Total cholesterol 220

Talking about total cholesterol is like wearing a tie-dyed t-shirt with the peace sign emblazoned on the front: So totally 60s and out of date.

But talk of total cholesterol somehow keeps on coming back. After I spend 45 minutes discussing a patient's lipoprotein patterns, for instance, they'll asking something like, "But what's my total cholesterol?"

To help put this ridiculous notion of total cholesterol to rest, let me paint several pictures of what total cholesterol can tell you. Let's start with a theoretical, but very common, total cholesterol value of 220 mg/dl. Recall that:

LDL cholesterol = total cholesterol - HDL cholesterol - triglycerides/5

Note that LDL cholesterol is nearly always a calculated value. (Yes, your doctor has been treating a calculated, what I call "fictitious," value.)

Rearranging the equation:

Total cholesterol = LDL cholesterol + HDL cholesterol + Triglycerides/5

This relationship means that a great many variations are possible, all under total cholesterol = 220 mg/dl. For example:

LDL 95 mg/dl + HDL 105 mg/dl + Triglycerides 100 mg/dl

(a relatively low-risk pattern for heart disease)

LDL 160 mg/dl + HDL 50 mg/dl + Triglycerides 50 mg/dl

(an indeterminate risk pattern, potentially moderate risk)

LDL 120 mg/dl + HDL 30 mg/dl + Triglycerides 350 mg/dl

(a potentially high-risk pattern)

LDL 60 mg/dl + HDL 25 mg/dl + Triglycerides 675 mg/dl

(an indeterminate risk pattern)


That's just a sample of the incredible variation of patterns that can all fall under this simple observation, total cholesterol 220 mg/dl.

Total cholesterol is an outdated concept, one ready long ago for the junk heap of outdated ideas. It's time to throw total cholesterol out in the trash along with beliefs like high-fat intake causes diabetes, whole grains are healthy, and the tooth fairy will leave you money when you leave your molars under the pillow.

Comments (17) -

  • MathWizz?

    5/24/2011 12:45:50 PM |

    Rearranging the equation:

    Total cholesterol = LDL cholesterol + HDL cholesterol + Triglycerides/5

    Should that not read

    Total cholesterol = LDL cholesterol - HDL cholesterol - Triglycerides/5

  • Nigel Kinbrum

    5/24/2011 12:50:10 PM |

    No, because the first equation is a mis-print and should read:-
    LDL cholesterol = total cholesterol - HDL cholesterol - triglycerides/5

  • Lyford

    5/24/2011 1:32:37 PM |

    LDL 60 mg/dl + HDL 25 mg/dl + Triglycerides 675 mg/dl - (an indeterminate risk pattern)

    Isn't that HDL low and the triglycerides very high?  Isn't that a very high risk?  If not, why not?  Just because the LDL is lowish?

  • simvastatin

    5/24/2011 5:27:49 PM |

    Usually, only the total, HDL, and triglycerides are measured. For cost reasons, the VLDL is usually estimated as one-fifth of the triglycerides and the LDL is estimated using the Friedewald formula.

  • normal cholesterol levels

    5/24/2011 5:53:16 PM |

    All adults age 20 or older should have a fasting lipoprotein profile — which measures total cholesterol, LDL (bad) cholesterol, HDL (good) cholesterol and triglycerides — once every five years.  This test is done after a nine- to 12-hour fast without food, liquids or pills. It gives information about total cholesterol, LDL (bad) cholesterol, HDL (good) cholesterol and triglycerides.

  • Tim

    5/24/2011 9:37:22 PM |

    Aren't all these numbers completely useless without knowing the total number of lipid particles, and possibly their diameters?

    That's what the NLA keeps harping on at least.

  • Jonathan Carey

    5/24/2011 11:10:48 PM |

    What is the risk pattern for 200 LDL + 92 HDL + 40 Trig = 300 TC?

  • JLL

    5/25/2011 8:46:15 AM |

    Jonathan Carey,

    From what I've gathered, such low triglycerides usually mean that LDL particle size is large -- correct me if I'm wrong on this -- and thus risk is pretty low. Besides, your HDL/LDL ratio is still okay.

    Then again, some of the new meta analyses suggest that LDL by itself is a better predictor of heart disease risk than LDL subfractions. Someone care to comment on this?

    Anyhow, you can check out my blog for tips on reducing LDL and increasing HDL:


  • Dr. William Davis

    5/25/2011 4:16:15 PM |


    Thanks, all, for catching my absent-minded typo.

  • Dr. William Davis

    5/25/2011 4:22:14 PM |

    Hi, JLL--

    One of the great difficulties in trying to squeeze such predictions out of basic lipid values is that so much is not revealed. For instance, if lipoprotein(a) is present, it will not be revealed by surface lipids, even if they are wildly favorable, yet cardiovascular risk is high.

    So I didn't mean to suggest that an alternative interpretation of lipids was desirable, but that total cholesterol was the least useful of all, misleading in fact.

    By the way, you are absolutely EXCELLENT work on your blog. It is one of my absolute favorites.

  • Daniel A. Clinton, RN, BSN

    5/26/2011 3:37:13 AM |

    A debate over Total Cholesterol was one of the factors that led to me quitting my last nursing job working in a outpatient pediatric office. The pediatricians decided to start screening cholesterol to comply with the LDL-centric screening recommendations (and with such harmful advice as "eat a low fat diet"). They then didn't even comply with the recommendation for fasting lipid panels, and instead just perfomed random fingerstick total cholesterols. This needless alarmed many parents, left some who should be concerned in the dark, and harmed many children who received destructive, fragrantly incorrect dietary advice.
    There was an email thread discussing it. I was the only one who voiced concerns about using total cholesterol as a screening tool. Naturally, I, the 25-year-old nurse couldn't know better than the AHA and AAP guidelines. It was perceived as ridiculous that I had intelligent, well-reasoned objections to their line of thinking. They were a nice, but somewhat mindless and subserviant group who did whatever their palm pilots told them was the "Best Practice." Funny how drugs how always the "Best Practice" nowadays.
    Getting back to total cholesterol, to me, checking a fasting lipid panel without also checking blood sugar and HbA1C is foolishness. I certainly believe HbA1C predicts heart disease risk far better than any cholesterol number or ratio.

  • JLL

    5/27/2011 11:22:57 AM |


  • kenneth

    5/27/2011 2:33:41 PM |

    Hey Dr. Davis, what do you make of the news of one of these latest studies which is saying that niacin is useless for preventing cardiac events? They seem to be putting the message out that statins are again the answer to everything and that niacin's actions to raise HDL translate to no good real world outcomes. Ironically the folks who make Niaspan, Abbott, funded this study which now stands to put a $1 product line in the landfill....

    I always thought niacin had a pretty good body of evidence behind it. I've been on a gram a day of IR and it's helping my numbers considerably.  I think it's called the AIM-HIGH study.  I'm not sure if it addresses niacin use as a primary treatment. It seems more to do with combining niacin and statins.

  • Kent

    5/27/2011 5:02:35 PM |

    Dr. Davis,

    Could you address this recent study on Niacin, perhaps as a separate topic?  The study was stopped early, and they're basically saying that Niacin failed and doesn't help prevent cariovascular events, so back to the drawing board.

  • Renfrew

    5/27/2011 8:29:32 PM |

    Yes, your opinion on NIACIN and possible health benefit (or lack thereof) would be most welcome. I know you have been an advocate of Niacin but in light of the llatest findings...Is this still your opinion?

  • nonegiven

    5/28/2011 12:07:40 AM |

    The better formula when triglycerides fall below 100:

    LDL = TC/1.19 + TG/1.9 – HDL/1.1 – 38 (mg/dL)

  • Harvey Resnick

    6/21/2011 2:58:40 PM |

    I am no longer receiving My Heart Scan Blog. Why is this? The last one I received was in April. I tried reapplying my address, it tells me that I am still listed. I am a Heart  Patient and have been following the no wheat program and have found that it is improving my health. Please look into this and have the Heart Blogs sent to me. Thank You, Harvey

Is Cocoa Puffs no longer heart healthy?

Is Cocoa Puffs no longer heart healthy?

Until recently, Cocoa Puffs enjoyed the endorsement of the American Heart Association (AHA) as a heart-healthy food.

For a price, the AHA will allow food manufacturers to affix a heart "check mark" signifying endorsement by the AHA as conforming to some basic "heart healthy" requirements.

Odd thing: The list of breakfast cereals on the check mark program has shrunk dramatically. When I last posted about this, there were around 50-some breakfast cereals, from Cocoa Puffs to Frosted Mini Wheats. Now, the list has been trimmed down to 17:

Berry Burst Cheerios-Triple Berry
Cheerios Crunch
Honey Nut Cheerios
Kashi Heart to Heart Honey Toasted Oat Cereal
Kashi Heart to Heart Oat Flakes & Wild Blueberry Clusters
Kashi Heart to Heart Warm Cinnamon Oat Cereal
Multi Grain Cheerios
Oatmeal Crisp Crunchy Almond
Oatmeal Crisp Hearty Raisin
Quaker Cinnamon Life
Quaker Heart Health
Quaker Life
Quaker Life Maple & Brown Sugar
Quaker Oat Bran
Quaker Oatmeal Squares - Brown Sugar
Quaker Oatmeal Squares - Cinnamon

According to sales material targeted to food manufacturers, the American Heart Association boasts that "The American Heart Association’s heart-check mark is the most recognized and trusted food icon today . . . Eighty-three percent of consumers are aware of the heart-check mark. Sixty-six percent of primary grocery shoppers say the heart-check mark has a strong/moderate influence on their choices when shopping."

So, is Cocoa Puffs no longer heart healthy?

I suspect that agencies like the AHA, the USDA, the American Diabetes Association as starting to understand that they have blundered big time by pushing low-fat, having contributed to the nationwide epidemic of obesity and diabetes, and that it is time to quietly start backpedaling.

While it's a step in the right direction, judging from the above list of breakfast cereal "survivors" of the check mark program, the criteria may have been tightened . . . but not that much.

Comments (17) -

  • Anne

    4/29/2010 3:50:05 AM |

    One step forward, two steps back.

    Chocolate Cheerios are good for the heart. If you don't believe this go here

  • Anonymous

    4/29/2010 6:09:16 AM |

    I had a bowl of bran flakes and checked my blood sugar. 141. Yikes!

  • Myron

    4/29/2010 7:49:24 AM |

    I have been down on wheat family of grains for a long time, but for other reasons than the health consequences tied to peak blood sugar elevations [and consequent hypoglycemic phases].  I'm down on the inflammatory oils and the allergy aspects.

    Have you investigated HEMP SEED?  It is high in protein and packed with good oils.   How does it rate with your diet suggestions?    Would it be good to run some trials?

  • Bryan Rankin

    4/29/2010 3:20:34 PM |

    "they have blundered big time by pushing low-fat ... it is time to quietly start backpedaling."

    They're backpedaling all right, but it's not because they are abandoning the low fat message.  The average consumer is not quite ignorant enough to believe Cocoa Puffs are healthy, and they don't want that 60% that are affected by their check mark to drop.

  • Anonymous

    4/29/2010 9:11:08 PM |

    Just got an AHA solicitation in the mail this week.  Like so many other organizations, they do not act in the best interest of the people they claim to serve.  My money and time are better spent pursuing the more promising preventative practices such as those promoted by TYP.

  • whatsonthemenu

    4/29/2010 11:02:29 PM |

    A colleague eats a Quaker oatmeal square for breakfast every morning.  Among the ingredients listed on the label is partially hydrogenated soybean oil, not enough, apparently, to bump the transfat content above .5 grams, so the nutrition label lists 0 grams of transfat.  No amount of transfat is healthy, yet this product has the AHA seal of approval. I used to eat granola bars when I thought they were healthy.  I read labels and noticed that quite a few use partially hydrogenated oils, including brands that boast of high fiber or Omega 3 content.

  • Lori Miller

    4/30/2010 12:19:48 AM |

    Maybe the people at Cocoa Puffs stopped writing checks. Who needs an endorsement when your product contains wheat, sugar and chocolate and is marketed to kids in an I-want-to-be-my-child's-friend mileau?

  • Larry

    4/30/2010 11:29:12 PM |

    As if these cereals aren't bad enough...
    KFC is selling their fried chicken in Pink "Buckets for the Cure" for Breast Cancer fund raising.
    It left me speechless.
    I've said it before... we're on our own.

  • Lynn M.

    5/1/2010 3:35:49 AM |

    The site Ted linked to ( has a list of Top 10 Cereals by Nutrition Score.  None of those top 10 are on the AHA list of heart-healthy cereals.

  • Venkat

    5/2/2010 11:17:53 PM |

    Dr Davis,

    This question is off the topic. I read your book Track your plaque a month back and had been to AZ heart institute and got my plaque measured.

    I am a Type 2 Diabetic for the past 11 years and am actively low carbing (<30g carbs per day) and 100% grain avoiding since May 2008.

    My calcium score was 0.

    But the staff was not able to say whether the machine they used was EBT/MDCT. They said it is newer than EBT. The machine had GE 64 slice VCT printed on it. Can you confirm if this is the one you are asking people to have it calcium scored?

    I live in Phoenix, AZ and had been to AZ Heart Institute (got the information from "Track your plaque" book).

    Please let me know if I got calcium score done in a machine in which I am supposed to do.

    Thanks for all the help.



  • Ned Kock

    5/3/2010 9:13:38 PM |

    > I had a bowl of bran flakes and checked my blood sugar. 141. Yikes

    It is a great idea to check blood glucose levels after meals, just bear in mind that they can vary rather erratically:

  • Anonymous

    5/4/2010 9:50:41 PM |

    Oats, oats, oats is the common thread of the "survivors." Either the oat industry is doing an excellent coordinated marketing attack or there is something to the claim that oats are good for cardiovascular health.

  • Anonymous

    5/6/2010 2:36:59 AM |

    I don't eat cereal of any kind. Have no desire to. A much healthier choice altogether would be cottage cheese with fruit or just fruit, scrambled eggs or even bacon cooked extra crispy.

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