Your body makes cholesterol.
Lots of it.
You need cholesterol to build cell membranes. Your body uses it to make steroid hormones and vitamin D. Your brain contains a remarkable amount of it.
In fact, your body considers cholesterol important enough that it doesn’t depend on you eating it.
It makes its own.
So here’s a question I’ve wondered about:
If cholesterol is essential to life, why have we spent decades talking about it like it’s poison?
Turns out that’s not quite the right question.
Cholesterol Isn’t the Bad Guy
Let’s clear this up first.
You need cholesterol.
Without it, you’re dead.
So when somebody says simply “cholesterol is bad,” that’s obviously too simplistic.
But cholesterol doesn’t float freely through your bloodstream.
Because it’s a waxy substance that doesn’t dissolve in water, your body packages and transports it inside particles called lipoproteins.
That’s where LDL enters the conversation.
LDL stands for low-density lipoprotein.
And here’s where the science becomes considerably less friendly to some of the things I’ve written about cholesterol in the past.
LDL Isn’t Just an Innocent Number
I’ve been skeptical about the cholesterol story for years.
Some of that skepticism remains.
I don’t think one number on a lab report tells you everything about your cardiovascular health.
But I’ve spent more time looking at the evidence, and there’s something I don’t think I can reasonably dismiss:
Higher lifelong exposure to LDL-containing particles contributes to atherosclerosis.
And this isn’t based on one study funded by a drug company.
Researchers have approached the question from several completely different directions.
People who inherit genetic mutations that produce extremely high LDL have much higher rates of premature cardiovascular disease.
People who inherit variants producing lower LDL tend to have lower cardiovascular risk.
Large observational studies show the relationship.
And randomized trials show that lowering LDL with several different kinds of medications reduces cardiovascular events.
When several independent lines of evidence point in the same direction, I pay attention.
But Your Body Still Needs Cholesterol
That’s the part that sounds contradictory until you separate cholesterol itself from the amount and location of cholesterol-carrying particles.
Your body needing cholesterol doesn’t mean more circulating LDL is always better.
Your body needs glucose too.
That doesn’t mean chronically high blood glucose is harmless.
Your body needs iron.
Too much iron in the wrong place can cause problems.
Biology apparently refuses to organize itself into good guys and bad guys for our convenience. 😂
The amount matters.
Where something is matters.
How long you’re exposed to it matters.
And the rest of your health matters too.
What About Statins?
This is another place where I’ve written too aggressively in the past.
Statins are among the most commonly prescribed medications in the world.
Drug companies certainly make money selling them.
That fact alone doesn’t tell us whether they work.
The better question is:
What happens to people who take them?
Randomized clinical trials have repeatedly found that lowering LDL with statins reduces cardiovascular events, particularly in people at higher cardiovascular risk.
And we have another useful clue.
Other medications that lower LDL through completely different mechanisms, including ezetimibe and PCSK9 inhibitors, also reduce cardiovascular events.
That makes it harder to argue that the entire benefit is some mysterious property unique to statins rather than lowering LDL-containing particles itself.
That doesn’t mean everybody with an LDL number above some arbitrary line automatically needs medication.
The updated 2026 ACC/AHA guideline emphasizes overall cardiovascular risk, lifestyle, LDL levels and, when appropriate, other information such as coronary artery calcium, ApoB and lipoprotein(a) when making treatment decisions.
Context matters.
Dietary Cholesterol Is Another Question
This is where the word cholesterol causes even more confusion.
The cholesterol you eat isn’t the same question as the cholesterol and lipoproteins measured in your blood.
For years, dietary cholesterol itself received enormous attention.
Our understanding has become more nuanced.
What you eat can affect your blood lipids, but people respond differently, and the overall dietary pattern matters considerably more than simply counting milligrams of cholesterol in an egg.
So “cholesterol is bad” isn’t particularly useful nutrition advice.
Neither is “cholesterol doesn’t matter.”
Welcome to biology. Apparently we don’t get bumper-sticker answers. 😂
I Still Don’t Want One Number Running My Life
This part of my thinking hasn’t changed.
I don’t want to look at one laboratory value in isolation and decide whether somebody is healthy.
I’d want to know more.
Blood pressure.
Blood sugar.
Smoking history.
Family history.
Activity.
Body composition.
Triglycerides.
HDL.
LDL.
And depending on the person, perhaps ApoB, lipoprotein(a) or a coronary calcium score.
Even the current cardiovascular guidelines increasingly emphasize assessing the whole person’s risk, rather than treating everybody identically.
That’s much more interesting to me.
I’ve Changed My Mind About Part of This
I think that’s worth saying plainly.
I’ve written things suggesting that the danger of LDL was largely a story maintained because pharmaceutical companies profit from statins.
I don’t think the evidence supports that claim.
Pharmaceutical companies absolutely have financial interests.
So do supplement companies.
Food companies.
Fitness companies.
People selling books.
People selling podcasts.
People selling newsletters.
Financial incentives are worth noticing.
But they don’t determine whether a scientific claim is true.
Evidence does.
And when I look at the totality of evidence around LDL and atherosclerosis, I think dismissing LDL because cholesterol itself is essential to the body goes too far.
I can be skeptical without deciding beforehand what the answer has to be.
In fact, that’s the whole point of skepticism.
So What Should You Do With Your Cholesterol Number?
Don’t panic over it.
Don’t ignore it either.
Ask questions.
What is my overall cardiovascular risk?
What does this number mean alongside everything else?
Would lifestyle changes meaningfully affect my risk?
Would additional testing tell us something useful?
If medication is being recommended, what is my likely absolute benefit, not simply the relative percentage quoted from a study?
And if you’re already taking a statin or another cholesterol-lowering medication, don’t stop because Dave Stevens wrote an article on the internet.
Talk to the person who knows your medical history.
Then make an informed decision.
Because cholesterol really is essential.
LDL really can contribute to cardiovascular disease.
And both of those statements can be true at exactly the same time.
Bodies are complicated like that.
And occasionally I have to change my mind.
Apparently I’m complicated like that too.