Cholesterol Basics: A Canadian Evidence-Based Guide
Key Takeaways:
- Cholesterol itself is not “good” or “bad”, but certain types increase cardiovascular risk
- Treatment targets depend on your overall cardiovascular risk, not just one lab number
- Most Canadians do not need frequent cholesterol testing
- Lifestyle changes are the foundation of care, with medications added when risk is higher
What Is Cholesterol?
Cholesterol is a waxy substance found in your blood and in many foods. Your body uses cholesterol to build cells and produce hormones. Problems arise when excess cholesterol contributes to plaque buildup in blood vessels, increasing the risk of heart attack and stroke.
Cholesterol is measured with a blood test called a lipid panel.
Understanding Your Cholesterol Results
A standard lipid panel includes several measurements, each providing different information.
LDL Cholesterol
Often referred to as “bad cholesterol” because higher levels are associated with plaque formation in arteries.
HDL Cholesterol
Sometimes called “good cholesterol.” Higher levels are generally protective, but HDL alone does not cancel out the risk associated with high LDL cholesterol.
Non-HDL Cholesterol
This includes all cholesterol particles that contribute to plaque buildup. Canadian guidelines increasingly emphasize non-HDL cholesterol, particularly when triglycerides are elevated.
Triglycerides
A type of fat in the blood that can increase with excess calories, alcohol intake, diabetes, and metabolic syndrome.
Canadian Cholesterol Targets
According to the Canadian Cardiovascular Society guidelines, cholesterol treatment is based on overall cardiovascular risk, not a single cholesterol number.
High Cardiovascular Risk
This group includes people with:
- Established heart disease or stroke
- Diabetes with additional risk factors
- Chronic kidney disease
- Very high calculated cardiovascular risk
Typical targets:
- LDL cholesterol less than 1.8 mmol/L
- Non-HDL cholesterol less than 2.4 mmol/L
Moderate Risk
- LDL cholesterol targets are often less than 2.0 mmol/L
- Decisions are individualized based on overall risk and patient preference
Low Risk
- Lifestyle changes are usually recommended
- Cholesterol-lowering medications are often not required
Why Cardiovascular Risk Matters More Than One Number
Two people with identical cholesterol levels can have very different risks of heart attack or stroke. Risk depends on multiple factors, including:
- Age
- Blood pressure
- Smoking status
- Diabetes
- Family history
This risk-based approach helps ensure treatment is used where it provides meaningful benefit, while avoiding unnecessary medication in low-risk individuals.
Lifestyle Is the Foundation of Cholesterol Management
Lifestyle changes improve cholesterol levels and reduce cardiovascular risk at all levels.
Key strategies include:
- Eating more vegetables, fibre, legumes, and whole grains
- Reducing saturated fats and ultra-processed foods
- Regular physical activity
- Weight management when appropriate
- Avoiding smoking
Even small, sustainable changes can lead to meaningful risk reduction.
When Are Cholesterol-Lowering Medications Used?
Statins are the most commonly prescribed cholesterol-lowering medications in Canada.
They are typically recommended when:
- Cardiovascular risk is high
- There is established heart or vascular disease
- Lifestyle changes alone are unlikely to achieve sufficient risk reduction
Medication decisions should involve shared decision-making, balancing potential benefit, side effects, and personal values.
Cholesterol Testing and Choosing Wisely
The Choosing Wisely Canada campaign promotes appropriate testing and treatment.
Key recommendations include:
- Avoid routine cholesterol testing in low-risk adults without a clear indication
- Do not repeat lipid testing more often than needed once results are stable
- Focus on overall cardiovascular risk rather than chasing small lab changes
More testing does not necessarily improve outcomes.
Cardiovascular Risk FAQs
What does “cardiovascular risk” mean?
Cardiovascular risk estimates your chance of having a heart attack or stroke over the next 10 years, based on several factors considered together.
How is cardiovascular risk assessed in Canada?
Canadian clinicians use validated risk calculators. A patient-friendly option is the Canadian Cardiovascular Disease Decision Aid, available at: https://decisionaid.ca/cvd
This tool helps you:
- Visualize your cardiovascular risk
- See how lifestyle changes affect risk
- Understand the potential benefit of medications such as statins
- Participate in shared decision-making with your clinician
If my risk is low, do I need medication?
Usually not.
For people at low cardiovascular risk, guidelines generally recommend:
- Lifestyle changes
- Periodic reassessment
- Avoiding unnecessary lifelong medication
This approach aligns with Choosing Wisely Canada recommendations.
If my risk is high, do lifestyle changes still matter?
Yes. Lifestyle changes are important for everyone.
When risk is high, medications are often added because lifestyle changes alone may not reduce risk enough. The goal is risk reduction, not simply achieving a specific cholesterol number.
Why isn’t total cholesterol emphasized anymore?
Total cholesterol does not accurately reflect cardiovascular risk on its own.
Canadian guidelines focus more on:
- LDL cholesterol
- Non-HDL cholesterol
- Overall cardiovascular risk
This leads to more appropriate and individualized care.
How often should cholesterol or risk be reassessed?
For most adults:
- Risk is reassessed every few years
- Repeat testing is done after significant lifestyle changes or medication adjustments
- Routine annual testing is usually unnecessary
Bottom Line
Cholesterol management in Canada is risk-based, evidence-driven, and individualized. Understanding your cholesterol results in the context of your overall cardiovascular risk leads to better decisions and avoids unnecessary testing or treatment.
If you have questions about your cholesterol results, discuss them with your primary care provider to determine the approach that best fits your health goals.