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total cholesterol is like wearing a tie-dyed t-shirt with the peace sign emblazoned on the front: So totally 60s and out of date.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Total cholesterol is an outdated concept, one ready long ago for the junk heap of outdated ideas.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