Cholesterol: Beyond Good and Bad

The Cholesterol Report Card That's Probably Missing the Point

Your lipid profile comes back with total cholesterol of 220 mg/dL, stamped in red, marked "HIGH." But that number alone reveals almost nothing about your actual heart attack risk.

Here's what research now shows about cholesterol:

So what actually matters? Let's break down the lipid panel properly.

Reading Your Report: Beyond "Good" and "Bad"

Total Cholesterol: The Misleading Number

Total cholesterol is the sum of all cholesterol in your blood. It includes HDL (the "good" one), LDL (the "bad" one), and 20% of your triglycerides.

Here's why it's misleading: someone could have total cholesterol of 250 with high HDL (good) and low LDL (good), or 200 with low HDL (bad) and high LDL (bad). Same total cholesterol, completely different risk profiles.

The reality: Total cholesterol alone is too crude a measure to be meaningful.

LDL Cholesterol: The Nuanced "Bad Guy"

LDL (Low-Density Lipoprotein) carries cholesterol to your tissues. When there's too much, it can deposit in artery walls and form plaques. That's why it's called "bad."

But here's what most reports don't tell you: LDL particle size matters enormously.

LDL Type	Characteristics	Risk Level
Large, fluffy LDL (Pattern A)	Bigger particles, less likely to penetrate artery walls	Lower risk
Small, dense LDL (Pattern B)	Smaller particles, easily lodge in arteries, highly oxidizable	Higher risk

Two people with identical LDL of 150 mg/dL can have vastly different risks. One might have mostly large particles (relatively safe), the other mostly small dense particles (dangerous).

Standard lipid panels don't measure this. Advanced testing (LDL particle number, apoB) can reveal the truth.

HDL Cholesterol: It's Not Just About Being High

HDL (High-Density Lipoprotein) is called "good" because it carries cholesterol away from arteries back to the liver for disposal. Higher is generally better.

But here's the catch: HDL functionality matters as much as quantity.

Some people have high HDL that doesn't work properly — it doesn't actually transport cholesterol effectively. Drugs that artificially raise HDL haven't reduced heart attacks, which proved that it's not just about the number.

Triglycerides: The Underrated Warning Sign

Triglycerides are fats in your blood, directly influenced by diet — especially carbohydrates and alcohol.

High triglycerides are perhaps the most overlooked red flag in Indian lipid panels. They indicate:

• Insulin resistance (prediabetes)
• Excess carbohydrate intake
• Metabolic dysfunction
• Higher risk of heart disease and pancreatitis

Triglyceride Level	Category	Interpretation
Below 100 mg/dL	Optimal	Ideal metabolic health
100-150 mg/dL	Normal	Acceptable, but worth monitoring
150-200 mg/dL	Borderline High	Metabolism is stressed — diet changes needed
200-500 mg/dL	High	Significant risk — immediate intervention required
Above 500 mg/dL	Very High	Pancreatitis risk — urgent attention needed

The Ratios That Predict Heart Disease Better Than Any Single Number

These ratios are far more useful than individual numbers:

Triglyceride/HDL Ratio

This is perhaps the single best predictor of insulin resistance and cardiovascular risk from a standard lipid panel.

TG/HDL Ratio	What It Means	Pattern
Below 2.0	Ideal	Large, fluffy LDL particles, low insulin resistance
2.0 - 3.0	Moderate risk	Mixed particle sizes
Above 3.0	High risk	Small, dense LDL particles, insulin resistance likely

Someone with "normal" LDL of 130 but TG/HDL ratio of 4.0 is at higher risk than someone with LDL of 160 and TG/HDL ratio of 1.5.

Total Cholesterol/HDL Ratio

• Optimal: Below 4.0
• Average: 4.0-5.0
• High risk: Above 5.0

LDL/HDL Ratio

• Optimal: Below 2.5
• Acceptable: 2.5-3.5
• High risk: Above 3.5

The Indian Cholesterol Story

Indians have a unique lipid pattern that makes us particularly vulnerable:

A 45-year-old Indian man with LDL of 140, HDL of 38, and triglycerides of 220 is at higher risk than a European with LDL of 160, HDL of 55, and triglycerides of 100.

Yet both might be told their cholesterol is "borderline" and given generic advice.

The Rice-Wheat Problem

Our traditional diet has shifted. Less millets, more refined grains. Less vegetables, more processed snacks. Less home cooking, more restaurant food.

The result? A carbohydrate-heavy diet that:

• Raises triglycerides
• Lowers HDL
• Creates small, dense LDL
• Drives insulin resistance

The irony: many Indians eat very little fat, thinking it will help their cholesterol. But it's often the carbohydrates — the rice, the rotis, the biscuits, the sweet chai — driving their abnormal lipids.

When Lifestyle Isn't Enough: The Statin Question

Let's be direct about statins because there's tremendous misinformation:

Statins save lives. In people with established heart disease or very high risk, the benefit is clear and significant. The number of heart attacks and strokes prevented far outweighs the side effects.

But statins are overprescribed. Many people with mildly elevated cholesterol and low overall risk are put on medications when lifestyle changes would suffice.

Who actually needs a statin?

Definite Statin Candidates:

• Prior heart attack, stroke, or established artery disease
• LDL above 190 mg/dL
• Diabetics aged 40-75 with additional risk factors
• 10-year cardiovascular risk above 20%

Probably Need a Statin:

• 10-year risk 7.5-20% with additional risk factors
• Strong family history of early heart disease
• Elevated coronary calcium score
• South Asian ethnicity (higher risk at same cholesterol levels)

Lifestyle First:

• 10-year risk below 7.5%
• Mildly abnormal lipids without other risk factors
• Young age with no family history

The Tests Beyond Basic Lipid Panel

For concerning patterns or strong family history, advanced testing can provide more insight:

Apolipoprotein B (apoB): Measures the actual number of atherogenic particles (ones that cause plaque). Better than LDL cholesterol alone.

Lipoprotein(a) [Lp(a)]: A genetic risk factor that's underrecognized. Elevated Lp(a) significantly increases heart disease risk and is largely unresponsive to lifestyle or standard medications. Every adult should know their Lp(a) at least once.

LDL Particle Number: Counts the actual number of LDL particles. More particles = more chances for them to lodge in arteries.

Coronary Calcium Score: A CT scan that detects calcium in coronary arteries. A score of zero is very reassuring. Higher scores indicate plaque presence and warrant aggressive treatment.

The Diet That Actually Improves Your Lipids

Forget "low-fat" diets. Here's what evidence actually supports:

What Worsens Your Profile:

• Refined carbohydrates: White rice, maida, biscuits, sweets — these raise triglycerides more than fat does
• Trans fats: Partially hydrogenated oils in processed foods, vanaspati — directly raises LDL
• Excess sugar: Especially fructose (including from "healthy" fruit juices) — raises triglycerides dramatically
• Alcohol: Even moderate amounts raise triglycerides

What Improves Your Profile:

• Fiber: Especially soluble fiber (oats, psyllium, beans) — lowers LDL by 5-10%
• Nuts: Handful daily — raises HDL, lowers LDL
• Fatty fish: Omega-3s dramatically lower triglycerides
• Olive oil: Monounsaturated fats improve HDL function
• Plant sterols: Found in some fortified foods — block cholesterol absorption

The Indian Kitchen Advantage:

Traditional Indian cooking offers powerful allies:

• Methi (fenugreek): Lowers triglycerides and LDL
• Amla (Indian gooseberry): Antioxidant that protects LDL from oxidation
• Haldi (turmeric): Anti-inflammatory, improves endothelial function
• Garlic: Modest lipid-lowering effect
• Oats: One of the most effective natural LDL-lowerers

Exercise: The Intervention That Fixes Everything

If there's one intervention that improves every aspect of the lipid profile, it's exercise:

• Raises HDL (one of the few things that reliably does)
• Lowers triglycerides
• Makes LDL particles larger and fluffier
• Improves insulin sensitivity
• Reduces inflammation

What kind? Both cardio and strength training. The combination is superior to either alone.

How much? 150 minutes of moderate activity per week. That's 22 minutes per day — a morning walk.

Common Questions About Cholesterol

"Should I stop eating eggs?"

No. For most people, dietary cholesterol has minimal impact on blood cholesterol. Eggs are nutritious. 1-3 eggs daily is fine for most people without diabetes or established heart disease.

"Is coconut oil healthy or harmful?"

It's complicated. Coconut oil raises LDL more than other plant oils. But it also raises HDL. The net effect is probably neutral for most people. Don't avoid it, but don't use it exclusively either.

"My LDL is high but my HDL is also high. Is that okay?"

Possibly. High HDL can be protective. Calculate your ratios. If TG/HDL is below 2 and Total Cholesterol/HDL is below 4, you're likely in a better position than someone with lower numbers but worse ratios.

"How often should I test?"

Adults over 20: every 4-6 years if normal, more often if abnormal or if risk factors are present. After 40: annually is reasonable.

"Can I reverse plaque in my arteries?"

Yes, it's possible with aggressive LDL reduction (below 70 mg/dL) combined with optimal lifestyle. This typically requires medication. Studies show plaque can regress with sustained very low LDL.

Your Cholesterol Action Plan

What Good Lipid Assessment Looks Like

Consider this example of comprehensive lipid assessment:

"LDL is 142, which is borderline. But HDL is 58 and triglycerides are 85, giving a TG/HDL ratio of 1.4 — excellent. The LDL particles are likely large and fluffy, not the dangerous small dense type. The 10-year risk is 4%. No statin is needed right now. The focus should be on keeping HDL high and triglycerides low through diet and exercise, with a recheck in a year."

That's very different from: "Cholesterol is high. Start a statin."

Context matters. Nuance matters. The whole story matters — not just one number on a report.

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