Understanding Cholesterol
And interpreting your blood tests
Cholesterol is a vital part of the building blocks of our bodies. 80 per cent is manufactured in the liver and only 20 per cent comes from diet. Here we'll look at the tests required for assessment of your cholesterol and metabolic health.
Blood Pressure
Easy to measure at home
Investing in your own blood pressure machine with a properly sized arm cuff is a wise investment. The blood pressure reading has two measurements, the first is called systolic and measures the pressure when the heart contracts or beats. And a second called diastolic, which is the pressure when the heart relaxes between beats.
Hypertension is high blood pressure. A rule of thumb for hypertension: If you are thin (no belly fat) with hypertension, try reducing salt for 4 weeks. Actively manage your stress and improve your sleep.
If you are overweight (with belly fat) with hypertension, it is likely sugar overload is the root cause. Try the Diet Whisperer 12-Week Reset Plan and then retest. Your salt does not need to be reduced unless the 12-Week Reset Plan fails to reduce your blood pressure to normal.
Lipoproteins (Cholesterol)
HDL-C and LDL-C
80 per cent of Cholesterol is manufactured in the liver and only 20 per cent comes from diet. Cholesterol is essential for life and is found in every cell in our body. It needs to be transported around the body in the blood, but cholesterol is not water soluble. Therefore, it is transported in tiny balls called lipoproteins, which makes it soluble for travelling in the blood.
The names given to our different lipoproteins can be confusing, but I shall simplify it here. They are classified by their 'density' and are labelled as follows:
LDL-C: Low density lipoprotein is LDL and because it carries cholesterol is called LDL-C.
HDL-C: High Density Lipoprotein is HDL and because it carries cholesterol is called HDL-C.
LDL-C is not all bad, and HDL-C is not all good. We can now break down these lipoproteins into small and large particles for both HDL-C and LDL-C. The evidence is emerging about HDL-C small particles, so let's put those aside. You can generally still correctly assume that HDL-C is the good guy, and guides to levels and units are set out later. Essentially, the higher the better.
LDL-C particles are now better understood. And we split it into:
a) Small dense particles, like bullets, penetrate the lining of our blood vessels furring them up with atheroma, the origin of cardiovascular disease.
b) Large fluffy particles, that seem to positively help with life, in particular our immune system.
The particles help us answer some previous conundrums:
- Up to 50% of people admitted with heart attacks have normal or low LDL-C.
- In over 60's a higher LDL-C is protective from death from all causes.
- In the Framingham study data indicates LDL has to be very high to correlate with CVD.
- Higher LDL-C in older people confers better immunity.
So, it's not how high your LDL is! It's which part is high, the helpful (large) or the harmful (small) particles.
Statins
Statins are drugs that lower LDL-C overall, but they lower the good more than the bad particles. Before a statin is started for prevention of heart disease, the particle types should always be established. And your doctor should explain exactly what the objective of starting the statin is. Because most doctors don't do the particle test, we will describe how to assess this using 'surrogate' markers.
After heart attacks it may well be the anti-inflammatory effects of statins that confers their benefit, rather than their effects on small dense LDL-C. Science has not sorted this out yet.
Science informs us that statins alone will only play a small part in saving us from heart disease. Taking exercise, not smoking, drinking sensibly, correcting our omega 6/3 ratio and having a normal waist circumference reduces cardiovascular risk by over 80 per cent. Conversely, for every 1 inch in waist circumference above normal, your risk of heart disease increases by 5%.
And if your small particle LDL is up, it's not fats in your diet that are causing this, it's usually the high amount of sugars in your diet.
The secret to understanding cholesterol is to use your test results to differentiate the good guys from the bad guys. Here's our guide, but you should always consult your doctor.
The total cholesterol TC:HDL ratio is less good than the triglyceride TG:HDL ratio (see Triglycerides below) for predicting heart disease, so we recommend the latter, see below. The TG:HDL ratio is also the best surrogate test outside of a fasting insulin blood test for insulin resistance (IR).
Triglycerides
(TG)
Triglycerides are fats stored in the fat cells of the body. When triglycerides are high in the blood, the risk of cardiovascular disease increases. High triglycerides are also a sign of metabolic syndrome and insulin resistance.
Raised TGs are a great indicator of diet quality and diet quantity. Both drinks and food.
Raised TGs, indicate a diet of processed foods and nutrient poor foods and drink (fruit juice and fizzy pops). It indicates excessive consumption of foods that are high in the sugars, glucose and fructose. Our body can safely metabolize small amounts of glucose and fructose. The recommended spoons of sugar per day is 5—6, whereas in the Western Pattern Diet (WPD), high in processed foods, packaged and fast foods we are now eating 47 teaspoons per day. This is mainly from hidden added sugar and high fructose corn syrup (HFCS). In excess, sugars are very toxic causing fatty liver, metabolic syndrome, and cardiovascular disease. They are associated with the causing, or worsening, of just about every chronic inflammatory disease (see TG:HDL ratio below).
Raised TGs is a 'surrogate test' indicating high bad small particle LDL-C.
For this scenario a very low carb diet like the Diet Whisperer 12-Week Reset Plan, should be trialled with further tests at week 12 to check progress. This is essential as there is a significant risk of cardiovascular disease if high TGs continue unabated. The great news is that with a little effort this can be turned around, and your risks massively reduced. Before commencing the 12-Week Reset Plan, it is worth talking to your doctor and getting all the tests outlined here, recording them and comparing them when the 12-Week Plan is completed. Calculators and converters are available on the calculator tab at the top of this page.
Normal; below 150 mg/dL (1.7 mmol/L)
Borderline; 151 to 199 mg/dL (1.8 -2.2 mmol/L)
High; 200-499 mg/dL (2.3 - 5.6 mmol/L)
Very high; above 500 mg/dL (5.7 mmol/L)
HDL LDL
And TG:HDL ratio
Insulin resistance (IR) is the central cause of all our modern metabolic problems and obesity. It is strongly correlated with almost every chronic disease. So, the opposite is also true. when you eliminate IR using the Diet Whisperer 12-Week Reset Plan, you will get back to normal healthy metabolism and normal weight.
In insulin resistance (IR), TGs go up and HDL goes down. Hence the importance of the ratio. Some of the ranges are listed below. There is also evidence about the functionality of HDL being altered by different foods. Poor oils and foods and drinks down-regulate its good functionality, and vice versa.
Good foods for HDL are ground nuts, Extra Virgin Olive Oil (EVOO), oily fish, and green tea. Bad foods are seed oils, vegetable cooking oils, foods with a high omega 6/3 ratio, highly refined carbs, sugars and high fructose corn syrup. Remember 75% of all processed foods (fast foods or packaged foods) contain added sugar.
- The TG:HDL ratio is a 'surrogate test' indicating insulin resistance.
- The TG:HDL ratio is a 'surrogate test' indicating metabolic syndrome.
- The TG:HDL ratio is a 'surrogate test' indicating a big increase in cardiovascular disease.
A high TG:HDL ratio elevates the risk of heart attack and stroke (cardiovascular disease or CVD) by up to 16 times! If your ratio is over 2.5 your risks of metabolic syndrome and CVD risks are significantly raised. This requires a very low carb diet, except of course for the very healthy high fibre greens, which should be increased. In other words, this is a dietary sugar overload problem and not a dietary fats problem. Your liver is fatty, and this is from the high dietary sugar load.
TG:HDL units are a ratio (ensure both are in the same units; either mmol/L or mg/dL).
- Normal: 1.1 - 2.1
- Abnormal: 2.1 -2.5 (indicating early insulin resistance)
- Serious: Over 2.5 (indicating high insulin resistance, high cardiovascular risk, and high small dense LDL cholesterol particles)
Try entering your fasting values in the calculator below.
a. If your HDL-C is over 60 (1.55) your CVD risk is minimal, full stop.
b. If your LDL-C is under 100 (2.59) your CVD risk is minimal, full stop.
You may need to see your doctor under the following circumstances for further tests:
c. If your HDL is less than 40 (1.03) in men, or less than 50 (1.29) in women your CVD risk is significantly raised.
d. If your LDL is 100-300 (2.59-7.76) your risk of CVD is rising (higher number = higher risk).
e. If your LDL is above 300 (7.76) this indicates a rare (1 in 300) familial (genetic) type of high cholesterol (seek expert opinion).
f. If your LDL is 100-300 (2.59-7.76) and your TG normal, that is under 150 (below 1.69) and fasting insulin is normal, this is a situation requiring a low fat, low sugar diet and a statin (seek expert opinion). It can also be an indication of a healthy high fat diet.
g. If your LDL is 100-300 (2.59-7.76) and your TG is over 150 (1.69) you most likely have fatty liver, metabolic syndrome with greatly increased CVD. Initially you would try a very low carb diet and check the results again in 3 months. Try the Diet Whisperer 12-Week Plan. Then re-test.
h. If your TGs are over 150 (1.69) and HDL is low this requires a trial of a very low carb diet to see if the ratio of TG:HDL improves over 3 months. Try the Diet Whisperer 12-Week Reset Plan. Then re-test.
These are the most useful combinations of 'cholesterol blood test' results. The above scenarios get to the root cause of the problem. Except for scenarios (e) and (f) commence the Diet Whisperer 12-Week Plan, supervised by your doctor, and then repeat the tests after 3 months, when you have completed the plan. You and your doctor should have a pleasant surprise.
Homocysteine levels
History of heart disease
High levels lead to furring of arteries, eventually leading to heart attacks and strokes. High levels also indicate poor liver mitochondrial health.
If you have a strong personal or family history of heart disease, then a Hcy blood test should be taken. Hcy is an amino acid that is inflammatory and should be cleared from the blood stream as soon as possible. Clearance is by vitamins B6, B12 and folate (also known as B9 or folic acid). If Hcy is raised, blood test should be done to assess for deficiencies in the vitamins.
Liver Function Tests
All signs of liver damage must be taken seriously
High levels lead to furring of arteries, eventually leading to heart attacks and strokes. High levels also indicate poor liver mitochondrial health.
If your liver tests fall into the ranges on the right, then see your doctor to arrange for liver scans, and a full assessment for non-alcoholic fatty liver disease.
Sick liver mitochondria are indicated by raised AST, raised fasting insulin, raised homocysteine, and raised uric acid (see below). It should be noted that mitochondrial liver damage is associated with:
- Low vitamin B9 also called folate or folic acid
- Too high levels of sugar in the diet
- Too high fructose in the diet (processed food and drink including fruit juices)
- Too high uric acid (see below)
A fatty liver is indicated by:
- Raised ALT
- Raised Fasting Insulin
- AST under 25 U/L OK. Over 25 Risk of mitochondrial dysfunction in the liver
- GGT under 35 U/L OK. Over 35 May have liver toxicity from alcohol or a high sugar diet.
Uric Acid
Indicates mitochondrial stress in the liver, resulting in increased fatty liver. This can result from excess dietary alcohol, glucose and fructose. Other foods high in purines may also raise uric acid like sardines, mackerel and anchovies.
If the levels are above those shown in the table, avoid excess dietary alcohol, glucose and fructose. Start the Diet Whisperer 12-Week Reset Plan and re-test after 3 months.
Men: normal is less than 6.0 mg/dL (0.354 mmol/L)
Women: normal is less than 7.0 mg/dL (0.413 mmol/L)
HbA1c
HbA1c measures the blood sugar “average” for the past three months. But beware, it has major variability and should not be relied upon. A fasting blood glucose, or OGTT is a much better test.
Nevertheless, HbA1c is used in clinical practice, but it will miss a significant number of patients with pre-diabetes and frank diabetes (up to half). A fasting blood glucose is accurate and gives an instant measure, which is both its weakness and its strength.
This is also missing the point rather in the world of prevention. They add nothing to assessing your “risk” of developing diabetes. Remember, Insulin Resistance (IR) is the start of a metabolic journey, that may take years or even decades to turn into full blown metabolic syndrome and diabetes, during which time your body will have been exposed to the associated inflammation. In other words, much damage will occur along the way: hypertension, furring of arteries, CVD, heart attacks, strokes, cancer, weight gain etc. Therefore, we need to do the correct tests if we are to prevent these things happening.
So, the blood tests to order ascertain your fasting insulin, and your insulin resistance, and there is no adult human being alive that would not benefit from knowing the results of these tests!
Test (a) Fasting Insulin
Test (b) Fasting Glucose
- Optimal: Less than 5.0 (Less than 100)
- Normal: 5.0 - 5.7 (100 - 116)
- Pre-diabetes 5.7 - 6.4 (117 -137)
- Diabetes 6.5 or higher (> 137)
Fasting blood insulin
units for fasting blood insulin (iu/dl)- Optimal: 2 - 6 (meaning optimal insulin sensitivity)
- Normal: 6 - 10 (meaning good insulin sensitivity)
- High: 10 - 25 (progressive and increasing insulin resistance)
- Very High: (full blown Insulin resistance)
Note: it is best to do three separate tests and take the average value, in the perfect world.
Fasting blood glucose
units for fasting blood glucose (mg/dl) and (mmol/l)- Normal: 70 - 90 (3.9 - 5.00)
- Pre-pre-diabetes 90 -100 (5.00 - 5.56)
- Pre-diabetes 100 -125 (5.51 - 6.90)
- Diabetes over 125 (above 7.00)
Fasting HOMA-IR
- Optimal 0.5 - 1.9
- Insulin resistance: 2.0 - 2.9
- Severe insulin resistance over 2.9
%
Please enter an input in %
hsCRP
High sensitivity CRP
This is an indicator of the body’s inflammation. Inflammation can result from infection, aging or disease. This more sensitive test reveals early sub-clinical inflammation, that may indicate you are heading to metabolic issues. It raises a very sensitive, early red warning flag for long term inflammation related chronic diseases, as listed above.
- Best: Less than 0.50
- Very good: Less than 1.00
- Average: 1.00 - 3.00
- High: 3.00 - 6.00
- Very high: over 6.00
30 min, 1-hour and 2-hour post meal glucose
If your blood sugar is raised after eating, then the levels indicate the magnitude of the problems. This is particularly important if a glucose monitor is worn. This is helpful in personalising your healthy eating, as you can ‘trial’ different carbs and see how they affect you personally. We know that different people’s blood glucose responds differently to differing foods.
For example, one person may get a big spike from a glass of beer, that has no such effect on another person. One person may get a big glucose spike to white rice, and not another. A guide to your results is the highest the glucose peaks at.
over 135 (7.35)
Damage to small blood vessels at levels
over 160 (8.89)
Glucose enters the urine at levels between
160-180 (8.89 - 10.00)
- Optimal: Less than 120 (6.67)
- Normal: Less than 160 (8.89)
- High risk: Over 160 (8.89)
Blood Tests
Further assess your metabolic status
The American Heart Association recommends Cholesterol tests should be performed every 5 years