Confused about cholesterol and not sure what to believe?
If you do any internet digging yourself, you have likely seen chatter in the health influencer world along the lines of "LDL cholesterol doesn't matter." or "You've been LIED to about cholesterol!" etc, etc.
In reality, it is much more complicated than that, but in general, what we know so far is that the evidence strongly suggests this to be false.
To keep it as simple and straightforward as possible, here's what I feel you need to know to understand the connection, and not get swayed by misinformation.
Data from a 20-Year follow-up from the Framingham heart study
The Framingham Study, the longest running epidemiological study on heart disease, gives us some intriguing insight into the connections between cholesterol and risks. Here are some key observations that have been made:
Isolated low HDL-C alone may increase your risk of heart disease by up to 93% (still significant after adjusting for population attributable risk (PAR)).
Isolated high LDL-C alone may increase your risk by up to 28% (still significant after adjusting for population attributable risk (PAR)).
Isolated high triglycerides may increase risk by up to 35%, but this is no longer significant when adjusted for population attributable risk (PAR).
Low HDL-C plus high LDL-C may increase your risk by up to 82% (still significant after adjusting for population attributable risk (PAR)).
Low HDL-C plus high triglycerides may increase your risk by up to 74% (still significant after adjusting for population attributable risk (PAR)).
High LDL-C plus high triglycerides may increase your risk by up to 52% (still significant after adjusting for population attributable risk (PAR)).
And what appears to be the most dangerous combination of all?
High LDL, low HDL, and high triglycerides together, which may increase heart disease risk by up to a whopping 228%.
This particularly risky combination typically occurs as a result of poor metabolic health, combined with diet and/or genetically induced high LDL numbers.
*Population Attributable Risk (PAR) is a measure used in epidemiology to estimate the proportion of a disease or health outcome in a population that can be attributed to a specific risk factor.
Cholesterol related markers: Understanding the nuances
When discussing low density lipoprotein aka “LDL” it’s important to understand that LDLs are particles (LDL-P). The cholesterol carried within these particles is referred to as LDL-C.
LDL particles (LDL-P) carry cholesterol (LDL-C), but your risk of heart disease tracks more closely with the number of LDL particles rather than just the amount of cholesterol they carry. In some cases, it is possible for to LDL-P and LDL-C to not match up, known as “discordance.” This helps explain why some studies show LDL-C isn’t always a consistent marker for heart disease risk. When adjusting for discordance and focusing on LDL-P, the inconsistency goes away. Apo-B is another marker that avoids the pitfalls of LDL-C and is a direct representation of heart disease risk.
Key Take-Aways:
Elevated LDL cholesterol (LDL-C) raises the risk of atherosclerotic cardiovascular disease (ASCVD), but the best markers to assess this risk are LDL particles (LDL-P) and apo B. These provide a more precise measure of cardiovascular risk. Additionally, these markers need to be assessed within the context of other risk factors to create a personalized approach.
How to Best Assess Your Risk
To better understand your heart disease risk, I recommend looking at a bigger picture.
Here’s what I like to test most often with most people:
Standard Lipid Panel: This shows your LDL-C, HDL-C, and triglycerides. I look for high-risk patterns, like high LDL-C, low HDL-C, and high triglycerides.
LDL-P: This helps identify cases where there’s a mismatch between your LDL-C and your true risk (LDL-P) - catching potential discordance.
Apo B: A key marker that can help capture risk from all plaque-forming lipoproteins.
Lp(a): A highly atherogenic, genetically-determined lipoprotein that adds unique risk.
Additional Markers: I will typically run additional markers to get an even broader view of things, such as metabolic health markers, inflammation, hormones, and certain nutrient markers. I may also run some genetic markers to get a better feel for certain situations.
My Bottom Line
Reducing heart disease risk isn’t as simple as focusing on one thing—whether it’s inflammation, blood sugar, triglycerides or LDL-C. The key is to assess your whole lipid profile and not fall for overly simplistic claims. The most accurate way to gauge risk is with comprehensive testing that goes beyond just basic numbers. That’s how I try to assess your heart health thoroughly in my practice.
Be cautious of anyone who says, "It’s all about [fill in the blank]." Cholesterol and heart disease risk are nuanced, and it’s crucial to understand all factors at play.
Stay informed, and always test thoroughly—don’t guess!