By Harveer Parmar, MD – Family Physician, Lewisville, TX
So here’s what I tell patients about cholesterol tests these days—the total number? It’s kind of… outdated. Not completely useless, but not the main thing we look at anymore. What really matters is the balance between HDL (“good” cholesterol) and LDL (“bad” cholesterol). It’s about ratios, not just totals.
I’ve had patients freak out over a “high total cholesterol,” but when we dig into the numbers, their HDL is great, triglycerides low, and LDL is stable. No statins needed.
“But doc, isn’t anything over 200 still considered high?”
Technically, yes—on your lab portal, it’ll flag anything over 200 as “high.” But here’s some context:
- HDL (High-Density Lipoprotein): Higher = better. Want above 40 for men, above 50 for women.
- LDL (Low-Density Lipoprotein): Lower = better, especially with cardiac risks.
- Triglycerides: Sugar-fat hybrids. Spike with carbs, alcohol, insulin resistance.
If your HDL is high, it can offset the risk of slightly elevated LDL. That’s why we look at the total cholesterol-to-HDL ratio.
“Wait—so what should my ratio be?”
The total cholesterol/HDL ratio is a stronger predictor of cardiac risk. Here’s the scale:
- < 3.5 = Excellent
- 3.5–5.0 = Moderate risk
- > 5.0 = Elevated risk
Example:
Total cholesterol = 220, HDL = 70 → Ratio = 3.14 (not bad)
Total cholesterol = 220, HDL = 35 → Ratio = 6.3 (yikes)
One Patient Who Changed My Mind About the “Numbers”
Mid-50s, fit, on keto. His total cholesterol? 245. But HDL was 97, LDL ~120, triglycerides: 45. We did a coronary calcium scan—zero. He’s still med-free, labs stable 2 years later. It changed how I view totals.
“But I have high LDL. Should I be on a statin?”
It depends. If you’ve had a heart attack or have diabetes, probably yes. But if you’re otherwise healthy? We look at:
- 10-year ASCVD risk
- Family history
- Lipid pattern
And we discuss options like coronary calcium scans or particle size panels.
“Can I improve my HDL without meds?”
Yes, but it’s tough. What helps:
- Aerobic exercise (30 mins, 4–5x/week)
- Omega-3s (fish or supplements)
- Moderate alcohol (if you already drink)
- Weight loss if needed
- Quit smoking (huge for HDL)
Diet helps, but genetics play a big role too.
Let Me Rant for a Second About Triglycerides
High triglycerides = metabolic warning sign. Often from sugar, alcohol, soda. When combined with low HDL, I screen for insulin resistance and prediabetes.
A Quick Teaching Moment (for the Med Students in the Room)
Pearl: Always calculate the ratio manually. Don’t trust EMR flags alone. Think about weight, A1C, lifestyle, family history—not just numbers. Use ASCVD calculator wisely.
“So what matters most—HDL, LDL, or the ratio?”
All three, in context:
- HDL: Protective
- LDL: Atherosclerosis risk
- Triglycerides: Metabolic health
- Ratio: Interpretation of all three
I’d rather see Total = 215 + HDL = 80, than Total = 180 + HDL = 35.
Common Questions I Get From Patients (Clinic FAQ)
“My total cholesterol is 240—is that dangerous?”
Not necessarily. Let’s look at your ratio and HDL before panicking.
“How do I know if I really need a statin?”
Depends on risk score, age, history, and pattern. It’s a conversation, not a mandate.
“Can I reverse high cholesterol naturally?”
Sometimes. Mediterranean diet, exercise, quitting smoking, and weight loss help.
“What foods raise HDL?”
Fatty fish, olive oil, nuts, avocado. But again—exercise beats diet for HDL.
“What if my LDL is high but HDL is too?”
That’s why we check the ratio. If under 3.5, we may just monitor.
“LDL or triglycerides—what’s more dangerous?”
Triglycerides over 250 with low HDL usually signals metabolic issues. I prioritize that first.
Final Thought From Your Friendly Neighborhood Family Doc
You are not your cholesterol number.
Don’t panic over total cholesterol alone. Don’t ignore the big picture. Look at the ratios, the lifestyle, the person. Talk to a doc who sees more than just labs. We’ve got tools. And you’ve got time.