Optimal Cholesterol Levels: A Functional Medicine Guide
"Cholesterol is neither good nor bad. It’s simply a molecule that your body needs. The problem is when it gets out of balance."
—Dr. Michael Brown, Nobel Prize Winner for cholesterol research
Cholesterol has become a buzzword that strikes fear into the hearts of many, but it’s misunderstood. Much like stress, pain, or sugar, cholesterol isn’t inherently harmful—it's essential for life. Every cell in your body relies on it to function, from building cell membranes to producing critical hormones like estrogen and testosterone. The real problem arises when cholesterol levels fall out of balance, increasing the risk for serious health issues like stroke, hypertension, peripheral artery disease, cognitive decline, and heart disease.
This article delves into the complexities of cholesterol, clearing up common misconceptions and helping you understand its vital role in your body, how to interpret your blood test results, and the ideal ranges to strive for.
Writing this took far more time to write than I’d like to admit, thanks to all the misinformation and old-school recommendations out there. I’m glad I did it and plan to use this as my lipid profile functional medicine guide moving forward.
What is Cholesterol?
Every single cell in your body relies on cholesterol as a building block—without it, your cells couldn’t maintain their structure or communicate properly. Cholesterol is also the starting material for crucial hormones like estrogen, testosterone, and cortisol, driving everything from stress response to reproductive health. Even your digestion depends on cholesterol, as it’s essential for the production of bile acids, which help break down fats.
The HDL, LDL, and Total Cholesterol we often reduce our cholesterol to represent just one part of the picture. To get the full picture, a comprehensive lipid profile is essential. This deeper dive assesses additional markers like triglycerides, VLDL, and non-HDL cholesterol, offering insight into all the moving parts that influence heart health. Advanced markers such as ApoB and Lp(a) provide a more accurate assessment of atherosclerotic risk, especially in patients with insulin resistance or inflammation.
Why Cholesterol Matters
Cholesterol helps build cell membranes, produce critical hormones like testosterone and cortisol, and aids in digestion through the formation of bile acids. Your body naturally produces the majority of the cholesterol it needs, primarily in the liver. When cholesterol levels become imbalanced, however, it can lead to a dangerous condition called atherosclerosis. This occurs when cholesterol and other substances accumulate in your artery walls, restricting blood flow and increasing the risk of heart disease and stroke.
One of the biggest misconceptions is that all cholesterol is harmful. In reality, LDL cholesterol can become problematic when it builds up in your arteries, but HDL (high-density lipoprotein) works to remove excess cholesterol from your bloodstream, helping protect against atherosclerosis. High LDL levels, combined with low HDL, are strong predictors of cardiovascular disease. Additionally, chronic inflammation plays a significant role in heart health; it can exacerbate the buildup of plaques in the arteries. A healthy cholesterol balance, combined with reduced inflammation, is critical for preventing life-threatening conditions, which remain the leading cause of death worldwide.
Testing Your Cholesterol
Many healthcare providers rely on a standard lipid panel to check their cholesterol, but this doesn’t tell the whole story. A standard lipid panel typically only measures total cholesterol, LDL, HDL, and triglycerides. These are important markers, but they don’t provide a complete picture of cardiovascular risk. To get a fuller understanding, it's crucial to request a comprehensive lipid profile, which includes other key parameters. These advanced markers can help assess the true risk of cardiovascular disease. Here’s what to test for:
Total Cholesterol
HDL (High-Density Lipoprotein)
HDL-C (HDL Cholesterol)
HDL-P (HDL Particles)
LDL (Low-Density Lipoprotein)
LDL-C (LDL Cholesterol)
LDL-P (LDL Particles)
Triglycerides
HDL/TG Ratio (HDL to Triglycerides Ratio)
TC/HDL-C Ratio (Total Cholesterol to HDL Ratio)
Non-HDL-C
Apolipoprotein B (ApoB)
Lp(a) (Lipoprotein(a))
Apolipoprotein A1 (ApoA1)
Interpreting Your Cholesterol Profile: A Functional Medicine Approach
While a basic lipid profile can act as a canary in the coal mine, healthcare providers often put too much emphasis on LDL-C without considering other markers which means that you may be being underrated.
Optimal Lipid Levels
LDL-C:
Below 100 mg/dL: Small, dense LDL particles are generally low enough not to pose a health risk.
Over 300 mg/dL: May indicate familial hypercholesterolemia (FH).
Between 100-300 mg/dL: Requires further assessment, particularly triglyceride levels and the triglyceride-to-HDL ratio.
Peter Attia takes this further stating, “Simply put, I think you can’t lower ApoB and LDL-C too much, provided there are no side effects from treatment. You want it as low as possible.” He recommends remarkably low LDL-C levels in the 10-20mg/dl range.
ApoB: < 60 mg/dL (high risk level is > 120 mg/dL)
Peter Attia recommends an even lower range. Read more here.
Triglycerides: < 80 mg/dL.
Triglyceride-to-HDL Ratio: Anything > 3 is strongly suggestive of metabolic dysfunctionAim for < 1.5 but optimal is < 1 according to Casey Means of Good Energy.
HDL-C: 50-90 mg/dL
Total Cholesterol to HDL ratio: < 3.5:1 (< 2:1 is best)
LDL-P: < 800 nmol/L (high risk level is > 1600 nmol/L)
Non-HDL-C: < 115 mg/dL (some say < 85 mg/dL is optimal)
Lp(a): < 10 mg/dL (high risk level is > 30 mg/dL)
TG Ratio: < 2 (Ideal is 1:1)
CRP: < 1 mg/L
Homocysteine: < 7 μmol/L
What to do if….
Triglycerides (TG): If over 500 mg/dL, treat immediately, prioritizing TG management. If below 500, proceed to LDL-C assessment.
LDL-C: Drug therapy is required if LDL-C exceeds 190 mg/dL, regardless of other findings. For lower levels, treatment depends on the patient’s risk profile.
HDL-C: Concern arises if HDL-C is below 40 mg/dL in men or 50 mg/dL in women.
TC/HDL-C Ratio: A ratio greater than 4.0 is problematic.
Non-HDL-C: Always calculate this, as it’s a better predictor than LDL-C, particularly when TG levels exceed 200 mg/dL. The non-HDL-C goal is typically 30 mg/dL higher than the LDL-C goal.
TG/HDL-C Ratio: Use this as another indicator of risk.
ApoB and Combination Therapy: In insulin-resistant patients, low HDL-C often signals elevated apoB particles, which are more atherogenic. Combination therapy may be necessary to manage both LDL-C and non-HDL-C goals when monotherapy fails.
Triglycerides, HDL, TG:HDL: If your triglycerides are greater than 100 and your HDL is less than 50, or the ratio of triglycerides to HDL is greater than 4, then you have metabolic syndrome.
While there are “optimal ranges,” “protocols,” “guidelines,” etc. these numbers need to be assessed by your healthcare provider. And here’s a tip, if they explain your cholesterol using “good” and “bad” and don’t look at a full panel, consider finding another provider.
Source 1, Source 2, Source 3, Source 4.
Takeaway
Cholesterol is not inherently harmful—it's a vital molecule essential for cell structure, hormone production, and digestion. The real issue with cholesterol lies in imbalances, which can increase risks for conditions like heart disease, stroke, and inflammation. Functional medicine takes a more comprehensive view by looking beyond standard LDL and HDL levels to include triglycerides, ApoB, Lp(a), and advanced markers that better indicate cardiovascular risk.
A standard lipid panel only tells part of the story. For a full risk assessment, consider advanced testing, such as an NMR Lipoprotein Fractionation Test, which reveals LDL particle types and inflammatory markers like CRP and homocysteine. These tests, coupled with lifestyle adjustments targeting metabolic health, can offer a more precise, effective approach to managing cholesterol and reducing cardiovascular risks. Remember, if your healthcare provider doesn’t look beyond “good” and “bad” cholesterol, you may benefit from a more comprehensive perspective.
FAQ
What are some common symptoms of high cholesterol?
High cholesterol itself often has no visible symptoms, however, it can lead to serious health issues, such as heart disease and stroke. Regular blood tests are essential for monitoring cholesterol levels.
How is high cholesterol diagnosed?
High cholesterol is typically diagnosed through a blood test called a lipid panel.
Can high cholesterol be hereditary?
Yes, high cholesterol can be hereditary, particularly in cases of familial hypercholesterolemia, a genetic condition that results in high levels of LDL cholesterol from a young age.
How often should cholesterol levels be checked?
Adults should have their cholesterol levels checked at least once every four to six years. Those with a family history of high cholesterol or heart disease may need more frequent testing.
Disclaimer: The information provided in this article is for educational purposes only and is not intended to serve as medical advice. Always consult a qualified healthcare professional before making any changes to your diet, exercise, or treatment plan, especially concerning cholesterol management and blood testing. Individual health needs may vary, and it’s essential to seek personalized guidance based on your unique circumstances.
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