Can you ignore total cholesterol if your HDL is high enough?

When trying to understand your cholesterol numbers you will come across two distinct pieces of advice – lower your overall cholesterol and make sure your total cholesterol to HDL ratio is good. However you seldom see these two pieces of advice discussed together. So what should you do if your overall cholesterol level is high, but so is your HDL?

Focus on HDL and total cholesterol

The simple answer is you need to focus on both. To minimize your chance of atherosclerosis and heart disease you need to keep your total cholesterol low and your HDL high. Just having a good HDL is not sufficient to protect you from heart disease.

If you want to reduce your risk to near zero then:

  • Keep your total cholesterol below 150
  • Keep your HDL above 45
  • Keep your LDL below 80

The cooperative lipoprotein phenotyping study

A good example of why just focusing on your HDL ratio is insufficient can been seen in the data from the cooperative lipoprotein phenotyping study. This study of 6,859 Americans was one of the first to show that coronary heart disease was not just correlated with high total cholesterol but also inversely correlated with high HDL.

In this study we can clearly see that those with a high total cholesterol and high HDL are at higher risk of heart disease than those with low total cholesterol and low HDL. And the lowest risk is for those with low total cholesterol and high HDL.

However because this study was done in America LDL less than 140 is considered to be low, so we don’t see what the impact of exceptionally low LDL levels would be.

The china study

To examine the impact of even lower cholesterol levels we can look at epidemiological studies in other countries, the most famous of which is probably the china study. In China where the average total cholesterol is 127 the risk of dying from heart disease is considerably less than in the US and is some areas the risk is near zero.

If we look at the areas with extremely low mortality rates from ischemic heart diseases we see two things:

  • The majority have total cholesterol lower than 150
  • Of those with total cholesterol greater than 150 (but less than 182) the majority have high HDL (>48)

In fact Dr William Castelli (former director of the Framingham study) noted that no one who maintained a cholesterol level lower than 150 in Framingham has had a heart attack.

Heart Attack Proof

The standard recommendation from the American Heart Association is to keep your total cholesterol below 200 mg/dL in order to lower your risk of heart disease – despite the fact that one in four heart attacks occur in people in the 180 to 210 range. One reason that this higher number is chosen is because this number is still attainable by people on a standard American diet and they do not believe that the dietary changes necessary to reach a lower more protective number would be acceptable to most Americans.

They may well be correct, however a number of medical professionals now believe that we should provide people with the information not just to reduce their heart attack risk, but to eliminate it. This includes people like Caldwell B. Esselstyn (author of Prevent and Reverse Heart Disease) his son Rip Esselstyn author of The Engine 2 Diet and T. Colin Campbell (author of The China Study).

Personally I am choosing to virtually eliminate the chance of heart disease by adopting a healthy plant-based diet.


HDL cholesterol and other lipids in coronary heart disease. The cooperative lipoprotein phenotyping study
Castelli et al. 55 (5): 767. (1977)

The China Study II (1989)
Monograph on Chinese ecological study

This entry was posted in Health. Bookmark the permalink.

5 Responses to Can you ignore total cholesterol if your HDL is high enough?

  1. Jecka says:

    I have hereditary high cholesterol. Even after losing 40 pounds and significantly decreasing my meat and dairy intake for the past two years, my total cholesterol is at an all time low… of 237. My HDL is great (65) and my triglycerides are, too (95). I don’t know how to interpret my results, but I do hope to get more tests done and actually sit down with a hematologist or something to figure this out.

    Your blog post was interesting to me and I think I may look into some of the books and references mentioned.

  2. Ronda Hackey says:

    The American Heart Association (AHA) recommends that a triglyceride level of 100 mg/dL (1.3 mmol/L) or lower is considered optimal. The AHA says this optimal level would improve your heart health. However, the AHA doesn’t recommend drug treatment to reach this level. Instead, for those trying to lower their triglycerides to this level, lifestyle changes such as diet, weight loss and physical activity are encouraged. Elevated triglycerides usually respond well to dietary and lifestyle changes. ;-.”

    Kindly visit our new homepage too

  3. Lonny Souphom says:

    Coronary artery disease has a number of well determined risk factors. The most common risk factors include smoking, family history, hypertension, obesity, diabetes, high alcohol consumption, lack of exercise, stress, and hyperlipidemia.”:'”

    Go look at our new blog site too

Comments are closed.