Hyperlipidemia is commonly known as high cholesterol.

The Health Promotion Board recommends the following cholesterol levels as optimal for both men and women.

LIpid Profile
For reporting, HDL level is defined as abnormal if it is <1.0
For reporting, LDL level is defined as abnormal if it is >3.3mmo/L

Note: A Lipid Profile will be considered abnormal if any of the lipid tests is borderline high and above.

Hyperlipidemia refers to a condition where there are high levels of cholesterol present in the body. 

Lipids are fatty substances in our blood which perform a variety of essential functions in our body. These roles include the production of hormones, storage of energy and forming the structure of cell membranes.

Excessively high levels of cholesterol can lead to the buildup of fatty deposits along the internal walls of blood vessels, resulting in the blockage of vessels which may then lead to complications such as coronary artery disease or strokes.

However, not all types of cholesterol are bad. 

• High-density lipoprotein (HDL) helps remove excess cholesterol from different parts of the body to the liver, and is considered a “good” cholesterol, while 

• Low-density lipoprotein (LDL) and triglycerides (TG) increase the risk of heart attacks and strokes and are considered ‘bad’ cholesterol.

While a high dietary intake of cholesterol and fat contributes to high cholesterol levels, there are other factors that can play a part too. 

These include factors such as hereditary metabolic disorders, pre-existing obesity and associated illnesses, and a sedentary lifestyle with minimal physical activity.

To improve your cholesterol levels and reduce the risk of developing hyperlipidemia, here are some steps you can take:

• Adopt a heart-healthy diet e.g. diet high in fruits and vegetables, while reducing intake of saturated and trans-fat.

• Incorporate physical activity into current lifestyle, aiming for 150 minutes of moderate-intensity exercise weekly.

• Quit smoking, if you are a smoker

• Go for regular health screenings

Have questions about hyperlipidemia and cholesterol management? Don't miss this chance to ask our specialist now!

To learn more about cholesterol, LDL and HDL, read this article!

About Dr Pamela Gopal

Dr Pamela Gopal is an Associate Consultant at the Post-Acute & Continuing Care Department of Sengkang Community Hospital (part of SingHealth Community Hospitals). 

She graduated from Duke-NUS Graduate Medical School in 2011, and attained her Graduate Diploma in Family Medicine and Master of Medicine in Family Medicine in 2016 and 2020 respectively.

In her current role at Sengkang Community Hospital (SKCH), Dr Pamela works with a multi-disciplinary team to provide holistic care to inpatients and optimise their medical conditions before their transition back  to the community.

Dr Pamela's clinical interests include clinical informatics, post-graduate education and evidence-based medicine. She believes in advancing healthcare through continuous learning and delivering better patient-centered care through education, and is a mentor to both medical students and post-graduate medical doctors.

Questions and answers on managing high cholesterol (hyperlipidemia)

1. Question by Joey

Dear Doctor,

My mum has high cholesterol. Apart from this, she also has high blood and now taking both blood thinner and blood pressure medication.  Lately, she has high cholesterol when she went for blood test. Is there any advice on how to manage her high cholesterol level

Secondly, will there be any issue if she consumes the high cholesterol medication together with the high blood pressure and blood thinner medication?

Lastly, are there any food which she might need to eat in moderation?

Answer by Dr Pamela Gopal

Dear Joey,

It is heartening to see your concern for your mother, and taking the efforts to understand her medical conditions. Depending on the level of high cholesterol, one can consider either lifestyle changes alone or in combination with cholesterol-lowering medication to reduce his/her cholesterol levels. 

It will be best for your mother to consult her physician regarding the need to start treatment, as the ideal lipid (cholesterol) targets vary depending on an individual’s comorbidities and risk factors. Meanwhile, she can consider implementing some changes to her lifestyle if she hasn’t already done so. Some of these changes include:

• Consider incorporating more fruits and vegetables in one’s diet and avoid excessive intake of foods which are high in saturated and trans-fat. Some examples of these foods include dairy and animal fats e.g., the fats found in chicken, pork, and beef etc, and foods which are high in hydrogenated oils.

• Adopt a physically active lifestyle, aiming for 150 minutes – 300 minutes of moderate-intensity exercise per week. This can help reduce LDL and increase HDL leves.

• Cut down on excessive alcohol intake as it can lead to increased triglyceride levels.

There are many patients who are taking a combination of blood pressure, blood thinning and cholesterol-lowering medication to control their various medical conditions. 

However, her physician will be in a better position to advise her on any potential drug-drug interactions based on the specific list of medications that she is currently consuming, as certain medications (e.g., antibiotics, anti-fungal medications etc.) may have some drug-drug interactions with statins (a commonly used cholesterol-lowering medication).

2. Question by Ee Ping

Dear Dr Gopal,

At which point should we take medicine for high cholesterol and the dosage?

My LDL level is 3.6, Total/HDL ratio is 4.3 - which ratio should I be looking at as there is a difference of opinions on whether I should take medicine. I do not have any other health issues. Pls advise.

Answer by Dr Pamela Gopal

Dear Ee Ping,

The decision to initiate cholesterol-lowering medication depends on the lipid profile of the patient, and his/her overall cardiovascular risk. This risk can be determined by looking at the patient’s medical conditions e.g., diabetes, coronary heart disease, previous stroke etc. In patients with no medical conditions, calculating the 10-year cardiovascular risk using the Singapore-modified Framingham Score will help stratify them into low, borderline, intermediate or high risk. 

The ideal LDL-C target for lower and borderline risk patients is less than 3.4 mmol/L. For patients in these risk groups with sub-optimal LDL-C values, a healthy diet and regular physical activity are still the first-line treatment. If lifestyle modifications are not able to sufficiently control the cholesterol levels, the decision to initiate medication will then be discussed.

Based on your lipid profile, it sounds like you might fall into the low to borderline-risk group. You can consider a trial of lifestyle modification and repeat your lipid panel in 3-6 months to assess for any improvement in LDL levels. Do also consult your physician to ascertain your target cholesterol levels based on your 10-year cardiovascular risk, as he/she will consider the above factors in his/her clinical assessment and manage accordingly.

3. Question by Patrick

Hi Dr Gopal,

My total cholesterol (6.36 mmol/L) is High.

This is mainly because my HDL (good) cholesterol is very high (3.24 mmol/L). My LDL (bad) cholesterol is within the desirable range (2.29 mmol/L).

Is there an issue with having too much HDL (good) cholesterol? Thank you for your advice.

Answer by Dr Pamela Gopal

Dear Patrick,

As you have correctly highlighted, the various components in a lipid profile (e.g., HDL and LDL) all contribute to the total cholesterol level. As such, it is more informative to look at the individual breakdown of LDL and HDL.  

HDL (high-density lipoprotein) is often labelled as “good” cholesterol due to its function in carrying excess circulating cholesterol in the bloodstream back to the liver for elimination.

High levels of HDL cholesterol are protective against the development of plaque in arteries, hence reducing the risk of heart disease and stroke. Current guidelines maintain a HDL cholesterol of greater than 1.0 mmol/L. 

Although there are no clear recommendations regarding the upper limit of HDL cholesterol, certain studies suggest that the benefits of HDL cholesterol taper off beyond levels of 90 mg/dL (2.3 mmol/L) in males. 

In fact, a recent clinical trial involving a medication aimed at increasing HDL levels demonstrated an increased risk for heart attacks when HDL levels became excessively high.

4. Question by Thomas

Dear Dr Gopal,

What do you recommend is the best way to control cholesterol?

Answer by Dr Pamela Gopal

Dear Thomas,

LDL (“bad” cholesterol) levels can be lowered by making modifications to your diet and activity levels, and in higher-risk individuals, cholesterol-lowering medications.

Dietary modifications include reducing saturated fat intake, and increasing the intake of wholegrains, fruits and vegetables, and healthy sources of protein. Saturated fat can be found in dairy and animal fats e.g., the fats found in chicken, pork, and beef etc. 

Replacing saturated fats with better fats such as walnuts, almonds and avocado can also help reduce LDL. Increasing plant proteins (e.g., soy protein) and viscous fibre (e.g., apples, eggplant, and oats) are other ways to lower LDL whilst decreasing the absorption of cholesterol in the intestines. One should also avoid excessive alcohol intake, as that can increase triglyceride levels.

Physical activity is beneficial in reducing “bad” cholesterol (LDL and triglycerides) and increasing “good” cholesterol (HDL). One should be able to see improvements in cholesterol levels by engaging in 150-300 minutes of moderate-high intensity exercise per week. 

For less active individuals, do be mindful to start gradually with light-intensity exercise with a shorter duration (e.g., less than 10 minutes) before progressing to longer duration and higher-intensity activities. Brisk walking is one of the safest forms of exercises to start with if one is uncertain of the level of exercise intensity. If in doubt, please consult your physician prior to initiating an exercise regimen.

5. Question by Joanna

Hi Dr Pamela,

I was told that I have carotid plaque so may I know what’s the cause and any treatment to rid it? How do I reduce high triglycerides level? Thank you for your time.

Answer by Dr Pamela Gopal

Dear Joanna,

Plaques are fatty cholesterol deposits which can form on the walls of arteries e.g. in carotid arteries. The build-up of this plaque is known as atherosclerosis and can result in strokes or heart attacks due to the blockage of major blood vessels. The development of plaques is caused by several factors such as high “bad” cholesterol levels, blood sugar levels, diet, smoking status and lack of physical activity. 

Controlling these risk factors through lifestyle and diet modifications, and cholesterol-lower medication (if indicated), can help to reduce atherosclerosis and its sequelae. 

Triglycerides are a type of fat (“lipid”) formed from excess calories consumed and stored in one’s fat cells for energy purposes. However, high levels of triglycerides (levels more than 2.3 mmol/L) can contribute to formation of atherosclerosis (plaque build-up) which is associated with increased risks of heart disease and stroke. Extremely high triglyceride levels (more than 10 mmol/L) can also cause acute inflammation of the pancreas. Some steps that you can take to reduce your triglyceride levels include:

• Adopt a physically active lifestyle, aiming for 150 minutes – 300 minutes of moderate- to high-intensity exercise per week, depending in your exercise tolerance.

• Incorporating a healthy diet through the following measures: 
  - Reduce saturated fat intake, which can be found in dairy and animal fats e.g., the fats found in chicken, pork, and beef etc. 
  - Avoid foods which are high in simple carbohydrates e.g., sugars and foods made with white flour or fructose, as these can increase triglyceride levels.
  - Reduce foods high in trans-fat, and foods with hydrogenated oils or fats.
  - Avoid excessive alcohol intake, as alcohol is high in calories and sugar which contribute to increased triglyceride levels.
  - Maintain a healthy body weight (BMI of 18.5-22.9), as triglycerides are formed from excess calories and stored as fat.

6. Question by Annie

Dear Dr Gopal,

I am delighted that we are given an opportunity to ask you about our lipid profile.

I am 52 this year and my lipid profile readings is as below:

Date taken: 30/11/2023
HDL 1.62
LDL 3.92
Triglycerides 1.24

Date taken: 14/7/2023
HDL 1.60
LDL 3.71
Triglycerides 1.29

I do not have any other medical conditions except I am left with half thyroid because of benign goitre.

a) Based on my age and the above readings, do I need to go on medication? When does one need to take the medication?

b) My mum was taking high cholesterol medication for many years till she was about 88 years old that doctor said she can drop this medication and she’s stable till now (she’s 92 years old). Cholesterol medication is unlike high blood pressure medication that can’ be stopped?

c) Is there any risk if the good cholesterol HDL went above the range of 1.6 (e.g., 1.8)?

d) Other than taking the doctor’s prescribed medication to lower cholesterol, is there any proven food or natural remedies that can help to reduce bad cholesterol (e.g. red yeast supplements)?

I thank you in advance for your kind advice and look forward to your replies.

Answer by Dr Pamela Gopal

Dear Annie,

The decision to prescribe cholesterol-lowering medications is typically based on an individual’s specific situation and clinical assessment by his/her doctor. He/she will need to determine your overall cardiovascular risk by looking at your medical history or calculating your 10-year cardiovascular risk using the Singapore-modified Framingham Score. This, then, will help stratify your risk into low, borderline, intermediate or high risk.

In your case, it sounds like you may be borderline to low risk, based on the information provided. The ideal LDL-C target for low and borderline risk patients is less than 3.4 mmol/L, and the initial management would still be a healthy diet and regular physical activity. Should these measures fail to sufficiently control the cholesterol levels, the decision to initiate medication will then be discussed. Do consult your physician to have an accurate assessment of your cardiovascular risk profile. This will give you a clearer idea of your LDL targets and help guide your goals of treatment.

It is good to hear that your mother’s cholesterol levels are well-controlled without the need for medication. Oftentimes, for patients who are on cholesterol-lowering medication and are practicing a healthy lifestyle, cholesterol levels can be reduced to such an extent that medication can be tapered off. Nevertheless, it is necessary to regularly check cholesterol levels to ensure that they continue to be within optimal targets.

High levels of HDL cholesterol are protective against the development of plaque in arteries, hence reducing the risk of heart disease and stroke. Current guidelines maintain a HDL cholesterol of greater than 1.0 mmol/L. Although there are no clear recommendations regarding the upper limit of HDL cholesterol, certain studies suggest that the benefits of HDL cholesterol taper off beyond levels of 90 mg/dL (2.3 mmol/L) in males. In fact, a recent clinical trial involving a medication aimed at increasing HDL levels demonstrated an increased risk for heart attacks when HDL levels became excessively high. 

Currently, there is no established data to conclusively prove that supplements reduce the risk of future heart events. Supplements may cause side effects, allergic reactions, or drug interactions with prescription medications. Also, the manufacture of supplements may not be standardised, and this can affect their efficacy. In fact, a well-balanced diet with plenty of natural foods such as vegetables, fruit, whole grains, legumes, seeds, and fatty fish contain many nutrients and healthy properties which are essential for heart health.

7. Question by Theng

Dear Dr,

Please advise eating one egg a day, is it too much? Or should it be only 4 per week?

Answer by Dr Pamela Gopal

Dear Theng,

While egg yolks are high in dietary cholesterol, it is not necessarily bad for our health.

Although an average egg contains approximately 4.6g of fat, only one-quarter of this comprises saturated fat. Eggs also contain many beneficial nutrients such as choline, lutein, vitamins A, B, D and folic acid, all of which contribute to improved health. 

Recent studies suggest that regular egg consumption (up to 7 eggs a week) in the general population does not increase the risk of heart disease.

However, for individuals with high blood cholesterol due to genetic factors or medical comorbidities e.g., diabetes, they would need to be more mindful of their dietary cholesterol intake. 

Also, it is recommended to include a wide variety of foods in your diet to attain the optimal amount of nutrition, instead of relying on eggs alone to fulfil one’s nutritional requirements. As such, the Health Promotion Board recommends up to 4 eggs a week as part of a healthy diet.

8. Question by Ivan

Dear Dr,

Does increased body-fat or ‘visceral’ fat lead to an elevated cholesterol level?

And if so, how do I address it? Thank you for your advice!

Answer by Dr Pamela Gopal

Dear Ivan,

There are many research studies that have shown an increased risk of health-related problems with visceral (organ) fat. Visceral fat is known to release hormones, fatty acids and inflammatory agents that lead to higher LDL (“bad” cholesterol), triglycerides, blood sugar and blood pressure.

One of the most effective ways to reduce visceral fat is to incorporate a healthy diet and exercise into your current lifestyle. 

One can consider increasing the amount of dietary fibre, which can be found in foods such as leafy vegetables, fruits, brown rice, or wholemeal bread. Foods which are high in saturated fats (e.g., fried foods, lard, meats high in fat), trans-fat and excessive alcohol should be avoided. 

Physical activity in the form of 150-300 minutes of moderate intensity exercise per week is also highly recommended.

9. Question by Antony

Dear Dr Gopal,

I have high cholesterol for many years and I was taking Eturion 80 mg under the instruction from my doctor.

After blood test, my cholesterol doesn’t drop and I feel pain in my leg muscles.

Having permission from my doctor, I reduce to 40 mg per evening.

How to reduce my cholesterol? I am also a heart patient.

Thank you for your advice.

Answer by Dr Pamela Gopal

Dear Antony,

From your description as being a “heart patient”, it sounds like you have a heart-related condition e.g., coronary artery disease, angina etc. 

In this instance, cholesterol-lowering medication such as high-intensity statins are typically initiated to reduce inflammation in coronary arteries and correspondingly, lower the risk of heart attacks. 

While statins work for most patients, there are some patients who either suffer from side effects such as muscle pain from high-dose statin consumption, or for whom the cholesterol levels are not adequately controlled to their target LDL levels despite good compliance. 

In your case, it would be advisable to check with your physician regarding your optimal LDL target level. He/she may also discuss adding other cholesterol-lowering medications such as ezetimibe to achieve the desired LDL targets while watching out for any potential side effects.

While medications are often efficacious in lowering cholesterol, one must be mindful to continue a healthy lifestyle in terms of diet and physical activity to reap maximal effects. Some measures you can consider implementing to lower your “bad” cholesterol include:

• Reducing saturated fat intake, which can be found in dairy and animal fats e.g., the fats found in chicken, pork, and beef etc.

• Increasing the intake of wholegrains, fruits and vegetables, and healthy sources of protein.

• Increasing plant proteins (e.g., soy protein) and viscous fibre (e.g., apples, eggplant, and oats) to lower LDL whilst decreasing the absorption of cholesterol in the intestines.

• Physical activity in the form of 150-300 minutes of moderate intensity exercise per week. If you are uncertain of the level of exercise intensity, consider starting with brisk walking as it is one of the safest forms of exercise. Do remember to consult your physician prior to initiating an exercise regimen.

10. Question by Jill

Hello Dr Pamela,

I’m currently taking Atorvastatin 10mg on alternate nights. My question is:

Is it ok to consume 2 capsules daily of Lingzhi (cracked spores powder capsules)?

I’m told not to eat grapefruit only.

Looking forward to your reply. Thank you.

Answer by Dr Pamela Gopal

Dear Jill,

Unlike prescription medications, supplements are not routinely subjected to stringent clinical trials. Currently, there isn't sufficient reliable evidence to determine if Lingzhi results in herb-drug interactions when administered with prescription medications. 

Also, some herbal supplements may affect the metabolism of medications, resulting in unexpected side effects. Do consult your doctor to evaluate for any potential drug interactions if you are keen to consider taking health supplements such as Lingzhi.

11. Question by Susan

Hi Dr,

May I know why when calcium score is high, it is considered having high cholesterol? Why is calcium taken as a measure for cholesterol? Isn't calcium good for bone?

Answer by Dr Pamela Gopal

Dear Susan,

I believe you are referring to the computed tomography (CT) calcium score test, which utilizes a CT machine to scan your heart and assess how much calcium is present in the arteries supplying your heart. It is a non-invasive procedure and can be used as a screening tool for coronary artery plaque build-up. 

In CAD, plaque build-up containing calcium and fatty substances e.g., cholesterol, can deposit in artery walls, causing narrowing of these vessels and compromising blood flow. This process is known as atherosclerosis. 

This can lead to an increased risk of heart attacks. The higher the calcium score, the higher the risk of future cardiovascular events due to atherosclerosis formation. The process described above is not the same as calcium (an essential mineral required by the body) consumed from dietary sources or supplements for maintenance of good bone health and other functions.

12. Question by Tyson

Hi Dr,

A Polyclinic doc asked me to go on a healthy diet and exercises after my recent LDL was borderline range, the rest HDL and others are okay.

After 5months, the LDL dropped to a healthy range. But this fluctuates over the years, sometimes in a healthy range sometimes not.

I am in my mid 50s and body fitness is above average with daily steps of more than 10K and hitting the daily MPVA (at least 30mins) too. I did not have any discomfort when doing such activities.

Do I require medication to control my LDL (borderline at times exceeding)?

Answer by Dr Pamela Gopal

Dear Tyson,

Well done on maintaining your LDL levels and consistently keeping active, do keep it up! 

Your current efforts in maintaining a healthy diet and an active lifestyle are important factors in controlling your LDL levels and lower the risk for developing other medical conditions such as high blood pressure, obesity, diabetes mellitus and coronary artery disease. 

However, one’s cholesterol profile can fluctuate according to changes in eating habits and activity levels, as what you have experienced. 

I would suggest that you consult with your doctor to evaluate your cardiovascular risk profile as that will determine the indication for initiating cholesterol-lowering medication. Doing so will also allow you to understand the specific LDL target that you should be achieving.

13. Question by Mew Lian

Dear Dr,

I have high LDL but my HDL and triglycerides numbers are very good. I eat healthily and exercise whenever I can.

I've learnt that LDL has different types. I want to do the tests for apo B and LpA so that I know if I really need to take statin.

Lipitor gives me muscle aches. Oats give me gas. I take coQ10 and omega 3 daily. I'm a female going to be 70 in July.

Thank you for any advice.

Answer by Dr Pamela Gopal

Dear Mew Lian,

It is heartening to know that you are practicing a healthy diet and exercising regularly. You are right in that there are different types of lipoproteins. 

Beside LDL particles, there are lipoprotein(a) (Lp(a)) particles which are similar to LDL but have more proteins attached. Paired with these LDL particles are a structural component known as apolipoprotein B (ApoB). As such, the amount of ApoB in one’s body reflects the total number of LDL and Lp(a) particles. 

Although some research studies have found ApoB to be a good estimate of cardiac events, this is relevant to certain patient populations with a propensity for smaller and denser LDL particles e.g., patients Type 2 diabetes. 

In most patients, attaining optimal LDL levels is still the primary goal of cholesterol management, as there is conclusive evidence that lower LDL levels is associated with a lower risk of cardiovascular events e.g., heart attacks, strokes etc. 

Current guidelines still advocate the use of a lipid panel for routine screening. Should you be keen on doing further testing to evaluate apo(B) and Lp(a) levels, you can approach your doctor who will be able to assess the indication for the tests and interpret the results in your clinical context and risk profile. 

Letting he/she know about your muscle ache with Lipitor administration is also useful, as your doctor may reduce your Lipitor dosage or switch to another statin if he/she determines that your symptoms are a side effect of the medication.

14. Question by Goh

Hi Dr, my questions are: 

(a) Is there a recommended cholesterol for different age groups? Currently the recommendations I saw online is a one-size fit all for all age group.

(b) I am age 63. Average blood pressure of 118/70, HDL of 1.81 and Triglycerides of 0.92. My LDL (3.99) remains high despite changing my diet, regular exercise and intermittent fasting. Do you recommend I do a Lp(a) blood test? Is high Lp(a) inherited and not treatable by Satin?

(c) What is the average cholesterol for Singaporeans for the 60-70 age group? Thank you.

Answer by Dr Pamela Gopal

Dear Goh,

To find out what your ideal LDL target should be, you can consult your doctor who will determine your cardiovascular risk profile based on several factors e.g., age, systolic blood pressure, smoking history, past medical history etc. Age is only one of the factors that is used to calculate your 10-year cardiovascular risk using the Singapore-modified Framingham Score. In our local MOH guidelines, the optimal LDL targets are guided by one’s cardiovascular risk profile and medical background, and not simply by age alone.

Based on the information that you have provided, your blood pressure, HDL and TG are optimal for your age. However, your LDL level may be considered high, and your doctor will be best able to advise if you fall into the low, borderline, intermediate or high-risk category for hyperlipidemia after a clinical assessment of your medical history and your risk profile and determine your ideal LDL target. Both you and your doctor can then make an informed decision as to whether cholesterol-lowering medication is indicated.

Lp(a) as a low-density LDL particle with an added apolipoprotein(a) attached, and its levels are 80-90% genetically determined. Recent research shows that while Lp(a) is also associated with increased risk of cardiovascular disease, lowering LDL levels is still the mainstay of cholesterol management. Unlike Lp(a) which does not demonstrate a clinically important reduction with statin treatment, established evidence shows that the risk of major cardiovascular events such as stroke, heart attacks etc. reduces by 20-25% for every 1 mmol/L drop in LDL-C with statin treatment. As such, you may wish to discuss with your doctor the indication for doing Lp(a) testing.

Meanwhile, do continue to keep up with your efforts of eating healthy and exercising!

15. Question by Georgie C

Dear Dr Gopal,

Thank you for taking time and effort to help us understand high cholesterol. My questions are:

a) When do you need to take medication e.g., Statins? If you are marginally high for 2 years, do you have to take statins?

b) What is the risk of doing so? And not doing so.

For context, I am 64, in good health, physically active and have no medical issues. Thanks.

Answer by Dr Pamela Gopal

Dear Georgie,

In managing high cholesterol, the initial management would still be a healthy diet and regular physical activity. These include:

• Reducing saturated fat intake, which can be found in dairy and animal fats e.g., the fats found in chicken, pork, and beef etc.

• Increasing the intake of wholegrains, fruits and vegetables, and healthy sources of protein.

• Increasing plant proteins (e.g., soy protein) and viscous fibre (e.g., apples, eggplant, and oats) to lower LDL whilst decreasing the absorption of cholesterol in the intestines.

• Physical activity in the form of 150-300 minutes of moderate intensity exercise per week.

Should the above measures fail to sufficiently control the cholesterol levels, your doctor will then discuss with you the need to start cholesterol-lowering medication. 

As a first step, I would recommend that you seek medical evaluation to determine your cardiovascular risk profile and optimal LDL target. Assuming that your cholesterol levels are persistently higher than your desired LDL target, your doctor will then initiate a discussion on medical therapy. 

Although statin consumption may result in side effects of muscle aches or weakness, increase in liver enzymes or small risk of newly diagnosed diabetes in select, at-risk populations, there are ways to monitor and mitigate these side effects.

Additionally, there is established evidence showing that the risk of major cardiovascular events such as stroke, heart attacks etc. can be reduced with effective statin therapy. 

Statins also reduce triglyceride levels (to a smaller extent), lower inflammatory markers and helps in stabilizing plaques, hence preventing detrimental outcomes from plaque rupture.

Ultimately, the benefits of statins do outweigh the small risk of side effects in majority of people.

16. Question by Steven

Hello Dr Pamela Gopal, I would like to ask:

a) My blood test revealed I have high total Cholesterol/HDL/LDL/Triglycerides – 8.2/2.7/5.2/0.83– and my doctor advised that I take statin. Is that my only option?

b) Is high cholesterol also hereditary, not just the result of diet? I am already doing 9 out of the 10 things recommended by an authoritative website my doctor and I looked at together about controlling cholesterol.

Answer by Dr Pamela Gopal

Dear Steven,

According to MOH lipid management guidelines, patients with an LDL value of more than 4.9 mmol/L and no known history of familial hyperlipidemia should consider treatment with a statin (type of cholesterol-lowering medication), in conjunction with lifestyle modifications e.g., healthy diet, regular moderate-intensity exercise, smoking cessation etc. 

Assuming that you have attempted the above lifestyle changes but still have persistently high cholesterol, you should discuss with your doctor the need for medical therapy.

This is especially so when certain risk factors tend to be inherited, such as high cholesterol, Type 2 diabetes, or high blood pressure. As such, one’s cholesterol levels may still be sub-optimal despite making changes to his/her lifestyle. 

However, this does not mean that you should not continue with your lifestyle changes. A healthy diet, regular exercise and smoking cessation can help lower the risk of developing other medical conditions such as high blood pressure, diabetes mellitus, obesity etc.

17. Question by Edde

Hi Dr, I have a question to ask:

I am 56 years old male and am on daily medication for my high blood pressure and high cholesterol. Now my blood pressure and cholesterol is under control due to the medicine I am taking.

Previously I am with a private GP and he issued me with Atorvastatin Atswift 20mg and Amlotens Amlodipine (added as mesilate monohydrate salt) 5mg. I have taken that (one tablet per day for each type) daily for two years.

Due to high costs, last year (third year) I switch from private GP to polyclinic. The doc at the poly prescribe me with Atorvastatin Atswift 20mg and Amlodipine 5mg.

Recently, I noticed that my muscle mass shrunk and my muscle strength is not as strong as before. For example, I go to gym and can lift 15kg with one arm with several reps and no issue. But now, I find it tough to do 15 kg reps.

I suspect that it is due to the change in the statin medicine brand. A lot of people said that statin can cause muscles to shrink. Is it true?

What is the solution is this?

Can I stop my statin medicine and monitor? Or ask the doc to switch to a different brand.

Thank you for your advice.

Answer by Dr Pamela Gopal

Dear Eddie,

Firstly, I would like to commend you on taking the efforts to control your high blood pressure and cholesterol. In general, the active components of branded or generic statins are the same, hence, the effectiveness of both medications should not differ. 

Under rare circumstances, a patient may experience side effects of generic medication while not with branded medicine, which can be related to differences in the manufacturing process and inherent components present other than the active compound. 

It will be best for you to discuss with your doctor regarding the need to reduce/stop the dose or switch to another statin if he/she has determined that your symptoms are related to statins, as statins may cause muscle ache or pain, but less commonly affecting muscle mass and strength. 

Also, it will be prudent for you to share your symptoms of decreased muscle strength and mass with your doctor so that other potential causes for this can be worked up.

18. Question by Karen

Dear Doctor,

I have borderline high cholesterol for a while, but not on medications.

Total cholesterol 6.03 (MMOL/L)
HDL 2.75 (MMOL/L)
LDL 3.06 (MMOL/L)
Triglycerides, serum 0.49 (MMOL/L)

Please advise if it is necessary for borderline high cholesterol patients like me to be on medications for preventative measures.

There are various medical professionals conflicting arguments that suggest taking medications and not taking medications.

Thank you for enlightening me.

Answer by Dr Pamela Gopal

Dear Karen,

The decision to initiate cholesterol-lowering medications is usually made after a discussion between your healthcare practitioner and yourself, considering your specific situation and a clinical assessment by him/her. 

Your doctor will need to determine your overall cardiovascular risk by looking at your medical history and/or calculating your 10-year cardiovascular risk using the Singapore-modified Framingham Score. This, then, will help stratify your risk into low, borderline, intermediate or high risk and determine your optimal LDL target. 

Should you truly have borderline LDL levels based on your target, initial management would still be a healthy diet and regular physical activity. If these measures fail to sufficiently control the cholesterol levels despite lifestyle modifications, the decision to initiate medication will then be discussed. 

Do consult your doctor to have an accurate assessment of your cardiovascular risk profile. This will give you a clearer idea of your LDL targets and help guide your goals of treatment.

19. Question by Yam

Dear Dr Pamela,

I've 3 stents inserted 2 years ago and also on atorvastatin for about 12 years. Which has possibly caused a side-effect on my lower calf muscles on both legs to be constantly tight and sore.

Topical gels, massages, and acupuncture had temporary effects. Only lifting my left high to do hamstring stretches bring instant relief, but are also short-lasting.

What can be done about this (though it is not truly a cholesterol issue)?

What are the more natural food or supplements I can take to depend less on the statin? Example red yeast, oats, resveratrol (red grape extract). 

Your advice is much appreciated.

Answer by Dr Pamela Gopal

Dear Yam,

Given your history of stent insertion, high-intensity statins are important to reduce inflammation in coronary arteries and correspondingly, lower the risk of heart attacks. You should have a discussion with your doctor to determine if your symptoms are related to other body systems e.g., musculoskeletal system, rather than attributing it to the side effects of statins alone. Further investigations may then be warranted to work up your lower calf symptoms.

No rigorous research studies that have proven that supplements can effectively reduce remove coronary artery plaques (cholesterol deposition). Conversely, there is established evidence showing that the risk of major cardiovascular events such as stroke, heart attacks etc. can be reduced with effective statin therapy.

20. Question by Eng Khiak

Dear Doctor,

I am on 20mg Rosuvstatin for many years and my memory is deteriorating. This may be due to the side effects of the high dosage of the statin.

My blood profile of cholesterol is always good. I recently cut my statin tablet into half and I shall review my cholesterol results next month.

If the cholesterol profile is good, should I stay on this half tablet dosage?

I am 76 years old and in good health. Thank you.

Answer by Dr Pamela Gopal

Dear Eng Khiak,

It is good to hear that you are taking the efforts to stay in good health. Since you are currently taking a reduced statin dosage and you have an upcoming lipid panel due, I would suggest that you wait for the results of your blood test before further adjusting the dose of your statin.

Should the upcoming results be within your ideal LDL targets, you can discuss with your healthcare practitioner regarding continuing statin medication at a reduced dose. It would also be prudent to inform your healthcare practitioner so that he/she can work up the potential causes of your memory loss, as there is no proven evidence linking this to a side effect of statins. 

Also, while medications are often efficacious in lowering cholesterol, one must be mindful to continue a healthy lifestyle in terms of diet and physical activity to reap maximal effects of cholesterol-lowering therapy.

21. Question by Poh LF

Hi Doctor Pamela Gopal,

’m 56 years old, female. My doctor (appointed using Healthy SG) advised me to take the cholesterol pill on daily basis and long term.

Currently I’m on Omeprazole pill long term & daily basis due to my GERD stomach problem.

Personally, I don’t want to take the cholesterol pill due to the side effects. Also, I’m already onomeprazole pill, I don’t feel good to take so much medication daily.

My family siblings are high cholesterol too and I believe this cholesterol problem is hereditary.

I’m taking organic rolled oats every morning and I try to be careful in my diet with daily walk of 10,000 steps most of the days.

I would like to seek your advice whether I can don’t take the pill for the time being? Can you also advice under what situation I must take the cholesterol pills without delay? Thank you.

Answer by Dr Pamela Gopal

Dear Poh,

The decision to initiate cholesterol-lowering medication depends on your lipid profile and overall cardiovascular risk. This risk can be determined by looking at your medical conditions e.g., diabetes, coronary heart disease, previous stroke etc. Calculating the 10-year cardiovascular risk using the Singapore-modified Framingham Score will help stratify your risk into low, borderline, intermediate or high risk. 

For patients in these risk groups with sub-optimal LDL-C values, a healthy diet and regular physical activity are still the first-line treatment. This is especially so when certain risk factors tend to be inherited, such as high cholesterol, Type 2 diabetes, or high blood pressure, like what you have mentioned. 

As such, one’s cholesterol levels may still be sub-optimal despite making changes to his/her lifestyle. It is hard to tell when an adverse event may happen, given that these medical conditions e.g., high cholesterol often may not exhibit any symptoms. 

When your risk factors are optimally controlled, either via lifestyle measures alone or with medication, the risk of coronary artery disease can be markedly reduced at an earlier age.

22. Question by Amasaiah

Hi Doctor,

I have been taking atorvastatin for a year now. My last medical review is good optimal. It was a 6-month review. Next review in August 2024.

Doctor says I can stop taking my medication. I am fearful that my cholesterol levels will return.

So my doctor says then take on an alternate day than every day.

I would like to know if I stop the medication and started taking “red yeast rice” supplements, does that mean I am better off? Am I doing good to my health and body. I have started exercising once to twice a week on the “365 programme” but still missed frequently due to work.

My diet is vegetable and fish with occasional meat and whole meal for breakfast. I ate fruits in varieties such as apples oranges plums peaches prunes.

I am 61 male, excellent heath no high blood no diabetes and cholesterol levels is optimal. Thank you for your time.

Answer by Dr Pamela Gopal

Dear Amasaiah,

It is heartening to know that you are taking excellent care of yourself and making efforts to exercise despite your busy schedule! 

Since your cholesterol level is in the optimal range, you may choose to maintain it through a healthy diet and regular exercise as discussed with your doctor. Conducting regular lipid panel screenings every 4-6 months will be useful in determining if your cholesterol levels are well-controlled with these lifestyle measures. Should your cholesterol levels exceed the target range persistently, you can re-start your cholesterol-lowering medications.

There is no established data proving the efficacy of supplements in reducing the risk of future heart events. Supplements may cause side effects, allergic reactions, or drug interactions with prescription medications. 

Also, the manufacture of supplements may not be standardised, and this can affect their efficacy. In fact, a well-balanced diet with plenty of natural foods such as vegetables, fruit, whole grains, legumes, seeds, and fatty fish contain many nutrients and healthy properties which are essential for heart health. 

Also, it will be beneficial to aim for 150 minutes of moderate-intensity exercise per week, depending in your exercise tolerance.

23. Question by Josephine

Dear Dr Pamela Gopal,

My blood test total cholesterol is 7.4; HDL 4; LDL 3.1; triglycerides 0.9 Ratio is 1.9.

Please advise whether am I having high cholesterol?  Do I need to take statin?

I love to eat pig’s skin, pork trotters and pork belly.  Are fats from meat good fats?

Thank you for your attention on this matter.

Answer by Dr Pamela Gopal

Dear Josephine,

While your HDL and TG levels are in the optimal range, your ideal LDL-C targets will need to be calculated in consultation with a doctor. 

Everyone’s target LDL levels varies depending on his/her medical conditions, clinical assessment and/or Singapore-modified Framingham Score to determine the 10-year cardiovascular risk. Based on this risk, your doctor can then determine if you have high cholesterol, and if cholesterol-lowering medication is warranted.

Dairy and animal fats e.g., the fats found in chicken, pork, and beef etc are high in saturated fat, and excessive intake of these foods can contribute to the development of high cholesterol levels. 

Replacing saturated fats with better fats such as walnuts, almonds and avocado can help reduce LDL levels. Consumption of plant proteins (e.g., soy protein) and viscous fibre (e.g., apples, eggplant, and oats) can also help lower LDL levels by decreasing the absorption of cholesterol in the intestines.

24. Question by Jasmine

Dear Dr,

My husband has a history of heart attack with stent inserted and stroke about 15 years back. He is currently taking 40mg Atorvastatin. 

Additionally, he is also on the following medications & supplements:

Bisoprolol fumarate 2.5mg
Aspirin 100mcg