Important cholesterol tests your doctor isn't telling you about.
Get to grips with your cholesterol just like this patient, so you can become an expert in your health.
Do you look at your cholesterol readings and feel relieved, anxious with a sprinkling of confusion all in one?
The conversation with your doctor may go something like this:
“Your total cholesterol is high, but your good cholesterol is high. However your bad cholesterol is also high.”
That doesn’t even make sense, and what do you do with that?
I will show why your results that look “worse” on paper might actually represent an improvement, or even the opposite.
Most patients don’t get the conversation I had with my patient today, and that conversation may be very relevant to you.
This article covers:
How I helped a patient with his cholesterol and the recommended changes
Understanding your cholesterol profile.
Results that your doctor may not be discussing with you
Whether to ask for more detailed tests
Why high HDL isn’t always better.
Last week, I sat down with a 47-year-old man to go through his cholesterol results.
His father, and father’s father had heart attacks in their late 50’s, but they were smokers.
He’s active, doing well above the recommended amounts of exercise per week, and is active at work.
His total cholesterol was only slightly raised. But his cholesterol ratio was 6.6.
His risk of a heart attack or stroke in the next five years was double what it should be at his age.
I helped him understand every number on his cholesterol panel, what each one meant and where we want to shift it too.
I showed him the difference in his risk if we reduced his blood pressure and changed his cholesterol profile.
“Karate is actually protecting you a fair bit. It’s really just the nutrition.” I said to him.
We built a plan: overhaul the diet, repeat bloods in three months, and I recommended a genetic cholesterol test given his family history.
The actions he is looking at.
Take a closer look at his breakfast and lunch times. The ones he has to make decisions with.
Consider the mediterranean diet and do further reading on the portfolio approach
Follow up education with the Zoe podcast on how to eat to lower cholesterol
Suggest to watch the ‘Live to 100’ on Netflix, a film about the ‘Blue Zones’
Review his blood pressure and cholesterol in 3 months
Do a specific cholesterol test called ‘lp little a’.
Consider a CT Coronary calcium score when he turns 50.
The recommendations I gave are not gold necessarily gold standard, or the normal information a patient gets.
But I’m giving information that’s informative, entertaining, going to keep his attention.
It’s more likely be shareable with his friends, family and ultimately, help him make a lasting change.
I printed out his risk profile, “This is a wake-up call for me, mate. I’m putting this on my fridge.” And he was deadly serious.
What Gets Tested?
When your GP orders a cholesterol profile (or a “lipid panel”), you’ll typically get back these results that looks something like this.
Total cholesterol: 5.4
HDL: 1.2
non-HDL: 4.2
LDL: 3.9
TC/HDL: 4.5
This is confusing as it’s not clear whether you should be looking at the headline total cholesterol.
Or whether you should factor in your HDL being in a healthy range (more than 1) or the fact that your LDL is raised.
I want to help you make better sense of this, so you can better read your own cholesterol profiles.
Let’s have a look at what these readings actually mean.
Total Cholesterol (TC)
The sum of all cholesterol in your blood, both ‘good’ and ‘bad’, and the rest in between.
This is your headline reading, but really it doesn’t tell us much about your overall risk.
LDL Cholesterol
Often called ‘bad’ cholesterol, these are particles with higher amounts of fat. They are more likely to be able to enter into the walls of arteries and drive the formation of plaque, and narrow your arteries.
HDL Cholesterol
HDL has a high protein content relative to lipid (hence 'high density').
It helps remove excess cholesterol from the bloodstream and transport it back to the liver.
Triglycerides (TG)
Triglycerides are the most common type of fat in your blood.
They are higher when we eat high levels of saturated fat.
But they are also produced by your liver from excess calories, particularly from carbohydrates and alcohol.
The higher your triglycerides, the more remnant and LDL particles you end up with (more explanations on this below).
Triglycerides also independently increase the risk of heart attacks and strokes, over and above what LDL alone tells us.
Non-HDL Cholesterol
The total cholesterol minus HDL. This is an important number because it captures all the potentially harmful cholesterol carrying particles, not just LDL.
These harmful types include LDL, VLDL, IDL, chylomicron remnants, and lipoprotein(a).
Standard cholesterol profiles also calculate the TC/HDL ratio, which feeds into the QRISK3 and the Australian Cardiovascular Risk scores.
This ratio gives a better idea of how much of your cholesterol is actually protective (HDL) relative to the total, and allows comparison between individuals.
Total Cholesterol / HDL ratio
This is the standardised ratio that most health professionals will communicate to their patients, and it helps to better contextualise your results quickly.
It’s much like the BMI, giving a standardised number that we can more accurately compare between people.
This calculation reflects the balance between your total cholesterol and the protective HDL.
The higher the number, the more unhealthy your overall cholesterol readings are.
Standard reference readings
Here’s a quick guide to what’s considered healthy, borderline, and high-risk. You will find a variety of what’s ‘normal’ if you do your own readings.
A healthy cholesterol
Total Cholesterol < 5.0 mmol
LDL < 3.0 mmol
HDL > 1.0 in men / > 1.2 in women
Triglycerides < 1.7 mmol
Non-HDL < 4.0 mmol
TC/HDL Ratio < 3.5
Trig/HDL Ratio < 1.0
Remnant cholesterol (non-hdl minus hdl) < 0.5
These ranges are a useful starting point, but as you’ll see below, they don’t always capture the full picture.
These reference points change depending on the country you’re in and the laboratory you’re using; and each doctor becomes comfortable working within set reference points.
These are the set points I view for having a healthy cholesterol profile.
But it can be confusing to really understand if you have an overall good cholesterol profile when some numbers are high and others are good.
There is no black and white answer on many cholesterol profiles. However some are clearly unhealthy.
The cholesterol results your doctor may not be communicating to you:
Remnant Cholesterol
This is not discussed commonly with patients or between even between doctors.
It is hidden within the literature, and easily calculated on your own cholesterol readings.
It is the non-HDL minus the LDL.
These particles can be considered as the most dangerous particles for development of cardiovascular disease, over and above the LDL on its own.
This is why guidelines now consider the non-HDL as a more important figure to look at than just the LDL.
While the LDL is ‘bad’, the remnant cholesterol (non-HDL minus LDL) is ‘very bad’, and health professionals are not communicating this to patients, nor are we even discussing this with our peers.
The key to understanding complex cholesterol readings:
Not all LDL is considered equally harmful, but all remnant cholesterol is considered higher risk.
Mendelian randomisation studies, which provide evidence of causation rather than just correlation, support remnant cholesterol as a causal risk factor for ischaemic heart disease.
In some studies, remnant cholesterol has been shown to predict cardiovascular disease beyond LDL and also apoB in primary prevention settings.
A standard deviation increase in remnant cholesterol is associated with greater risk of both all-cause and cardiovascular mortality.
There are two additional calculations that research increasingly suggests are valuable:
Trig/HDL Ratio
This is simply your triglyceride level divided by your HDL.
It’s not routinely reported, but this can be easily calculated.
As a simple rule: your triglycerides should ideally be lower than your HDL. That gives you a ratio below 1, which is excellent.
If it’s above 1.5, you may be entering an amber zone of warning, and above 2.0, your risk profile becomes less favourable, and into the danger zone.
Note: these are not standardised in the guidelines, but are approximate thresholds that I work with.
While it is not commonly communicated, I really like this ratio.
It tells me a bit more about my future risk; those triglycerides are going to impact on the formation of non-hdl.
Low triglycerides means the cholesterol being released is more likely to form HDL particles because it doesn’t combine with the triglycerides.
The negative of the TG/HDL ratio
It’s more a short-term marker, because triglycerides can have significant variability depending on the fat and alcohol that you have consumed in the last 2-3 days.
What the guidelines tell us
NICE (UK)
NICE is the first major guideline body to endorse non-HDL cholesterol as the sole lipid treatment target, recommending a greater than 40% reduction in non-HDL cholesterol for primary prevention of CVD.
Europe
The 2019 and 2025 ESC/EAS guidelines recommend non-HDL cholesterol and apoB as secondary treatment targets.
This is particularly in patients with high triglycerides, diabetes, or metabolic syndrome.
Australia
Australian CVD prevention guidelines use the TC/HDL ratio within their risk assessment equation.
The recent literature from Australian cohort studies supports non-HDL as a strong predictor of CVD risk within the Australian population.
The Lancet
The lancet have published a large population-based study showing that a 50% reduction in non-HDL cholesterol was associated with a reduced risk of cardiovascular events by age 75.
The greatest benefit was found the earlier that cholesterol interventions started.
Should you be asking for more detailed cholesterol tests?
ApoB
ApoB is now the new addition to cholesterol testing.
Cardiologists simply do not put much energy to this test, yet in the longevity and lifestyle medicine space this test has become popular, even some doctors being adamant about the importance of this test.
But cardiologists and lipidologists in the traditional medical establishment don’t seem to care for it. Your specialist in unlikely to do this.
So why the difference?
When ApoB might help
Your LDL but the non-HDL is higher than expected, or your triglycerides remain elevated.
This is where the argument for ApoB testing comes from; because it is the core structural protein carried by every atherogenic (harmful) lipoprotein particle.
ApoB gives you a direct count of the total number of atherogenic particles in your blood.
So two people with the same amount of LDL might have varying amount of of ApoB harmful particles.
When is ApoB going to be helpful?
When the LDL and non-HDL are higher than expected or don’t match what we expect.
For example, if a patient makes a significant change in their lifestyle, but their LDL and total cholesterol profile rises.
There could be a number of reasons for this; but we want to know if the LDL increase is related to an increase in more harmful LDL particles (where there is more ApoB).
What Do Guidelines Say About ApoB?
The 2020 European Society of Cardiology and the European Atherosclerosis Society guidelines rank ApoB as the most accurate marker.
The 2026 American College of Cardiology and American Heart Assocation guidelines recommends ApoB as a risk-enhancing factor for individuals at intermediate cardiovascular risk, particularly when triglycerides are ≥ 1.97 mmol/l
The American Association of Clinical Endocrinology recommends specific ApoB targets.
Non-HDL-C and ApoB are recommended as secondary treatment targets
Does it really add much more?
I’m still not convinced it’s much more helpful than having an in-depth understanding of your standard cholesterol profile; understanding non-hdl and triglycerides as part of it.
However if you want one direct number to work with then it is likely going to be something that is helpful.
Challenge me if you think we need to do more ApoB for patients.
Really help me understand high quality clinical justifications for doing this test.
If it’s not meaningfully changing my decisions on supporting my patients over and above a standard cholesterol profile, I can’t really be justified in requesting it for every patient, or recommending it.
I understand that for some patients, knowing this number may be useful.
Don’t forget Lp(a) - pronounced ‘l, p, little a’
High levels of lp(a) are harmful and 90% is genetically determined.
It doesn’t change easily with lifestyle modifications or with standard cholesterol lowering medicines.
It is pro-inflammatory, pro-atherogenic and pro-thrombotic. If you haven’t gathered, that is bad.
It’s very useful to check in those with family history of early heart disease, and you only need to check it once.
Especially if we’re not clear if the family risk is related to environmental (e.g. sedentary life, high stress environments, smoking and work-related hazards), or whether it is a true increased genetic risk.
It helps me to guide treatment, as if you have Lp(a) we are going to treat your cholesterol much more aggressively.
And consider more screening tests earlier, compared to if you didn’t have it.