5 myths and misconceptions about high cholesterol

If you want to take better care of your heart health, you’ve probably heard it’s important to keep your cholesterol in check. But what does that really mean for your health?

While these fatty molecules sometimes have a bad reputation, your body needs some cholesterol to work as it should. And there are a variety of factors that play a role in whether you may develop high cholesterol and when you should start treatment to manage your risk of heart disease.

5 common myths about cholesterol and its treatment

From diets to tests to treatment options, there are a lot of misconceptions about cholesterol. Get to know the facts so you can take steps that make a positive difference for your health.

Myth #1: All cholesterol is created equal.

Cholesterol isn't just one thing. It's a family of particles with different shapes, sizes and impacts on your health. LDL cholesterol, often labeled the "bad" kind, actually comes in different forms:

• Large, fluffy LDL particles are less harmful.
• Small, dense LDL particles are much more dangerous because they penetrate artery walls more easily and promote plaque buildup.

And here's the twist: These small, dense LDL particles are primarily driven by diets high in refined carbohydrates and sugars—not fat.

When you eat a lot of processed carbs, like white bread, pastries and soda, your liver turns that excess energy into triglycerides and small LDL particles. These are the real culprits behind heart disease—not the occasional egg or piece of steak.

Bottom line: It's not just how much LDL you have but what kind. And small, dense LDL comes mostly from sugar and refined carbs—not fat.

Myth #2: People with "normal" cholesterol don't need treatment.

Having "normal" cholesterol on a standard blood test doesn't necessarily mean you're safe from heart disease. Heart attacks don't happen because of high cholesterol alone. They happen because of plaque, the buildup of inflamed, fatty deposits in your arteries. This plaque can start forming long before cholesterol numbers look abnormal.

That's why looking for evidence of plaque is crucial. Some tests include:

• Coronary calcium scoring (CAC) can detect hardened plaque in the heart arteries.
• Carotid ultrasound (CIMT) measures the thickness of neck arteries, another early clue.
• Blood markers like oxidized LDL (oxLDL) and Lp-PLA2 can reveal hidden inflammation and vascular stress.

If plaque or inflammation is found, lipid-lowering medications should be considered, even if cholesterol looks “normal.” These drugs don't just lower cholesterol—they reduce inflammation, stabilize plaque, and help prevent heart attacks and strokes.

Bottom line: A normal cholesterol test doesn't mean you're in the clear. Plaque and inflammation—not just numbers—should guide treatment.

Myth #3: Cholesterol is primarily a diet problem.

You can't “eat your way” into or out of a cholesterol problem. For most people, cholesterol levels are largely determined by genetics, not diet. In fact, your liver makes 75-85% of your body's cholesterol because your body needs it for hormone production, brain health and cell repair.

Some people inherit conditions like:

• Familial hypercholesterolemia (FH)
• Elevated lipoprotein(a) [Lp(a)]
• Abnormal ApoB levels

These can cause high cholesterol regardless of how healthy your diet is. That said, diet still matters—just not in the way we used to think. A high-carb, high-sugar diet can worsen cholesterol profiles by:

• Raising triglycerides
• Increasing small, dense LDL
• Promoting insulin resistance and inflammation

Bottom line: Cholesterol problems are mostly inherited. Diet can make them worse, but even the healthiest diet might not be enough without medical treatment.

Myth #4: Lipid treatment is dangerous.

Statins and other cholesterol-lowering drugs are among the most studied and effective medications in history, yet many people fear them based on myths or isolated anecdotes.

Let's set the record straight:

• True statin intolerance (where no statin is tolerable at any dose) occurs in less than 5% of patients.
• Serious liver damage from statins is extremely rare—less than one in several thousand.
• There is no reliable evidence that statins cause dementia or cognitive decline. In fact, the opposite is true: Vascular dementia—caused by small vessel disease in the brain—is one of the most common forms of dementia, and statins help reduce this risk. A major review published in the Journal of the American College of Cardiology in June 2021 concluded that statins do not impair cognition and may even offer protection against vascular brain damage.

Bottom line: Statins are safe for the vast majority of people, do not cause dementia, and significantly reduce the risk of heart attack and stroke.

Myth #5: A standard lipid panel is sufficient.

The standard cholesterol test most doctors use today hasn't changed much since the 1970s. It gives you:

• Total cholesterol
• LDL
• HDL
• Triglycerides

That's useful but far from complete. Advanced lipid testing goes much deeper. These newer tests assess:

• LDL particle size and number to identify small, dense particles
• Lipoprotein(a), a major inherited risk factor missed by standard panels
• IDL, VLDL, which are other atherogenic particles that drive plaque
• Inflammatory markers, such as oxLDL, Lp-PLA2 and MPO

This deeper analysis provides a clearer, more personalized picture of your heart risk and can help guide more effective prevention strategies.

Bottom line: The basic cholesterol test is outdated. Ask your doctor about advanced lipid testing for a more complete view of your cardiovascular health.

Healthy steps for your heart health

While high cholesterol and its treatment are commonly misunderstood, with the right knowledge, you can take steps to improve your heart health. If you haven’t checked on your heart recently, take time to visit your primary care doctor and ask about the tests you need to get a full picture of your heart health.

If you’ve been told you have high cholesterol, plaque buildup or other risk factors for heart disease, visit a heart specialist who can provide additional testing and options for your care. Together, you can take steps to address your risk factors early—before they lead to lasting effects.