and strokes; HDL carries it away. On a Pakistani lipid report an LDL under 100 mg/dL is desirable and 160 mg/dL or above is high, but the number alone never decides treatment — what matters is your total risk, combining LDL with age, blood pressure, smoking, diabetes and family history. Cutting banaspati, fried food and organ meats, walking most days and losing weight from the waist will typically lower LDL by 5 to 15 per cent; a statin lowers it by 30 to 50 per cent and is the treatment where risk is high or where cholesterol is very high from a young age. High cholesterol produces no symptoms whatsoever, so the only way to know is a blood test.
Health writers · Aslam Clinic
What cholesterol is
is a waxy fat that every cell in the body needs — it goes into cell walls, into vitamin D, into bile, and into the sex and stress hormones. Most of it is made by the liver rather than eaten, which is why diet alone can only move the number so far. Because fat does not dissolve in blood, it is carried around in protein packages, and it is those packages, not the cholesterol itself, that make the difference.
Low-density lipoprotein — — carries cholesterol from the liver out to the tissues. When there is more of it than the body needs, it lodges in the walls of arteries, where it is oxidised, attracts immune cells, and builds into a plaque. That process is , and it runs silently for decades before it narrows an artery enough to cause or ruptures and blocks one entirely. High-density lipoprotein, HDL, does the opposite job, collecting excess cholesterol and returning it to the liver, which is why a high HDL is a good sign rather than a bad one.
are a separate kind of fat, and they respond much more sharply to what you eat and drink than LDL does — a single heavy, sugary or alcohol-containing evening can move the number. Very high triglycerides also carry their own risk, of inflammation of the pancreas.
Reading your lipid report
| What is measured | Desirable | Borderline | High |
|---|---|---|---|
| Total | Under 200 mg/dL (5.2 mmol/L) | 200-239 mg/dL | 240 mg/dL (6.2 mmol/L) or more |
| — the one that matters | Under 100 mg/dL (2.6 mmol/L) | 130-159 mg/dL | 160 mg/dL (4.1 mmol/L) or more |
| HDL cholesterol — protective | 60 mg/dL (1.6 mmol/L) or more | 40-59 mg/dL | Under 40 mg/dL is itself a risk factor |
| Under 150 mg/dL (1.7 mmol/L) | 150-199 mg/dL | 200 mg/dL (2.3 mmol/L) or more | |
| Non-HDL cholesterol (total minus HDL) | Under 130 mg/dL (3.4 mmol/L) | 130-189 mg/dL | 190 mg/dL or more |
Two practical notes on the report itself. Most laboratories still ask for a nine to twelve hour fast, mainly because triglycerides rise after a meal; a non-fasting sample is acceptable for LDL and is increasingly used. And LDL is usually calculated rather than measured directly, from a formula that becomes unreliable when triglycerides are above about 400 mg/dL — which is why a report with very high triglycerides may carry a direct LDL measurement instead.
Why the number alone does not decide treatment
This is the part most often misunderstood. Two people can have exactly the same LDL of 150 mg/dL and need entirely different things. A 35-year-old woman who does not smoke, has normal and no has a very low chance of a heart attack in the next ten years, and her LDL of 150 is best addressed with food and walking. A 58-year-old man who smokes, has diabetes and a pressure of 155 has a high chance, and the same LDL of 150 is a reason to start a today.
Doctors therefore use a risk calculator that combines age, sex, smoking, blood pressure, diabetes and cholesterol into a percentage chance of a heart attack or stroke over the next ten years. Most calculators were built on European or American populations and underestimate risk in South Asians, so a correction — commonly multiplying by around 1.5 — is applied. Anyone who has already had a heart attack, a stroke, a stent or bypass surgery skips the calculation entirely: their risk is established, and treatment is intensive from the start.
What raises it
- Trans fats, which raise LDL and lower HDL at the same time. In Pakistan the main sources are banaspati or vanaspati ghee, commercial bakery items, and oil reused for frying over and over.
- Saturated fat in quantity — desi ghee, cream, full-fat dairy, fatty mutton and beef, and the fat rendered from nihari and paya.
- Refined carbohydrate and sugar, which raise particularly sharply — sweetened tea several times a day, cold drinks, mithai, white bread and rusk.
- Sitting still. Physical activity raises HDL, and inactivity lowers it.
- Excess weight around the middle, which raises triglycerides and lowers HDL together.
- Smoking and all tobacco, which lower HDL and damage the artery lining that cholesterol then enters.
- Other conditions — , , kidney disease, liver disease — each of which can raise lipids and each of which is checked before blaming diet.
- Genetics, which for some people matters more than everything above combined.
Familial hypercholesterolaemia
Roughly one person in 250 worldwide inherits a fault that leaves the liver unable to clear LDL properly. Cholesterol is high from childhood, does not respond much to diet, and causes heart attacks unusually early — in the forties or even the thirties without treatment. The clues are an untreated LDL above about 190 mg/dL in an adult, a parent or sibling with a heart attack before 55 in men or 65 in women, fatty deposits in the Achilles tendon or over the knuckles, and a pale ring around the cornea before the age of 45.
It matters here because it is treatable and because finding one person finds a family: each child of an affected parent has a one in two chance of carrying it, and cousin marriage — common in this region — makes the more severe form, where a fault is inherited from both parents, less rare than it is elsewhere. If any of the clues above apply to you, ask specifically about family testing rather than only about your own tablets.
Food that genuinely changes the number
Expect diet to lower LDL by around 5 to 15 per cent — real, worth doing, and not the same as what a achieves. The changes with the best evidence, translated into what is actually on the table here:
- Replace banaspati with a liquid oil — canola, sunflower, olive or rice bran — and stop reusing frying oil. This is the highest-value single change available in a Pakistani kitchen.
- Eat more soluble fibre: oats and jau, chana, all the daals, kidney beans, apples, guava, and psyllium husk (isabgol), which lowers LDL by a few per cent on its own.
- Eat fish twice a week — rahu, trout, mackerel or sardines — in place of red meat.
- Use nuts as the snack: a small handful of almonds or walnuts daily, unsalted, in place of namkeen or biscuits.
- Keep organ meats occasional. Kaleji, maghaz, gurda and paya are very high in cholesterol and saturated fat.
- Choose whole-grain roti over white bread, naan and rusk, and keep rice portions modest.
- Cut sweetened drinks and sweetened tea. Triglycerides respond to sugar faster than to fat.
- Grill, bake, steam or air-fry in place of deep frying — the same food, a different number.
Movement matters through a different route. Aerobic activity mainly raises HDL and lowers triglycerides rather than lowering LDL directly, but the effect on overall cardiovascular risk is larger than the lipid numbers suggest. Thirty minutes of brisk walking on five days a week is the standard advice, and it does not need a gym.
Medicines
are the first-line treatment and among the best-studied medicines in existence. They block the liver enzyme that makes cholesterol, lowering LDL by 30 to 50 per cent depending on the drug and dose, and they also stabilise existing plaque so it is less likely to rupture. All of them are available in Pakistan as inexpensive generics. Which statin and what dose depends on how far your LDL needs to fall and on what else you take — it is a prescriber's decision, not a shelf choice.
The commonest complaint on a statin is muscle aching, reported by a small minority. It is usually mild, often improves on a different statin or a lower dose, and serious muscle injury is rare. Liver enzymes are checked before starting and again after a few months. Statins slightly raise the chance of developing in people already close to it — a real effect, and a small one next to the heart attacks and strokes they prevent in those same people. They are not used in pregnancy or while trying to conceive.
Where a statin alone is not enough or is not tolerated, other classes are added: ezetimibe, which blocks absorption of cholesterol from the gut; bempedoic acid; and injectable PCSK9 inhibitors for familial hypercholesterolaemia and for people with established heart disease who need a much larger reduction. Fibrates and prescription omega-3 preparations are used mainly for very high rather than for LDL. None of these is a substitute for the food and activity changes; they are added to them.
How often to re-test
If your lipids are normal and you have no other risk factors, every three to five years is enough. After a change of diet, expect to wait about three months before re-testing — lipids move slowly, and a test two weeks after starting oats tells you nothing. After starting or changing a statin, the usual pattern is a repeat lipid profile and at around three months, then annually once stable.
When to see a doctor
Book an appointment if you have never had a lipid profile and you are a man over 35 or a woman over 45, if you have , high or a family history of heart disease before 60, or if a report has come back with an LDL of 160 mg/dL or more. Ask specifically about inherited cholesterol if a close relative had a heart attack before 55, or if your untreated LDL is above 190 mg/dL. And use the emergency guidance near the top of this page for chest pain or stroke symptoms — those are never a cholesterol appointment.
Common questions
Still not sure what to do?
Reading about a symptom only goes so far. A doctor who can ask you questions and examine you will get further in ten minutes than any article can.
