Don’t Be Fooled by Your Total Cholesterol Number

We all know that elevated cholesterol is an indicator of heart disease risk, but the truth is most of us have no idea what our cholesterol data tells us. Even if you’ve been a good steward of your heart health and have your cholesterol checked regularly, most doctors only tell you the basic results of your blood tests — and that doesn’t tell the whole picture.

You probably know your total cholesterol level, and perhaps you even know that the Centers for Disease Control and other medical experts suggest your total cholesterol should be less than 200 mg/dL. This common wisdom also suggests that your LDL (“bad” cholesterol) should be less than 100 mg/dL, your HDL (“good” cholesterol) should be 40 mg/dL or higher and your triglycerides should be less than 150 mg/dL.

Too often we look at our total cholesterol number and if it’s under 200 we figure we’re fine. Unfortunately, I can tell you hundreds of stories about seemingly “healthy” people who had cholesterol levels under 200 and still had a heart attack. Myself included.

So if these numbers don’t tell the whole picture, what’s a better indicator of your cholesterol-related health? Well, a study published in the American Heart Association journal Circulation found that those people with the highest triglyceride-to-HDL cholesterol ratios had a sixteen times greater risk of heart disease than those with the lowest ratios.LDL-cholesteral-particle-size-matters

Why? It turns out not all LDL cholesterol is the same, so just knowing your LDL number doesn’t tell you much. In fact, LDL particle size is a much better predictor of heart disease. Some LDLs are large and fluffy while other LDLs are small and sticky. The small sticky cholesterol plays a more critical role in determining your cardiovascular health and it turns out a higher triglyceride to HDL ratio is more indicative of small sticky LDL.

The triglyceride to HDL ratio also indirectly measures insulin resistance, and that is a predictor of diabetes — and diabetes is also a major risk factor for heart disease.

Ideally, you want no more than a 2:1 ratio of triglycerides to HDL cholesterol. So, if your triglycerides are 100 mg/dl, your HDL cholesterol should be 50 mg/dl. — Dr. Stephen Sinatra, cardiologist

It turns out a better strategy for lowering your risk for heart disease is to lower your triglycerides and/or raise your HDL. Ironically, the first line of defense for elevated cholesterol recommended by most cardiologists is a statin to lower your LDL. But statins don’t affect your triglycerides to HDL ratio.

It’s also possible to get a newer type of blood test that measures particle size. The Vertical Auto Profile (VAP) test or a similar test is available at most labs and can give you a sense of whether you are one of the unlucky ones who create small sticky (known as pattern B) cholesterol. Here’s a pretty good explanation of why VAP is better. The site suggests the standard cholesterol test fails to identify as many as 60% of people who are at risk for cardiovascular disease.

Cholesterol is much more complicated than a single number. Don’t let that total cholesterol number fool you into complacency. If you have other risk factors (like diabetes, high blood pressure, elevated blood sugar, family history of heart disease) you shouldn’t assume your total cholesterol number or even your LDL number means you’re safe. Check out your triglycerides to HDL ratio and ask your doctor for an advanced cholesterol test.

Oh, and as I’ve mentioned before, if you have these risk factors you might consider having a coronary artery scan as well.

 

The Fish Oil Conundrum

It’s hard enough to know what to eat to lower your risk of heart disease, but it’s even more complicated to know what, if any, supplements to take. If I had a nickel for every claim I’ve seen on the Internet about herbs, essential oils, vitamins, and other supplements that help your heart, well, I’d have a shit ton of nickels. I’m a skeptic by nature, but beyond that I prefer to act based on fact versus hyperbole.

But one thing we know for sure is that fish oil is good for your heart. Right? Well, the real answer is — it depends on what you mean by “good for your heart.” Despite all the studies done over the last few years, there is no proof that taking omega-3 fatty acids (fish oil) will decrease your risk of having a heart attack. OK, well, fish oil lowers cholesterol at least, right?

“If you’re taking supplements like fish oil or a multi-vitamin in the hopes of improving your cholesterol counts, save your money.” — Cleveland Clinic

It turns out that fish oil has been proven to lower your triglycerides, which is a significant risk factor for heart disease. But it does not lower your cholesterol. Which I think would be a surprise to most people. It certainly was to me.

I had very high triglycerides, which I believe was one of the main factors that led to my heart attack at age 45. So in the years following my heart attack I started taking fish oil supplements and that, along with significantly decreasing my consumption of bread and other processed carbs, lowered my triglycerides dramatically. How dramatically? Prior to my heart attack and before drug therapy to lower it, once or twice my trigs were measured well north of 500. The medical consensus on triglycerides suggest they should be below 150. These days my trigs have been consistently around 100.

But then about a year ago a blood test showed they had crept back up to around 175. I had been slacking on my diet, eating a bit more carbs and sugar than I should have been, so I redoubled my efforts to stay away from processed carbs and sugar and doubled down on my fish oil, going from 2,000 mg a day to 4,000 mg a day. My trigs immediately nosedived back down under 100.

All’s well, yes? As college football commentator Lee Corso says — not so fast my friend. In the months following my increased fish oil consumption, my LDL cholesterol started creeping up. From 35, to 42, to 48 to my most recent results in which my LDLs came in at 59. Still lower than the recommendations, but over about a one year period that’s a 70 percent increase!

Was I doing something else differently that could cause my LDL levels to skyrocket? I hadn’t changed any of my medications. I was eating more unsaturated fat, but that is good fat (avocado, olive oil, nuts, etc.). Could it be the fish oil? Can fish oil actually raise LDL levels? If so, how come I didn’t know this before upping my daily dose by 2,000 mg a day?

Off to the Internet I went and sure as shit, there is evidence that high doses of fish oil can increase LDL levels.

“Despite their excellent ability to reduce triglycerides naturally, EPA and DHA actually increase LDL cholesterol, concerning some doctors and medical researchers.” — University Health News

Sometimes no matter what you do you can’t win! Something I was doing successfully to lower my triglycerides may be raising my bad cholesterol. While I’m not 100 percent sure fish oil is the culprit of my increased LDLs, there’s one way to find out — take less fish oil and retest my blood. I have an appointment with my doctor this week to discuss just that and I’ll report back on his take on the matter. In the meantime, if you are one of the nearly 20 million Americans taking fish oil be sure to keep an eye on your LDL levels.