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CHOLESTEROL SERIES · ARTICLE 1 OF 12
What is cholesterol?
A plain-English guide for South African families.
Roughly one in three South African adults has high cholesterol. About half of them don’t know it. Of the half who do know, many are not on treatment, or are on treatment that isn’t bringing the numbers down enough. The damage shows up, eventually, as heart attacks and strokes — which together kill more South Africans every year than HIV, TB and road accidents combined.
High cholesterol is not unusual. It is not a sign of moral failure or a bad diet alone. It is a partly inherited, partly lifestyle-driven condition that responds beautifully to small, ordinary changes — and to medication when it is needed. The first step is understanding what it actually is, what the four numbers on the test mean, and why it is dangerous in the quiet way that it is.
Before you read on
This is information, not medical advice. If you think you or someone you love has high cholesterol, see a clinic nurse or doctor for a blood test and, if needed, treatment. Both are free at public clinics.
What cholesterol actually is
Cholesterol is a waxy, fat-like substance that sits in every single cell in your body. It is not poison. It is essential — your cells need it to keep their walls firm, your nerves need it to send messages, your hormones (oestrogen, testosterone, cortisol) are built from it, and your body uses it to make vitamin D and the bile acids that digest food.
The body needs cholesterol so much that it makes most of it itself. About 75 – 80% of the cholesterol in your blood comes from your liver, manufactured fresh every day. Only 20 – 25% comes from food. This is why simply “eating less cholesterol” doesn’t always lower blood cholesterol by much — the liver compensates.
The problem is not having cholesterol. The problem is having too much of the wrong kind, carried in the blood for too long. Over years, that excess slowly gathers in the walls of the arteries, forming sticky deposits called plaque. Plaque narrows the arteries, stiffens them, and sometimes cracks open — at which point the body forms a clot, the blood flow stops, and the part of the body downstream of the blockage starts dying. That is what a heart attack or a stroke is.
High cholesterol is not the disease. Slow plaque build-up in your arteries is the disease. High cholesterol is what feeds it.
The four numbers on a cholesterol test
When your clinic takes blood for a cholesterol test (called a lipid panel), four numbers come back. They are usually written together on one page. Knowing what each one means makes the test result much easier to read.
Number What it is What you want LDL “Bad” cholesterol — delivers cholesterol to your cells and to your artery walls Low HDL “Good” cholesterol — carries cholesterol back to the liver to be removed High Triglycerides A different kind of blood fat, stored when you eat more energy than you burn Low Total cholesterol LDL + HDL + a small slice of triglycerides — the headline number Low – middle
LDL — the “bad” one, in plain English
LDL stands for low-density lipoprotein. Think of LDL particles like delivery trucks. They pick up cholesterol from your liver and deliver it to cells around the body that need it. When there are too many delivery trucks on the road, some of them get stuck in the artery walls, dump their cargo, and start the plaque-building process.
LDL is the single most important number on the test. Almost every cholesterol treatment is aimed at bringing LDL down.
HDL — the “good” one
HDL stands for high-density lipoprotein. Think of HDL particles like garbage trucks. They pick up cholesterol from artery walls and bring it back to the liver to be broken down and removed.
More HDL means more cholesterol is being cleared out of your arteries. Exercise, healthy fats and moderation with alcohol raise HDL; smoking and a sedentary lifestyle lower it.
Triglycerides — the third fat
Triglycerides are not cholesterol. They are a separate kind of blood fat that the body makes from the excess calories you eat. Too much sugar, too much refined starch and too much alcohol all push triglycerides up. So does diabetes.
High triglycerides, on their own, increase heart attack and stroke risk and — at very high levels — can cause a sudden, painful inflammation of the pancreas.
Total cholesterol — the headline
The total is the sum of LDL, HDL, and a small fraction of triglycerides. It is useful as a quick screen, but the LDL on its own is more meaningful, because the total can be high for the right reason (lots of HDL) or the wrong reason (lots of LDL). Most clinics now look more carefully at LDL than at total.
What counts as normal and what counts as high
South African guidelines (Lipid and Atherosclerosis Society of Southern Africa) measure cholesterol in millimoles per litre — mmol/L. The targets depend on your overall heart-disease risk, but for a healthy adult with no other conditions:
Number Optimal Borderline High / a problem Total cholesterol under 5.0 5.0 – 6.2 over 6.2 LDL (“bad”) under 3.0 3.0 – 4.0 over 4.0 HDL (“good”) over 1.2 (women) / 1.0 (men) 0.9 – 1.2 under 0.9 Triglycerides under 1.7 1.7 – 2.3 over 2.3
If you already have diabetes, high BP, a previous heart attack, kidney disease, or a strong family history of heart trouble before age 55, your target LDL will be much lower — usually under 1.8 mmol/L, and sometimes lower still. Your clinic will tell you which target applies to you.
If your LDL is above 4.9 mmol/L
That is unusually high and may suggest a genetic condition called familial hypercholesterolaemia. It is more common in South Africa than almost anywhere else in the world — roughly 1 in 100 Afrikaner, Indian and Ashkenazi Jewish South Africans carries the gene, compared with 1 in 250 internationally. Your clinic should screen first-degree family members and consider starting treatment early. We cover this in detail in article 11 of this series.
The silent killer companion
If you have read the High Blood Pressure Series, you know that high BP is called “the silent killer” because it has no symptoms until something major happens. High cholesterol is the same. There is no pain. No discomfort. No warning sign you can feel. The plaque builds quietly, year after year, while you feel fine.
Many South Africans only find out their cholesterol is high after their first heart attack or stroke — and by then a lot of damage has already been done. Some never find out at all; the first heart attack is also the last.
The myth that you would “feel” high cholesterol is dangerous. Most people don’t. The only way to know is a blood test.
There are a few very rare visible signs — yellowish lumps under the skin around the eyes (called xanthelasma), or thick yellowish deposits on the tendons at the back of your ankle or the back of your hand. These are usually signs of severely high cholesterol, often the familial kind. If you see them on yourself or a family member, ask for a lipid panel.
The only way to know your cholesterol is to measure it.
Who tends to have high cholesterol
The main risk factors:
• Age. Cholesterol drifts up through life. Men start to see rises from around age 35; women later, often after menopause when oestrogen drops.
• Family history. If a parent or sibling had a heart attack or stroke under 55, your own cholesterol is worth checking — and if it’s high, the family probably has a genetic kind.
• Being of Indian, Afrikaner, or Ashkenazi Jewish ancestry. All three South African communities have unusually high rates of familial hypercholesterolaemia because of “founder effects” — a small number of original settlers passing the gene on widely.
• A diet high in saturated and trans fats. Fatty red meat, polony, biltong, full-fat dairy, palm oil, fried takeaways and some baked goods all raise LDL.
• A diet high in refined carbohydrates and sugar. These push triglycerides up and lower HDL.
• Carrying extra weight, especially around the middle.
• A sedentary lifestyle.
• Smoking. Lowers HDL and accelerates artery damage.
• Diabetes. Most diabetics have a “lipid profile” that pushes risk up sharply — low HDL, high triglycerides, and LDL particles that are particularly damaging.
• High blood pressure. The two conditions damage arteries together; the combined damage is bigger than either alone.
• Chronic kidney disease and an under-active thyroid. Both can push cholesterol up indirectly.
How it is diagnosed
Diagnosis is straightforward: a single blood draw, taken from the arm at a clinic or pharmacy, sent to a lab, and back in a day or two. The test is called a lipid panel and it costs nothing at a public clinic.
For decades, clinics asked you to fast for 8 – 12 hours before the test (a glass of water only, nothing else). Newer guidelines accept a non-fasting test for routine screening — the LDL number is similar either way, though the triglycerides are higher straight after a meal. If your first test is borderline or your triglycerides are very high, you may be asked to repeat the test in the fasting state to confirm.
When to start testing:
• Adults with no known risk factors: from age 35 (men) or 40 (women).
• Adults with any risk factor (family history, diabetes, high BP, smoking, obesity, Indian / Afrikaner / Ashkenazi Jewish ancestry): from age 20, repeated every 5 years.
• Anyone already diagnosed with diabetes, high BP, kidney disease or heart disease: every year.
• Children with a strong family history of early heart attack or familial hypercholesterolaemia: at least once before age 18.
Where to get a cholesterol test — free or cheap
Any public clinic — a lipid panel is part of chronic care screening and is offered to adults over 35 (or younger if there is a risk factor). No cost.
Most retail pharmacies (Clicks, Dis-Chem, Pick n Pay) — a finger-prick screening test for total cholesterol costs around R50 – R100 and gives a quick result while you wait. A full lipid panel from a private lab costs around R150 – R350.
Workplace wellness days — most include a cholesterol check, free and often without an appointment.
What high cholesterol does if you leave it alone
Picture your arteries as smooth, flexible pipes. Each time too many LDL particles bump into the artery wall, a small amount of cholesterol slips into the wall and sticks. White blood cells come to clean it up but get stuck themselves, forming a kind of pimple inside the artery wall called a plaque.
Over years, the plaque grows. The artery becomes narrower; the wall becomes thicker and stiffer. Some plaques stay quiet for decades. Others crack open. When one cracks, the blood reacts as it would to any wound — it forms a clot. The clot blocks the artery. The tissue downstream — heart muscle, brain tissue, sometimes a leg — starts dying within minutes.
The places where this damage shows up first:
• The heart — coronary artery disease, angina, and heart attack. The single biggest cause of premature death in South African adults.
• The brain — stroke from plaque in the carotid arteries that supply the brain.
• The legs — peripheral artery disease, which causes pain on walking and, in severe cases, foot ulcers and amputation.
• The kidneys and the eyes — to a lesser extent than high BP and diabetes, but the damage adds up when more than one condition is present.
We go into detail on each of these in article 3 of the series. The point for now is that none of them are inevitable. Cholesterol responds reliably to treatment — sometimes through food and exercise alone, more often with a small daily tablet — and the response saves lives.
The good news
High cholesterol is one of the most treatable conditions in medicine.
• It can be measured with a single blood draw, free at any public clinic.
• It responds to ordinary food — oats, beans, fish, leafy greens, nuts. We cover the full list in article 5.
• It responds to walking, which is also free.
• When food and exercise aren’t enough, statin tablets bring LDL down by 30 – 50% — among the largest single-drug effects in medicine. The generics cost almost nothing on the public sector and have a strong safety record built up over 35 years of use.
• Bringing LDL down by 1 mmol/L (say, from 4.0 to 3.0) cuts heart attack and stroke risk by about 20% over 5 years. The effect is bigger over longer periods.
High cholesterol is not a sentence. It is a manageable condition that responds to consistent, kind, ordinary care.
The bigger picture
Cholesterol is part of the metabolic triad — high BP, diabetes and high cholesterol — that drives most of South Africa’s premature heart attacks, strokes and kidney failures. Almost everyone in our country either has one of the three, will get one, or loves someone who does. The three travel together because they share risk factors, and they reward you for treating them together because each one quietly multiplies the damage of the others.
If you have read this far, you are already ahead of most South Africans on this topic. The next steps are smaller than they sound: a blood test, a conversation with a clinic nurse, and — if needed — a small tablet taken every morning with breakfast. The rest of this series will walk you through each of those steps in turn.
The next article in the series unpacks how to know if you have high cholesterol — the test itself, what the numbers actually mean for your personal risk, what to do on the day you find out, and how to talk to your clinic about your results.
Where to get more help
Heart and Stroke Foundation South Africa — heartfoundation.co.za · 021 422 1586 — patient information, support, and a free risk calculator.
Your nearest public clinic — free lipid panel as part of chronic care, free statin medication for those who qualify.
Lipid and Atherosclerosis Society of Southern Africa — lasousa.org — guidelines and patient resources.
Phila Today High Blood Pressure Series and Diabetes Series — recommended companion reading. The three conditions travel together for most South Africans.
Phila Today Cholesterol Series — next: the silent problem — how to know if you have high cholesterol.
Phila Today · Article 1 of 12 in the Cholesterol Series