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Don't panic over your cholesterol number


"My total cholesterol is high."

"My LDL is high."

"Do I need medication?"


These are very common questions.

Over the past few months, quite a number of my clients in their 40s, 50s and 60s have come to me feeling worried after their health screening.


Heart disease remains the leading cause of death worldwide, responsible for roughly 1 in 3 deaths globally. A large proportion of these deaths are due to atherosclerotic cardiovascular disease (ASCVD), where fatty plaque gradually builds up inside the arteries that supply the heart and brain. This process can eventually lead to heart attacks and strokes.


So yes, cholesterol matters. But today, we can understand cholesterol much better than we could decades ago.


Just the other day, I went for a lipid test and was asked to return to the clinic for the doctor to review my results. He told me that my total cholesterol and LDL were elevated, although not at a dangerous level. I was not surprised because I do eat a fair amount of fats.


After explaining these two numbers, he moved on to other health markers. I paused and asked, “Doctor, what about my HDL and triglycerides?” He went back to the report and saw that my HDL was 96 mg/dL, while my triglycerides were only 51 mg/dL.


I found this quite interesting because my HDL was very high, which would naturally push up my total cholesterol reading, while my triglycerides were very low. Yet these two markers were not initially discussed.


It made me wonder why the focus was mainly on total cholesterol and LDL, without first looking at the fuller picture. This experience reminded me that cholesterol should not always be judged by one or two numbers alone.


Think of total cholesterol like stepping on a weighing scale


Imagine standing on a weighing scale. The scale gives you one number. But that number includes your muscles, body fat, bones, organs and water. It doesn't tell you what makes up your weight. Total cholesterol is similar. It is a broad number made up of several different cholesterol components. Looking at total cholesterol alone doesn't tell the whole story.


What is LDL?


LDL stands for Low-Density Lipoprotein. Many people call it "bad cholesterol," but that description is only partly true. LDL actually has an important job. Its role is to carry cholesterol from the liver to the rest of the body. Every cell in your body needs cholesterol to make cell membranes, hormones, vitamin D and bile acids. Without LDL, your body wouldn't function properly. The issue isn't that LDL exists. The issue is when there are too many harmful LDL particles circulating in the bloodstream.


Not all LDL particles are the same


Scientists have found that LDL particles come in different sizes.


Type A

  • Larger

  • More buoyant

  • Less likely to enter artery walls

Type B

  • Smaller

  • Denser

  • More likely to enter artery walls

  • More likely to contribute to plaque formation


Both carry cholesterol. The difference is how they behave inside the bloodstream.


Why ApoB is becoming more important


Every LDL particle has one ApoB protein on its surface. Think of ApoB as the license plate on every cholesterol delivery truck. If every truck has one license plate, counting license plates tells you how many trucks are on the road. That is exactly what an ApoB test does. It tells you how many cholesterol-carrying particles are circulating in your bloodstream.


Research increasingly shows that the number of ApoB-containing particles predicts cardiovascular risk better than LDL cholesterol alone, especially when LDL-C and ApoB do not agree. This is why many lipid specialists now include ApoB as part of a more complete assessment.


Don't stop at LDL


If your total cholesterol or LDL comes back elevated, don't panic. Pause and look at the bigger picture. Some useful markers include:

  • HDL cholesterol

  • Triglycerides

  • ApoB

  • Lp(a) - usually only needs to be measured once because it is largely genetic


HDL – the "good" cholesterol


HDL helps transport excess cholesterol back to the liver for recycling. In general, higher HDL is associated with lower cardiovascular risk, although HDL should always be interpreted together with your overall health and other blood markers. Many clinicians like to see HDL around 60 mg/dL (1.55 mmol/L) or higher, while lower levels may indicate increased risk. Regular exercise, maintaining a healthy weight, not smoking, and eating healthy fats can help support healthy HDL levels.


Triglycerides


Triglycerides are another type of fat in the blood. When triglycerides are elevated, it often reflects excess calories, excess refined carbohydrates, insulin resistance, obesity, or poorly controlled diabetes.


Generally:

  • Below 150 mg/dL (1.7 mmol/L) is considered desirable.

  • Lower levels are generally associated with better metabolic health.


One simple clue: Triglyceride-to-HDL ratio


A simple calculation that many clinicians and researchers use as a metabolic health clue is:

Triglycerides ÷ HDL. A lower ratio is generally better. A ratio below 1 (using mmol/L units) is often associated with good insulin sensitivity and lower cardiovascular risk, although this ratio should not be used on its own to diagnose heart disease. A higher ratio may suggest insulin resistance and poorer metabolic health.


What tests can you consider?


If you want a more complete picture, you could discuss these with your doctor:

Level 1

Standard lipid profile

  • Total cholesterol

  • LDL

  • HDL

  • Triglycerides

Level 2

Review your triglyceride-to-HDL ratio as one piece of the overall picture.

Level 3

  • ApoB

  • Lp(a) (usually only needs to be measured once because it is largely genetic)

Level 4

If you and your doctor want an even clearer assessment of plaque burden, consider a Coronary Artery Calcium (CAC) score. This is a quick CT scan that measures calcium deposits inside the coronary arteries. It does not require contrast dye and can help estimate the amount of calcified plaque already present. It's a quick CT scan, usually around 10–15 minutes, though total appointment time may be longer.


My final thoughts


I’m not sharing this to tell anyone to stop taking their medication, especially if it has been prescribed by a doctor. I'm also not saying high LDL or high total cholesterol should be ignored.


What I'm saying is that we now have better tools than we had 30 or 40 years ago. Rather than making decisions from one or two numbers alone, we can often build a much more complete picture of heart health. If you've been told your cholesterol is high, take it seriously—but don't stop at the first number. Ask questions. Understand your results. Have a conversation with your doctor, and decide on the approach that's right for you.


If you're one of my clients and you'd like to chat about cholesterol after class, I'm always happy to share what I've learnt and discuss the science together. At the end of the day, your health is your responsibility.


Keep strength training. Stay physically active. Eat well. Sleep well. Manage your metabolic health. Those habits will do far more for your heart over the long term than chasing one number on a lab report alone.

Suggested Clinics for Lipid Testing

We are not affiliated with any of the medical providers listed below. These are shared for general reference only.


Disclaimer

This content is for education only, not medical advice. Always check with your doctor or healthcare provider before changing your diet, exercise, or lifestyle.


 
 
 

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