Think you’re heart-healthy? Your cholesterol may tell another story

Regular exercise, a balanced diet and maintaining a healthy weight are among the best things you can do for your heart. But they do not always tell the whole story.

For some people, especially those already at high cardiovascular risk, lifestyle changes alone may not be enough to bring low-density lipoprotein cholesterol, or LDL-C, down to safer levels.

Often called “bad cholesterol”, LDL-C can contribute to the build-up of fatty deposits in artery walls, increasing the risk of heart attack and stroke over time.

Part of the reason lies in how cholesterol is produced. While diet contributes to cholesterol levels, most of the cholesterol circulating in the body is produced internally, primarily by the liver.

Genetics and other biological factors can, therefore, keep LDL-C high even in people who eat well and exercise regularly.

An estimated one in three Malaysian adults, or about 7.6 million people, live with high cholesterol, while around four in 10 have elevated LDL-C levels.

About half may not know they have it, as high cholesterol does not have come with obvious symptoms.

Who needs to pay closer attention?

People with a higher cardiovascular risk may need a more structured approach to cholesterol management. This includes those with a history of heart attack or stroke, as well as people with diabetes, high blood pressure, obesity, very high LDL-C, or several risk factors at the same time.

Cardiologist Dr Lim Bee Chian said lifestyle measures remain important, but medication may also be needed in higher-risk individuals for whom “relying on lifestyle changes alone may not be sufficient to bring LDL-C down to recommended targets”.

“In these instances, medical treatment is often required alongside diet and exercise to meaningfully reduce cardiovascular risk,” he said.

LDL-C targets are not the same for everyone; they depend on a person’s overall cardiovascular risk, with higher-risk individuals generally advised to aim for lower levels.

For example, those at high risk may be advised to keep LDL-C below 1.8 mmol/L, while some people at very high risk may need even lower targets. The goal is not simply to lower LDL-C once, but to keep it consistently controlled over time.

A useful way to look at cardiovascular protection is through three areas working together:

• diet, to reduce saturated fat intake and improve overall dietary quality;
• exercise, to support heart fitness, weight management and general wellbeing;
• medical treatment, when prescribed, to help achieve and maintain cholesterol targets.

Healthy eating tips

Dietitian Celeste Lau said heart-healthy eating does not need to be complicated. Small, consistent changes are often more useful than dramatic short-term diets.

Cutting back on saturated fats, choosing healthier substitutes and improving overall food quality can all help support better cholesterol control.

The emphasis, she said, should be on habits that can realistically be maintained.

Exercise plays an equally important role, but it should suit the individual. For people with cardiovascular disease or other health concerns, physical activity may need to be structured so the heart is challenged safely rather than pushed too hard.

Walking groups, low-impact exercise and personalised programmes can all be useful, particularly when performed regularly.

Physiotherapist Nathalie Goh also noted that consistency matters more than intensity alone. “When done regularly and safely, exercise becomes an important part of long-term cardiac rehabilitation, helping to improve functional capacity, independence and overall quality of life,” she said.

For some patients, cholesterol-lowering medication becomes necessary even when they are already eating well and staying active. Treatment options can include statins, ezetimibe, PCSK9 inhibitors and newer RNA-based therapies, depending on how much LDL-C needs to be reduced and how an individual responds.

The choice of treatment should be guided by a healthcare professional and based on overall cardiovascular risk rather than cholesterol numbers alone.

Importantly, the need to take medication should not be viewed as one’s failure to maintain healthy cholesterol levels.

The larger message is simple: healthy living remains essential, but it is not always enough by itself. Someone can exercise regularly, eat sensibly and still have LDL-C levels that require medical attention.

That makes regular health screening important, particularly because high cholesterol can remain hidden for years. Knowing your numbers – and understanding what they mean for your personal risk – may be just as important as counting your steps or watching what is on your plate.

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