Hypercholesterolemia is a condition where there is an abnormally high level of cholesterol in the blood. It is the major modifiable risk factor for cardiovascular death worldwide, and it remains the leading cause of mortality despite advances in treatment and prevention.
In this interview, we speak with Dr. Peter Lansberg, an internationally recognized expert in lipidology and founder of The Dutch National Lipid Clinic Network, the Dutch Lipid Clinic Criteria for Familial Hypercholesterolemia (FH), and a very successful Dutch National FH screening program. He shared insights on the persistent underestimation of hypercholesterolemia and the critical role of early intervention. Dr. Peter shares his perspective on why prevention still struggles to take center stage, why cholesterol kills silently, the role of patient education and trust, and how early, targeted intervention, especially in managing cholesterol, can change the course of patient health.
Mr. Peter, your scientific and clinical work spans decades, focusing not only on the treatment of familial hypercholesterolemia but also on disease prevention, including through screening. Do you think prevention requires more education or medicine?
If we truly want to make a difference in prevention, broad-based education is essential. First of all, doctors, especially family physicians, must recognize and emphasize the importance of prevention. Second, patients themselves often underestimate or ignore its value. When we talk about prevention, we’re referring to critical lifestyle factors such as diet, smoking, and alcohol consumption, all of which pose significant challenges. Addressing these issues cannot be the sole responsibility of healthcare professionals. Support is needed at higher levels, including from ministries of health and government institutions. A stronger, system-wide focus on prevention is crucial.
Today, hypercholesterolemia remains the primary “silent killer” worldwide. Why does it stay so unnoticed?
One major issue is the consistent underrecognition of high cholesterol as a modifiable risk factor for cardiovascular disease. Alongside hypertension and diabetes, elevated LDL cholesterol remains a top contributor to mortality. Unlike high blood pressure or diabetes, where treatment starts once thresholds are exceeded, cholesterol is often overlooked unless levels are very high.
A widespread misconception is that 200 mg/dL of total cholesterol is “normal.” In reality, this is just the population average, not a biologically safe level. Atherosclerosis can begin at much lower LDL levels. In fact, the optimal range for LDL cholesterol might be between 50 and 70 mg/dL.
Patients often resist treatment when their cholesterol is below 200 mg/dL because they assume it’s normal. But “normal” doesn’t mean healthy. This misunderstanding delays treatment and allows irreversible damage to occur. The key is to start managing cholesterol early, before disease develops, using safe, affordable medications.
Cholesterol is the root cause of atherosclerosis, which then increases the risk of other conditions like hypertension and diabetes. Prevention should start early, just like brushing your teeth before decay begins. Waiting until symptoms appear is too late. A shift in thinking is needed among both doctors and patients to focus on early intervention.
Self-medication, unregulated diets, and discontinuation of medications are very common in Georgia. How should we explain to a patient that high cholesterol requires treatment, even when there are no symptoms?
The main issue is a lack of trust. Decades ago, patients followed doctors’ advice without question. Today, social media spreads convincing misinformation, creating confusion and doubt. That’s why education by doctors, healthcare workers, and the government is essential. Trust can not be built with a single conversation. It takes time, repetition, openness, and a non-judgmental approach.
Patients often agree in the clinic but ignore advice later. We need to acknowledge this and adjust our communication accordingly. For example, when I prescribe statins, I say: “If you feel mild muscle aches, don’t worry, it can be a sign the medication is working.” This helps patients feel informed, reduces surprise, and improves adherence. Building trust means preparing patients, listening to them, and guiding them with clarity and empathy.
We often hear the question “What is better: diet or medication?” What is your position? And how should we approach a patient who trusts only natural methods?
If someone wants only natural solutions, they must also fully commit to a natural lifestyle: living in nature, cooking on firewood, walking everywhere. I once read about a man who did just that: obese, with high blood pressure, cholesterol, and diabetes, he went to live in the mountains. After three months of walking and eating simple food, his health improved dramatically. But this isn’t realistic for most people. We live in a modern world with electricity, cars, heating, and air conditioning, none of which are “natural.” Just as we accept these conveniences, we should also acknowledge that modern medicine offers tools, such as medications, that help us maintain our health in this environment. For example, fluoride in toothpaste prevents tooth decay, something natural methods can’t do as effectively. These ideas may seem obvious to doctors, but not to every patient. That’s why trust is essential. When patients trust us, they’re more open to guidance, even if it challenges their beliefs. Trust is the foundation for change.
The discussion about statins has been ongoing for years. How do you view the safety of statins, and what would you say to a skeptical patient?
Statins are among the most well-studied and widely used medications, with over 300 million users worldwide and nearly 40 years of clinical experience. Like any drug or even common substances like peanut butter or water, they can have side effects, but serious ones are scarce. The most common issue is mild muscle pain, which usually improves over time. Continuing statins despite minor symptoms often leads to full resolution within a year. Concerns about statins causing diabetes are exaggerated. While they may slightly accelerate its onset in predisposed individuals, many other common drugs do the same. Importantly, statins significantly reduce cardiovascular risk, especially in patients with diabetes or metabolic syndrome. Liver enzyme changes are generally temporary and not a sign of actual liver damage. Statins are even used safely in many patients with liver disease. Actual liver injury from statins is infrequent, around one in a million cases. Overall, statins are very safe. They are one of the safest drugs in our whole Armentarium, and the benefits far outweigh the harms of the statins.
New generation drugs (PCSK9 inhibitors, inclisiran, etc.) are already being used in high-risk patients. What does this change in practice?
These drugs are very effective, but their biggest challenge is cost. While they show good early safety data, we don’t have the long-term experience we have with statins, which are affordable and well-studied over decades. Pharmaceutical companies heavily promote new drugs, often funding the studies behind them. This can create pressure and confusion for doctors. If we prescribed PCSK9 inhibitors to everyone who qualifies, the system would become financially unsustainable. That’s why these new drugs should be reserved for patients who genuinely need them, those with very high cholesterol or who can’t tolerate standard treatments. For them, these therapies can be life-changing.
In managing hyperlipidemia, how effective are lifestyle changes, and how frequently do they need to be complemented by pharmacological treatment?
Lifestyle and tailored treatment both play critical roles in managing cardiovascular risk in hyperlipidemia. Lifestyle is foundational; healthy eating, regular physical activity, and maintaining a healthy weight are essential for preventing cardiovascular disease. In cases where someone has a poor diet (e.g., high in saturated fats or fast food), improving lifestyle can lead to significant improvements in cholesterol and other risk factors. However, for many patients, lifestyle alone isn’t enough to manage lipid levels. That’s where tailored treatment comes in. Standard therapies, such as statins and ezetimibe, are effective, safe, widely available, and supported by strong clinical trial data. For high-risk patients, such as those with familial hypercholesterolemia or recurrent cardiovascular events, newer treatments like PCSK9 inhibitors or ANGPTL3 inhibitors can be used. PCSK9 inhibitors, in particular, may even be used temporarly: such as after an acute coronary event to reduce LDL and stabilize vulnerable plaques aggressively. This short-term intensive approach can be cost-effective when followed by maintenance therapy with standard medications to keep LDL below 70 mg/dL or even closer to 50 mg/dL, which is now achievable with current, affordable treatments.
You work on familial hypercholesterolemia (FH), a disease that is often diagnosed late. How should we recognize it in everyday practice? And at what age should we start screening?
In the Netherlands, FH became our fifth national screening program. We used genetic testing and a method called cascade screening, starting with an “index” patient confirmed by DNA, then testing close relatives. Since FH is inherited (50% chance), this approach is both practical and cost-efficient. Countries like Slovenia and parts of the UK now include cholesterol checks in childhood vaccination programs, helping identify FH early. If a child has very high cholesterol, there’s a 90% chance it’s FH. A DNA test confirms it, and then the family is screened in both directions. To manage FH properly, we need: Clinical and genetic diagnosis of the index case, Cascade screening in families, and a national registry to track cases and outcomes.
This may be too complex for low-resource countries, but specialized lipid clinics are emerging worldwide. These centers allow proper diagnosis and treatment, especially for FH patients who qualify for drugs like PCSK9 inhibitors. Governments may not support the broad use of expensive medications, but are more open to allowing specialist-prescribed treatment. For every FH patient diagnosed, up to nine family members may also have it. So, it’s not just about treating one person, it’s about identifying and protecting the whole family.
What is your recommendation for a country where genetic testing is not available to everyone? Can we still do effective screening?
Yes, screening is still possible, but it’s harder without DNA testing. That’s why we strongly promoted genetic confirmation in our program. Without it, diagnosis can be uncertain, especially when cholesterol levels are borderline, like around 200 mg/dL. Patients may feel anxious without clear answers. With genetic testing, the diagnosis is precise: you either have the mutation or do not. This also helps guide cascade screening, since the same mutation typically runs in the family. That clarity makes the process much more effective for both patients and doctors.
The Netherlands was one of the first to introduce national FH screening. How do you think small countries should develop a strategy that prioritizes prevention over treatment?
One effective long-term strategy is seen in Japan, where every elementary school has a dietitian who helps prepare traditional, healthy meals. Children are involved in food preparation and educated about healthy lifestyles from a young age, which builds lifelong habits — similar to how early brand attachment works in marketing. This model could offer a high return on investment in public health.
In terms of screening, Slovenia has implemented universal cholesterol testing for children aged 3–5 during routine vaccinations. If high cholesterol is found, family members are tested too, as part of a practical cascade screening for familial hypercholesterolemia. Another strong example comes from Croatia, where a physician-led outreach program screens people in small villages for blood pressure and lipids, supported by students and public awareness campaigns. These low-cost efforts significantly raise cardiovascular risk awareness and engage local healthcare providers to replicate similar initiatives.
What would you say to a young doctor who sees metabolic problems in patients but doesn’t know where to start? Diet or something else? Medication?
First, gain knowledge, attend conferences, read reviews, and follow reliable sources of updated clinical information. For example, regular newsletters on cholesterol and cardiovascular risk can keep you informed about key issues such as diabetes, hypertension, and lipid management. Next, recognize how common these conditions are in many countries; over 50% of the population has diabetes, metabolic syndrome, or is at risk. Assess key risk factors in your patients, then focus on patient education by explaining the importance of lifestyle and the value of medications. Structured group education programs, such as those involving multidisciplinary teams, can significantly enhance patient understanding, motivation, and long-term adherence.
What does “good doctor/professor” mean to you in 2025?
First, they must truly love what they do and be empathetic toward patients. Second, they need to stay up to date. Medicine evolves quickly, and learning never stops. Third, they should work in a supportive environment that allows them to provide accessible, consistent care.
Trust is key, and it’s built over time. Just like in friendships, consistency and genuine connection are what make a doctor truly trustworthy.
