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Short Summary
Main recommendation: Use the triglyceride-to-HDL ratio, with HDL kept in the denominator, as a better predictor of cardiovascular risk than total cholesterol or LDL alone, and aim for a ratio near 1 to 1.5. Dr. Westman explains that ratios adjust a bad marker by a protective one, so raising HDL and lowering triglycerides both improve the result. He also notes most doctors still rely on older LDL- or total-cholesterol-based ratios.
Key Points
- Ratios such as total cholesterol/HDL and LDL/HDL predict heart disease and stroke better than any single number, though they are not perfect predictors.
- The newer metabolic syndrome approach replaces total cholesterol or LDL on top with triglycerides, divided by HDL.
- HDL is treated as protective: Dr. Westman notes that on US-unit lab reports, an HDL above about 60 is generally considered protective, and reports often label it that way.
- Triglycerides are described as a "bad actor" that many doctors overlook, and they travel on VLDL and LDL particles linked to atherosclerosis.
- Dr. Westman says cholesterol itself is essential, and the lipoprotein particles carrying it are what matter for risk.
Details Worth Noting
- Concrete instructions:
- Calculate the triglyceride-to-HDL ratio by dividing the triglyceride value by the HDL value on your lab report.
- Aim for a ratio around 1 to 1.5, with an ideal target near 1 to 1, which Dr. Westman says his studies suggest is very protective and not indicative of insulin resistance or diabetes risk.
- To improve the ratio, lower triglycerides (the top number) or raise HDL (the bottom number); either change improves it.
- Ask your doctor to account for HDL in risk assessment, since many guidelines still focus on the older LDL-based approach.
- Ratios adjust one value against another in the same way BMI adjusts weight for height.
Bottom Line
Your triglyceride-to-HDL ratio, not LDL alone, is the more useful number to check on your lipid panel, and it improves when triglycerides fall and HDL rises.
