When Do I Need to Worry About Heart Disease?

Reviewed by Dr. Jonathan Bonnet, MD, MPH and Judy Singer, RD

Heart disease accounts for roughly 1 in 4 deaths in the United States each year. Data also shows that nearly half of all Ameircans adults have at least one of the key risk factors for heart disease—and over half of cardiovascular events in men and just under one-third of cardiovascular events in women take place in people 64 and younger. But how many Americans know their risk level?

As experts and researchers continue to develop new therapies and treatments, prevention remains one of the top goals in heart health care.

Understanding the risk factors, which lifestyle modifications are effective, and when and how to screen can help to lower your risk of heart disease, including heart attack and stroke.

How does cholesterol cause heart disease?

Conversations about cholesterol and heart disease often go together, but the connection between the two may not always be clear.

In order to understand how cholesterol can cause heart disease, one must first understand the role cholesterol plays in the body.

Cholesterol is an organic molecule found throughout our body—we eat, make, store, and excrete cholesterol. In fact, most of the cholesterol in our body is made by our body. And it’s essential for living.

Within the context of heart health, we’re exclusively talking about blood cholesterol.

If someone has high levels of cholesterol in their blood, they can develop fatty deposits in blood vessels, which can eventually make it harder for sufficient blood to flow through the arteries. In serious cases, these deposits can break to form a clot that causes a heart attack or stroke.

More specifically, development of atherosclerosis (hardening of the arteries) requires three things:

  1. Lipoproteins (cholesterol containing transporters)

  2. Inflammation

  3. Endothelial dysfunction (damage to the blood vessel walls)

Because all three of these are required for developing atherosclerosis, having only one of these markers isn’t necessarily problematic on its own. However, it's hard to know exactly what your risk of each of these actually is, so why not do our best to minimize all of them?

When should I start paying attention to heart health?

Many healthy young adults don’t consider heart health to be a top preventive health priority.

But both the American Heart Association (AHA) and the American College of Cardiology (ACC) agree that the most important way to prevent heart disease is to promote a healthy lifestyle throughout life.

Scores of scientific literature draw the connection between healthy habits established as early as childhood and heart health in mid-to-late life.

Starting in your 20s, working with your doctor to get the right lab tests done and interpret your personal and family health history can help to identify your personal risk of heart disease. Depending on individual risk factors, there may be several recommendations you can implement to reduce your risk earlier in life.

If I eat well and exercise, am I still at risk for heart disease?

Eating a diet rich in whole, nutritious foods and exercising regularly is an excellent strategy for preventing many chronic conditions and supporting your overall physical and mental well-being. However, not every disease is fully preventable, including heart disease. Uncontrollable factors including age, sex, and genetics could still put you at risk for the disease.

Some of the controllable or manageable risk factors of heart disease include:

  • High blood pressure

  • High blood cholesterol levels (specifically ApoB containing lipoproteins such as LDL cholesterol)

  • Smoking

  • Diabetes

  • Lack of physical activity

  • Alcohol consumption

  • Stress

Risk factors that cannot be controlled include:

  • Age

  • Sex (men are at greater risk)

  • Family history

  • Race

Which tests matter?

Getting lab tests done is crucial to understanding your health markers. What’s more, the right type of test can make a difference.

For example, if any of your test results come back abnormal, understanding what the particle counts are (as opposed to standard concentration levels found in a traditional lipid panel) can help your doctor to offer individualized health and diet recommendations.

When screening for heart disease, your doctor may recommend one or more of the following tests:

  • ApoB

  • Lp(a)

  • Blood glucose

  • Blood pressure

  • Blood vessel markers (ADMA, SDMA)

  • Fasting lipid profile, including:

    • Total cholesterol

    • HDL cholesterol

    • LDL cholesterol

    • Triglycerides

  • Inflammatory markers

  • NMR Lipoprotein Analysis (i.e. lipoprotein particle counts and sizes)

  • Weight or body composition analysis

Your doctor may also want to discuss your smoking habits, physical activity and diet to determine your risk for heart disease.

Should I lower my cholesterol intake to help lower my cholesterol levels?

The truth? It depends. As frustrating as it may be to follow, dietary guidelines in response to cholesterol management have changed in recent years, and new evidence continues to shift our thinking and understanding in this space.

In reality, there isn’t enough compelling evidence to demonstrate that cholesterol from food raises blood cholesterol in the body. Part of this is because even when consumed in higher quantities, most of this exogenous (external, or not internally produced) cholesterol isn’t absorbed by the body.

Additionally, tracking the impacts of cholesterol consumed from food isn’t straightforward, because it’s just one component of many in any given type of food—in other words, no slice of cheese or filet of steak is 100% cholesterol and contains other nutrients that impact lipid levels too.

But another component found in foods high in cholesterol, saturated fat, has also been under scrutiny when it comes to heart health.

Should I lower my saturated fat intake to help lower my cholesterol levels?

Again, it depends.

Over the past 40 years, increased saturated fat intake has been strongly associated with increased LDL cholesterol levels and consequently with an increased risk for heart disease. These beliefs were based primarily on observational findings of populations with fairly high-intakes of carbohydrates. But what about a high-fat, low-carbohydrate diet?

A recent randomized, controlled trial of people with a BMI over 25 found that a diet restricted in carbohydrates but high in saturated fat improved metabolic health markers, including insulin resistance, without negatively affecting total cholesterol, LDL cholesterol, LDL particle size, blood pressure, and other measures of chronic inflammation in adults without a pre-existing heart condition.

These results suggest that previous beliefs about the adverse effects of saturated fat intake on cholesterol levels and heart disease risk may not be universally true, and that a high-fat, low-carb diet may actually be beneficial for improving the metabolic health of some individuals.

To make matters more confusing, not all saturated fats are created equal. For example, full fat and fermented dairy products seem to not impact cholesterol levels negatively. Depending on what you replace saturated fat with, your health status could improve, worsen, or remain the same. Decreasing your saturated fat intake and substituting it for vegetables will almost certainly improve your health, but swapping saturated fat for sugar will almost certainly make things worse.

At the end of the day, what matters most is eating a balanced diet of whole, minimally processed foods in appropriate quantities.

The bottom line

Recent findings suggest that a more nuanced and personalized approach to heart health and nutrition may be worth researching further. That’s where Forfend can help.

In many cases, no doctor can prescribe the ideal diet for you without looking at your lab results and understanding how your body responds to different food types.

Thankfully, heart health screening and personalized health recommendations go hand in hand—by getting the right labs and tests done, Forfend can help you understand your individual health risks and create a customized care plan for you.


2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. (2019).

About Heart Disease. (2021).

Atherosclerosis: a nutritional disease of childhood. (1998).

Effects of a low-carbohydrate diet on insulin-resistant dyslipoproteinemia—a randomized controlled feeding trial. (2021).

Heart-Health Screenings. (2019).

High cholesterol. (2021).

Know Your Risk for Heart Disease. (2019).

Risk Factors for Coronary Artery Disease: Historical Perspectives. (2017).

Risk of Premature Cardiovascular Disease vs the Number of Premature Cardiovascular Events. (2016).

Saturated Fats Versus Polyunsaturated Fats Versus Carbohydrates for Cardiovascular Disease Prevention and Treatment. (2016).

Test ID: ADMA. (n.d.).

Test ID: APOAB. (n.d.).

The Evidence for Saturated Fat and for Sugar Related to Coronary Heart Disease. (2017).

The straight dope on cholesterol - Part I. (2012).

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