• Gavin Guard, Medical Director

The Ultimate Guide to Understanding Your Cholesterol Numbers

Key Takeaways

  • There is no such thing as “good” or “bad” cholesterol

  • LDL-C (“bad cholesterol”) is a fairly poor marker of true cardiovascular risk

  • A comprehensive evaluation and management of cholesterol imbalances if often necessary

Intro


Your doctor tells you that your “bad cholesterol is high” and your “good cholesterol is low”. What does this mean and is it an accurate statement?



What do these cholesterol numbers tell (or not tell) you?

Cholesterol values are very important biomarkers and are one of the best indications of your heart disease risk. It’s important to have a complete understanding of what your cholesterol values mean so that you can make educated lifestyle (and medication) changes with your healthcare provider.


What is cholesterol?


Cholesterol is a “sterol” molecule, a ring-shaped carbon-based molecule that is made by almost every cell in our body.


We also get it from our diet too. However, an average of only 25% of cholesterol in our blood comes from our diet. This is not to say diet has minimal impact, but rather dietary cholesterol has relatively little impact on your blood cholesterol on average. However, you may be part of the 10-15% of the population that is very sensitive to dietary cholesterol. Thus, a personalized approach to your nutrition is necessary.


Cholesterol is one of the most important parts of your cell membranes. This is important since it dictates the ability of your cells to communicate with one another as well as maintain fluid balance. Cholesterol is also the precursor molecule to all sex hormones such as testosterone, progesterone, estrogen, and cortisol. However, even at very low cholesterol levels, your body is still capable of producing adequate sex hormones.


Cholesterol is also the molecule that is best-known for causing heart disease. Imbalances of cholesterol types and numbers creates an environment where it is taken into the blood vessel wall and creates an inflammatory response. This eventually leads to “atherosclerosis” or plaque build up in the arteries. With time, the plaque can rupture and create a heart attack! We want to prevent this from happening for as long as possible.


Cholesterol is not water soluble. Ever tried mixing oil with water? It doesn’t work, right? In the same way, cholesterol cannot freely float in your blood. Thus, it must be packaged into tiny vesicles called “lipoproteins”.


Keep on reading as I describe what “bad” and “good” cholesterol really mean.


What is LDL (aka “bad cholesterol”)?


I like to explain cholesterol numbers by having you imagine that your blood is like a river. In the river, cholesterol “passengers” need to ride on the lipoprotein “boats”. There are few types of boats, the most important being “LDL boats” and “HDL boats”. Each type of boat carries a certain number of cholesterol “passengers”.



Cholesterol is packaged into different forms of "boats" in the blood

When your cholesterol is measured, it is reported as “LDL-C”. This “C” stands for cholesterol. So what we are really measuring is the amount of cholesterol ferried around in your LDL lipoproteins/ “boats”.


Therefore, we really cannot say your “good cholesterol is ___” or your “bad cholesterol is ___”. Cholesterol is neither good nor bad, but rather, packaged in different “boats”.

Nevertheless, the amount of cholesterol in your LDL “boats” is an important part of your health. The cholesterol in the LDL “boats” are the ones that typically get into your arterial walls and contribute to heart disease.


The truth is that many people are walking around with great “LDL-C” values but are still at high risk of heart disease.

What is HDL (aka “good cholesterol”)?


In the same way, HDL-C is the amount of cholesterol carried around in your HDL “boats”. This cholesterol is typically being transported from your tissues/blood vessels back to the liver- a good thing for the most part!


This is why higher HDL-C values are usually seen as “good”. However, medications designed to increase HDL-C have historically failed at reducing heart disease and heart attacks. In addition, earlier studies that have shown this link between HDL-C and heart disease did not account for other biomarkers that we can now measure.

The Best Marker for Knowing Heart Disease Risk


As I mentioned, you may be one of the many people with “normal LDL-C” but still at high risk of heart disease. For example, 50% of 140,000 hospitalized patients with heart disease had normal LDL-C!


So what’s a better marker?


The answer: ApoB or LDL-P


Going back to the river and boat analogy, we usually measure the amount of cholesterol “passengers” but rarely know how many total LDL “boats” there are in the river.


Knowing the amount of LDL “boats” in your blood is THE best predictor of heart disease.

We can know how many cholesterol-carrying particles are in your blood by measuring what’s called “ApoB” or “LDL-P” (stands for LDL-particle). ApoB is like a little "name tag" on all LDL boats. Measuring the amount of "name tags" gives you a marker for total number of boats. More boats means a higher chance of one of those boats running into the side of the river to cause an accident (atherosclerosis).


More cholesterol "boats"= higher heart disease risk

Let’s see what a leading expert in this field has to say about this. Dr. Alan Sniderman says, “LDL-C is not adequate. Non-HDL-C is not adequate. As I mentioned previously, a substantial minority of those with elevated cholesterol have a normal ApoB, and they are NOT at high cardiovascular risk.”


One study showed that LDL particle count was about TWICE as strongly related to cardiovascular disease rates than LDL-C.

Another study showed that LDL particle count (amount of “boats”) is not always similar to the degree of LDL-C (amount of cholesterol “passenger”). Even if LDL-C is high, a low LDL particle count means a low risk for cardiovascular disease.


Furthermore, when we manage patients to achieve their LDL particle goals, they had better survival rates than when they reached their LDL-C goals.


The Bottom Line


The next time you are told that your “good cholesterol is ___” and your “bad cholesterol is ___”, you will know exactly what your doctor means.



You can kindly ask them, “How do you really know my heart disease risk without knowing how many LDL particles I have?”


You can ask for LDL-P or ApoB levels along with your standard lipid panel to better understand your heart disease risk.

There are many more markers important for understanding your heart disease risk. This includes knowing your blood sugar balance and levels of inflammation. Many times, inflammation stems from the gut. Therefore, a comprehensive evaluation and management strategy is necessary. That’s exactly what I do everyday in my clinic and would love to help you too. You can schedule a free 15-minute health strategy session where I can give you an idea of how I would approach your care.

I hope you found this information useful and helpful in your journey back to a healthier and happier life.

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