What is cholesterol?
Laboratory tests measure three main fractions:
- Total cholesterol – the sum of all fractions
- LDL cholesterol (low-density lipoprotein) – transports cholesterol from the liver to peripheral cells
- HDL cholesterol (high-density lipoprotein) – transports excess cholesterol back to the liver for breakdown
According to the earlier simplification, LDL was “bad” cholesterol and HDL was “good” cholesterol. The modern approach is more nuanced: both fractions perform physiological functions, and the problem begins when LDL particles become oxidised, meaning that they are damaged.1
The key point in one sentence
The most important factor in atherosclerosis is not the high LDL cholesterol level on its own, but the extent to which LDL particles are exposed to oxidative damage. High LDL together with oxidative stress represents the real risk.
How does atherosclerosis develop? – The modern approach
According to a 2024 review in the Journal of Advanced Research, atherosclerosis is now understood not as simple “fat deposition”, but as a chronic inflammatory process. We present the steps of the process in three main stages.1
As LDL particles circulate in the bloodstream, they are continuously exposed to oxidative stress. The sources of oxidative stress are diverse: chronically high blood glucose and insulin resistance, smoking, air pollution, trans-fat intake, physical inactivity, chronic inflammation and age. If the body's antioxidant capacity cannot neutralise free radicals effectively, LDL is converted into oxidised LDL (oxLDL). The body's immune system treats oxLDL as a foreign substance.
OxLDL passes through the inner layer of the vessel wall (the endothelium) and accumulates in the layer beneath the vessel wall. Macrophages engulf oxLDL and become so-called foam cells. These foam cells form the core of the growing plaque. The plaque gradually narrows the vessel's cross-section, and this process can continue for decades without symptoms.1,2
A chronic inflammatory process begins inside the plaque: T cells, cytokines and inflammatory mediators appear. The so-called unstable plaque may rupture – platelets then adhere to the injury and a blood clot forms. This causes myocardial infarction, ischaemic stroke or peripheral artery occlusion.
This model explains why a normal LDL level on its own does not necessarily protect a person from cardiovascular events. The extent of oxidative stress, markers (ApoB, Lp(a)) and inflammatory parameters (hs-CRP) together provide a more complete picture.
What cholesterol level is considered high?
Hungarian and European guidelines (ESC/EAS 2019, 2021 update) use the following thresholds in the general population. Stricter targets may apply in people at higher risk (diabetes, previous myocardial infarction or a family history).
| Parameter | Optimal | Borderline | High |
|---|---|---|---|
| Total cholesterol | < 5,2 mmol/l | 5,2–6,2 mmol/l | > 6,2 mmol/l |
| LDL cholesterol | < 2,6 mmol/l | 2,6–3,4 mmol/l | > 3,4 mmol/l |
| HDL cholesterol (men) | > 1,0 mmol/l | 0,9–1,0 mmol/l | < 0,9 mmol/l (unfavourable) |
| HDL cholesterol (women) | > 1,2 mmol/l | 1,0–1,2 mmol/l | < 1,0 mmol/l (unfavourable) |
| Triglycerides (fasting) | < 1,7 mmol/l | 1,7–2,3 mmol/l | > 2,3 mmol/l |
Important context
The value on its own says little. An LDL level of 4,0 mmol/l means something quite different in a young, non-smoking athlete with normal blood pressure and little abdominal fat than in a 60-year-old smoker with diabetes and hypertension. A complete cardiovascular risk assessment (SCORE2 or the ESC calculator) provides the real picture.
What complications can untreated high cholesterol cause?
High LDL together with oxidative stress can cause significant vascular damage over years or decades. The following complications are demonstrably associated with persistently elevated LDL levels:
Rupture of a plaque in a coronary artery leads to the formation of a blood clot, which blocks the blood supply to part of the heart muscle. Alongside LDL reduction, blood pressure control and stopping smoking are at least as important in prevention.
Blockage of plaques in the carotid or cerebral arteries can cause an acute interruption of the blood supply to brain tissue.
Narrowing of the leg arteries can cause pain while walking (intermittent claudication), persistent circulatory problems, and in severe cases wound-healing problems and a risk of amputation.
Narrowing of the renal arteries can lead to declining kidney function and high blood pressure that is difficult to control.
How can cholesterol levels be influenced? – Two main approaches
According to the modern view, there are two main approaches to treating high cholesterol, and the two do not necessarily exclude each other – they complement one another:
- Lifestyle and dietary changes – target the cause
- Drug therapy (primarily statins) – reduce the consequences
The question is not “which one is right?”, but what a particular person needs. A 50-year-old person newly found to have borderline LDL and otherwise low risk needs a different approach from a 65-year-old person with diabetes who has previously had a myocardial infarction.
Statins – what does the latest evidence say?
Statins (atorvastatin, rosuvastatin, simvastatin, pravastatin, etc.) are currently the most commonly prescribed cholesterol-lowering medicines. However, the assessment of their effectiveness and safety has become more nuanced in recent years: it is worth understanding both sides fairly.
What can statins do? – The benefits
Statins inhibit cholesterol synthesis in the liver (by blocking the HMG-CoA reductase enzyme), thereby reducing LDL levels. Clinical studies show that statins reduce the risk of cardiovascular events, particularly in people who have already had a myocardial infarction, stroke or who are at high risk (secondary prevention). In primary prevention, however, the absolute benefit is more modest than many people think.
2022 JAMA Internal Medicine meta-analysis (Byrne et al.)
A pooled analysis of 21 randomised controlled trials (the statin and control groups together included more than 130 000 participants). Statin treatment achieved a modest absolute risk reduction in primary and secondary prevention combined:3
- All-cause mortality: ARR 0,8% (RR reduction 9%)
- Myocardial infarction: ARR 1,3% (RR reduction 29%)
- Stroke: ARR 0,4% (RR reduction 14%)
In other words: one fewer person in every 100 died, which is important information when making an individual decision. This does not mean that statins are useless, but that the person's level of risk determines whether starting treatment is worthwhile.
2022 BMJ systematic review (Cai et al.)
62 studies involving 120 456 participants in primary prevention, followed for an average of 3,9 years. Statins reduced the risk of major cardiovascular events, and in the study population the benefit outweighed the risk of adverse effects.4
What should be considered? – Adverse effects and long-term risks
Statins have several adverse effects and long-term consequences that are worth knowing about. Based on the latest evidence, we highlight the following:
Muscle symptoms – CTT Collaboration 2022 (Lancet)
Individual participant data from 19 placebo-controlled trials (123 940 people, with an average follow-up of 4,3 years). The reported frequency of muscle pain or weakness was 27,1% in the statin group versus 26,6% in the placebo group. The difference was small (RR 1,03) and was seen mainly during the first year. According to the authors, the statin actually causes only about one fifteenth of muscle symptoms; the rest are a nocebo effect – in other words, information heard about the medicine or illness can itself trigger symptoms.5
This does not mean that muscle pain “does not exist” – rather, genuine statin-related muscle symptoms are less common than previously thought. Severe rhabdomyolysis (breakdown of muscle tissue) is very rare, but the risk exists and urgent medical care is required.
New-onset diabetes – CTT Collaboration 2024 (Lancet Diabetes & Endocrinology)
This 2024 analysis was the most detailed to date. Based on individual data from 19 placebo-controlled trials:6
- Low- or moderate-intensity statin: incidence of new-onset DM 1,3% per year versus 1,2% with placebo – relative risk increase 10%
- High-intensity statin: incidence of new DM 4,8% per year versus 3,5% with placebo – relative risk increase 36%
Most new cases of DM (62%) occurred in people whose blood glucose parameters were already around the diabetes threshold at baseline. In other words, if someone has prediabetes, a high-dose statin may be more likely to “tip them over” into diagnostic DM.
Other adverse effects in primary prevention – BMJ 2021
According to the analysis by Cai et al., in primary prevention statins increase the following non-cardiovascular risks, expressed per 10 000 patients per year:4
- Liver function disorder: +8 cases (OR 1,33)
- Declining kidney function: +12 cases (OR 1,14)
- Eye diseases (e.g. cataract): +14 cases (OR 1,23)
- Self-reported muscle symptoms: +15 cases (OR 1,06)
The authors' conclusion: in the study population, these additional risks did not outweigh the cardiovascular benefit, but they require discussion at an individual level.
What does this mean in practice?
A statin is neither an evil medicine nor a miracle cure. It is a tool with well-defined clinical benefits and a proven adverse-effect profile. The decision is always individual and must take into account not only the LDL level, but the complete risk profile (age, blood pressure, smoking, family history, blood glucose and waist circumference). The decision to start or stop a statin should always be made together with the treating doctor.
Lifestyle approach vs. medicine – what does the latest research say?
One particularly interesting finding in the evidence from recent years is that certain structured dietary programmes achieve at least as much in terms of absolute benefit as statins in primary prevention – and in some cases may even exceed them.
2024 meta-analysis of the Mediterranean diet (Sebastian et al., Curr Probl Cardiol)
4 large RCTs, 10 054 participants, 2–7 years of follow-up. Compared with the control diet, the Mediterranean diet produced:7
- Major cardiovascular event (MACE): OR 0,52 (48% relative risk reduction)
- Myocardial infarction: OR 0,62
- Stroke: OR 0,63
- Cardiovascular mortality: OR 0,54
2023 BMJ network meta-analysis – comparison of dietary programmes (Karam et al.)
40 RCTs, 35 548 participants, comparing seven different structured dietary programmes. Of the programmes studied, the Mediterranean and low-fat diets showed the greatest reductions in mortality and events:8
- Mediterranean diet – mortality: OR 0,72 (17 fewer people per 1000 over 5 years)
- Mediterranean diet – cardiovascular mortality: OR 0,55
- Mediterranean diet – stroke: OR 0,65
- Mediterranean diet – non-fatal myocardial infarction: OR 0,48
Since 2021, the ESC/EAS guidelines have emphasised that lifestyle intervention is the cornerstone of every cardiovascular prevention strategy. Drug treatment does not replace it, but complements it.
What can you do? – Practical steps
Diet
My advice – change your diet!
A Mediterranean-style diet: plenty of vegetables, pulses, fish, extra virgin olive oil and nuts, with wholegrain cereals in moderation. Reduce your intake of refined carbohydrates (sugary drinks, pastries and white flour) and trans fats (margarine and many industrially produced baked goods). Reducing saturated fats (in butter and fatty red meat) will not solve the problem on its own, but overall it may contribute to achieving a more favourable lipid profile.
Exercise
The WHO and ESC guidelines recommend at least 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity aerobic exercise per week, supplemented by strength training twice a week.
- Aerobic exercise – walking, jogging, cycling and swimming – may improve HDL levels and reduce triglycerides
- Strength training – may increase muscle mass and improve insulin sensitivity
- Yoga and tai chi – may complement aerobic exercise by helping with stress regulation
Other lifestyle factors
- Stopping smoking – this is, on its own, one of the most effective steps for cardiovascular protection
- Stress management – chronic stress contributes to oxidative load. More about long-term stress →
- Sleep quality – regular night-time sleep of 7–9 hours improves metabolism
- Reducing waist circumference – desirable: men < 94 cm, women < 80 cm
- Alcohol consumption – according to the 2018 Lancet publication and the WHO's 2023 position, there is no safe amount of alcohol from a cardiovascular perspective. Earlier recommendations for “moderate red wine” consumption have not stood up in light of newer evidence.
Natural support – what does the latest meta-analysis say?
Food supplements and herbal products do not replace lifestyle measures or necessary drug treatment, but according to recent meta-analyses, some may contribute to achieving a more favourable lipid profile. Important: the effect is generally modest, and findings from study populations (metabolic syndrome or diabetes) cannot necessarily be applied to everyone.
| Ingredient | Meta-analysis | Observed effect |
|---|---|---|
| Garlic | Fu et al. 2023, 19 RCT9 | Significant reductions in TC, LDL and triglycerides in metabolic syndrome |
| Turmeric/curcumin | Dehzad et al. 2023, 64 RCT11 | TC –3,99 mg/dl, LDL –4,89 mg/dl, HDL +1,80 mg/dl (low certainty of evidence) |
| Ginger | Salih et al. 202312 | Significant reduction in TC and triglycerides; not significant for LDL |
| Flaxseed / ALA | Musazadeh et al. 202513, Yin et al. 2023 | Reduced triglycerides in diabetes; no consistent effect on LDL |
Realistic expectations
No single spice or food supplement replaces a complete lifestyle approach. According to meta-analyses, the effect is generally moderate, and it is not realistic to expect a high LDL level to be normalised with garlic or turmeric alone. They are better viewed as useful additions to lifestyle and diet than as stand-alone treatments.
When is medical consultation and consideration of drug treatment essential?
There are situations in which lifestyle changes alone are not enough, and starting a statin (or another lipid-lowering medicine) may be clearly indicated. In these situations, avoiding drug treatment represents a serious risk.
Situations in which drug treatment should be seriously considered
- Previous myocardial infarction, stroke or revascularisation – in secondary prevention, statins have been shown to reduce the risk of further events
- Diabetes over the age of 40, with additional risk factors
- Familial hypercholesterolaemia – genetically determined, very high LDL (often > 5 mmol/l)
- High calculated 10-year cardiovascular risk (based on SCORE2)
- Chronic kidney disease, stage 3 or more severe
- Previous PAD or confirmed coronary artery calcium (high CAC score)
Support at home – devices that may help with monitoring
Reducing cardiovascular risk is a long-term project, in which regular self-monitoring and tracking activity can be a real help.
Blood pressure monitors
Alongside cholesterol, blood pressure control is the second pillar of cardiovascular prevention. Measuring blood pressure at home gives a more accurate picture than a measurement at the clinic (it rules out the white-coat effect). Validated upper-arm monitors are recommended.
Activity trackers and heart-rate monitors
These are useful tools for tracking 150 minutes of moderate-intensity exercise per week and monitoring your heart-rate range. Visual feedback can help you establish a long-term routine.
When should you be especially cautious?
Certain situations require medical supervision when using interventions aimed at lowering cholesterol. In the following situations, do not start any medicine, new food supplement or strict diet on your own:
- Pregnancy and breastfeeding – statins and certain food supplements are contraindicated
- Active liver disease – statins may affect liver function; careful monitoring is required
- Severe kidney disease – some statins require dose reduction
- Previous rhabdomyolysis or elevated muscle enzymes – restarting a statin only under medical supervision
- High-dose garlic or ginger supplements while taking anticoagulants – an additive blood-thinning effect is possible
- Diabetes (especially prediabetes) – high-dose statins may increase the risk of new-onset DM; individual assessment is required
Important information
The information in this article is for guidance only and does not replace an individual medical consultation. If you take a statin, do not stop it on your own – always discuss this with your treating doctor. If you want to introduce a new food supplement while taking regular medication, ask your doctor or pharmacist about possible interactions.
Frequently asked questions
Atherosclerosis usually develops without symptoms over years or decades. Unfortunately, the first symptom is often the myocardial infarction or stroke itself. High LDL does not by itself predict a definite outcome – but it increases risk. Assessment of the complete risk profile (age, blood pressure, blood glucose, smoking and family history) with your treating doctor is recommended.
Discuss it with your treating doctor! A lifestyle approach is effective in many cases, particularly in primary prevention and in people at lower risk. However, in high-risk situations (previous myocardial infarction, confirmed coronary artery disease or familial hypercholesterolaemia), dietary changes are not enough on their own. One possible compromise is to reassess the values after 3–6 months of lifestyle efforts.
Both have physiological roles in the body. LDL becomes problematic when it is oxidised, and a high blood level provides more substrate for this process. HDL does have a protective role, but a high HDL level on its own does not guarantee complete protection. Particle size, particle number and the oxidative environment all matter together.
There is no single answer that applies to everyone. Recent meta-analyses suggest that limiting refined carbohydrates (sugary drinks, white flour and pastries) may improve the metabolic profile. A very strict, ketogenic-style diet can surprisingly cause LDL to rise in some people – so a gradual, sustainable change and periodic laboratory monitoring are the most useful strategy. For personalised guidance, it is worth seeking help from a dietitian.
According to meta-analyses, these spices may have a favourable effect on the lipid profile, but the effect is generally modest (a reduction of a few mg/dl in LDL). They may be useful as part of a healthy diet, but in cases of high LDL or clearly elevated risk, they cannot replace a comprehensive lifestyle approach or necessary medical treatment.
Do not stop on your own! Speak to your treating doctor. According to recent data, most muscle pain in people taking statins is not caused by the statin. Your doctor may consider several options: reducing the dose, trying another statin, a trial period without the medicine (drug holiday) or measuring CK levels. Sudden discontinuation, especially in secondary prevention, may increase the risk of cardiovascular events.
Summary – Quick overview
Sources
- Xing Y, Lin X (2024). Challenges and advances in the management of inflammation in atherosclerosis. Journal of Advanced Research, 71:317-335. PubMed: 38909884 | DOI
- Gianopoulos I, Daskalopoulou SS (2024). Macrophage profiling in atherosclerosis: understanding the unstable plaque. Basic Research in Cardiology, 119(1):35-56. PubMed: 38244055 | DOI
- Byrne P, Demasi M, Jones M, et al. (2022). Evaluating the Association Between Low-Density Lipoprotein Cholesterol Reduction and Relative and Absolute Effects of Statin Treatment: A Systematic Review and Meta-analysis. JAMA Internal Medicine, 182(5):474-481. PubMed: 35285850 | DOI
- Cai T, Abel L, Langford O, et al. (2021). Associations between statins and adverse events in primary prevention of cardiovascular disease: systematic review with pairwise, network, and dose-response meta-analyses. BMJ, 374:n1537. PubMed: 34261627 | DOI
- Cholesterol Treatment Trialists' (CTT) Collaboration (2022). Effect of statin therapy on muscle symptoms: an individual participant data meta-analysis of large-scale, randomised, double-blind trials. Lancet, 400(10355):832-845. PubMed: 36049498 | DOI
- Cholesterol Treatment Trialists' (CTT) Collaboration (2024). Effects of statin therapy on diagnoses of new-onset diabetes and worsening glycaemia in large-scale randomised blinded statin trials. The Lancet Diabetes & Endocrinology, 12(5):306-319. PubMed: 38554713 | DOI
- Sebastian SA, Padda I, Johal G (2024). Long-term impact of mediterranean diet on cardiovascular disease prevention: A systematic review and meta-analysis of randomized controlled trials. Current Problems in Cardiology, 49(5):102509. PubMed: 38431146 | DOI
- Karam G, Agarwal A, Sadeghirad B, et al. (2023). Comparison of seven popular structured dietary programmes and risk of mortality and major cardiovascular events in patients at increased cardiovascular risk: systematic review and network meta-analysis. BMJ, 380:e072003. PubMed: 36990505 | DOI
- Fu Z, Lv J, Gao X, et al. (2023). Effects of garlic supplementation on components of metabolic syndrome: a systematic review, meta-analysis, and meta-regression of randomized controlled trials. BMC Complementary Medicine and Therapies, 23(1):260. PubMed: 37481521 | DOI
- Bashiri S, TaghipourSheshdeh F, Foshati S, et al. (2025). The Effect of Aged Garlic Supplementation on Blood Pressure and Lipid Profile: A Dose-Response Grade-Assessed Systematic Review and Meta-Analysis of Randomized Controlled Trials. Phytotherapy Research, 39(12):5669-5694. PubMed: 40628369 | DOI
- Dehzad MJ, Ghalandari H, Amini MR, Askarpour M (2023). Effects of curcumin/turmeric supplementation on lipid profile: A GRADE-assessed systematic review and dose-response meta-analysis of randomized controlled trials. Complementary Therapies in Medicine, 75:102955. PubMed: 37230418 | DOI
- Salih AK, Alwan AH, Khadim M, et al. (2023). Effect of ginger (Zingiber officinale) intake on human serum lipid profile: Systematic review and meta-analysis. Phytotherapy Research, 37(6):2472-2483. PubMed: 36786398 | DOI
- Musazadeh V, Nezamoleslami S, Faghfouri AH, Shidfar F, Aryaeian N (2025). The effect of flaxseed supplementation on anthropometric indices, blood pressure, and lipid profile in diabetic patients: A GRADE-assessed systematic review and meta-analysis of randomized controlled trials. Diabetes & Metabolic Syndrome, 19(5):103241. PubMed: 40499336 | DOI
