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CHOLESTEROL SERIES · ARTICLE 2 OF 12
The silent problem
How to know if you have high cholesterol.
In article 1 we said that about a third of South African adults have high cholesterol, and about half of them don’t know it. That second fact is the bigger problem. The condition does most of its damage in the years before anyone gets diagnosed — quietly, invisibly, with no symptoms to warn you that something is wrong.
This article is about closing that gap. Why the same cholesterol number means very different things for different people. Who should be testing younger and more often than the average adult. The six-step “what to do on the day you find out” guide. And the trap that the BP series readers will already recognise: feeling fine, and using that to talk yourself out of treatment.
If you remember nothing else
Ask for a lipid panel at your next clinic visit. It takes a single blood draw. It is free at any public clinic. The result determines whether anything else in this series matters for you.
Why it is called “silent”
High cholesterol does not hurt. There is no nerve in the artery wall that says, “there is too much LDL in here today”. The body simply keeps doing its job, even while plaque is slowly building inside the arteries.
This is why the diagnosis usually comes one of three ways:
• A routine check at a clinic. Someone goes in for a hypertension review, a chronic medication refill, a diabetic follow-up, or a workplace wellness day — and the lipid panel is added on.
• A family member’s diagnosis. A parent, sibling or child gets diagnosed, asks others in the family to test, and the result comes back high.
• An event. A heart attack. A stroke. Severe leg pain on walking that turns out to be peripheral artery disease. By this stage, cholesterol has often been high for ten years or more, and significant plaque has already built up.
The first two are how we want it to happen. The third is what we are trying to prevent. The only way to swing the odds toward the first two is to actively go and get tested.
You cannot wait for your body to tell you. Your body will not tell you until it is too late.
The same number can mean different things
This is the part that confuses many people, so it’s worth a careful explanation. Two people can walk out of a clinic with exactly the same LDL number — say, 3.2 mmol/L — and one of them gets reassured, while the other gets started on a tablet. Why?
The reason is that the meaning of any cholesterol number depends on your overall cardiovascular risk — not just the number itself. South African and international guidelines treat cholesterol as one part of a bigger calculation that estimates your risk of a heart attack or stroke over the next 10 years.
Four broad categories
Risk category Who you are Your LDL target Low risk Adult under 40, no risk factors, normal weight, non-smoker, healthy BP and blood sugar under 3.0 mmol/L Moderate risk One or two risk factors (mild high BP, family history, overweight, current smoker) under 2.6 mmol/L High risk Diabetes, kidney disease, multiple risk factors, or 10-year heart attack risk above 10% under 1.8 mmol/L Very high risk Previous heart attack or stroke, familial hypercholesterolaemia, advanced diabetes under 1.4 mmol/L
So that LDL of 3.2: completely fine for a 35-year-old non-smoker with no other risk factors. A clear problem for a 60-year-old diabetic with high BP. The number is the same; the meaning is different.
Don’t get too caught up in the categories. The point is simple: when you discuss your result with your clinic, the question isn’t just “is my LDL high?” but “is my LDL too high for me, given everything else about me?”
The risk calculator your clinic uses
Most South African clinics use a tool called the SCORE or the Framingham risk calculator. It takes your age, sex, smoking status, blood pressure, total cholesterol, HDL, and diabetes status, and gives a 10-year risk percentage for heart attack and stroke. Anything above 10% is generally considered high risk; above 20% is very high.
You can ask your nurse or doctor to show you your number. People who know their 10-year risk tend to take treatment more seriously.
Who should be testing younger and more often
The general rule is: every adult should have at least one cholesterol test by age 35 (men) or 40 (women), and the test should be repeated every 5 years if normal, more often if not. But some groups should start much younger.
If this describes you Start testing How often No risk factors, otherwise healthy Age 35 (men) / 40 (women) Every 5 years if normal Parent or sibling with heart attack or stroke under 55 From age 20 Every 2 – 5 years Indian, Afrikaner or Ashkenazi Jewish ancestry From age 20 Every 3 – 5 years Diabetic From diagnosis Every year Known high BP From diagnosis Every year Current smoker From age 25 Every 3 – 5 years Overweight or sedentary From age 30 Every 3 – 5 years Previous heart attack, stroke, or stent Already started Every 3 – 6 months until target, then annually Already on a statin Already started Every 6 – 12 months Child of a parent with familial hypercholesterolaemia Before age 18 As advised — often annually
If you have not had a cholesterol test in the last five years, and you are over 35, you are overdue. There is no reasonable excuse — it is free, it is a single blood draw, and the result determines what every article that follows in this series will mean for you.
What to do on the day you find out
Many people leave the clinic with a result above the target and feel a sudden weight drop into the chest. That is normal. Heart attack, stroke, dementia — those words are heavy. Here is what to do next.
1. Don’t panic.
High cholesterol caught at any stage is a manageable condition. You have caught it. You can do something about it. The people who really suffer from it are the ones who never got tested. You now know — and that puts you ahead of most.
2. Check the rest of the panel and your overall risk.
The LDL number alone doesn’t tell the whole story. Look at your HDL, your triglycerides, your total. Look at your blood pressure if it was checked at the same visit. Ask your nurse for your overall 10-year heart attack risk if they can calculate it. The full picture, not the LDL number alone, is what determines the next step.
3. Ask about the baseline tests.
Three other tests are useful when high cholesterol is first diagnosed: a fasting blood sugar (to check for diabetes you didn’t know about), a kidney function blood test (since kidney problems push cholesterol up), and a thyroid test (an under-active thyroid can do the same). All are free as part of chronic care. Most clinics will do them automatically once cholesterol is found high.
4. Start with the lifestyle changes.
For most people, the first treatment is food and exercise. We cover both in detail in articles 5, 6 and 7. The most useful first moves:
• Eat a bowl of plain oats most mornings.
• Add a serving of beans or lentils most days.
• Cut fatty red meat to once a week.
• Walk for 30 minutes most days.
• If you smoke, plan a quit date.
Pick two of these and start this week. Add the others over the following weeks.
5. Be honest about whether you are at high or very high risk.
If you have diabetes, kidney disease, a previous heart attack, or a strong family history of early heart attack — lifestyle changes alone are usually not enough. Most people in these groups need a statin to reach the LDL target. This is not a sign that the lifestyle changes are pointless; it is a sign that you are starting from a higher risk that needs both levers pulled at the same time.
6. Take the medication if it is prescribed.
This is the place where, in our experience, more South Africans fail their cholesterol treatment than anywhere else. The tablet feels unnecessary because you feel fine. You take it for a month, your LDL comes down, and you stop. Within a few weeks, the LDL is back up. The plaque continues to build quietly. Ten years later, the body finally complains — in the form of a heart attack or a stroke — and by then a lot of the damage is permanent.
We go into detail on the medication, the side effects, and the (mostly overstated) scare stories about statins in article 9. For now, the rule: if a statin is prescribed, take it every day, for as long as your clinic recommends.
The “but I feel fine” trap
You will feel fine for many years. Then you will have a heart attack or a stroke and you will not feel fine. By that point the choices have been made — years earlier — by whether or not you took the tablet every day.
The medication is not a sign that something is going wrong day to day. It is the protection that lets you live a normal life without your arteries paying the price.
What about the cholesterol controversy?
You may have read articles online, or heard from someone in the family, that “cholesterol is not actually a problem” or “statins are dangerous” or “everyone is being over-treated”. These claims have a tiny grain of truth and a lot of misleading packaging. Worth addressing them directly.
• The LDL-and-heart-disease link is one of the best-established findings in modern medicine. It has been tested in dozens of randomised trials in millions of people over 40 years. Lower LDL means fewer heart attacks and strokes. The size of the effect is reliable and large.
• Statin side effects are real but rare. The widely cited muscle-pain stories are mostly from observational studies that did not include placebo groups. When trials include placebos, the difference in muscle complaints between people on statins and people on sugar pills is much smaller than headlines suggest. We cover this in article 9.
• Over-treatment is a real but small risk. Low-risk young adults with mildly raised cholesterol may not benefit much from a statin. This is why the risk-based categories above matter — the goal is not to treat every elevated LDL, but to treat the LDLs that are doing real harm in real people.
• Dietary cholesterol (eggs, prawns) is no longer the villain. Old advice to avoid them has been quietly walked back. Eggs are fine for almost everyone. The real dietary issue is saturated and trans fat, which we cover in article 6.
The bigger picture
The silent problem with cholesterol is fundamentally a knowledge problem. Most people who have it would do something about it if they knew. The challenge is finding out — and then taking the information seriously enough to act on it.
If this article has prompted you to ask for a lipid panel, that is the whole point. Tell two other people in your family to test as well. High cholesterol travels through families both genetically (sometimes via familial hypercholesterolaemia) and culturally (same kitchen, same habits, same risk). One tested person often turns into three or four.
The next article in the series is the one we placed early on purpose: the complications of untreated high cholesterol. Heart attack, stroke, peripheral artery disease. What each one looks like, why high cholesterol causes it, and what’s actually reversible if you catch the cholesterol in time.
Where to get more help
Heart and Stroke Foundation South Africa — heartfoundation.co.za · 021 422 1586 — patient information and a free heart-disease risk calculator.
Your nearest public clinic — free lipid panel, free chronic care, free statin medication for those who qualify.
Most retail pharmacies — Clicks, Dis-Chem, Pick n Pay — finger-prick cholesterol checks for around R50 – R100.
Lipid and Atherosclerosis Society of Southern Africa — lasousa.org — guidelines and patient resources.
Phila Today Cholesterol Series — next: the complications nobody wants to talk about — heart attack, stroke and peripheral artery disease.
Phila Today · Article 2 of 12 in the Cholesterol Series