Congratulations Dr. McBride. Your discussion today may be the first I’ve read on Substack from a physician that recognizes complexity and either/or thinking, speaking metaphorically, leads the stampeding herd into a canyon with no exit, where many arrows await.
Ever since I was 17 and running 5 miles 4x a week doctors have said, You have high cholesterol but we aren’t going to worry about that now. I’m now mid 60’s, no HBP, CRP of .5, and total cholesterol number can be up to 260. But HDL is very high, triglycerides are normal, and LDL is borderline. I run walk 4 miles a day and don’t smoke. I’m resistant to statins and my doctor is not pushing me to take them. Thank you for this post. I pay close attention to this matter. Seems like nobody has read the final chapter in the cholesterol story. But you are close, seems like.
I recently got my lipid panel back. I'm 28 years old and otherwise healthy. I do strength training pretty regularly and I don't eat a lot of red meat. Despite my best efforts, my LDL went up to 183. HDL and Triglycerides are in the normal range. Regardless, my doctor prescribed me Crestor without talking to me about it. Any advice?
Huh - I suspect I would want a lot more information before I put you on a statin at your age. First I’d want to see a repeat panel, done fasting x 12 hrs, and after a few mos of low cholesterol, high fiber eating :)
Good to know. Granted, this was 3 months after I got my first lipid panel which had lower LDL and HDL, but higher triglycerides. I attempted exercise, cut back on red meat and fatty foods, incorporated vegetables, and intermittent fasting to get the results in my first comment. Perhaps one of those complex panels you were talking about?
Last November my total cholesterol/LDL was 214/138. In April it had shot up to 288/206. I had recently had shingles and was treated with prednisone and antivirals. I’m not sure if this is pertinent, but I also have Hashimotos and my normally controlled TSH was elevated. Could this dramatic increase in my lipid panel be tied to shingles and/or treatment?
I’d like clarity on dietary cholesterol (eggs, shrimp) vs saturated fats. Eggs and shrimp are good, lean sources of protein in a non-meat diet. Do you have guidance on if reducing saturated fats is more effective in reducing cholesterol than eliminating egg yolks? (In an otherwise healthy, active middle-age person with no family history of heart disease.)
Dietary cholesterol from eggs and shrimp has a modest effect on blood cholesterol for most people. Saturated fat—found in red meat, butter, cheese, and some oils—has a much stronger impact, mainly by reducing the liver’s ability to clear LDL from the blood.
Most people adjust their internal cholesterol production when they eat cholesterol-rich foods, but saturated fat consistently raises LDL. Research shows that reducing saturated fat lowers cholesterol more effectively than cutting out egg yolks or shrimp.
For a healthy, active middle-aged person without a family history of heart disease, it's generally better to limit saturated fat while keeping eggs and shrimp as part of a balanced, nutrient-rich diet. Focus on overall eating patterns rather than eliminating specific foods. Does that help?
Completely agree! Traditional cholesterol tests focusing on LDL-C may overlook important risk factors for cardiovascular disease. LDL particle count (LDL-P) and particle size are more accurate predictors, as smaller, denser particles are more likely to penetrate artery walls, become oxidized, and contribute to plaque formation. Studies confirm that high LDL-P levels correlate with increased heart disease risk, regardless of LDL-C levels. Strategies like statins, PCSK9 inhibitors, dietary changes, exercise, and weight loss can help lower LDL-P and improve heart health outcomes.
Thank you for this! I have high LDL (it kept creeping up now at 190) and good HDL (now at 69), tryglicerides at 80. I am 55 and am healthy, active, with low BP and blood sugar. I don't have family history of heart disease but my mom also has high cholesterol so it's most likely genetic. I was ready for more lifestyle changes (I am not eating much red meat but like dairy, so doctor said I could try a more vegan diet, even the portfolio diet for a few months). I didn't want to take statins. My doctor recommended I did a Coronary Calcium Scoring and it came zero. I was so happy.
Thank you so much for this article. Last November my total cholesterol/LDL was 214/138. In April it had shot up to 288/206. I had recently had shingles and was treated with prednisone and antivirals. I’m not sure if this is pertinent, but I also have Hashimotos and my normally controlled TSH was elevated. Could this dramatic increase in my lipid panel be tied to shingles and/or treatment? Is it time for a statin?
I keep reading about this topic because I wonder about my risk. Is there specific blood tests I should get in my next panel to determine true risk? Thanks!!
Thanks Dr McBride. I am 61 and relatively healthy, but…TriG > 250, HDL < 35, A1C =6.5 so (I think) borderline. I prefer natural methods to improve so walking daily and taking many supplements including Fish oil, etc. Also, I rarely ever get sick. Lost uncles and grandparent to heart disease. Mom to cancer but she smoked for years. Thank you. :-)
Sounds like you have what we call "the metabolic syndrome" and given your family history I'd prob want to see a calcium score and consider meds (in addition to lifestyle changes) to improve lipid levels and drop that A1C .. of course discuss w your own doc :)
My biggest challenge is a lack of exercise. Office work for 40 years catches up. Time to pick up some weights and do some jumping jacks. Seriously! Thanks for your feedback. :-)
Full lipid panel (total, LDL, HDL, triglycerides) is standard… and then, depending on those results plus underlying health issues + age + genetics, ask your doctor about hsCRP, Lp(a), ApoB, and NMR lipoprofile which can tell if you have small or large LDL particles
BTW, what is your opinion about supplements like Fish Oil, vitamin D, C, B complex, K, etc to help with overall health and relative to lowering A1C, Triglycerides, etch. I’ve taking them for years and wonder if I’d be worse off had I not. Thoughts?
Thank you for this! Sharing with my husband (who has a history of “high cholesterol and takes a statin) and printing to take with me to my next PCP visit to discuss.
My question is why not use a statin if it lowers your risk from medium to low or low to lower? I had previousely spent time understanding the Farmingham risk calculation with my results but have resolved that I have one risk factor so I'll reduce it. If I had an acceptable Farminham number and I smoked I'd put my energy into that one risk. There's a new more detailed risk caluculator in the US now but it doesn't include LP(a) either so rather than look at the risk as asseptable or not acceptable I think a better approach is to see what the risk fators are and adjust them where possible because the other big risk factor that keeps getting worse and we can't change is age.
I think my doctor explained C-Reactive Protein but the refresher helped. Checking my results it's very low so maybe my risk is low and if the statin was causing me side effects I might give it second thought but so far so good.
Even in people with "acceptable" Framingham scores, reducing LDL can further reduce lifetime risk—especially if other factors like age, family history, or elevated LP(a) are present. Think of it less as “acceptable or not” and more as: which modifiable risks can I optimize?
Risk calculators like Framingham or the newer ASCVD pooled cohort equations don’t account for LP(a), family history, inflammatory markers like hs-CRP, or imaging data like CAC scores. As you said, age is non-negotiable and increases risk steadily. That makes treating modifiable factors (LDL, BP, glucose, smoking, etc.) even more important as we age.
If you’re not having side effects and you’re comfortable with the long-term decision, a statin is a simple, evidence-based way to lower lifetime risk, even if your short-term risk is modest. Your low CRP supports the idea that your inflammatory risk is low, which is great. But LDL is still an independent risk factor—statins lower both LDL and CRP, a nice bonus.
Eggs contain cholesterol—about 186 mg per large egg, all in the yolk. But for most people, dietary cholesterol has little effect on blood cholesterol. It’s the saturated and trans fats that are bigger drivers of high LDL levels.
Most healthy ppl can safely eat up to one egg a day without raising heart disease risk. Eggs also offer protein, B vitamins, choline, and antioxidants. Unless you have a specific condition like familial hypercholesterolemia or high cardiovascular risk, eggs can be part of a balanced diet.
One who is hetero/homozygous for APOE-4 may find their response to Statins or Fish Oil differs from those in whom this condition is not present. Thoughts on this or the new studies on LMHR?
Congratulations Dr. McBride. Your discussion today may be the first I’ve read on Substack from a physician that recognizes complexity and either/or thinking, speaking metaphorically, leads the stampeding herd into a canyon with no exit, where many arrows await.
Thanks, Jim! Well said!
Ever since I was 17 and running 5 miles 4x a week doctors have said, You have high cholesterol but we aren’t going to worry about that now. I’m now mid 60’s, no HBP, CRP of .5, and total cholesterol number can be up to 260. But HDL is very high, triglycerides are normal, and LDL is borderline. I run walk 4 miles a day and don’t smoke. I’m resistant to statins and my doctor is not pushing me to take them. Thank you for this post. I pay close attention to this matter. Seems like nobody has read the final chapter in the cholesterol story. But you are close, seems like.
this is such a terrific, simplified explanation! Thank you, Dr. McBride🧡
I recently got my lipid panel back. I'm 28 years old and otherwise healthy. I do strength training pretty regularly and I don't eat a lot of red meat. Despite my best efforts, my LDL went up to 183. HDL and Triglycerides are in the normal range. Regardless, my doctor prescribed me Crestor without talking to me about it. Any advice?
Huh - I suspect I would want a lot more information before I put you on a statin at your age. First I’d want to see a repeat panel, done fasting x 12 hrs, and after a few mos of low cholesterol, high fiber eating :)
Good to know. Granted, this was 3 months after I got my first lipid panel which had lower LDL and HDL, but higher triglycerides. I attempted exercise, cut back on red meat and fatty foods, incorporated vegetables, and intermittent fasting to get the results in my first comment. Perhaps one of those complex panels you were talking about?
Last November my total cholesterol/LDL was 214/138. In April it had shot up to 288/206. I had recently had shingles and was treated with prednisone and antivirals. I’m not sure if this is pertinent, but I also have Hashimotos and my normally controlled TSH was elevated. Could this dramatic increase in my lipid panel be tied to shingles and/or treatment?
Hypothyroidism, if untreated, def can affect cholesterol levels
I’d like clarity on dietary cholesterol (eggs, shrimp) vs saturated fats. Eggs and shrimp are good, lean sources of protein in a non-meat diet. Do you have guidance on if reducing saturated fats is more effective in reducing cholesterol than eliminating egg yolks? (In an otherwise healthy, active middle-age person with no family history of heart disease.)
Dietary cholesterol from eggs and shrimp has a modest effect on blood cholesterol for most people. Saturated fat—found in red meat, butter, cheese, and some oils—has a much stronger impact, mainly by reducing the liver’s ability to clear LDL from the blood.
Most people adjust their internal cholesterol production when they eat cholesterol-rich foods, but saturated fat consistently raises LDL. Research shows that reducing saturated fat lowers cholesterol more effectively than cutting out egg yolks or shrimp.
For a healthy, active middle-aged person without a family history of heart disease, it's generally better to limit saturated fat while keeping eggs and shrimp as part of a balanced, nutrient-rich diet. Focus on overall eating patterns rather than eliminating specific foods. Does that help?
Completely agree! Traditional cholesterol tests focusing on LDL-C may overlook important risk factors for cardiovascular disease. LDL particle count (LDL-P) and particle size are more accurate predictors, as smaller, denser particles are more likely to penetrate artery walls, become oxidized, and contribute to plaque formation. Studies confirm that high LDL-P levels correlate with increased heart disease risk, regardless of LDL-C levels. Strategies like statins, PCSK9 inhibitors, dietary changes, exercise, and weight loss can help lower LDL-P and improve heart health outcomes.
https://ramkrishnan.substack.com/p/why-ldl-particle-count-and-size-matter
Thank you for this! I have high LDL (it kept creeping up now at 190) and good HDL (now at 69), tryglicerides at 80. I am 55 and am healthy, active, with low BP and blood sugar. I don't have family history of heart disease but my mom also has high cholesterol so it's most likely genetic. I was ready for more lifestyle changes (I am not eating much red meat but like dairy, so doctor said I could try a more vegan diet, even the portfolio diet for a few months). I didn't want to take statins. My doctor recommended I did a Coronary Calcium Scoring and it came zero. I was so happy.
Thank you so much for this article. Last November my total cholesterol/LDL was 214/138. In April it had shot up to 288/206. I had recently had shingles and was treated with prednisone and antivirals. I’m not sure if this is pertinent, but I also have Hashimotos and my normally controlled TSH was elevated. Could this dramatic increase in my lipid panel be tied to shingles and/or treatment? Is it time for a statin?
Also, I’m 56 year old female. Very active and not overweight.
Hypothyroidism, if untreated, can increase lipid levels -
The decision to be on a statin is very nuanced and depends on the factors I mentioned above - hence the need to d/w your primary care doc :)
I keep reading about this topic because I wonder about my risk. Is there specific blood tests I should get in my next panel to determine true risk? Thanks!!
Thanks Dr McBride. I am 61 and relatively healthy, but…TriG > 250, HDL < 35, A1C =6.5 so (I think) borderline. I prefer natural methods to improve so walking daily and taking many supplements including Fish oil, etc. Also, I rarely ever get sick. Lost uncles and grandparent to heart disease. Mom to cancer but she smoked for years. Thank you. :-)
Sounds like you have what we call "the metabolic syndrome" and given your family history I'd prob want to see a calcium score and consider meds (in addition to lifestyle changes) to improve lipid levels and drop that A1C .. of course discuss w your own doc :)
My biggest challenge is a lack of exercise. Office work for 40 years catches up. Time to pick up some weights and do some jumping jacks. Seriously! Thanks for your feedback. :-)
Full lipid panel (total, LDL, HDL, triglycerides) is standard… and then, depending on those results plus underlying health issues + age + genetics, ask your doctor about hsCRP, Lp(a), ApoB, and NMR lipoprofile which can tell if you have small or large LDL particles
BTW, what is your opinion about supplements like Fish Oil, vitamin D, C, B complex, K, etc to help with overall health and relative to lowering A1C, Triglycerides, etch. I’ve taking them for years and wonder if I’d be worse off had I not. Thoughts?
Thank you for this! Sharing with my husband (who has a history of “high cholesterol and takes a statin) and printing to take with me to my next PCP visit to discuss.
My question is why not use a statin if it lowers your risk from medium to low or low to lower? I had previousely spent time understanding the Farmingham risk calculation with my results but have resolved that I have one risk factor so I'll reduce it. If I had an acceptable Farminham number and I smoked I'd put my energy into that one risk. There's a new more detailed risk caluculator in the US now but it doesn't include LP(a) either so rather than look at the risk as asseptable or not acceptable I think a better approach is to see what the risk fators are and adjust them where possible because the other big risk factor that keeps getting worse and we can't change is age.
I think my doctor explained C-Reactive Protein but the refresher helped. Checking my results it's very low so maybe my risk is low and if the statin was causing me side effects I might give it second thought but so far so good.
Even in people with "acceptable" Framingham scores, reducing LDL can further reduce lifetime risk—especially if other factors like age, family history, or elevated LP(a) are present. Think of it less as “acceptable or not” and more as: which modifiable risks can I optimize?
Risk calculators like Framingham or the newer ASCVD pooled cohort equations don’t account for LP(a), family history, inflammatory markers like hs-CRP, or imaging data like CAC scores. As you said, age is non-negotiable and increases risk steadily. That makes treating modifiable factors (LDL, BP, glucose, smoking, etc.) even more important as we age.
If you’re not having side effects and you’re comfortable with the long-term decision, a statin is a simple, evidence-based way to lower lifetime risk, even if your short-term risk is modest. Your low CRP supports the idea that your inflammatory risk is low, which is great. But LDL is still an independent risk factor—statins lower both LDL and CRP, a nice bonus.
If cholesterol is high, should one avoid or limit egg consumption?
Eggs contain cholesterol—about 186 mg per large egg, all in the yolk. But for most people, dietary cholesterol has little effect on blood cholesterol. It’s the saturated and trans fats that are bigger drivers of high LDL levels.
Most healthy ppl can safely eat up to one egg a day without raising heart disease risk. Eggs also offer protein, B vitamins, choline, and antioxidants. Unless you have a specific condition like familial hypercholesterolemia or high cardiovascular risk, eggs can be part of a balanced diet.
One who is hetero/homozygous for APOE-4 may find their response to Statins or Fish Oil differs from those in whom this condition is not present. Thoughts on this or the new studies on LMHR?