Cholesterol is an organic molecule that is used in the construction of your body’s cells and in the synthesis of various essential vitamins, hormones, and bile acids. Cholesterol is absolutely critical for life; you would quickly die without it. Almost all of the cholesterol circulating in your blood comes from your liver and, in the great majority of people,
this level is not affected by the amount of cholesterol found in the foods they eat. In others, dietary cholesterol consumption plays a minor role.

Contrary to older models that held that cholesterol is just “bad” and that cardiovascular disease was simply the result of too much cholesterol in the blood clogging up the arteries, newer research has shown that there are an array of cholesterol transport sub-types (called “lipoproteins”) and that the types, ratios and quantities of these lipoprotein subtypes are associated with and predictive of disease. Here are the types of measurements you may see on a “blood lipid panel”:

  • Total cholesterol
  • HDL cholesterol
  • LDL cholesterol
  • VLDL cholesterol
  • Triglycerides
  • LDL “Pattern A” (large, fluffy LDL)
  • LDL “Pattern B” (small, dense LDL)

While this list seems pretty long, we can summarize these measurements and what they mean for your health pretty easily. It appears that high levels of HDL are protective: people with high HDL are at low risk of disease.  High levels of small, dense LDL (“Pattern B”) indicate a high risk of disease. High overall LDL and/or high triglyceride levels are also predictive of disease. Most scientists think that this is simply due to the fact that high levels of these two values typically go together with high levels of small, dense LDL.

Unfortunately, most lipid panels do not report LDL “Pattern B” levels.  Fortunately, the ratio of triglycerides to HDL provides a good estimation of your cardiovascular risk because HDL is part of the mix (remember, HDL is protective) and because high triglyceride levels are associated with high levels of small, dense LDL. In the Alliance, we use this ratio to estimate your risk whenever it is available.

If you have low levels of triglycerides and high levels of HDL and (see table below) then you likely have minimal risk of heart disease. On the other hand, if your triglyceride levels are high relative to HDL, then you are at high risk. The LDL/HDL and Total Cholesterol/HDL ratios are also highly correlated with disease risk and are used more often on standard blood panels simply because they were studied first.

What Do I Look For?

The rapid progress in our knowledge of blood lipids has not always been matched by the use of better blood lipid measurements. Thus, it is not uncommon to have only total cholesterol, HDL and LDL when you receive a blood panel. Because the Cholesterol to HDL ratio was the first to be studied, you may have this value on your report as well. Triglyceride measurements are common but not universal. Because the research regarding the triglyceride to HDL ratio is relatively new, it is not typical for reports to include this ratio. It is easy to compute, though: just divide the triglyceride number by the HDL number. Cutting-edge doctors will request LDL subtype pattern analysis but, because of the expense and the fact that they aren’t needed to get a firm handle on risk, this isn’t nearly as common.

With these notes in mind, here are some guidelines for interpreting your blood panel ranked in order from best (most predictive) to worst (least predictive). You will want to discuss your specific findings with your physician as they will have insight into your case that goes beyond the simple numerical guidelines found here.

Measure Optimal Low/Elevated Risk High Risk
Triglyceride : HDL Ratio 2.0 or less 2.01-3.99
(elevated risk)
4 or higher
LDL : HDL Ratio Less than 2.5 2.5-3.49 3.5 or higher
Cholesterol : HDL Ratio Less than 3.5 3.5-4.99 5.0 or higher
HDL Level 60+ 40-59
(moderate risk)
<40 for men,
<50 for women
LDL Level Less than 100 100-129 130 or higher
Total Cholesterol Level Less than 200 200-239
(elevated risk)
240 or higher

What Causes Unhealthy Lipid Patterns?

While eating cholesterol doesn’t cause an unhealthy cholesterol pattern, it is nonetheless true that a high-risk result is largely due to an unhealthy diet (in most people: people who suffer from familial hypercholesterolemia typically have an unhealthy pattern regardless of diet). In particular, a diet dominated by simple carbohydrates, processed foods, sweetened and alcoholic beverages, and artificial (“trans”) fats are associated with both unhealthy cholesterol patterns and metabolic and/or cardiovascular disease. In contrast, diets rich in vegetables and other high-fiber foods and natural sources of protein and fat are associated with healthier cholesterol patterns.

There are no “magic” foods out there and advice for controlling an unhealthy lipid pattern is pretty much the same as the advice for overall healthy eating: eat real food.  If it is grown from the ground or had a mother, then it is likely to be good for you. If it doesn’t look like anything you’d find in nature, it probably isn’t.

If you do suffer from a high risk cholesterol pattern and exercise and diet haven’t helped, your doctor may recommend statin therapy. Statins reduce LDL cholesterol by inhibiting a liver enzyme that plays a key role in its production.  Statins have been shown to reduce the rate of cardiovascular events in people at high risk for disease – especially those with a prior heart attack.  While there is some controversy over whether statins are being prescribed too quickly, only your doctor can know whether they are appropriate in your specific case.

21 Replies to “Cholesterol and the Risk of Heart Disease”

  1. Your post, Cholesterol and the Risk of Heart Disease | The Motivation Alliance, is really well written and insightful. Glad I found your website, warm regards!

  2. entered my glucose level for in history levels. Entered 89 as my glucose & my doctors reference range on the lab report is 70-105. However, when I entered the number in my profile history on your web site, it marked it as “low risk”. Why isn’t it “optimal”?

    1. Hi Deryl, we don’t use “optimal” in describing glucose; just high risk or low risk. This is quite standard terminology for glucose since it is only predictive when it falls outside the reference ranges.

  3. My results say i was fasting but I wasn’t. I even watched the nurse write on the paper that it was non-fasting. Now my numbers looked screwed up. Can y’all fix that?

    1. Hi Stephanie, we would suggest you speak to your doctor about the results of your test and how it was taken. It sounds like there may have been some miscommunication that needs to be cleared up somewhere. Good luck!

  4. thanks for this page. The information is quite helpful in keeping track of my cholesterol since it was on the high side last time. It gives me the safe levels that I should strive to achieve

  5. Concerned regarding gradual increase of A1C even with dietary changes. Opportunity for growth for me continues to be exercising at least 3times a week consisitently for a least 30 mins to a hour. I think I need educational sessions re: diabetes and other ways to decrease A1C.

    Interested in Partners InHealth please advise when or if it would be offered this year.

    Looking for any additional resources to Promote a healthier me and to decrease risk factors

  6. Another comment I would make is that the liver is the main source of cholesterol. It manufactures cholesterol from carbohydrates and fat. The liver’s production is proportional to body weight. Hence, lower body weight reduces liver production of the LDL particles.

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