An article written by Dr Edward Leatham, Consultant Cardiologist

The views and opinions expressed in this article are my own and do not necessarily represent consensus, the article is for information only as is not designed to replace or substitute a formal medical opinion.

Tags: Cholesterol, Coronary heart disease, LDL

Who Is This Article For?

This article is written with two key audiences in mind:

• Health-conscious individuals aged 20–30 who want to make informed choices about long-term heart health.
• Parents and caregivers with a personal or family history of heart disease looking to protect the next generation.

If you’re in your 20s, you probably don’t spend much time thinking about heart disease. Career goals, relationships, and enjoying life often take priority. But just like investing early for a pension, the decisions you make now can yield major health dividends later.

Why Young Adults Should Care About Heart Health

You are not too young

Young adults are not immune to cardiovascular conditions. Rare inherited cardiac disorders such as Brugada syndrome, long QT syndrome, and various cardiomyopathies can affect people in their teens and twenties, sometimes leading to sudden cardiac death. More common than these rare syndromes is familial hypercholesterolaemia (FH), a genetic disorder that affects roughly 1 in 250 people. Individuals with FH have elevated LDL cholesterol levels from birth. If untreated, men with FH face a 50% chance of a heart attack by age 50. Yet, fewer than 10% of affected individuals are diagnosed.

When is a Cholesterol test Worth considering?

• If you have a family history of premature heart disease (before 60).
• If you notice physical signs such as tendon xanthomas (lumps over tendons) or arcus cornealis (a white ring around the iris) under the age of 40.
• If you have never had a cholesterol test—it’s simple, inexpensive, and potentially life-saving.

For the majority, it’s also worth knowing about the Early Origins of Heart Disease

Even for the majority who don’t have a rare condition or FH, heart disease doesn’t just appear out of nowhere in middle age—it starts early. Fatty streaks in coronary arteries have been observed during post-mortems of young people who died in road accidents.

Emerging evidence shows that lifetime exposure to LDL cholesterol and high glucose variability are some of the strongest predictors of cardiovascular risk. Just as lung cancer risk is tied to pack-years of smoking, heart disease risk correlates with cumulative LDL levels and impaired glucose metrics  over time.

This is why some people in their 20s with risk factors (like diabetes or a family history of heart disease) are starting statin therapy preventatively. However, many are understandably hesitant to start medication so early. Lifestyle changes remain the cornerstone of early prevention.

The Impact of Family History

If you have a first-degree relative (parent or sibling) who had heart disease before 60, your own risk is significantly elevated even if you don’t have FH. But even second-degree relatives (grandparents, aunts, uncles) provide valuable genetic clues.

Genetics vs Lifestyle

Around 50% of cardiovascular risk is genetic. But the other 50%? That’s in your control.

The formula is simple:
Genetics + Lifestyle = Overall Risk.

When to Take Family History Seriously

Tests and metrics to consider in your 20s

Even if you feel healthy, these tests can provide useful insight:

• 12-lead ECG – screens for inherited arrhythmias
• Lipid profile – checks total, LDL, HDL cholesterol, and triglycerides
• Lp(a) – evaluates genetic cholesterol risk
• HbA1c / CarbR test – assesses diabetes and glucose variability
• Waist-to-height ratio – central obesity marker; if it exceeds 0.5, it needs work!

If your LDL cholesterol exceeds 4.9 mmol/L (190 mg/dL), or your total cholesterol exceeds 7.5 mmol/L (290 mg/dL) and you have a history of heart disease in your family, you should see your GP as you may have familial hypercholesterolaemia, where high levels from birth considerably elevate your risk.

For the majority of adults aged 20-30, who do not have FH, a healthy LDL cholesterol level is generally considered to be below 2.58 mmol/L  (100 mg/dL). This is considered the “optimal” level. Levels between 2.58 – 3.3 mmol/L (100 and 129 mg/dL) are considered “near optimal,” while 3.3-4.1 mmol/L (130 to 159 mg/dL) are considered “borderline high”.

In fact there is emerging evidence that the lower the LDL cholesterol and the earlier you can achieve, the lower the future risk: if you are at higher future risk, the evidence is very clear, so why wait?

Lifestyle Foundations for Heart Health

1. Avoid Smoking

Whether you smoke regularly or socially, the advice is simple: stop. There’s no safe level of tobacco exposure for the heart.

2. Know your key health metrics

Be aware of your cholesterol, LDL cholesterol, BMI and height to waist ratio as these are simple, easy to measure metrics that can determine your future health. Dig a little deeper  with a continuous glucose monitor (CGM) or a CarbR test and you will discover that plenty of 20-30 year olds, despite having a normal HbA1C test, have glucose spikes outside the health range in response to high glycaemic foods.

Once you have seen this for yourself, on yourself,  you can identify how your body responds to different foods and you should feel empowered to engage in diet and lifestyle changes that will improve both your short term and long term health.

3. Improving Your Diet

• Cut down on saturated fats by choosing lean meats, less red more white meats and fish.
• Opt for low-glycaemic index foods such as oats, brown rice, legumes, and vegetables.
• Replace cooking in beef, bacon and other animal fats with unsaturated fats like olive or rapeseed oil.
• Limit processed snacks and other high glycaemic foods
• Add plant sterols to your diet—these natural compounds can help lower cholesterol.

Highly processed, high-glycaemic carbs are increasingly linked to metabolic stress, obesity, and type 2 diabetes. There is a strong genetic and racial predisposition explaining why people of South Indian, Middle Eastern, and Hispanic descent are especially predisposed to carbohydrate sensitivity that can lead to diabetes and weight issues in midlife.

4. Physical Activity

Aim for 60 minutes daily of moderate-to-vigorous activity or 10,000 steps or more. Move more, sit less. If you have no time for formal exercise, build physical activity into your week. Organise your commute into work around a brisk walk, make a habit of using the stairs instead of the elevator or escalator.

5. Sleep and Stress

Chronic stress and poor sleep disrupt hormonal balance, increasing heart risk. Try:

• Mindfulness and breathing exercises
• Consistent sleep schedule

Smarter Eating for Cardiovascular Health

Avoid:

• Sugary cereals, syrups and fruit juice for breakfast
• White bread, pancakes, pastries
• Fast food and snacks high in saturated fats
• Unhealthy snacking between meals

Choose:

• Eggs, Greek yoghurt, or oats with seeds
• Whole fruits (not juice)
• Healthy fats: nuts, seeds, oily fish, avocados
• If you feel hungry between meals, drink more water switch to healthy snacks olives and nuts.

Try:

• The Harvard Healthy Eating Plate where a rule of thirds for each food group is advised.
• CGM-based food testing to understand your glycaemic responses. Many non diabetics are astounded by the effects of a standard pre made sandwich or packet of crisps has on their own blood glucose,  a great way to inspire healthier lunchtime choices.
• Pre-meal vegetables to reduce glucose spikes

Intermittent Fasting: Evolution-Inspired Eating

Our ancestors ate during periods of feast and famine. Constant grazing in modern life leads to fat storage and metabolic overload.

Intermittent fasting, or simply spacing out meals and avoiding late-night snacking, can be beneficial—especially for those with a family history of metabolic disease.

Making Your Environment Heart-Smart

At Home:

• Cook fresh meals using unprocessed ingredients
• Store healthy snacks in visible places
• If you have a family history of raised blood pressure,  adopt low salt habits for example replace salt with herbs and spices
• Drink water or herbal teas instead of sugary drinks

At Work/University:

• Advocate for healthy meal options and strategies that encourage engagement in physical activity and exercise, for example start an initiative to get people to use stairs instead of the elevator to get to the floor 1-3 at work.
• Support initiatives that limit junk food marketing, and foster healthier food outlets.

Take-Home Summary

Final Thoughts

The path to cardiovascular disease starts earlier than many realise. For young adults and families affected by heart disease, early action can save lives.

This isn’t just about adding years to your life—but adding life to your years.

Let’s create a generation where heart disease is the exception, not the rule.

Resources for Further Reading

1. Cardiovascular Prevention: Why Waiting Until 60 Is Too Late
2. Test your health at home (and CarbR test)
3. https://www.nhs.uk/health-assessment-tools/calculate-your-waist-to-height-ratio
4. LDL: the lower the better

5. How Low Can You Go? New Evidence Supports No Lower Bound to Low-Density Lipoprotein Cholesterol Level in Secondary Prevention 2023

6. Cholesterol measuring 2024 guidance 
7. Gain of function mutations in PCSK9 regulators
8. The latest ESC and locally developed guidelines on LDL targets
9. My glucose spikes: so what?
10. The Harvard healthy eating plate
11. Familial Hypercholesterolaemia NHSE

For related stories, search the site using the tags: Cholesterol, Coronary heart disease, LDL.

The Naked Heart is an educational project owned and operated by Dr Edward Leatham. It comprises a series of blog articles, videos and reels distributed on Tiktok, Youtube and Instagram  aimed to help educate both patients and healthcare professionals about cardiology related issues.

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