Most of us are unfamiliar with our cholesterol “numbers” until midlife. But – if new US guidelines become the norm in the UK – we could be tested as young as 20, or even in childhood.
According to the Centers for Disease Control and Prevention (CDC), regular testing should start at age 20, especially for those with risk factors such as smoking, obesity or a family history of heart disease. The guidelines even suggest children should be tested once between the ages of nine and 11, and again between 17 and 21.
So should we in the UK follow the lead of our American cousins and begin testing at an earlier age? How often should we do so? And how important are cholesterol readings as a signal of future heart health?
We asked UK heart disease expert Dr Iqbal Malik for his advice.
Jump to:
- How your heart risk is calculated
- Who should take statins?
- What is the best age to start testing for cholesterol?
- Is there a simpler way to find out your heart health?
- Four ways to reduce your cholesterol without statins
How your heart risk is calculated
Dr Iqbal Malik, 59, is the lead for structural heart disease at NHS Hammersmith Hospital, as well as a private doctor at London Cardiovascular Clinic in the West End. He is an expert in preventative care. “I’m a bit like a plumber,” he says. “I open blocked pipes, close holes and change valves.”
According to Dr Malik, UK and European guidelines are more “slack” on primary prevention. “The first check most people will have is the midlife health check at their GP, from the age of 40,” he says. The midlife health check is available every five years until a patient turns 74.
Patients are invited to the health check by letter from their GP. At the very least, you will have a quick finger-prick test that reveals your “total cholesterol”, sometimes expressed as a ratio of total cholesterol to HDL (high-density lipoprotein, or “good” cholesterol).
Others will have a full lipid profile, with blood taken from the arm. This measures your levels of HDL cholesterol, triglycerides (another type of blood fat) and LDL (low-density lipoprotein, or “bad” cholesterol), as well as providing a more accurate total cholesterol reading.
Armed with these figures, along with your height, weight, waist measurement, blood sugar, blood pressure and lifestyle details – such as whether you smoke – a medical professional will calculate your QRISK. This is a number that estimates your risk of a cardiac “event”, such as a heart attack or stroke, in the next 10 years.
Who should take statins?
Patients in the UK with a 10 per cent risk are usually offered statins, medications that lower “bad” (LDL) cholesterol by inhibiting a liver enzyme, reducing cholesterol production and increasing LDL removal from the blood. “The ceiling for statin prescription has already come down significantly – it used to be 20 per cent,” says Dr Malik. “In the US, 5-10 per cent is seen as ‘borderline’, so a doctor may want to start you on a statin then.”
“No risk calculator is perfect,” he says. “But the question is, what level of risk is the patient prepared to take? In medical practice, there are two types of patient – the ‘maximiser’ and the ‘minimiser’. The maximiser will accept all advice and medication to reduce future risk, while a minimiser wants to avoid disruption to their current lifestyle and will certainly avoid medication.”
A high QRISK score is more of a warning than a diagnosis. If you start medication, you will probably have a follow-up in two to three months, followed by an annual review with your GP.
Should you go on statins if your doctor suggests it?
“Speak to cardiologists over 50 and a large number of them are on statins because they believe the prescription is evidence-based,” says Dr Malik. “I am more than happy to tell my patients I’ve been taking statins for 15 years.”
“As a doctor, I am not there to force a patient to do anything, just to give them advice,” he says. “But there is a mountain of evidence for the efficacy of statins. Prescriptions have gone up because they are now cheap and the NHS can afford to treat more people.”
Dr Malik says there is “hysteria” around statins. “You read terrible things about statins, but Google is a dangerous doctor and bad news travels quickly,” he says. “Good news doesn’t. Statins don’t cause cancer or dementia. Yes, your HbA1c might rise a point or two, but statins are not going to ‘give you’ diabetes – you will still live longer than if you didn’t take them.”
While some patients experience muscle aches and digestive issues while on the drugs, these can often be resolved by adjusting the type of medication.
“If my risk was over 10 per cent in the next 10 years, I wouldn’t be frightened of statins,” says Dr Malik. “They are a better insurance policy than going to Holland and Barrett and spending large amounts on ginseng, garlic, selenium, vitamin E and zinc.”
Should we be testing our cholesterol at the age of 20?
If there is a strong family history of cardiovascular disease or high cholesterol, a person should consider being tested at a young age, says Dr Malik. You may need to push for this check. “Early testing is also wise if the patient has kidney disease or an inflammatory condition such as lupus, HIV or rheumatoid arthritis.”
But Malik believes the benefits of widespread testing this early in life are less clear.
“At the age of 20, most people will be ‘minimisers’ and won’t want to be medicalised,” he says. “Most are also unlikely to change their behaviour on the advice of a GP. You won’t pick up most cases of extremely high cholesterol by screening all 20-year-olds.” Many people at this age are unlikely to respond to GP invitations.
What about testing children, as suggested in the new US guidelines? “There isn’t the evidence base to suggest this will be worthwhile,” says Dr Malik.
What is the best age to start testing for cholesterol?
“I think we more or less have it right on the NHS,” says Dr Malik. “Forty-plus is the right age to start – again, as long as you aren’t high risk.”
The most important thing, he adds, is that patients attend their midlife health check. Current uptake is lower than it should be. According to the National Audit Office, only 44 per cent of eligible adults in England attended their NHS check between 2019 and 2024, and more than half a million people declined the invitation in the first three months of 2025.
Should we test our cholesterol more often?
“We are cost-constrained on the NHS,” says Dr Malik. “In my private practice, I would suggest patients have a check-up, including cholesterol and blood sugar tests, every three years. Some ‘maximisers’ come annually.” The NHS currently tests every five years.
How do you know your heart is healthy from your cholesterol numbers?
The cholesterol test is not conclusive, but “it will give you a hint”, says Dr Malik. “For a more accurate picture, you also need a proper examination, including your blood pressure, blood sugar and a pulse check.”
What should your cholesterol numbers look like?
Dr Malik says:
Total cholesterol (TC): “On total cholesterol, the ideal is to be below five. The average midlife patient will have a level of 5.5 to 6.” There is no single “ceiling” at which you should start worrying, as this depends on your QRISK.
Total cholesterol to HDL ratio: This is calculated by dividing your total cholesterol by your HDL (high-density lipoprotein, or “good” cholesterol). “The important figure to look at is the ratio to HDL. Ideally, it should be below 4:1 – and definitely below 5:1.”
LDL (low-density lipoprotein, or “bad” cholesterol): “If you look at your LDL independently, the lower the better. As long as it is under two, you are doing OK. If you’ve had a heart attack, less than 1.4 is the target.”
“Men have an average HDL of one and an LDL of three. For women it is similar, although their HDL is higher before menopause.”
“If you have had a heart attack, you want your LDL to be as low as possible – definitely less than 1.4.”
“Cholesterol is just one measure in midlife health checks – others are also important, such as weight, waist measurement, age and HbA1c blood sugar. A pulse check for atrial fibrillation, or an irregular heart rhythm, is also important.”
Is there a more definitive way to find out your heart health?
“Risk scores try to predict whether you have cardiovascular disease now and whether you will develop it in the future,” says Dr Malik. “But a CT coronary angiogram (CTCA) can look directly at the health of your heart’s blood vessels and is more accurate.”
A CTCA is a non-invasive 3D imaging test that uses X-rays and an iodine-based contrast dye to visualise the heart’s blood vessels and detect coronary artery disease. “Because a CTCA involves radiation and a dye injection, it is not a first-line test,” says Dr Malik. “I use it in private practice to calibrate risk for some patients with no symptoms. In the NHS, it is used mainly for patients who already have symptoms.”
“I would suggest a CTCA if you want to know if you have early disease. If you do, I would think about statins.”