Is Total Cholesterol Misleading?

Under 200. That's the usual target for total cholesterol as reported in popular media. But are all 200s the same?

I just received my profile from a recent blood test. Here's what it said.
Total cholesterol: 204
LDL (bad cholesterol): 131.6
HDL (good cholesterol): 57
Triglycerides: 77

The total is computed as LDL+HDL+Tri/5. These are fairly typical numbers for me as compared to the last half dozen years, although my HDL usually is a few points higher and my LDL and tri usually are a few points lower. This 204 would normally place me at borderline high. However, my doctor is not very concerned, and neither am I. Why?

First of all, I have only one risk factor (being a male over age 45). Second, my HDL is on the high side for men my age and this leads to a favorable LDL/HDL ratio of only 2.3. Further, at 5'10" and 142 pounds, my BMI is about 20.5. As an avid runner, my resting pulse is in the low 50s, my blood pressure is typically 110/70 (and sometimes as low as 105/60), and a recent echo cardiogram showed no problems. OK, so what's the beef? Surely mitigating factors and health status need to be considered instead of a single number, right? Yeah, but there's more to it than that. It's an unfortunate but true observation on my part that people tend to focus on the one number and that number can be misleading. I know a lot of people who can recite their total cholesterol value but have no idea of the "numbers inside". I doubt that they are atypical.

Consider two men with minimal risk factors, Ralph and Larry. For the sake of simplicity, let's assume both have a triglyceride value of 75. Ralph's LDL and HDL are 140 and 30 while Larry's are 125 and 65. Ralph's total cholesterol is 185 while Larry's is 205. If we just look at the total, Ralph seems to be in a much better position than Larry, yet Larry's LDL is considered safe while Ralph's is borderline high, and similarly, Larry's HDL is considered protective of heart disease while Ralph's is definitely too low.

Knowing the tendency of folks to "like it simple", I wonder why there isn't a single "cholesterol index" that could combine these considerations. Why do we bundle all forms together when high HDL is considered protective, yet it raises the "scary" total? It seems that a fudge factor could be added for the LDL/HDL ratio (just like there's one for triglycerides). I think it would be a little easier for people to grab onto, and then their doctor could look at the numbers inside and the patient's lifestyle, and offer the most promising strategies to combat a too-high index.

Oh, and my doc says I should probably watch my diet a little closer. I tend to agree as I do have a tooth for the cookies.

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I don't think I've ever told someone with a bmi of 20 to watch their diet (except perhaps Na if they're hypertensive). The favorable HDL/LDL, and the fact that there are no other risk factors makes this an excellent profile.

If you were diabetic or had CHD, you would likely need to be on a statin to further reduce risk.

It's true that lipid management is not a no-brainer...neither is the rest of medicine.

Hey Jim do the economy a favor and get on some good pharm's to take that number down to a respectable ie: unattainable level. Big pharm will thank-you. And that running you do...totally unnecessary. Just recline and decline like the rest of our fat fat country does. Oh if I offended anyone who is fat I'm sorry just LSW!!

By jonbutcher (not verified) on 08 Apr 2009 #permalink

I have a bit of a favour to ask. Could someone point me to the studies that actually show the relationship between high cholesterol and heart disease? I've been looking for a while, but lately, most studies seem to involve lowering the numbers.


I have a very similar issue. My LDL is in the good range, but my HDL is high, which boosts my total to just over 200 (I think it was 203). I'm 23 and have excellent blood pressure. My only other risk factor is that I'm overweight. I'm not too concerned about the total, considering the individual numbers are good, but I do try to eat a little better.

My total cholesterol tends to center right on 200 (range of 186 to 215, from what I remember). This is with an HDL of 70 or so, the number that seems to be static. Interestingly, it doesn't seem to matter whether I subsist on a vegan diet or load up on lard sandwiches and straight vodka--the numbers remain the same.

No one in my family dies of heart-related illness. That might be because we go batshit crazy before that can happen, but this doesn't explain my 99-year-old golf-nutty grandmother in Florida. It merely explains Florida.

I've read a few places that dietary cholesterol accounts for only 3-6% of blood cholesterol levels. (Sorry I can't remember the sources). It also seems that for some people, diet is a moderate factor and for other people, diet is not a factor at all. The biggest factors are exercise and family history.