Under 200. That’s the usual target for total cholesterol as reported in popular media. But are all 200s the same?

I just received my profile from a recent blood test. Here’s what it said.
Total cholesterol: 204
LDL (bad cholesterol): 131.6
HDL (good cholesterol): 57
Triglycerides: 77

The total is computed as LDL+HDL+Tri/5. These are fairly typical numbers for me as compared to the last half dozen years, although my HDL usually is a few points higher and my LDL and tri usually are a few points lower. This 204 would normally place me at borderline high. However, my doctor is not very concerned, and neither am I. Why?

First of all, I have only one risk factor (being a male over age 45). Second, my HDL is on the high side for men my age and this leads to a favorable LDL/HDL ratio of only 2.3. Further, at 5’10″ and 142 pounds, my BMI is about 20.5. As an avid runner, my resting pulse is in the low 50s, my blood pressure is typically 110/70 (and sometimes as low as 105/60), and a recent echo cardiogram showed no problems. OK, so what’s the beef? Surely mitigating factors and health status need to be considered instead of a single number, right? Yeah, but there’s more to it than that. It’s an unfortunate but true observation on my part that people tend to focus on the one number and that number can be misleading. I know a lot of people who can recite their total cholesterol value but have no idea of the “numbers inside”. I doubt that they are atypical.

Consider two men with minimal risk factors, Ralph and Larry. For the sake of simplicity, let’s assume both have a triglyceride value of 75. Ralph’s LDL and HDL are 140 and 30 while Larry’s are 125 and 65. Ralph’s total cholesterol is 185 while Larry’s is 205. If we just look at the total, Ralph seems to be in a much better position than Larry, yet Larry’s LDL is considered safe while Ralph’s is borderline high, and similarly, Larry’s HDL is considered protective of heart disease while Ralph’s is definitely too low.

Knowing the tendency of folks to “like it simple”, I wonder why there isn’t a single “cholesterol index” that could combine these considerations. Why do we bundle all forms together when high HDL is considered protective, yet it raises the “scary” total? It seems that a fudge factor could be added for the LDL/HDL ratio (just like there’s one for triglycerides). I think it would be a little easier for people to grab onto, and then their doctor could look at the numbers inside and the patient’s lifestyle, and offer the most promising strategies to combat a too-high index.

Oh, and my doc says I should probably watch my diet a little closer. I tend to agree as I do have a tooth for the cookies.