Blood Work Series – Part 3: Cholesterol (And Why It’s Not What You Think)
Last week in Part 2 of the Blood Work Series, we talked about metabolic health — fasting glucose, HbA1c, and triglycerides — and how those numbers tell us whether sugar and fat are lingering in the bloodstream where they shouldn’t be.
Today we’re tackling cholesterol.
This is where things get controversial.
And confusing.
Let’s simplify it.
What Is a Standard Lipid Panel?
A standard lipid test (lipid panel) measures:
Total Cholesterol
HDL (High Density Lipoprotein)
LDL (Low Density Lipoprotein)
Triglycerides
Most doctors glance at LDL, circle it in red if it’s above 130, and start talking about statins.
But that’s an oversimplification.
Cholesterol itself is not the enemy.
It’s essential for:
Hormone production
Brain function
Cell membrane integrity
Vitamin D synthesis
If cholesterol were inherently dangerous, your body wouldn’t manufacture it.
HDL and LDL: What Are They Really?
Cholesterol doesn’t float freely in the blood. It’s transported inside lipoprotein particles.
HDL is often labeled “good cholesterol” because higher levels are associated with lower cardiovascular risk.
LDL is labeled “bad cholesterol,” but that framing is incomplete.
LDL’s job is to deliver cholesterol to tissues that need it.
The issue is not LDL itself.
The issue is what happens to it.
Does a Standard Lipid Panel Predict Heart Disease?
A standard lipid panel has limited predictive value on its own, especially in metabolically healthy individuals.
Many people who experience cardiac events have “normal” LDL levels.
Many people with elevated LDL never experience one.
Risk prediction improves dramatically when cholesterol numbers are combined with:
Inflammation markers (like hs-CRP)
Blood sugar markers
Blood pressure
Smoking status
Body composition
Family history
Cholesterol in isolation is a blunt tool.
Context matters.
The Real Problem: Small, Damaged LDL Particles
Not all LDL particles are created equal.
There are:
Large, buoyant LDL particles (less concerning)
Small, dense LDL particles (more atherogenic)
Small, dense LDL particles are more likely to:
Penetrate the arterial wall
Become oxidized
Trigger inflammation
Contribute to plaque formation
These particles tend to increase in the presence of:
High sugar intake
Insulin resistance
Chronic inflammation
Highly processed food intake
A standard lipid panel does not tell you particle size or particle number.
For that, you need an NMR Lipoprofile.
This test measures:
LDL particle number (LDL-P)
Particle size
HDL particle count
That gives you a much clearer picture of actual cardiovascular risk than LDL-C alone.
Oxidation, Endothelial Dysfunction, and Plaque Formation
Here’s the mechanism most people never hear about.
Cholesterol does not randomly stick to arteries.
Plaque formation is typically a response to:
Endothelial dysfunction — damage to the inner lining of the artery
Oxidative stress
Inflammation
When the endothelial lining becomes damaged (often from high blood sugar, smoking, chronic stress, or inflammation), LDL particles can enter the arterial wall.
If those LDL particles become oxidized, the immune system responds.
That inflammatory response is what begins the atherosclerotic process.
So the issue isn’t cholesterol alone.
It’s oxidation + inflammation + vascular damage.
Fix the terrain, and the risk changes dramatically.
What About Lipoprotein(a)?
One of the most under-tested but highly predictive markers is Lipoprotein(a).
Lipoprotein(a) test, often abbreviated Lp(a), is largely genetically determined.
If elevated, it can:
Increase clotting tendency
Promote arterial plaque formation
Increase lifetime cardiovascular risk
Diet and exercise have limited impact on Lp(a).
If yours is elevated, you need to know — especially if there is a strong family history of early heart disease.
Most standard labs do not include this.
It must be requested.
When LDL Really Matters: Familial Hypercholesterolemia
There is an important exception to the “LDL isn’t the whole story” conversation.
A small percentage of the population has Familial Hypercholesterolemia (FH).
This is a genetic condition that causes extremely high LDL levels from a young age, often > 190–220 mg/dL consistently.
In those individuals:
LDL levels absolutely matter
Early plaque development is common
Intervention is critical
This is not the majority of people.
But it’s important to acknowledge.
What About Low Cholesterol?
Chronically low total cholesterol is associated with:
Higher all-cause mortality
Increased risk of hemorrhagic stroke
Depression
Hormonal dysfunction
Many long-lived populations demonstrate cholesterol levels that would be flagged today.
This doesn’t mean “higher is always better.”
It means suppression at all costs is not the goal.
Resilience and metabolic health matter more than a single number.
What Are Ideal Cholesterol Numbers?
In a metabolically healthy individual with low inflammation:
HDL: > 60 mg/dL
LDL: 100–189 mg/dL
Triglycerides: < 100 mg/dL
Triglyceride : HDL ratio: ideally < 2
Inflammation must be low.
That’s the context piece most people miss.
High LDL + low inflammation is a very different picture than high LDL + high inflammation + high blood sugar.
My Numbers
From my most recent labs:
Total Cholesterol: 217
HDL: 48
LDL: 155
By conventional standards, my LDL gets flagged.
But that’s incomplete without context:
My triglycerides are low
My metabolic markers are strong
My diet is largely whole foods
Inflammation is low
It’s also worth noting that my HDL is lower than I’d like it. Ideally as my current injuries heal I can transition back to more aerobic training, maybe tighten up my diet following the holiday season, and add a few points to my “good cholesterol.”
Coronary Artery Calcium (CAC) Scan
If you want to know whether plaque is already present, one of the most useful tools available is a Coronary Artery Calcium Scan.
This low-radiation CT scan measures calcified plaque in the coronary arteries.
A score of:
0 → Very low near-term risk
Higher scores → Increasing plaque burden
This does not predict future cholesterol behavior.
It tells you what’s happening right now.
For many people, a CAC scan is more actionable than obsessing over LDL alone.
How to Improve Your Lipid Profile
The same foundational habits improve nearly every marker we’ve discussed in this series:
1. Remove Processed Foods
Lower refined sugar and ultra-processed oils.
Stabilize blood sugar.
Reduce oxidative stress.
2. Increase Aerobic Conditioning
Zone 2 aerobic work improves:
HDL
Triglycerides
Insulin sensitivity
Endothelial function
3. Reduce Inflammation
Sleep.
Manage stress.
Get sunlight.
Eat micronutrient-dense whole foods.
When inflammation drops, LDL becomes less dangerous.
Final Thought
Cholesterol is not the villain.
Inflammation is.
Metabolic dysfunction is.
Oxidative stress is.
When you address root causes, cholesterol numbers often improve — and when they don’t, you dig deeper with better tools.
Blood work isn’t about fear.
It’s about clarity.