Most people don’t have a cholesterol test until it’s almost too late

Are you leaving it too late to understand your long term heart health

Cholesterol is one of the most talked about concepts in medicine and one of the least well understood.

For many people, it sits in the background as a future concern. Something to think about later in life. A test you have in your forties or fifties when it finally appears on a routine blood result.

But by then, the story has often already been unfolding for decades.

Atherosclerosis, the gradual build up of fatty plaques inside the arteries, does not begin in mid life. It develops silently over many years, often starting in childhood, influenced by genetics, metabolism, inflammation and lifestyle. By the time cholesterol is first flagged as high, meaningful vascular change may already be established.

This is not about fear or blame.

It is about timing, insight and choice.

And ultimately, it is about learning how to build your own health story, rather than inheriting one by default.

Key takeaways

• Cholesterol related damage begins decades before symptoms appear

• You can feel completely well while arteries are slowly changing

• Standard cholesterol tests are helpful but often incomplete

• Advanced markers can uncover hidden risk earlier

• Early testing allows lighter, more effective intervention

• Tracking trends over time matters more than single numbers

• Your future health is shaped by what you measure and when

Why cholesterol is more than just a number

Cholesterol itself is not the enemy. Your body needs it to build cell membranes, produce hormones and synthesise vitamin D. It also plays a critical role in brain and nerve function.

The problem is not cholesterol’s presence, but how it is transported around the body and how long potentially damaging particles circulate in the bloodstream.

Cholesterol cannot travel freely in the blood. It is carried inside lipoprotein particles, and these particles behave very differently when it comes to long term cardiovascular risk.

A standard cholesterol test usually includes:

• Total cholesterol

• LDL cholesterol

• HDL cholesterol

• Triglycerides

These results are a helpful starting point, but they are still estimates. They tell us how much cholesterol is being carried, not how many cholesterol carrying particles are actually interacting with artery walls, and not how aggressively they may be contributing to plaque formation.

This is why two people with very similar cholesterol results on paper can have completely different cardiovascular outcomes over time.

Crucially, raised cholesterol causes no symptoms at all.

You can feel well, exercise regularly and eat reasonably, while vascular damage progresses quietly in the background. Arteries can stiffen and plaques can develop without any signal that something is wrong.

Without testing, there is no feedback.

Without feedback, health becomes guesswork.

Understanding good and bad cholesterol

There are different types of cholesterol carrying particles, and they behave very differently in the body:

• LDL cholesterol transports cholesterol from the liver to tissues and arteries and is most closely associated with plaque build up

• HDL cholesterol helps transport cholesterol away from artery walls back to the liver for processing and removal

Over time, excess LDL particles can penetrate the lining of arteries. Once inside the arterial wall, cholesterol can trigger inflammation, immune activation and plaque formation. As plaques grow, arteries become narrower and stiffer, reducing blood flow and increasing the risk of heart attack, stroke and other cardiovascular events.

You can feel fit, active and healthy while cardiovascular disease is already developing.

The problem with waiting until mid life for your first test

Doctors and scientists have long recognised that cholesterol accumulation begins decades before middle age. Autopsy and imaging studies show early plaque formation and arterial change in young adults, long before blood tests become abnormal.

Yet in practice, cholesterol testing is often delayed until routine health checks in someone’s forties or fifties, or after another risk factor appears.

This delay matters because:

• Cholesterol causes no warning signs

• Damage accumulates slowly and compounds over time

• Genetics can significantly amplify risk

• Earlier intervention requires far less intensity

Cardiovascular risk behaves like compound interest. The earlier it starts, the greater the long term impact.

By the time a first test is performed in mid life, there may already be years or decades of vascular change that could have been reduced with earlier awareness and intervention.

Why cholesterol checks should not wait until later

Cholesterol testing is simple and widely available. It is usually performed as part of a lipid profile measuring:

• Total cholesterol

• LDL cholesterol

• HDL cholesterol

• Triglycerides

If results show raised LDL levels or an unfavourable balance, action can be taken early through changes to nutrition, physical activity, weight, sleep and stress, and where appropriate medication, long before serious arterial disease develops.

From a prevention and longevity perspective, waiting many years between tests risks missing slow but meaningful shifts in direction.

Health is not static.

It is a trajectory.

Why standard cholesterol testing does not tell the full story

Two people can have identical LDL cholesterol levels and very different cardiovascular risk.

One may have fewer, larger cholesterol particles.

Another may have many smaller, denser particles that penetrate artery walls more easily.

On paper, their LDL looks the same. Biologically, their risk is not.

This is why understanding cholesterol particle number and balance matters.

ApoB: seeing what LDL alone can miss

Apolipoprotein B reflects the number of atherogenic particles circulating in the bloodstream. Each LDL, VLDL and remnant particle carries one ApoB molecule.

In practice, it is common to see LDL cholesterol that appears acceptable while ApoB is raised, often alongside insulin resistance or metabolic stress.

It is possible to be reassured by a standard cholesterol test while arterial risk continues to accumulate.

ApoA1 and balance: protection matters too

Apolipoprotein A1 reflects the body’s capacity to remove cholesterol from arteries.

Looking at ApoA1 alongside ApoB, particularly the ApoB to ApoA1 ratio, helps us understand balance rather than focusing on a single number. It captures the relationship between particles driving plaque formation and those supporting cholesterol clearance.

This often identifies cardiovascular risk years earlier than conventional thresholds.

Lipoprotein a: the inherited risk most people never discover

Lipoprotein a is a genetically determined lipoprotein that increases lifetime cardiovascular risk independently of lifestyle.

Many people with raised lipoprotein a feel well and have normal cholesterol results, yet carry significantly higher long term risk due to inherited factors.

It is not included in routine cholesterol testing. Measuring it once in adulthood can be transformative for understanding long term risk.

Why testing can change your future health

Testing does more than detect disease. Done early, it changes direction.

It makes invisible processes visible.

It replaces population averages with personal insight.

It allows earlier, lighter intervention.

It enables trend tracking over time.

The most powerful health decisions are made long before symptoms appear.

This is how you move from reacting to problems to actively building your own health story.

What I test and why

From my perspective as your doctor, cardiovascular health is assessed using a layered and personalised approach.

Core lipid assessment

• Total cholesterol

• LDL cholesterol

• HDL cholesterol

• Triglycerides

Advanced markers

• ApoB

• ApoA1

• ApoB to ApoA1 ratio

• Lipoprotein a

Always interpreted alongside

• Blood glucose and insulin markers

• Inflammatory markers

• Blood pressure

• Body composition

• Family history and life stage context

This allows us to understand not just risk, but timing, trajectory and proportional response.

How often should you test

Guidelines vary and testing should always be individualised.

However, from a proactive and longevity focused perspective, an annual lipid review offers clear advantages. It allows trend tracking rather than reliance on one off snapshots, shows whether lifestyle changes are actually working, and identifies upward drift before problems develop.

This is about direction of travel, not labels or fear.

Most people only check cholesterol in mid life, but by then silent damage may already be underway.

Earlier and more thoughtful testing helps you understand risk before it becomes serious, act sooner with less intensive intervention, and preserve cardiovascular health over decades rather than years.

Your heart health is not just about numbers.

It is about understanding your body early enough to shape what comes next.

Your health story is not written for you.

With the right insight and timing, you get to build it.

Next steps

If you want a clearer understanding of your cardiovascular risk beyond standard cholesterol testing, this is the approach I take in my work.

Through personalised assessment, advanced markers and long term tracking, the focus is on helping you take control of your future health rather than responding to problems when they appear.

Your health story is not written for you.

With the right insight and timing, you get to build it.

Part 2: How to read your cholesterol results

This section is designed to help you understand your results clearly and calmly. Cholesterol numbers are signals, not verdicts. What matters most is context, balance and change over time.

Total cholesterol

This is the combined amount of cholesterol carried by different particles. On its own, it tells us very little. A higher total cholesterol can reflect protective HDL just as easily as harmful LDL. It should never be interpreted in isolation.

LDL cholesterol

LDL reflects how much cholesterol is being delivered to tissues and arteries. Higher levels increase the chance of cholesterol entering artery walls over time. However, LDL does not tell us how many particles are doing the carrying, which is why it can underestimate risk in some people.

HDL cholesterol

HDL reflects the body’s ability to remove cholesterol from circulation and artery walls. Higher levels are generally protective, but function matters as much as quantity. HDL should always be viewed as part of a wider picture.

Triglycerides

Triglycerides are circulating blood fats closely linked to metabolic health. Raised levels often signal insulin resistance, excess sugar intake, alcohol excess or reduced metabolic flexibility. They are a powerful marker of lifestyle impact.

ApoB

ApoB tells us how many atherogenic particles are circulating. This is one of the strongest markers of long term cardiovascular risk. You can have a normal LDL cholesterol with a raised ApoB, indicating hidden risk.

ApoA1

ApoA1 reflects protective cholesterol transport. It helps us understand whether your body has sufficient capacity to clear cholesterol from arteries, particularly when viewed alongside ApoB.

ApoB to ApoA1 ratio

This ratio reflects balance. It shows whether plaque forming particles outweigh protective ones and often provides clearer insight than individual cholesterol numbers alone.

Lipoprotein a

This is an inherited risk marker. Levels are genetically set and largely unaffected by lifestyle. Measuring it once in adulthood helps identify lifelong cardiovascular risk, especially if there is a family history of early heart disease.

The most important thing to remember

Your cholesterol results are not a diagnosis or a judgement.

They are information.

What matters most is:

• The pattern

• The trend over time

• How results fit with your wider health picture

Used properly, cholesterol testing is not about fear.

It is about clarity, timing and control.

And that is how you continue to build your own health story.