What Does My Cholesterol Level Mean?
Depending on how you look at it, cholesterol can be an incredibly simple topic, or an incredibly confusing one. Contemporary medicine teaches that cholesterol is “bad” and should be low. That seems pretty simple, right? Get it tested, if it’s high start a drug to lower it.
Times have changed. Now, cholesterol is much more complex, and we all need to be armed with knowledge before we sit down with our doctors to evaluate our cholesterol levels.
Here is my guide to you and your doctor for evaluating your cholesterol.
1. Understand the difference between Total Cholesterol (TC) and high density lipoprotein (HDL) and low density lipoprotein (LDL)
If you doctor is referring to your total cholesterol (TC) and is making decision based on your TC— Run, don’t walk. Run away and find another doctor. TC is comprised of low density lipoprotein (LDL), so-called “bad cholesterol” even though it isn’t bad. High density lipoprotein (HDL), so-called "good cholesterol", and remnant cholesterol (VLDL and IDL). Initial studies in the 1960s and 70s looked at TC and risk of cardiovascular disease (CVD) and found a weak association. That was prior to when scientists learned how to measure LDL and HDL.
Studies then looked at the individual lipoproteins (i.e. LDL and HDL) and found the higher the LDL, in general, the higher the risk for CVD. And the higher the HDL< the lower the risk of CVD. So, while talking about TC was cutting edge in the 60s and 70s, it is woefully outdated today. That is why if your doctor is still evaluating and treating TC—Run!
2. Does Your Doctor Know Your TC to HDL and TG to HDL Ratios?
If your doctor does not know your ratios, this is another reason to run away and find another doctor (We are doing lots of running here, bonus exercise!) Studies in the early 2000s and more recently have shown that total cholesterol to HDL ratio (TC:HDL) and triglyceride to HDL ratio (TG:HDL) are BETTER predictors of cardiovascular risk than isolated LDL, TC or HDL.
By incorporating TG and HDL into the analysis, these ratios incorporate the impact of remnant cholesterol and track with insulin resistance, both strong predictors of CVD. These ratios are calculated from a standard lipid profile, so they do not require any special testing or special labs. They are widely available for everyone to see. So if your doctor is not using them to evaluate your lipids, it's time to find a new one.
3. Understanding a Familial hypercholesterolemia (FH) diagnosis
Familial hypercholesterolemia (FH) is a diagnosis that requires (wait for it…) a family history! As the name suggests, it is an inherited condition passed from generation to generation. All too often, doctors will see an LDL level over 190 and make the diagnosis of FH. If your doctor makes that diagnosis that based on level alone without a family history, run!
There is a well-accepted scoring system, The Simon Broome Criteria, to help determine if someone has FH. This equation factors in age of diagnosis, absolute level of LDL, in addition to family history of early onset hyperlipidemia or early onset heart disease. It makes a big difference if you have FH or not. Don’t let your doctor label you as having FH without applying the full criteria. Just wait for the look on their face when you respond, “What was my Broome score? Did it confirm I have FH?” and hope you don't hear crickets.
4. What is Advance Lipid Testing?
Advance lipid testing may be helpful. And it may not. Advanced lipid testing can tell us the size, density, and inflammatory characteristics of our lipoproteins. This can help further risk stratify the potential danger of our lipids. For instance, small, dense LDL tend to correlate more strongly with CVD, whereas so-called pattern A LDL (the larger, less dense version) does not correlate as well.
Here is the interesting part. Those with high TG and low HDL almost uniformly have small dense LDL and increased inflammation. Conversely, those with low TGs and high HDL have Pattern A, larger less dense LDL. Are you starting to see a pattern? Low TG and high HDL=good. High TG and low HDL=bad.
Sometimes, however, there can be variation in this equation. Therefore, I usually suggest people get advanced lipid testing one time to see if their results correlate. If they do, then you can just follow your ratios to predict your advanced results. Why not get them all the time? They are frequently not covered by insurance and can be expensive.
5. Interpret your lipids in context
Lipids don’t exist in a vacuum. They exist in your body, so it's important to take into account what else is going on in your body. Insulin resistance and inflammation can directly affect your lipids and increase your risk in general. Hypertension, obesity, and family history of heart disease also play crucial roles in determining your risk.
Therefore, if your doctor checks only your lipids and bases decision on those labs alone—Run! Instead, you should get a hsCRP, Hgb A1c, fasting glucose, insulin and HOMA-IR, BP measurement, family history assessment, and complete history. This is the context in which your lipids should be evaluated. Not alone in a vacuum.
6. Why test a risk factor that may be related to CVD risk when you can test the disease itself?
Good question, right? To truly know what your lipids mean to you, you also need to know if you have evidence of CVD. Coronary artery calcium scores and Carotid Intima Media Thickness (CIMT) are two easy, relatively inexpensive tests, that you can get to show you whether or not you have current evidence of CVD. The presence or absence of disease significantly impacts the risk of lipid levels.
So, What Does Your Cholesterol mean to You? It depends.
It depends on many factors, and only by evaluating ALL of those factors can you truly know what impact your lipids may be having on our health. Anything short of this evaluation is an inadequate and antiquated approach to lipids.
Now you are forewarned and forearmed, and you can walk into your doctor’s office ready to ask the important questions and help guide the workup so that you can know what your cholesterol means to you.
Thanks for reading, and as always, please let us know If you have any comments or questions.
Bret Scher MD FACC
Founder, Boundless Health
31 thoughts on “What Does My Cholesterol Level Mean?”
So what if I have low TG (105) and low HDL (34)? I’m 46 yo male generally healthy.
Hi Mike. Thank you for your comment. While I cannot comment specifically on your situation,I can tell you the most common reasons for low HDL are genetics, not enough exercise, not enough fat in the diet, and some medications We cant change our genetics, but we can alter gene expression to a degree. So I could suggest that you take a look at your exercise program, your nutrition, and evaluate any drugs that you are on with your physician. Also, remember, to take everything in context and evaluate the whole picture, not just isolated labe values. I hope that helps!
Dear Dr. Scher, I have a patient (34 years old) with those exact numbers who eats LCHF, works out 3 or 4 times a week, sleeps well, but I can't get his HDL to go up, and his TG are always around 100. His ApoB/ApoA is also over 0.60 (around 0.8-1.0) but everything else is in order, low RCP, Hba1C, low Insuline, he´s not taking any medication, only supplements like Omega 3, Antioxidants, probiotics. In this case, should I just stay with the genetics theory and keep taking care of the environment? Can I not get alarmed over his APoB/ApoA ratio? Greetings from Chile
Hi Paulina. I am sure you understand that I can’t give you specific advice on your patient. I can say, however, that HDL can certainly be hard to naturally elevate in some individuals, and there is likely a genetic component to that. As for TGs, alcohol, coffee and sneaky carbs (sweeteners, sugar alcohols, keto treats) can affect some where as they have no effect on others. I usually try to eliminate all of those in some circumstances. I hope that helps!
Dear doc…following keto diet …not completely…my name isAntonella Micheli age 54 height 1.60 cm weight 41 ,workout a lot…do some intermittent fasting 15 hours…suffer from ulcerative colitis feeling better tummy wise…went gor blood test doctor scared me…cholesterol total…346 HDL92 LDL 241 Triclicerides70… must i worry…they suggest statin…can they get worse?….thank you
Thank you for your detailed comment! Unfortunately, Dr. Scher is unable to give medical advice on his blog. If you would like a more detailed evaluation and answer to your questions, you could always consider an individualized consult. We wish you the best and hope to hear from you soon.
Lower your carb intake and most important your Fructose intake. Fructose is metabolized on the liver as triglycerides. Lower the intake of too much sugar, also excese glucose (more than the cell can absorbs) eventually will be metabolized as fat (triglycerides) too.
Thanks for your comment Albert. Good point that sugar reduction is absolutely crucial. Eating too much fructose, especially in the presence of excessive glucose, is horribly damaging and directly leads to fatty liver disease. Yet that seems to be the most common go-to diet in the SAD. Thanks again for you rcomment.
What are the proper ratios of TC/HDL and HDL/LDL
Hi Paula. In general, we like to see TC/HDL <4 with <3 being outstanding. TG/HDL <2 with lower better as long as HDL is >50. Of course there are always factors that can impact these numbers (medications, other medical conditions, energy demands etc) so these are general targets that may differ for individuals. Hope that helps!
I think that once your TRI/HDL ratio is over 1.5, you are likely insulin resistant. I think it is time to lower this ratio as my dear friend was recently diagnosed as pre-diabetic and their TRI/HDL ratio is 1.5. This is not the first time I have seen this. I think by the time you get to 2.0, you are well on your way to type 2 diabetes.
Good points. TG:HDL ratio does track very well with insulin resistance. Definitely someting “we” doctors need to focus on more. Thanks for sharing!
Great overview. Assuming it's readily available, would you also recommend everyone have a CAC scan done to head off any potential immediate red flags? It would seem that for the minimal cost of a scan, the net benefits could be huge.
Thanks for your comment Tim. I am a big fan of cornary calcium scores. They have relatively low radiation exposure, are readily available, and not too epensive. Plus, they can show an actual burden of disease, not just a surrogate blood marker, and help fine tune one’s cardiovascular risk. But here’s the down side, they are difficult to follow closely, and wont show regression. In addition, we know drugs like statins increase coronary calcium scores, but don’t know if that’s a good thing or a bad thing. So for an initial diagnosis, I love it. To follow every 5-10 years, its great. However, I also usually recommend people get a Carotid Intima Media Thickness (CIMT) test. Although the risk data is not as robust as for CAC, it has zero radiation, and it is much easier to follow over short timeframes, over the course of just a few months. Plus it can show regression in addition to progression. That makes CIMT much more valuable for serial measurements compared to CAC. A combination of the two of them tends to be th emost powerful risk predictors. I hope that helps!
My cholesterol level was 9.4. I didn't do the whole test and only had that reading. I went for a carotid Doppler test and this showed a 60% occlusion on the left side. I'm on statins now as my brother had a stroke and it seems my siblings all have high cholesterol. Should I have done something different?
Hi Carol. It’s so hard to give medical advice based on limited data. I can tell you in general that a total cholesterol level is inadequate to make informed clinical decisions, and I always recommend a full lipid profile. Also, the decision to go on a statin or not is highly individualized. I make it my goal to work with individuals to find what is right for them and not to provide knee jerk recomendations based on general guidelines. Please make sure your doctors are listenting to you, they understand your goals and concerns, and they treat you like an individual.
Hi Brett, these are my stats: TC 233; TG 51; HDL 50; Calculated LDL 173; VLDL 10.
Ratio of TC/HDL = 4.6 (I guess this indicates the need for increased HDL)
Ratio of TG/HDL = <1
Glucose was 93
Due to the LDL needing to be <130. The medical provider suggested statins which I did not agree to. I was eating two eggs a day at the time and now have 4-6 a week and other animal fat (bacon / sausage) as well as fish for breakfast. I have also reduced my carbs/sugar intake. I am fairly trim BMI 23.5 and exercise daily with high intensity. I think that according to your page I should be increasing my HDL. If TC/HDL and TG/HDL are the main signals how do we read LDL's, since mine is 'high'. What diet is going to drop LDL and increase HDL?
Hi Jeremy. Thank you for your message. I cannot comment specifically on your case without a more formal evaluation and full consult. But I can say that in general, the best ways to naturally raise HDL are regular exercise, eating more fat and eating fewer carbs. There are supplements such as omega 3 fatty acids that can be helpful, and niacin raises the number but its unclear if it increases the function- and that is the key. We all want more higher functioning HDLs, not just total number. I hope that helps. Bret
I agree with you blog on all the points raised. I absolutely concur with getting fructose down to mitigate the rise of TG. By doing this my TG were 1.08 last time I checked. Following a minor heart event requiring a single stent 18 months ago I had been buried in Statins – 80 mg of Atorvastatin. Came off 4 months later having opted for a better diet in reducing TG and upping HDL. Not quite sure what the best way to safely? up HDL is.I see many using Coconut Oil but in this I am quite skeptical as it may cause further Cardio issues down the line. An Oxford University biochemist who lived out in the East reported that the indigenous folk don't touch Coconut Oil with a barge pole!! Any safe Cardio methods of upping HDL will be most appreciated. Thank you.
Hi Paul. Thank you for your message. Of course, I can’t say for certain what the right thing for you is as I would need much more information. In general, the best ways to naturally raise HDL (and more importantly, have better functioning HDL- it’s not all about the number) are regular exercise, eating more fat and less carbs. There is no magic and no secret. Almost every single drug and supplement trial has shown no benefit to artifically raising HDL, but naturally raising it likely does confer benefit. I hope that helped! If you want to get more into you rpersonal detail, you can always sign up for a consult with me here https://lowcarbcardiologist.com/about-dr-bret/consult-with-dr-scher/
Thanks again for you rmessage! Bret
Well, I lost 2 stone on a liberal carb (c.130 g) and low sugar (c.36g) diet. Having Conns Syndrome does play a part in having to deal with Metabolic Syndrome. The right diet and a good exercise regime has been crucial to my goals with the caveat that diet has to be low Na and high K. Oh what a web we weave!!
Thanks for taking the trouble to reply.
Paul- Your response brings up possibly the most important point of all. We are all individuals, and we all have our own unqiue circumstances. What works for one may not work for another. Thus the need to find our own personalized path. You are a perfect example. Thanks for sharing!
Hello Dr.Scher, I really enjoyed this article. I've been on a keto diet, lost 70 lbs, my LDL is 168 and hdl is 40, my calcium score test number is 1, and my particle size test was A pattern. My doctor agreed with me to not get on statins but is concerned about the ldl ,what do you recommend, please advise thank you.
Hi Juan. I wish I could give you a simple answer, but the decision to take stains or not is a complicated decision that involves far more than just your lipid evaluation. Hopefully your doc is looking at your overall health picture, your goals, your wishes and your concerns, and then coming up with a deision. Th etrap so many docs fall in to is LDL=X therefore statin is indicated or not indicated. That is far too simplistic when our concern is overall health, not just pretty lab values.
Really interesting read, thanks. Topic close to my heart (no pun intended) as my dad died of ischaemic heart disease in his late 40’s. I’m now 45. I excercise regularly (running) and weight is generally just over ideal BMI.
Based on results below, should I make any changes to lifestyle / diet (I do like my eggs…2 a day).
Serum cholesterol 5.5 mmol/L
Serum triglycerides 1.13 mmol/L
Serum HDL cholesterol level 1.4 mmol/L
Serum LDL cholesterol level 3.59 mmol/L
Serum cholesterol/HDL ratio 3.93
Se non HDL cholesterol level 4.1 mmol/L
Hi Tom. Unfortunately I can’t make specific suggestions without knowing much more about your history and your lifestyle. I can say in general that I am far more focused on TG:HDL ratio, TC:HDL ratio and LDL particle size and inflammation than I am about someone’s absolute LDL level. But lipids are just one piece of the puzzle and have to be interpreted in context of a thorough health evaluation. Hopeflly your doctor can see the whole picture and work with you to find the right path
Thanks for coming back to me. I’ve since read your book and adjusted diet to Mediterranean. Made a lot of sense!
4 months ago I have started LCHF diet with intermitent fasting 3 times a week 36 hours each. I have T2D, and I was doing great in terms of blood glucose, but when I got my blood work results after 3 months my Tryglicerides were 650! I had never had more than 350 in my life, and that was really scary.
I cut all the saturated fat urgently, but now it turnes out that what was supposed to be the major part of my diet became a no-no. Any adivice? Had anybody have the same experience? Thank you!
Hi Jorge. This is a rare reaction to a LCHF diet but it does happen. Unfortunately I can’t give you specfic advice online. I can in general alcohol, coffee, and sugar substitutes can effect TGs. But for some it is simply an idiopathic response to the dietary change. The key is finding the right version of low carb that works better for you. I would be happy to help. You can learn more about my health coaching consults on my website here https://lowcarbcardiologist.com/about-dr-bret/consult-with-dr-scher/#.W6rxza2ZPaY
Hi, I discovered your work from the Peak Human podcast you were on, which I really enjoyed. In the past six months I’ve altered my diet to align a little more with what you describe. Intermittently, for the past 6-7 years I’ve had some odd symptoms that match CV issues, but also overlap with anxiety episodes, which I began having also about 6-7 years ago. It all began around 2011 when I was 36 or 37 with PVCs, they gave me a stress test which I aced, I also remember them injecting some kind of agent into my chest to do an X-ray and nothing came back, the PVCs didn’t go away, a year later I wore a Holter for two days and they didn’t notice anything besides PVCs. At this time I also had bloodwork that came back high LDL, if I remember correctly like 360.
Fast forward to February this year, I’ve had an EKG which I was told was perfectly healthy, despite being very kind and taking the time to explain things to me the doctor seemed to think I was a bit of a hypocondriac and told me to take blood pressure readings, which I have, and they’re consistently mid-120s over mid-80s unless I’m having a panic or anxiety attack type of issue. Heart rate is typically 55-65 bpm.
Sorry to be so long-winded and I know you can’t diagnose people from comments, but here’s my question: Is it possible for FH to skip a generation? I’m pretty sure my dad’s biological dad died from a sudden heart attack at 48, but my dad lived to be 75 until he passed from liver cancer a year ago. I would think that with all the tests he’d undergone in the 3 years prior to his passing, they would have caught a really high LDL if in fact he had FH. I know I need to get current bloodwork done which I intend to do ASAP.
Thanks for your question! You’re correct, unfortunately Dr. Scher is unable to give medical advice on his blog. If you would like a more detail devaluation and answer to your questions, you could always consider an individualized consult.
We hope that helps!