Who Should Be on a Statin?

Updated July 2026

I started a company that makes food to help lower cholesterol, but I still prescribe statins because some people genuinely should be on them. The key is prescribing only when the indication is clear, and always alongside diet, since drugs alone are an incomplete solution. So who actually needs one?

Who should be on a statin?

Four groups, where the evidence is strong enough that the guidelines call for one:

• Known heart or vascular disease (prior heart attack, stroke, bypass surgery, stent, peripheral vascular disease).
• Diabetes, generally at age 40 and older.
• Familial hypercholesterolemia, genetically driven very high LDL, usually defined as an LDL at or above 190 mg/dL.
• A calculated 10-year risk of heart disease above the treatment threshold.

Why do the first two groups get a statin regardless of their LDL?

Because the benefit is about outcomes, not the number. In people with established heart disease or diabetes, statins consistently reduce heart attacks, strokes, and death regardless of starting LDL. We don't medicate to make a number look good, we medicate to change what happens to you. The LDL value is just a proxy for how much risk we're lowering, and not all of a statin's benefit even comes from lowering cholesterol. If you have established heart disease, I'll work hard to keep you on a statin for life. If you have type 2 diabetes, which can sometimes be reversed with lifestyle change, I leave the door open to stopping it if the diabetes resolves.

What if your only problem is a high LDL?

Then I don't reach for the prescription pad right away. An LDL at or above 190 is often at least partly genetic, but I've still seen big drops from diet alone. Just recently a patient took her LDL from 285 to 169 in a couple of months simply by changing how she ate. So when a high LDL is an isolated finding, I try a concerted lifestyle change for at least three months first, keep going as long as it's working, and only add a statin if we plateau above goal.

Should you be on a statin just because a risk calculator says so?

This is the category I'm least enthusiastic about. The calculator applies population data to individuals, leans heavily on age, and ignores family history. So a healthy 70-year-old woman with normal cholesterol and long-lived relatives can screen as a statin candidate, while a 45-year-old man with an LDL of 170, some extra weight, a recent smoking history, and a family full of early heart attacks does not. I always try to look at the whole person, go through every way to lower risk and not just cholesterol, and sometimes order a coronary calcium scan for a far more individualized picture.

Should everyone over 75 be on a statin?

Not automatically. A study of more than 300,000 veterans over 75 with healthy hearts found that those on statins had a 25% lower risk of dying from any cause, results that will push more doctors to prescribe more. But the study never checked whether eating better or exercising more would have done the same, and never reported side effects. Anyone with a history of heart attack, stent, bypass, stroke, or peripheral vascular disease should be on a statin regardless of age. For everyone else, age by itself isn't a reason to medicate without weighing diet, lifestyle, and individual risk.

The bottom line

Whether or not I prescribe a statin, I always emphasize food. Diet lowers cholesterol, independently reduces heart risk, and makes statins work better, so you need lower doses and face fewer side effects. A statin can be exactly the right call. It just should not be a reflex. For the full picture, see the guide to statins.

If you're new to this site and found this useful, I write one of these evidence-based articles every week. You can get them in your inbox by joining my email list at the bottom of this page. No spam, no requirement to buy anything, just practical knowledge.