EXPERT INSIGHT

In many parts of Asia, there’s a common belief that being slim or eating traditional foods offers natural protection against heart disease. However, as Dr Chan, Consultant Cardiologist, explains, this assumption can be misleading, and sometimes dangerous. Cholesterol-related risk frequently goes undetected not because people ignore their health, but because they appear healthy on the surface.

Being slim doesn’t always mean low risk

While maintaining a healthy weight is generally protective, it doesn’t guarantee cardiovascular safety, particularly among Asian populations. Many individuals fall into what clinicians describe as “skinny fat” category. They appear slim externally but carry a disproportional amount of visceral fat around internal organs. This hidden fat is metabolically harmful and is associated with insulin resistance, abnormal cholesterol levels, fatty liver disease and cardiometabolic syndrome, even when body mass index (BMI) is normal. In practical terms, a person can look healthy on the outside while carrying hidden cardiovascular risk on the inside.

Traditional Asian foods can support health, but they don’t guarantee protection

Traditional foods such as tempeh, natto, kimchi and other fermented products are often beneficial for gut health. They may help reduce inflammation and are linked to improved insulin sensitivity and lipid metabolism. However, many fermented foods are also high in salt, which can raise blood pressure when consumed in excess.

Cultural diets and body size can contribute to heart health, but they are not guarantees of protection. A proper assessment requires looking beyond appearance or food traditions, and instead evaluating cholesterol levels, blood sugar, blood pressure and visceral fat, even in individuals who appear slim and “healthy”.

Understanding good, bad and total cholesterol

LDL cholesterol is commonly referred to as “bad” cholesterol because it deposits cholesterol into the walls of blood vessels. Over time, this leads to plaque formation, arterial narrowing and increased risk of heart attack and stroke.

HDL cholesterol, often called “good” cholesterol, helps transport excess cholesterol away from the blood vessels and back to the liver. While higher HDL is generally favourable, it doesn’t negate the harm caused by elevated LDL.

Total cholesterol provides only a broad overview. It represents the combined amount of LDL cholesterol, HDL cholesterol and other cholesterol particles in the blood.

A person may have normal total cholesterol yet dangerously high LDL, or elevated total cholesterol largely driven by HDL.

For this reason, Dr Chan emphasises that meaningful cardiovascular risk assessment must look beyond a single number and instead consider individual cholesterol fractions alongside metabolic risk factors, particularly in Asian populations where outward appearance may be misleading.

EXPERT TIP

In many Asian diets, white rice and cooking oils are consumed daily. While these foods are culturally ingrained, how they’re chosen, prepared and balanced within the overall diet plays an important role in cholesterol and heart health.

Strong evidence supports a Mediterranean-style dietary pattern, which has consistently been associated with lower cardiovascular risk and improved longevity. Importantly, this doesn’t require abandoning Asian cuisine. Instead, it involves adjusting the foundation of daily eating, prioritising whole grains, vegetables, legumes, healthy fats and fish, while reducing refined carbohydrates and ultra-processed foods. The dietary pattern emphasises:

• whole grains instead of refined grains
• fruits, vegetables and legumes
• nuts and seeds
• olive oil as the primary cooking fat
• moderate intake of fish
• minimal processed foods and added sugars

In contrast, refined carbohydrates such as white rice, white bread and sugar-sweetened foods are rapidly absorbed. This leads to repeated blood sugar spikes, contributing to insulin resistance and chronic inflammation. Over time, this metabolic environment promotes:

• higher triglyceride levels
• lower HDL (good) cholesterol
• increased formation of small dense LDL particles, which are particularly harmful

These changes can increase cardiovascular risk even when body weight remains within a normal range.

Small, sustainable adjustments are often more effective than drastic dietary overhauls. Practical, culturally relevant swaps include:

• replacing white rice with brown rice, red rice, quinoa or mixed grains
• choosing olive oil or canola oil instead of repeatedly reheated or highly refined seed oils
• increasing intake of legumes, tofu, tempeh, vegetables and fatty fish such as salmon or mackerel

With consistent dietary changes, LDL cholesterol may begin to improve within four to six weeks, while triglyceride levels often respond earlier, sometimes within two to three weeks.

Dietary improvements are most effective when paired with regular movement. Physical activity supports cholesterol control by raising HDL cholesterol, lowering triglycerides, improving insulin sensitivity and reducing visceral fat.

Evidence-based recommendations include at least 150 minutes of moderate-intensity aerobic activity per week such as brisk walking, cycling or swimming, along with two days of resistance training using bodyweight exercises, resistance bands or weights.

Resistance training plays an important role in metabolic health. By increasing muscle mass, it helps improve insulin sensitivity, a key driver of abnormal cholesterol patterns in many Asian populations.

Together, these lifestyle changes can lead to measurable improvements within weeks, reinforcing that cholesterol control is shaped not only by medication or body weight, but by everyday dietary and activity choices sustained over time.

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In many parts of Asia, patients often rely on food cures, supplements or herbal remedies recommended by family members or found online. In clinical practice, this raises the question of which beliefs are harmless and which may unintentionally delay effective treatment.

These conversations require sensitivity. Cultural traditions and natural remedies are deeply rooted, but patient safety must remain central. Rather than dismissing these beliefs, the focus is on clarifying what is supported by evidence and where the limitations lie.

Myth 1:

Many patients report taking:

• fish oil or omega-3 supplements
• red yeast rice
• various herbal or plant-based products

The reality: Fish oil (omega-3) can help lower triglycerides, but it doesn’t meaningfully lower LDL cholesterol, which is the main driver of heart attacks and strokes.

Red yeast rice does lower cholesterol because it contains a statin-like compound. However:

• the dose is unpredictable
• quality control varies
• there’s no monitoring of liver or muscle safety

Many patients are surprised to learn that they’re effectively taking an unregulated statin.

Many herbal products lack robust evidence, standardisation or long-term safety data. Supplements may play a supporting role, but they’re not substitutes for proven therapies in people at moderate or high cardiovascular risk.

Myth 2:

This belief is common, particularly with products marketed as:

• “plant-based”
• “natural”
• “no cholesterol”

The key misconception is that dietary cholesterol is only part of the picture.

The body produces most of its cholesterol in the liver. Even when foods contain zero cholesterol, the liver can still produce cholesterol from:

• saturated fats
• trans fats
• excess refined carbohydrates

As a result, someone can eat a “plant-based” diet and still have high LDL cholesterol, especially when genetic risk is present.

Myth 3:

This belief often stems from fear of side effects, dependency or stigma around long-term medication use.

Cholesterol exposure is cumulative. The longer LDL remains elevated, the more plaque builds up in the arteries. Delaying treatment can make cholesterol harder to control later.

Early, effective treatment often allows for:

• lower doses
• fewer medications
• better long-term outcomes

Ironically, postponing therapy frequently results to more intensive treatment later.

Food choices and supplements can support heart health, but they can’t override genetics or replace therapies proven to prevent heart attacks and strokes. In modern cardiology, particularly in Asia, the goal isn’t to choose between tradition and science, but to use science to protect lives while respecting cultural beliefs.

EXPERT INSIGHT

According to Dr Chan, family history matters because it should trigger earlier, not later, action. While genetics and age are non-modifiable factors, cardiovascular risk itself isn’t.

When clinicians refer to family history of heart disease, they’re not describing a distant relative who experienced a heart attack in their 80s. A significant family history involves a first-degree relative such as a parent, sibling or child who developed cardiovascular disease early:

This distinction is important because early-onset cardiovascular disease often reflects inherited risk rather than lifestyle alone.

We can’t change the genes we’re born with or reverse ageing, but this doesn’t make heart disease inevitable. It means individuals with inherited risk must be more proactive about modifiable factors, particularly cholesterol.

Genetics can be viewed as the background terrain. While the slope of the hill can’t be altered, the speed of descent, and the decision to brake early, remain within our control. This is why individuals with strong family history often benefit from earlier cholesterol assessment and more proactive management, even when they feel entirely well.

Lowering cholesterol is where intervention has the greatest impact. LDL cholesterol plays a causal role in atherosclerosis, and decades of evidence show a clear relationship between LDL levels and cardiovascular risk. The lower the LDL cholesterol, the lower the risk, with no proven threshold at which benefit stops.

This relationship is especially relevant for people with strong family history. Lowering LDL cholesterol earlier in life can offset much of the excess risk associated with genetics, family history and age. While inherited risk cannot be erased, its impact can often be substantially reduced.

Early cholesterol screening alters the trajectory by providing time. Rather than identifying disease after a heart attack, screening allows risk to be detected years or even decades earlier, when blood vessels are still healthy and plaque burden is minimal or absent.

At this stage, lifestyle measures and lower-intensity therapy are often sufficient. The earlier abnormalities are identified, the easier they are to control, the less aggressive treatment tends to be, and the greater the long-term benefit.

Dr Chan notes that shifting public mindset toward prevention requires reframing cholesterol testing not as a response to illness, but as a baseline measure of cardiovascular health. For individuals with strong family history, early screening isn’t excessive caution. It’s one of the most effective ways to prevent disease before symptoms ever appear.

EXPERT INSIGHT

When patients are unable to tolerate statins or fail to reach their cholesterol targets with standard treatment, the next question is how clinicians decide whether newer options such as PCSK9 inhibitors are appropriate. This decision becomes even more nuanced in Asia, where cost and availability can influence access to advanced therapies.

Dr Chan explains that statins remain the first-line treatment for cholesterol management, and for good reason. They are highly effective, affordable, supported by decades of clinical evidence, generally well tolerated, and familiar to both doctors and patients. For the majority of individuals, statins alone are sufficient to reduce cardiovascular risk to a clinically significant degree.

However, not all cholesterol targets are the same. Some patients, particularly those who have already experienced a heart attack or stroke, require very low LDL cholesterol levels. In these high-risk groups, an LDL level considered acceptable for the general population may still leave significant residual risk.

In clinical practice, there are several situations where statins alone may fall short. Some individuals require LDL targets that can’t be achieved even with high-dose statin therapy. Others have familial hypercholesterolaemia, a genetic condition in which LDL cholesterol remains elevated despite optimal medication and lifestyle measures. A smaller proportion develop statin intolerance or side effects, including significant muscle symptoms or liver enzyme abnormalities that limit long-term use.

These are the scenarios in which additional or alternative therapies are considered.

PCSK9 inhibitors typically come into play when statins aren’t tolerated, LDL cholesterol targets are not achieved despite maximal standard therapy, or cardiovascular risk is sufficiently high that further LDL lowering is clearly beneficial. These medications work through a different biological pathway from statins and can reduce LDL cholesterol substantially, often by 50 to 60 percent on top of existing treatment. Importantly, they allow clinicians to reach LDL levels that were previously very difficult, and sometimes impossible, to achieve safely.

Decisions around newer cholesterol-lowering therapies should never follow a one-size-fits-all approach. Cardiovascular risk level, expected benefit, affordability and patient preference must all be considered together.

Cost remains a legitimate concern, particularly in Asian healthcare systems. That said, access has improved over time. Prices of PCSK9 inhibitors have fallen since their initial introduction, and in settings such as Singapore, assistance schemes and funding pathways are available to support eligible patients.

Patients are therefore advised not to self-exclude based on assumptions about cost alone. If advanced therapy may offer benefit, a conversation with a healthcare professional can help clarify available options and support schemes.

Dr Chan emphasises that treatment decisions should never be driven by fear, whether fear of medication, cost, or long-term commitment. The role of the clinician is to help patients understand their individual risk, clarify realistic targets, and choose therapies that balance effectiveness, safety and practicality over the long term.

Ultimately, the aim isn’t simply to escalate treatment, but to ensure cholesterol lowering is matched to an individual’s long-term cardiovascular risk, using the safest and most appropriate tools available.