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Heart Disease Risk: Can Ratios Help?


It’s time for your yearly checkup and your doc wants to check your cholesterol, but if you have heard some people talk about cholesterol, you may wonder if it really makes any difference? 

There are a lot of rumors floating around about cholesterol.  Maybe you’ve heard that half the people who have a heart attack don’t even have high cholesterol.  While the figures are fuzzy on that, it is true that a fairly high percentage of people who have heart attacks do not have high cholesterol.  

As more is learned about heart disease, you can understand why.  What really causes heart disease is anything that causes plaques to form in the arteries.  Cholesterol is a component of plaque, but there has to be an injury in the artery first.  What causes injury?  Things like smoking, high blood pressure and inflammation.  The theory is that cholesterol is used to patch the injuries or damage that is done in arterial linings, and certain cholesterols are more plaque causing than others.

So cholesterol is involved; it’s just not the only thing that influences risk.  Since risk isn’t just a function of how high one’s cholesterol is, some people think that looking at cholesterol ratios is important.

So let’s talk about ratios and how you can use them to keep you on the road to good health.


First, let’s take a moment to review cholesterol and lipoprotein, and how they’re different.

Cholesterol is a fatty substance that circulates throughout your body. We need some cholesterol because it is used to:

  • Manufacture sex hormones — estrogen, progesterone and testosterone
  • Build cell membranes and keep them fluid when the temperature changes
  • Help you digest fat from your food, absorb fat-soluble Vitamins A, D, E and K, and synthesize Vitamin D from the sun
  • Insulate your nerves

The liver manufactures cholesterol because your body needs it, but lifestyle factors can make you produce excesses.  The theory is that by keeping cholesterol low, you reduce a raw material needed to form plaques. 

The current guidelines are to keep your cholesterol below 200 milligrams per deciliter (mg/dl) of blood. A range of 200–239 mg/dl is considered borderline high and 240 mg/dl or over is considered high cholesterol. 

However, as statistics show, the levels alone don’t always correlate well to true risk of heart disease.  We can still get heart disease even with normal amounts of cholesterol if the other factors are present.

What we need to know is how to prevent plaques.  That is where lipoprotein levels and ratios may be helpful.


Lipoprotein is not the same as cholesterol. It is the transportation system within your blood for fats.  You need lipoproteins to carry fat-like substances because fat doesn’t dissolve in water and the bloodstream is mostly water.

Cholesterol and triglycerides are carried through the blood in a protein coat. The combined package is called lipoprotein (lipo for fat and protein for the coat).  Think of it as a boat transporting passengers through canals (your arteries.)  Protein is the boat. Cholesterol and triglycerides make up the passengers.

There are different kinds of lipoproteins:

  • High-Density Lipoprotein (HDL) is “dense” because it has more protein in relation to cholesterol. It’s like a big boat with few passengers. It picks up and transports cholesterol out of the body. 

HDL has traditionally been thought of as the “good” cholesterol because it seemed to be protective against heart disease when levels are higher, though a new study has called this into question.  The study found that people who have genes that translate to higher HDL do not always have lower heart disease risk.[i]   But don’t let that sway you. The current recommendation is still to try to keep your numbers over 60 mg/dl until the issues are better studied.

  • Low-Density Lipoprotein (LDL) is less dense because it has less protein and more cholesterol. It’s like a tiny boat stuffed full of passengers. It transports cholesterol to your organs and tissues to provide it as needed.  LDL is considered the “bad” cholesterol that raises the risk of heart disease.  

The medical recommendation was to keep it under 129 mg/dl, but more recently 100 mg/dl or lower has been suggested as optimal.  In other words, the lower the better, but not everyone agrees due to the fact that low levels may compromise other areas — immunity[ii] and brain function for example.[iii]   

  • Very Low-Density Lipoprotein (VLDL) is LDL combined with triglycerides. Triglyceride is simply the scientific word for fat.  Triglycerides can come from fat in foods you eat, or the liver can make triglycerides from excess sugars in the bloodstream.

VLDL is “very bad” cholesterol, but it’s bad primarily because of what it carries — triglycerides. Triglycerides raise risk for heart disease significantly because they increase production of small, dense LDL particles.  More recently, science has found that these are the most atherogenic, or plaque-causing, lipoproteins.[iv]

When researchers combined 17 studies to look at 46,413 men and 10,864 women, they found a 30% increased risk in men and a 75% increase in women when triglycerides were high.[v]  So it’s also important to know your triglyceride level.

 “VLDL” should fall within 5 and 30 mg/dl.

Triglycerides should be tested only when fasting, and should be below 150 mg/dl, with 100 mg/dl or below being optimal.  Anything above 150 is considered a sign of metabolic syndrome and increases risk for diabetes and heart disease. 


So the bottom line with cholesterol is that you can have relatively high levels and still not get heart disease. Or you can have normal levels and still get heart disease.  That’s why ratios of the different lipoproteins started being evaluated: for their ability to predict heart disease.

Total cholesterol to HDL ratio has been used for several years now as an indicator of risk, which made sense since higher HDL levels are considered protective.  But as more is learned, one ratio is being found to be more predictive than the others — the triglyceride to HDL ratio.  Here is how it is calculated and what it means: 

  • Total Cholesterol/HDL Ratio compares your total cholesterol to your HDL level. To determine your ratio, divide your HDL into your total cholesterol number.  For example, if your cholesterol level is 200 mg/dl and your HDL level is 40 mg/dl, your ratio is 5:1. 

A ratio of 3.1:1 is considered optimal, while <4.4:1 is considered low risk, 4.5-5.1:1 is considered moderate risk and >5.1:1 is considered high risk. 

This example shows a cholesterol level that is not that high, but because the HDL is low, it could translate to increased risk according to the 5:1 ratio.

  • LDL/HDL Ratio compares your bad cholesterol to your good cholesterol. You divide your HDL into your LDL.

For example, if your LDL is 140 and your HDL is 40, your ratio is 3.5:1.

A ratio of <2.5:1 is considered optimal, while <3.1:1 is considered low risk, 3.1-4.1:1 is considered moderate risk and >4.1:1 is considered high risk.  

Some people flip this ratio around for an HDL/LDL ratio.  Simply divide LDL into HDL, in which case you would want these numbers to remain above 3:1 or more optimally 4:1 or more, but either way you are getting the same information.

  • Triglyceride/HDL Ratio compares your triglycerides to your good cholesterol. Out of all the ratios, studies find this one to be the strongest predictor as to whether a person will get heart disease.[vi] You simply divide your HDL into your triglyceride number.  

You want your ratio below 2. Four is considered high and 6 is way too high.[vii] [viii]  

When triglycerides elevate, VLDL goes up and HDL levels typically drop, but the reverse is also true. When you can lower your triglycerides, HDL will almost always increase.  The good news is triglycerides are also very responsive to dietary and lifestyle changes. 

To summarize:




Total Cholesterol to HDL









Triglyceride to HDL




How to Improve Your Ratios

You can improve your HDL and lower your LDL and triglycerides with a few simple lifestyle changes.

  1. Exercise. [ix]  There is clear evidence that regular exercise lowers risk for heart disease, primarily by improving insulin sensitivity. With good insulin sensitivity, glucose is cleared from the blood more efficiently and triglycerides are better controlled.  With that, HDL increases.  This is why HDL typically increases with exercise.  Exercise also helps by being a major factor in helping people maintain a healthy weight.  Studies show that even very low amounts, as low as 12 minutes per day, decrease risk in people who were previously sedentary.  However, that amount is not enough to control weight.  Thirty minutes at least five days per week is recommended. If you don’t have 30 minutes all at once, it’s okay; even breaking it up into three 10-minute segments is helpful.
  2. Stop smoking. [x] [xi] Puffing on cigarettes lowers your HDL and raises your LDL. If you quit smoking, cholesterol typically drops back down to a non-smoker level. Hopefully if you still smoke, you are looking at options for quitting. 
  3. Avoid trans fats. Trans fats raise blood cholesterol levels more than dietary cholesterol or saturated fat.[xii]  Be sure to read labels. If you see any word that looks or sounds like “hydrogenated,” it’s a trans fat. You find trans fats in packaged, processed and junk foods: things like frozen dinners, cake mixes, fried foods, even hamburger buns! If a package says “zero trans fat,” don’t believe it. The FDA allows .5 grams of trans fat per serving without the manufacturer having to declare it.
  4. Add or increase phytosterols. Foods like vegetables, vegetable oils, nuts, nut butters and berries contain phytosterols. These are compounds similar to cholesterol that keep cholesterol in foods from absorbing into your bloodstream. When scientists looked at 590 people who added phytosterols to their diet, cholesterol dropped by 10% and LDL dropped by 15%.[xiii]
  5. Control triglycerides.  Conventional medical recommendations are to use a low-calorie, low-fat diet and avoid excessive intake of alcohol, which increases production of triglycerides.   However, if a traditional diet is not effective, as many past Life Time Flourish articles have indicated, most studies find that lower-carbohydrate diets are very effective at lowering triglycerides while low-fat diets are not always effective.
  6. Control inflammation.  Heart disease happens from a combination of cholesterol, injury to the arteries and inflammation.  Anti-inflammatory diet guidelines are geared toward lowering post-meal insulin elevations, because they are highly inflammatory, while increasing intake of foods that are anti-inflammatory, like fish oil and fruits and vegetables.
  7. Lose weight, if overweight. All studies find that if you can manage to lose weight, lipid profiles usually improve.  This is easier to do if you take steps to improve insulin sensitivity as discussed above and in many Life Time Flourish articles.

There are also supplements that are effective in helping to control cholesterol and triglycerides.

  1. Red Yeast Rice* is an ancient Chinese medicine and food which studies have shown to be effective for lowering LDL while raising HDL.[xiv]  The recommended dosage is 1.2 grams of red yeast rice extract per day. Make sure you buy red yeast rice from reputable manufacturers, as there have been some versions sold over the Internet that actually contained statin drugs.
  2. Niacin* is a B vitamin that can lower cholesterol and triglycerides. Take it with B12 or food to reduce the “niacin flush.”  A 26-week trial found that niacin raised HDL 33%, compared to 7% with the cholesterol drug Lovastatin.  While it didn’t lower LDL quite as much (23%, compared to 32% with the drug), it still lowered LDL enough to make a positive impact.[xv]  The effective dosage usually starts with 1 gram.
  3. Tocotrienols are a specific type of vitamin E that has strong evidence of improving lipid profiles.  They are an excellent choice if triglycerides are a problem, because they specifically target triglycerides and VLDL.[xvi] [xvii]  They have been found to be strongly anti-inflammatory, lowering oxidized LDL and C-reactive protein.[xviii]  The dosages in studies have ranged from 140 to 360 mg daily. 

*It’s best to use Red Yeast Rice and Niacin under medical supervision because liver enzymes need to be monitored.  While my clinical experience with Red Yeast Rice is that it is much gentler than statins, it works very similarly to the drugs, and in theory could have some of the same side effects.  The most common side effect I have seen with it is stomach upset.

Written By Jim LaValle, RPh, CCN


[ii] Yang X. Independent associations between low-density lipoprotein cholesterol and cancer among patients with type 2 diabetes mellitus. Canadian Medical Association Journal. 2008;179:427-437

[iii] Martinez-Carpio PA, et al. Relation between cholesterol levels and neuropsychiatric disorders. Rev Neurol 2009;48(5):261-4


[v] John E. Hokanson, Melissa A. Austin “Plasma Triglyceride Level is a Risk Factor for Cardiovascular Disease Independent of High-Density Lipoprotein Cholesterol Level: A Metaanalysis of Population-Based Prospective Studies”European Journal of Preventive Cardiology April 1996 vol. 3 no. 2 213-219

[vi] Da luz PL, Cesena FH, Favarato D, Cerqueira ES. Comparison of serum lipid values in patients with coronary artery disease at <50, 50 to 59, 60 to 69, and >70 years of age. Am J Cardiol. 2005;96:1640–3.

[vii] J. Michael Gaziano,et al. Fasting Triglycerides, High-Density Lipoprotein, and Risk of Myocardial Infarction Circulation. 1997; 96: 2520-2525.

[viii] Boizel, Robert, et. al. “Ratio of Triglycerides to HDL Cholesterol Is an Indicator of LDL Particle Size in Patients With Type 2 Diabetes  and Normal HDL Cholesterol Levels” Diabetes Care 23:1679–1685, 2000

[ix] Kelley, George A., Kelley, K.S. “Aerobic exercise and HDL2-C: A meta-analysis of randomized controlled trials.” Atherosclerosis Volume 184, Issue 1, January 2006, Pages 207–215.

[x] Zhang Y. “Influence of smoking on cholesterol concentrations in serum lipo-protein of healthy subjects.” Zhonghua Liu Xing Bing Xue Za Zhi. 1992 Apr;13(2):97-100.

[xi] Muscat, Joshua E, et. al. “Cigarette smoking and plasma cholesterol” American Heart Journal Volume 121, Issue 1, Part 1, January 1991, Pages 141–147

[xii] De Roos, Nicole M. et. al. “Replacement of Dietary Saturated Fatty Acids by Trans Fatty Acids Lowers Serum HDL Cholesterol and Impairs Endothelial Function in Healthy Men and Women” Arteriosclerosis, Thrombosis, and Vascular Biology. 2001; 21: 1233-1237

[xiii] Moghadasian, Mohammed H.,  Frohlich, Jiri J. “Effects of dietary phytosterols on cholesterol metabolism and atherosclerosis: clinical and experimental evidence” The American Journal of Medicine Volume 107, Issue 6 , Pages 588-594, December 1999

[xiv] Wang,  J, Lu Z, et al. “Multicenter clinical trial of the serum lipid-lowering effects of a Monascus purpureus (red yeast) rice preparation from traditional Chinese medicine. Curr Ther Res 1997;58:964-977.

[xv] Illingworth, D. Roger, et. al. “Comparative Effects of Lovastatin and Niacin in Primary HypercholesterolemiaA Prospective Trial” Arch Intern Med. 1994;154(14):1586-1595

[xvi] Qureshi AA, Bradlow BA, Brace L, et al. Response of hypercholesterolemic subjects to administration of tocotrienols. Lipids. 1995;30(12):1171-7.

[xvii]  Zaiden N, Yap WN, Ong S, et al. Gamma delta tocotrienols reduce hepatic triglyceride synthesis and VLDL secretion. J Atheroscler Thromb. 2010;17(10):1019-32.

[xviii] Singh U, Devaraj S. Vitamin E: inflammation and atherosclerosis. Vitam Horm. 2007;76:519-49.

This article is not intended for the treatment or prevention of disease, nor as a substitute for medical treatment, nor as an alternative to medical advice. Use of recommendations in this and other articles is at the choice and risk of the reader.

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Reader Comments (4)

I'm having trouble with your article for one reason. Your association of HDL and LDL with a description of a boat and passengers is completely backward. High density means that a large amount of mass is packed into a smaller volume. Low density has the equivalent mass in a larger volume, or has the same volume with less mass. You have told us that HDL has a large boat (volume) with few proteins (mass), and that LDL has a tiny space (volume) crammed full of proteins (mass).

This makes my brain hurt.

August 12, 2012 | Unregistered CommenterLiz Gregory

Could you please post the rest of your note about red yeast rice side effects? It seems to have truncated at the end of the article. Thanks.

August 12, 2012 | Unregistered CommenterYasmin

To Jim Lavalle:
Like Yasmin above, I, too, would like to see the end of the asterisk section regarding the effects of taking red yeast rice. I'd like to know what you found to be the most common side effect. As a Type I diabetic, I've been taking RYR for about two years now as a replacement for the statin drugs and am interested in knowing whether there are side effects similar to the synthesized drugs that I should be concerned about.
Please reply at your earliest opportunity.

August 13, 2012 | Unregistered CommenterSteve S

Hi Liz,
Thanks for the question. In hindsight calling HDL a big boat was not the best choice. It is indeed the smallest particle of the lipoproteins, however, I did not say that it has few proteins. I actually said it has more protein in relation to cholesterol, which is true. In regards to protein content it is a bigger boat. HDL particles contain about 55% protein on average, compared to 20-22% protein in LDL. LDL is bigger particle size, but has less protein with more cholesterol. It's always hard taking a technical topic and making it readable and understandable. So I appreciate the comment and the chance to clarify!

Yasmin and Steve,
In regards to my comment in the asterisk - I apologize that it was cut off. I am not sure what you are able to see or not, so I will repeat the info. Red Yeast Rice is a natural product that works almost exactly like a drug, statins. It does have potential, therefore, for similar side effects, ie stomach upset, muscle pain or weakness and liver damage. Therefore, please monitor for side effects if you want to use it. In my experience, I have had many patients who could not tolerate statins but could tolerate Red Yeast Rice. I have had a couple of patients who got stomach upset from it. I have never personally had anyone get elevated liver enzymes from it, but we still monitor for that. If you experience any side effects, discontinue using it. Also, be aware that the FDA posted warnings about Red Yeast Rice products sold over the internet that actually had statins in them. Do not buy this product from an unknown manufacturer. There are sites set up on the internet that sell products and if you look, you cannot find who manufactures it or where. Please research your product companies, and make sure you buy only from reputable companies. At the very least you should be able to find a real address with real people. The website should have phone numbers you can call for info, as well as information about their product quality measures. Good companies buy high quality raw ingredients, they test raw materials/ingredients for purity and they test their final product as well.

Jim LaValle, R.Ph.

August 13, 2012 | Unregistered CommenterJim LaValle, R.Ph. CCN

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