It's All about Balance, Even Cholesterol


It is difficult to know who to believe when it comes to the impact of cholesterol on risk for developing heart disease. If you believe your television set, we could all benefit by taking medication (or three) for lowering our heart disease risk, yet we also know you have to treat a whole lot of people for high cholesterol before just one heart attack is prevented!

If you believe much of what you read online, cholesterol doesn’t matter, and all you have to worry about is getting the right ratio of fatty acids in your diet, or via supplements, and all will be well.

If you believe your family doctor, or at least most family doctors, you should probably take a statin (because the guidelines say so), but you don’t need to take any steps to improve your diet, get more exercise, or reduce stress (because the guidelines say so). Unfortunately, most of the data that gets incorporated into “guidelines” is either so corrupted by the influence of pharmaceutical companies (because the “experts” like to make a few extra bucks on the side consulting and performing pharmaceutical-sponsored clinical trials), omits the data on diets like the Mediterranean diet, or is based on studies performed on lots of middle-aged white men (i.e., not women, or racial minorities, who are at the highest risk for heart disease).

So, who do you believe? Well, I suppose I am asking a lot to believe me, after all I’m just another doctor - which are really a dime a dozen, (well maybe a co-pay a dozen). Hopefully, you are at least intrigued by my attempts at frankness to keep reading!


Total cholesterol vs. LDL vs. HDL vs. their Ratio

Most of you know that LDL is the “bad” type and HDL is the “good” type. (See Complementary Corner 11/06 for more information). “Total” cholesterol is the sum of LDL, HDL and VLDL cholesterol, but VLDL is rarely measured directly. VLDLs mostly carry fats, called triglycerides.

In the past five years, a large international study called INTERHEART was published, providing very convincing data about the importance of cholesterol and the risk for having a heart attack. INTERHEART is unique because, unlike some previous studies, it was performed internationally, including 52 countries and almost 30,000 participants. INTERHEART compared the contribution of LDL, HDL, total cholesterol, the ratio of LDL to HDL, and the ratio of total cholesterol to HDL. According to the study’s findings, the ratios predicted risk far more accurately than either total cholesterol, or LDL cholesterol alone! (1)

So, if the ratio is most important, then what is the optimal ratio? According to INTERHEART’s findings, we are all at increased risk if our ratio of total cholesterol to HDL cholesterol is greater than 2.7!  And having a less than optimal ratio, world wide, accounts for approximately 32-54% of all heart attack risk! (1)

Some examples of optimal ratios include the following:

total cholesterol = 175, HDL=65
total cholesterol = 200, HDL=74
total cholesterol = 220, HDL=81

So, you can quickly see that reaching an optimal ratio is possible while maintaining high levels of LDL cholesterol, but it requires also having very high healthy HDL cholesterol.


How Can I Reach a Healthy Ratio?

Well, simple math suggests that reaching an optimal ratio can be reached by three main strategies:

1. Lowering LDL
2. Raising HDL and/or
3. Lowering VLDL.

For the purposes of this article, I am going to focus on the last two, because lowering LDL was covered in good detail here.


Lower VLDL and triglycerides

Lowering VLDL is not discussed in great detail in most clinical recommendations, mostly because VLDL is not commonly measured or reported. However, VLDL is elevated when triglycerides are elevated. In diabetes, it is recommended that triglycerides be lower than 150 mg/dl. This can be achieved by primarily watching your diet. Interestingly, until recently, dietary recommendations focused on lowering fat in the diet in order to lower triglycerides becayse lowering saturated fat (the type in red meat, pork, dark meat poultry and full fat dairy), in particular, does lower triglycerides.

However, better designed nutrition research also demonstrates that lowering dietary carbohydrates actually has a large effect on lowering triglycerides, and replacing saturated fat with unsaturated fats such as olive oil and oils from nuts is actually more beneficial than replacing fat with more carbohydrates! (2) In diabetes in particular, lowering dietary carbohydrates is one of the most effective dietary methods for lowering blood glucose, as well. The two are intimately connected, as when more carbohydrates and fat are eaten than get burned off from daily activity and exercise, the body stores these extra calories as triglycerides. As triglycerides get high, the body looks for places to store them, including around our waist and in our liver!

What is discussed even less than how to lower triglycerides, is the impact triglycerides have on HDLs! It is nearly impossible to raise HDL cholesterol when triglycerides are too high. This is because when triglycerides are too high the body runs out of places to put them, and runs out of places to move them around in the blood. The body actually shifts triglycerides out of VLDL and into both HDL and LDL cholesterol. There are two primary downsides of this change when it comes to HDL. The first is that when HDLs are filled with triglycerides they become smaller and denser and the body eliminates them from the blood stream much more quickly. Unfortunately the rate of production stays the same, so HDLs actually go down (or don’t come up) when triglycerides are too high.(3)

The other negative affect of having too many triglycerides in HDLs is that HDL can no longer do their job as well. HDLs actually protect LDLs from oxidation (review Complementary Corner 11/06 for more information on the impact of oxidized LDLs), and when HDLs become too triglyceride-filled they are no longer as protective to LDLs. So, not only does having triglycerides too high keep you from getting your HDLs high (and thus improving your ratio), but it also leads to having more oxidized LDLs in circulation. Yikes!


Raising HDL

The section above discusses the important link between triglycerides and HDLs, so the first step to raising HDLs, and getting your ratio closer to 2.7, is making sure your triglycerides are under control. After that, the approaches described below work more quickly and with a greater total effect.

Several medications can be used to raise HDLs. Triglyceride-lowering drugs such as fenofibrate, may be necessary to lower triglycerides which stay too high despite reducing dietary carbohydrates and saturated fats. Because of the link between triglycerides and HDLs, medications that lower triglycerides do typically raise HDLs.

Another medication that is probably the best option for raising HDLs is niacin. Niacin is a B vitamin that can be used in very large dosages as a medication to both lower LDL and raise HDL. Niacin works by reducing the clearance of HDLs by the liver. Again, I would be sure your triglycerides are low first, because although this hasn’t been definitively proven, reducing the clearance of less effective HDLs can’t be nearly as good as reducing the clearance of optimally effective HDLs! Niacin does have side effects, including a flushing reaction which can be very uncomfortable. However, for most people, the flushing gets less significant in a few days to weeks, and can be reduced by following a few simple recommendations, including taking it with a snack, taking it at bedtime, avoiding alcohol soon after taking it, and, if necessary, taking a low dose aspirin about 20-30 minutes before hand. Niacin is not recommended if you have liver problems, or have gout, and some people develop mild inflammation of the liver when they start taking it; your doctor should check your liver periodically if you begin niacin therapy.

Finally, although I am sure few of you want to read this, statin medications do raise HDLs, but not nearly as well as niacin.


Lifestyle Options

There are two primary lifestyle approaches to raising HDL cholesterol: exercise and moderate alcohol consumption. Exercise is the time tested approach to raising HDL cholesterol, and this effect is part of the reason why people who exercise regularly have a lower risk of developing heart disease.

Alcohol consumption has a bad connotation in our society, because of its potential for addiction and because it is often used as an excuse for lack of self-control. However, for those people - even people with diabetes - who can handle alcohol responsibly and not over-indulge, moderate alcohol consumption may actually be good for you. Those who choose to drink moderate amounts of alcohol not only develop less heart disease, they also live longer (4,5). “Moderate” is defined as up to two drinks per day for men, and one drink per day for women. A “drink” is defined as a 12 oz. beer, 5 oz. of wine and 1-1.5 oz. of spirits (depending on the proof). Because red wine is also high in the potent LDL-protecting antioxidant resveratrol, I believe to be best choice for heart disease protection (although the data does show all alcohol to be protective).

There are a few special considerations for people with diabetes regarding alcohol. As mentioned, recent studies suggest moderate alcohol intake in diabetes is associated with improved blood sugar control, even in those individuals who did not previously consume it (6).However, many alcohol beverages contain a moderate to high amount of carbohydrates, especially mixed drinks and dark beers, and so these carbs need to be included in your daily carb intake. Also, because many people with diabetes have mild inflammation in the liver due to triglyceride storage, it may not be appropriate to consume alcohol at all! Also, many medications do not mix with alcohol, so talk with your doctor about the safety of your medications with alcohol. Finally, alcohol is not a solution to depression. If you think you may be depressed, please do not start consuming alcohol, and ask your doctor for an effective treatment.



For those of you who have always thought there was more to heart disease then just your LDL cholesterol, you are absolutely right. Your HDL and VLDL are important too! Although the focus of most doctors is on LDL cholesterol (because statin drugs work very well at lowering it- thus it is easy for them), it is truly the ratio of total cholesterol to HDL cholesterol that appears to be the most important risk factor to optimize. This is good news because it provides options other than just statins for optimizing your risk factors to avoid heart disease! Remember, the optimal ratio is very low - around 2.7- so if your LDL is too high, and you have changed your diet and do not want to take a statin medication, it is important that you raise your HDL through lifestyle, and when necessary taking appropriate medications to lower triglycerides and/or raise HDL.

Low carbohydrate intake, minimal saturated fat, moderate alcohol use, and regular exercise remain guaranteed approaches to optimize your ratio and lower your cardiovascular risk.

Salud! Ryan Bradley, ND, MPH

December, 2008



  1. McQueen MJ, Hawken S, Wang X, et al. Lipids, lipoproteins, and apolipoproteins as risk markers of myocardial infarction in 52 countries (the INTERHEART study): a case-control study. Lancet. Jul 19 2008;372(9634):224-233.

  2. Hollenbeck CB, Coulston AM. Effects of dietary carbohydrate and fat intake on glucose and lipoprotein metabolism in individuals with diabetes mellitus. Diabetes Care. Sep 1991;14(9):774-785.

  3. Singh IM, Shishehbor MH, Ansell BJ. High-density lipoprotein as a therapeutic target: a systematic review. JAMA. Aug 15 2007;298(7):786-798.

  4. van Dam RM, Li T, Spiegelman D, Franco OH, Hu FB. Combined impact of lifestyle factors on mortality: prospective cohort study in US women. BMJ. 2008;337:a1440.

  5. Ferreira MP, Weems MK. Alcohol consumption by aging adults in the United States: health benefits and detriments. J Am Diet Assoc. Oct 2008;108(10):1668-1676.

  6. Shai I, Wainstein J, Harman-Boehm I, et al. Glycemic effects of moderate alcohol intake among patients with type 2 diabetes: a multicenter, randomized, clinical intervention trial. Diabetes Care. Dec 2007;30(12):3011-3016.