Ignore cholesterol until middle age? Here’s why that’s a bad idea

Heather Bowers doesn’t recall all the details of her first cholesterol screening. It was at a college health fair two decades ago, and even though her numbers came back “borderline high,” she responded in a way that many people in their 20s might.

“I just didn’t think about it,” she said, “because I was young, and I didn’t think it would make a difference.”

But when she turned 39, Bowers had a stroke. Was it related to cholesterol? Nobody can say. “But I’ll always wonder: Would better cholesterol management have prevented it?”

Unhealthy cholesterol levels are a major risk factor for heart disease and stroke. Bowers, now a nursing professor at Purdue University Northwest in Hammond, Indiana, has attempted to address the issue. But she agreed cholesterol management is not something young adults usually worry about.

That’s a problem, experts say. “People can have high cholesterol for years or even decades and not be affected by it,” at least outwardly, said Dr. Anandita Kulkarni, a preventive cardiologist in Plano, Texas. “And when it gets to a point that it becomes apparent or clinically significant, then it’s really too late.”

So the sooner people address unhealthy cholesterol levels, the better, said Kulkarni, medical director of cardiovascular disease prevention and cardio-obstetrics at Baylor Scott & White Health-The Heart Hospital Baylor Plano.

“I kind of think about it as investing,” said Kulkarni, who also is an associate professor at Texas A&M University College of Medicine. “You start early, and it compounds over time.”

Which is why, she said, young adults should understand a few cholesterol basics.

What is cholesterol?

Cholesterol is a waxy substance found throughout the body. It’s used to build cells and make vitamins and hormones. Your liver makes all the cholesterol you need.

Blood cholesterol is not the same as dietary cholesterol, which is found in food from animal sources. But eating a diet high in saturated and trans fats can contribute to unhealthy blood cholesterol levels. Over time, that can lead to atherosclerosis – a buildup of plaque inside the lining of your arteries.

Who needs a cholesterol test?

Pediatricians usually screen children for high blood cholesterol between the ages of 9 and 11 and again between the ages of 17 and 21, said Kulkarni, who helped write a scientific statement on heart disease risk factors for teens entering young adulthood in the Journal of the American Heart Association in March.

Those screenings can help a doctor decide how frequently someone should be tested as an adult, she said. In general, the American Heart Association recommends that all adults 20 or older have their cholesterol checked every four to six years as long as their risk remains low.

What do the numbers in a cholesterol test mean?

A blood test called a lipid profile or lipid panel will show total cholesterol, LDL cholesterol, HDL cholesterol and triglyceride levels.

LDL is often called bad cholesterol because it increases the risk of heart disease, stroke and other health problems. HDL is dubbed good cholesterol because having a higher level is associated with lower risk of those problems.

Triglycerides are a type of fat that, combined with high LDL or low HDL cholesterol, is linked with artery plaque.

Why should young adults care about cholesterol?

“Clinical studies show that atherosclerosis starts in childhood,” Kulkarni said, but many people don’t get the appropriate care “because of the misconception from clinicians that they’re young and everything is going to be OK.”

In a study published in the Journal of the American College of Cardiology in 2021, around 27% of young adults had LDL levels that would benefit from treatment. But only 56% of young adults had their cholesterol checked. By comparison, 87% of people age 40 to 74 had done so.

Knowing your numbers early matters. A study published in Circulation in 2023 linked elevated childhood cholesterol levels with an increased risk of problems such as heart attack and stroke in midlife. A separate, long-term study found that LDL cholesterol levels in people age 18 to 30 was associated with a key measure of arterial plaque 15 to 20 years later.

If you’re not sure of your numbers – ask. Kulkarni has seen patients who thought they’d been screened, then discovered they had unhealthy levels that had gone untreated “for years and even decades.”

What should someone do?

• Start with a baseline measurement of key components of heart health, Kulkarni said – not just cholesterol but blood sugar and blood pressure as well.

• Know what your cholesterol numbers mean. With her patients, Kulkarni focuses on LDL and triglyceride levels. “That’s usually the first thing that I look at when I look at a lipid panel, because that has one of the most robust associations with the development of heart disease.”

• Know your family history. Much of the risk of high blood cholesterol is genetic, Kulkarni said.

  Some people inherit genes that raise their levels of lipoprotein(a), or Lp(a), a type of LDL cholesterol. A separate test can determine whether you have this condition, which can raise your risk of heart disease or stroke.

  Race and ethnicity also may affect cholesterol levels.

• Make healthy choices.

  From a dietary standpoint, cut back on foods high in saturated fats to lower your LDL cholesterol, Kulkarni said. “The bigger offenders are things like red meat and high-fat dairy – whole milk, heavy cream, ice cream.” The American Heart Association recommends aiming for a dietary pattern that achieves less than 6% of total calories from saturated fat.

  From an exercise standpoint, she recommends a combination of cardio as well as strength training. Federal physical activity guidelines recommend adults engage in at least 150 minutes of moderate-intensity physical activity or at least 75 minutes of vigorous-intensity physical activity each week, or a combination of both. Adults also should do muscle-strengthening exercises at least two days a week.

• Medications, including statins, can help manage cholesterol and reduce the risk of heart attack or stroke. “We've got a lot of great medicines to reduce and prevent and slow down plaque deposition,” Kulkarni said. “But those medicines don’t act overnight. They work over a period of days to weeks to months to years.”

• Get reliable information. “There’s a lot of misinformation with regard to cholesterol, especially on social media platforms,” Kulkarni said. “It’s always really important that you get your medical information, whether it’s about cholesterol or anything else, from a vetted source.”

Lessons from a stroke survivor

After college, Bowers worked as a nurse, saw her primary care provider regularly and tried different medications to address her cholesterol levels. But she struggled with side effects from some, and others were too expensive.

And then, in 2023, when she was 39, she woke up in the middle of the night while visiting her mom in South Dakota. “My leg just kept buckling.”

By the time doctors realized she’d had a stroke, it was too late for powerful clot-dissolving drugs that might have lessened the harm. “I had no movement on my left side, and I could not wiggle my fingers,” she said.

During her recovery, she developed another serious problem – pulmonary emboli, dangerous blood clots in her lungs.

She recovered enough to continue working on the dissertation she’d just started. In August, she successfully defended that dissertation and earned her doctorate in nursing education.

“I’m stubborn, so that helps,” she said.

Bowers needs a cane to walk, and the stroke damaged the part of her brain that lets her feel emotion. But as a teacher, she’s able to share her perspective with younger people who might be tempted to ignore risk factors such as cholesterol.

Even if you don’t experience something as dramatic as stroke, she says, “how you take care of yourself as a young adult has a huge impact on how your health is as you age.”

And if you do face a dramatic health issue, she said, “you don’t want to be in my shoes, playing the game of, ‘Which puzzle piece caused this?’ If you can at least address cholesterol, that’s one less puzzle piece of risk factors that you have to try to figure out.”

Learn more about managing your cholesterol, including how to keep it at healthy levels, at heart.org.