Beyond “High Cholesterol": Reframing the Conversation on Lipid Panels

It's about more than "good" vs "bad" numbers

May 27, 2025

ICYMI 👉

Tune in (here or on the app) Friday 5/30 at 3 pm ET for our next live Q&A! This week is ASK ME ANYTHING.

New feature! 📣 All subscribers can write me questions in REAL TIME to answer live. As always, paid subscribers can submit their questions for me to answer right here!

MARK YOUR CALENDARS for a live conversation with primary care doctor and writer, Adam Cifu, MD — Tuesday 6/3 at 5 pm ET right here. We’ll discuss who to trust in medicine and public health, and what’s the deal with the FDA’s new COVID vaccine guidance. 💊

A few months ago, my patient Mark expressed concern about his high cholesterol. He'd arrived fifteen minutes early to his appointment, armed with highlighted printouts of the lab tests I ordered, and a list of questions. He’d even started planning his lifestyle and dietary changes. At 52, Mark was naturally concerned that his father had a heart attack at age 58. His total cholesterol was 210, with an LDL of 116—numbers that barely cross conventional thresholds. But the red flag on his report next to this number had him visibly shaken.

Two days later, I saw another patient, Lisa, for her annual physical. When I mentioned her LDL had crept up to 155, she shrugged it off completely. She noted that her “good HDL cholesterol” was at 62, and she made it clear she did not want any further discussion about it. She planned to take some fish oil and leave it at that.

Both patients were operating from the same framework we've been teaching patients for decades: HDL is "good" cholesterol that protects your heart, while LDL is "bad" cholesterol that clogs arteries. Take statins if your numbers are concerning. Avoid eggs. Case closed.

This binary approach, while convenient for quick explanations during our all-too-brief appointments, vastly oversimplifies a complex biochemical reality. It can leave patients like Mark unnecessarily worried and patients like Lisa with a false sense of security. Neither serves their health in the long run.

Today, I want to explore why our traditional approach to cholesterol discussions falls short, what your lipid panel is actually telling you, and how a more nuanced understanding can empower you to make targeted, personalized health decisions.

fried egg on black pan — Photo by James Kern on Unsplash

Beyond Good vs. Bad: What Your Lipid Panel Actually Measures

When you receive a standard lipid panel, you typically see four primary numbers:

Total Cholesterol: All the cholesterol in your blood
LDL (Low-Density Lipoprotein): Traditionally called "bad cholesterol"
HDL (High-Density Lipoprotein): Traditionally called "good cholesterol"
Triglycerides: Fats in your blood from excess calories

This panel, while useful, is essentially measuring the concentration of different lipid-carrying vehicles in your bloodstream, not the actual risk they pose to your arteries.

Think of it this way: LDL particles are like delivery trucks carrying cholesterol through your bloodstream. Traditional tests measure how much cargo (cholesterol) these trucks are carrying collectively, but not how many trucks there are or their size—which turns out to be crucial information.

The Particle Problem: Size and Number Matter

Here's where our understanding has evolved significantly: not all LDL particles are created equal. Small, dense LDL particles can more easily penetrate arterial walls and become oxidized, leading to inflammation and plaque formation. Larger, “fluffier” LDL particles, while still containing cholesterol, appear less likely to cause damage.

Two people can have identical LDL numbers but vastly different cardiovascular risks depending on their particle size distribution. Yet standard lipid panels don't distinguish between them.

Similarly, HDL functionality matters more than quantity. Some people with high HDL numbers still develop heart disease because their HDL isn't effectively performing its primary job: helping to remove excess cholesterol from the body.

What about Inflammation?

The cholesterol-centric view of heart disease risk overlooks another critical factor: inflammation. Cholesterol deposits alone don't cause heart attacks. Rather, it's the inflammatory process that can destabilize arterial plaques, causing them to rupture and trigger clots that block blood flow.

This explains why some people with "perfect" lipid panels still have heart attacks, while others with elevated LDL never develop cardiovascular disease. Their inflammatory profiles differ significantly.

Markers like high-sensitivity C-reactive protein (hs-CRP), which measures systemic inflammation, can provide crucial context to your lipid results. Yet these tests aren't routinely ordered or discussed in many primary care settings.

Reframing the Cholesterol Conversation

So how might we better discuss lipid panels with patients? Here's my approach:

First, I explain that lipid measurements exist on a continuum rather than in tidy categories of "normal" versus "abnormal." A total cholesterol of 210 mg/dL might be perfectly fine for one person but concerning for another, depending on their overall risk profile.
Second, I place cholesterol numbers in the context of other risk factors: family history, blood pressure, smoking status, blood sugar control, physical activity, and inflammatory markers. An LDL of 140 means something different for a 45-year-old active woman with no other risk factors versus a 60-year-old man with diabetes and hypertension.
Third, I discuss advanced testing options when appropriate. For patients at intermediate risk or those with family histories of premature heart disease, tests like apolipoprotein B (apoB), LDL particle number, or lipoprotein(a) can provide more precise risk assessment.

The Role of Coronary Calcium Scoring

Coronary calcium scoring also offers a valuable additional layer of information beyond standard lipid panels. This specialized CT scan detects calcified plaque in the coronary arteries, providing direct evidence of atherosclerosis rather than just risk factors.

For patients with borderline or conflicting lipid results, a calcium score can help determine who truly needs more aggressive intervention. A score of zero suggests the absence of plaque, and a non-zero score indicates its presence.

The test is most valuable for people at intermediate cardiovascular risk—those with some risk factors but no clear indication for aggressive treatment. My patient Lisa, for example, with her borderline cholesterol levels, or those with family histories of heart disease, or those with other cardiovascular risk factors like hypertension or diabetes might benefit from a calcium score to better direct treatment.

Patients at very low risk typically don't need the test, while those already known to be high-risk should receive comprehensive treatment regardless of calcium scores.

Beyond Statins: Targeted Interventions

This nuanced understanding opens the door to more personalized interventions beyond "take a statin" or "avoid eggs." For patients with elevated small, dense LDL particles, reducing refined carbohydrates and sugars often proves more effective than limiting dietary cholesterol. For those with high triglycerides, moderating alcohol consumption and increasing omega-3 fatty acids may be key.

Regular physical activity improves particle size and HDL functionality even when it doesn't dramatically change the numbers on your standard lipid panel. Anti-inflammatory diets rich in colorful vegetables, olive oil, and fatty fish address the inflammatory component that standard cholesterol-lowering approaches might miss.

Questions to Ask Yourself and Your Doctor

If you've been told you have high cholesterol, I encourage you to ask these questions:

Beyond my basic lipid numbers, what does my overall cardiovascular risk profile look like?
Might advanced lipid testing provide valuable additional information in my case?
Given my specific lipid pattern, which dietary and lifestyle modifications are most likely to help?
Does a coronary artery calcium score makes sense for me?
If medication is recommended, how does it address my particular lipid pattern and risk factors?

Remember that cardiovascular health extends beyond numbers on a lab report. Your lipid panel offers valuable information, but it's just one piece of a complex puzzle that includes inflammation, genetics, lifestyle, and other biomarkers. My podcast episode about cardiovascular health is here.

So, tell me—what burning questions do you have about heart health and cholesterol? I’m all ears! (You can also bring them to me LIVE on Friday!)