High Cholesterol — What to Do Next
Your cholesterol is high on paper, but what does it actually mean for your health? Understanding your lipid panel, why the LDL/HDL ratio matters more than total cholesterol, and what to do about it — written for Australian patients.
The Quick Answer
High total cholesterol alone doesn't tell the full story. What matters is the breakdown — specifically, how much LDL (“bad”) cholesterol you have relative to HDL (“good”) cholesterol, and where your triglycerides sit.
The key concept: cholesterol numbers only mean something in the context of your overall cardiovascular risk. A total cholesterol of 6.5 mmol/L in a 35-year-old non-smoking woman with high HDL and no family history is a very different clinical scenario from the same number in a 60-year-old male diabetic smoker. Australian guidelines now emphasise absolute risk assessment over cholesterol numbers alone.
The good news: for the majority of people with elevated cholesterol, a combination of dietary changes, exercise, and weight management can make a significant difference. When medication is needed, modern statins are safe, effective, affordable, and PBS-subsidised.
Understanding Your Lipid Panel
Australian lipid panels typically include total cholesterol, LDL, HDL, triglycerides, and sometimes non-HDL cholesterol and the total:HDL ratio. Targets are based on Heart Foundation and RCPA guidelines.
Total Cholesterol
A useful screening number, but tells only part of the story. A total cholesterol of 6.0 mmol/L with very high HDL is less concerning than 5.0 mmol/L with very low HDL. Your GP will always look at the full breakdown.
LDL Cholesterol (“bad”)
The primary treatment target. LDL deposits cholesterol in artery walls, driving atherosclerosis. For people with existing heart disease, diabetes, or high risk, the target is below 1.8–2.0 mmol/L. For low-risk individuals, below 3.4 mmol/L is generally adequate.
HDL Cholesterol (“good”)
HDL removes cholesterol from artery walls and transports it back to the liver for disposal. Low HDL is an independent risk factor for heart disease. Exercise, moderate alcohol, and weight loss raise HDL. Extremely high HDL (≥2.5 mmol/L) may not confer additional protection.
Triglycerides
Triglycerides are fats from your diet and liver production. Strongly influenced by recent food intake (fast for 10–12 hours before testing), alcohol, refined carbohydrates, and sugar. Very high triglycerides (≥5.5 mmol/L) carry a risk of pancreatitis and need urgent treatment.
Non-HDL Cholesterol
Calculated as total cholesterol minus HDL. Captures all atherogenic lipoproteins (LDL + VLDL + remnants). Many cardiologists consider this a better predictor of cardiovascular risk than LDL alone. Does not require fasting to be accurate.
Total:HDL Ratio
A simple ratio that puts total cholesterol in context. A person with total cholesterol of 6.0 but HDL of 2.0 has a ratio of 3.0 (excellent). Someone with total 5.5 and HDL of 0.9 has a ratio of 6.1 (high risk). This ratio is one of the strongest single predictors of heart disease.
Risk Context Matters — It's Not Just the Number
Modern cardiovascular medicine treats risk, not just cholesterol. Your GP uses an absolute risk calculator that combines multiple factors to determine your individual risk level.
Absolute cardiovascular risk score
Australian guidelines (2023 updated) use an absolute risk calculator factoring in age, sex, blood pressure, cholesterol, smoking, diabetes, and kidney function to produce a 5-year risk percentage.
Impact: Low risk (<5%): lifestyle first. Moderate (5–10%): lifestyle + consider medication. High (>10%): lifestyle + medication recommended.
Age and sex
Cardiovascular risk increases significantly with age, particularly for men over 45 and women over 55 (post-menopause). Oestrogen has a protective effect on cholesterol profiles, which diminishes after menopause.
Impact: A total cholesterol of 6.0 mmol/L in a 30-year-old is very different from 6.0 in a 65-year-old with diabetes. Context is everything.
Family history
Familial hypercholesterolaemia (FH) affects approximately 1 in 250 Australians. If a parent or sibling had a heart attack before age 60, or if your LDL is persistently above 5.0 mmol/L, genetic testing may be warranted.
Impact: FH patients need early, aggressive treatment with statins — often from their 20s. Untreated FH carries a 50% risk of coronary events by age 50 in men and age 60 in women.
Smoking status
Smoking damages blood vessel walls, lowers HDL, promotes LDL oxidation, and dramatically accelerates atherosclerosis. The combination of high cholesterol and smoking is multiplicative, not additive.
Impact: Quitting smoking is the single most impactful cardiovascular risk reduction available — more effective than any medication. Risk halves within 1 year of quitting.
Blood pressure
High blood pressure forces blood against artery walls with greater pressure, accelerating plaque formation. The combination of high cholesterol and hypertension is particularly dangerous.
Impact: Treating both simultaneously (e.g., statin + antihypertensive) provides compounding risk reduction. A 10 mmHg reduction in systolic BP and 1 mmol/L reduction in LDL reduces cardiovascular events by approximately 45%.
Diabetes
Type 2 diabetes alters lipid metabolism, producing smaller, denser LDL particles that are more atherogenic. Even with “normal” LDL levels, diabetic patients have higher cardiovascular risk.
Impact: All type 2 diabetics over 40 are considered at least moderate cardiovascular risk. Most will benefit from a statin regardless of cholesterol numbers. Australian PBS subsidises statins for this group.
Evidence-Based Lifestyle Changes
For most people, lifestyle modifications are the first line of treatment. These changes work — multiple clinical trials show they can lower LDL by 20–30% when combined.
Reduce saturated fat intake
Saturated fat is the strongest dietary driver of LDL cholesterol. Major sources in the Australian diet include butter, cheese, fatty meat, pastries, biscuits, and coconut/palm oil. Replacing saturated fat with unsaturated fat (olive oil, avocado, nuts, oily fish) can lower LDL by 5–10%. The Heart Foundation recommends limiting saturated fat to less than 7% of total energy intake.
Increase soluble fibre
Soluble fibre binds cholesterol in the gut and prevents it from being absorbed. Best sources: oats (3 g beta-glucan/day lowers LDL by ~7%), psyllium husk, legumes (chickpeas, lentils, beans), barley, and fruits (apples, citrus). Aim for 25–30 g total fibre daily, with at least 10 g from soluble sources.
Regular aerobic exercise
At least 150 minutes per week of moderate-intensity exercise (brisk walking, cycling, swimming) raises HDL by 5–10%, lowers triglycerides by 15–25%, and slightly reduces LDL. The benefit is dose-dependent — more exercise produces greater improvement. Even 30 minutes of walking 5 days per week makes a measurable difference.
Achieve and maintain healthy weight
Losing 5–10% of body weight lowers LDL by 5–15% and triglycerides by 20–30%, while raising HDL. Visceral fat (abdominal obesity) is particularly harmful to lipid profiles. Waist circumference targets: <94 cm for men, <80 cm for women (Australian thresholds).
Moderate alcohol intake
Alcohol raises HDL modestly but also raises triglycerides. The NHMRC 2020 guidelines recommend no more than 10 standard drinks per week with at least 2 alcohol-free days. Heavy drinking (≥4 drinks/day) significantly raises triglycerides and overall cardiovascular risk.
Include plant sterols/stanols
Plant sterols (found in fortified margarines like Logicol, fortified milks, and supplements) block cholesterol absorption in the gut. A daily intake of 2–3 g lowers LDL by 6–10%. They work additively with other lifestyle changes and even with statins. Available over the counter in Australian supermarkets.
When Medication Is Recommended
Statins are the most prescribed cardiovascular medication in Australia. Understanding when and why they are recommended helps you make an informed decision with your GP.
When statins are recommended
Australian guidelines recommend statin therapy when: (a) absolute cardiovascular risk is high (>10% over 5 years), (b) LDL remains above target after 3–6 months of lifestyle changes, (c) existing cardiovascular disease (secondary prevention), (d) diabetes with additional risk factors, or (e) familial hypercholesterolaemia. The decision is based on overall risk, not cholesterol numbers alone.
How statins work
Statins (atorvastatin, rosuvastatin, simvastatin, pravastatin) block the enzyme HMG-CoA reductase in the liver, reducing cholesterol production. This forces the liver to pull more LDL from the bloodstream, lowering LDL by 30–50% depending on the dose. They also modestly raise HDL and lower triglycerides.
Australian PBS criteria
Statins are listed on the PBS for patients with established cardiovascular disease, diabetes with additional risk, familial hypercholesterolaemia, or high absolute risk. The PBS-subsidised cost is $7.70 (general) or $1.60 (concession) per script. Without PBS, statins are still affordable at $10–30/month from Australian pharmacies.
Side effects vs benefits
The most commonly reported side effect is muscle aches (myalgia), affecting 5–10% of patients. Most cases are mild and resolve with dose adjustment or switching to a different statin. Serious side effects (rhabdomyolysis, liver damage) are extremely rare (<0.01%). For every 10,000 people taking a statin for 5 years, approximately 1,000 cardiovascular events are prevented — far outweighing the risks for high-risk patients.
What if you can’t tolerate statins?
Alternatives include ezetimibe (blocks cholesterol absorption, lowers LDL by 15–20%, PBS-listed), PCSK9 inhibitors (evolocumab, alirocumab — injectable, lowers LDL by 50–70%, PBS-listed for FH and very high risk), bempedoic acid (newer, PBS-listed 2024), and fibrates (for high triglycerides). Your GP or cardiologist can tailor a combination.
How long do you take statins?
For most patients, statin therapy is lifelong. Cholesterol levels return to pre-treatment levels within weeks of stopping. However, the benefit is ongoing — each year of statin use further reduces cumulative cardiovascular risk. Stopping should only be done in consultation with your GP, typically if side effects are severe or life expectancy is limited.
Frequently Asked Questions
My total cholesterol is 6.5 but my GP isn’t worried. Why?
Because total cholesterol alone doesn’t determine risk. If your HDL is high (say 2.0 mmol/L), your total:HDL ratio is 3.25, which is excellent. Your GP is looking at the full lipid panel, your age, blood pressure, family history, and other risk factors. A 35-year-old non-smoker with high HDL and no family history has a very different risk profile from a 60-year-old diabetic smoker with the same total cholesterol.
Do I need to fast before a cholesterol test?
Traditionally yes — 10–12 hours fasting was standard. However, recent evidence shows that non-fasting lipid panels are adequate for most screening purposes. Total cholesterol, HDL, and LDL are only minimally affected by food. Triglycerides are the most food-sensitive component and may be 20–30% higher after eating. Australian guidelines now accept non-fasting samples for initial screening, but your GP may request a fasting sample if triglycerides appear elevated.
Can I lower cholesterol with diet alone?
For many people, yes — especially if cholesterol is only mildly elevated and overall cardiovascular risk is low. A combined approach (reducing saturated fat, increasing fibre, plant sterols, exercise, weight loss) can lower LDL by 20–30%. However, genetics play a significant role. Some people maintain high LDL despite an excellent diet because their liver overproduces cholesterol. If 3–6 months of intensive lifestyle changes don’t reach target, medication should be considered.
Are eggs bad for cholesterol?
Current evidence shows that dietary cholesterol (from eggs, prawns, etc.) has a much smaller impact on blood cholesterol than saturated fat. The Heart Foundation’s position is that most people can eat up to 7 eggs per week as part of a healthy diet. If you have familial hypercholesterolaemia or existing heart disease, discuss egg intake with your GP or dietitian.
What is the difference between LDL and non-HDL cholesterol?
LDL measures one type of atherogenic particle. Non-HDL cholesterol (total minus HDL) captures ALL atherogenic particles — LDL, VLDL, intermediate-density lipoprotein, and remnant particles. Non-HDL is increasingly preferred by cardiologists because it accounts for the full atherogenic burden, doesn’t require fasting, and is a better predictor of cardiovascular events than LDL alone.
Is cholesterol testing covered by Medicare?
Yes. A lipid profile ordered by a GP is fully covered by Medicare when clinically indicated (risk assessment, monitoring treatment, investigating cardiovascular disease). For routine cardiovascular risk screening, Australian guidelines recommend a first lipid check at age 45 (or 35 for Aboriginal and Torres Strait Islander peoples) and then every 5 years or more frequently based on risk.
Related Reading
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This information is based on guidelines from the National Heart Foundation of Australia, the Royal College of Pathologists of Australasia (RCPA), and the 2023 Australian Cardiovascular Risk Guidelines. Reference ranges and targets may vary based on individual risk profile. SmarterBlood provides educational information only and is not a substitute for professional medical advice.