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The relationship between cholesterol and heart disease is more complex than commonly believed
By: Kimberly Drake
Being told that you have high cholesterol can feel like a verdict: Start taking a statin or risk a heart attack or stroke.
However, recent studies suggest that high cholesterol is not as uniformly harmful as once thought. Still, the message has swung hard in the other direction on social media, where claims range from “high cholesterol might save your life” to “high cholesterol is the secret to living to 100-plus.”
So, is high cholesterol really “good” or “bad”?
The reality is more nuanced than either extreme suggests. The more useful question may not be whether high cholesterol is harmful, but when—and in whom—it becomes risky.
The ‘Lipid Paradox’
Some health influencers on social media have turned the tables on cholesterol, promoting it as a key to longevity instead of something that needs to be lowered with aggressive treatment.
Much of this internet discussion traces back to real research. A 2023 Swedish study followed older participants for 35 years and found that those with higher total cholesterol were more likely to live to 100. In a separate 2025 study, researchers found that adults aged 90 or older with low-density lipoprotein cholesterol (LDL-C)—or so-called “bad” cholesterol—levels above 130 milligrams per deciliter (mg/dL) lived longer than those with levels below that threshold. This is notable, given that the American Heart Association considers an optimal LDL-C level to be at or below 100 mg/dL.
However, a 2023 study, which analyzed data from more than 4 million veterans aged 18 or older, offered a key caution. The higher rates of coronary heart disease deaths among older participants with low cholesterol levels appeared to reflect what researchers called “reverse causality,” a phenomenon in which the data seem to show that A causes B, when in reality it is B that causes A. In other words, a serious underlying illness may drive cholesterol down, not the other way around.
The researchers called this the cholesterol or “lipid paradox”—the counterintuitive observation that low LDL-C and total cholesterol levels are unexpectedly associated with poorer health outcomes in studies.
“My concern with the current ‘lipid paradox’ hypothesis is that, it is also known that very low cholesterol levels in the elderly (especially over 80 years old) is most often a marker of … underlying chronic disease like cancer,” Dr. Marschall Runge, a cardiologist and former executive vice president for medical affairs at the University of Michigan, told The Epoch Times.
“The reported studies supporting the ‘lipid paradox’ did not account for these variables.”
Dr. Eddie Hackler, a cardiologist in Atlanta, told The Epoch Times, “Simply put, low cholesterol often reflects underlying illness, frailty, malnutrition, or chronic disease that independently increases mortality risk.” In other words, higher cholesterol in older adults may mean that they are disease-free or well-nourished, factors that independently lower the risk of death. That could explain the association between high cholesterol and longevity reported among older participants in studies.
However, there is no evidence to discount the proof that high cholesterol increases the risk of heart disease in the general population, Runge noted.
“For the vast majority of adults (young and middle-aged), high LDL cholesterol remains a primary driver of atherosclerotic cardiovascular disease and reduction of LDL cholesterol saves lives,” he said.
Questioning the Cholesterol Narrative
There is more to the cholesterol debate than just science. History plays a role, too.
Cholesterol became a dietary “villain” in 1953, when physiologist Ancel Keys introduced the lipid–heart hypothesis: the idea that high intakes of total fat, saturated fat, and dietary cholesterol lead to atherosclerosis (hardening of the arteries). Keys argued that reducing fat and cholesterol, and replacing saturated fat found in animal products with polyunsaturated fat from plant-based oils and fatty fish, could lower cholesterol and the risk of heart disease.
This led to a 1968 American Heart Association dietary recommendation that people eat less than 300 mg of dietary cholesterol per day and eat no more than three whole eggs per week, as eggs are a prominent dietary source of cholesterol.
However, later studies complicated that picture. Although having high cholesterol increases the risk of heart disease, some clinical studies found that replacing saturated fat with polyunsaturated fat did not reduce heart disease death, and that in some cases, mortality rates increased.
Additionally, studies have shown that for most people, eating dietary cholesterol (such as in eggs) does not significantly raise blood cholesterol or meaningfully affect heart disease risk.
Concerns about the pharmaceutical industry’s involvement in the fight against cholesterol have also triggered skepticism. Statins, which are cholesterol-lowering medications, became mainstream in the late 1990s and grew into a lucrative market. According to a 2022 report, the global statin market is expected to reach $15.2 billion by 2027.
Statins are typically used for people with LDL levels of 190 mg/dL or higher, or 70 mg/dL to 189 mg/dL for people with diabetes or elevated cardiovascular risk. However, they carry side effects, prompting questions about whether the benefits outweigh the risks for all patients.
What Cholesterol Does in the Body
Despite its reputation, cholesterol is not inherently harmful—it is essential for health and vitality.
Cholesterol is a structural component of every cell in the body and helps preserve cell membrane integrity, according to Runge. It also benefits brain function.
“The brain contains about 25 percent of the body’s cholesterol, which is crucial for synapse formation and nerve signal transmission,” he said.
Cholesterol is also a building block for all steroid hormones, including cortisol, aldosterone, estrogen, progesterone, and testosterone. It helps the body produce vitamin D during sun exposure and is necessary for the liver to produce bile acids, which are essential for digesting fats and absorbing fat-soluble vitamins such as A, D, E, and K.
“Suffice it to say, humans born with very low cholesterol levels can have any of a number of debilitating disorders,” Runge said.
Despite cholesterol’s benefits, high cholesterol levels can lead to plaque buildup in the veins and arteries. However, it’s a common misperception that cholesterol buildup “clogs” arteries like grease builds up in a drain. In reality, high cholesterol stimulates inflammation in arterial walls, which leads to plaque formation, he said.
Existing inflammation or damage in arterial walls is also a driver of plaque buildup.
LDL particles, which carry cholesterol, circulate in the blood. If there are too many particles, or if the artery wall is damaged by smoking, high blood pressure, or other conditions, the LDL particles can penetrate and become trapped in the inner lining of the artery, Runge said. Once trapped, LDL particles undergo oxidation, a chemical process that triggers an immune response.
The body perceives these oxidized LDL particles as foreign invaders. The immune system then sends macrophages (white blood cells) to “eat” the particles.
“The macrophages gorge themselves on cholesterol until they become fat-laden ‘foam cells,’” Runge said. “These foam cells die and accumulate, forming a fatty streak. Smooth muscle cells migrate to cover this streak, forming a fibrous cap. This accumulation is the plaque.”
As plaque builds, it can narrow the artery and reduce or block blood flow, resulting in a stroke or heart attack. If the plaque becomes unstable and ruptures, it can trigger the formation of blood clots that block an artery and cause a heart attack or stroke.
Research suggests that statins may help lower heart disease risk because they decrease inflammation, in addition to lowering cholesterol, which may help reduce plaque formation.
Who Is More at Risk
Although high cholesterol can be a driver for heart disease in anyone, Runge noted that people with specific health conditions should be especially concerned about controlling their cholesterol, specifically LDL-C and apolipoprotein B, a primary protein component of harmful cholesterol particles that drives plaque buildup in arteries.
High cholesterol is riskier for anyone who has already had a heart attack or stroke or who has been diagnosed with peripheral artery disease. It is also more concerning for those with Type 1 or Type 2 diabetes or high blood pressure, as these conditions can damage blood vessels and the inner lining of arteries, making them more susceptible to plaque formation.
Additionally, chronic kidney disease can lead to distinct lipid abnormalities and raise cardiovascular risk.
Familial hypercholesterolemia, a hereditary condition that causes extremely high LDL cholesterol levels because of gene mutations, is a less common but significant risk factor for heart disease and heart disease-related death, Runge said. Patients with this condition should begin cholesterol-lowering treatment at an early age, before arterial damage has progressed.
People with high lipoprotein(a), a genetically inherited form of cholesterol, are another group at higher risk of heart disease, especially if they also have high total cholesterol levels.
An elevated 10-year atherosclerotic cardiovascular disease risk score is another important factor, Hackler said. Doctors can determine a person’s 10-year and 30-year risk using tools such as the American Heart Association’s Predicting Risk of Cardiovascular Disease EVENTs (PREVENT) calculator.
People with autoimmune conditions have a higher risk of heart disease in general, and high cholesterol compounds that risk. For example, people with lupus have a 50 percent greater risk of heart disease than those without the condition. This is due to disease-related chronic inflammation, accelerated plaque buildup in the arteries, damage to the inner lining of the blood vessels, and the presence of specific antibodies that raise heart disease and stroke risk, studies suggest.
