Years ago, the standard approach to heart health was simple: check your cholesterol levels. 

A simple blood test measuring total cholesterol and low-density lipoprotein (LDL) levels was often used to determine a person’s risk of heart disease. If your LDL was high, it was seen as a red flag. If it was within the normal range, you were considered safe.

But, over time, we’ve learned that this old method doesn’t provide the full picture. That means individuals who suffer from life-threatening cardiac events would have passed a routine cholesterol check without concern. 

So, what are we missing?

The quality of cholesterol, not just the quantity and how cholesterol is transported in the body, the balance between different lipoproteins, and metabolic health markers like the triglyceride-to-HDL ratio.

 

How Your Body Processes Fats and Cholesterol

Every time you eat a meal that contains fats, whether it’s nuts, avocados, ghee, or fried food, your body needs to break it down, absorb it, and transport it to where it’s needed. Unlike proteins and carbohydrates, which dissolve easily in water, fats don’t mix well with blood. This presents a challenge: How do these fats move efficiently through your bloodstream to reach your cells for energy or storage?

Here, lipoproteins come into play. They are specialized carriers that help fats travel safely through your blood. But before fats reach the bloodstream, they undergo a process of digestion, packaging, and distribution.

Step 1: Digestion and Absorption of Fats

The process begins in the digestive system:

  • When fats enter the stomach and small intestine, they are emulsified (broken down into smaller droplets) with the help of bile from the liver.
  • Enzymes called lipases break these droplets into free fatty acids and monoglycerides, which are then absorbed through the lining of the small intestine.
  • These fatty components are repackaged into tiny transporters called chylomicrons, which enter the bloodstream and deliver fat to cells for immediate energy use or storage.

This entire process ensures that fats can be efficiently absorbed and utilized, but their journey doesn’t end here.

Step 2: The Role of Lipoproteins in Fat Transport

Since fats can’t travel alone in the liquid environment of blood, they need a carrier. This is where lipoproteins come in. These are small particles made of fats (lipids) and proteins, designed to carry cholesterol and triglycerides throughout the body.

  1. VLDL (Very Low-Density Lipoprotein): VLDL is produced by the liver and plays a critical role in moving triglycerides, a type of fat that your body uses for energy. VLDL transports triglycerides to muscle and fat cells. It then undergoes a transformation, turning into LDL (low-density lipoprotein). The problem arises when VLDL levels are too high, which usually means elevated triglycerides. This is a warning sign for insulin resistance, a condition that increases the risk of type 2 diabetes and cardiovascular disease. 
  2. LDL (Low-Density Lipoprotein): LDL is often labeled as ‘bad cholesterol’, but the reality is more complex. LDL carries cholesterol to different parts of the body, where it is used for essential functions like hormone production and cell repair. The real issue isn’t the presence of LDL itself, it’s the type of LDL particles that matter.
    • Small, dense LDL: This type of LDL is harmful because it can easily slip into artery walls, leading to oxidation, inflammation, and plaque buildup. It’s strongly linked to an increased risk of heart disease.
    • Large, smooth LDL: This type is less likely to get stuck in arteries and is considered less harmful.

Most standard cholesterol tests only measure total LDL, without differentiating between small dense and large fluffy LDL. This can lead to misleading results. Someone with high LDL but mostly large, smooth particles may have a lower risk than someone with lower total LDL but mostly small, dense particles.

 

The Shocking Truth About Cholesterol—Why This Ratio is More Important Than LDL
Source: da Luz, P. L., Favarato, D., Faria-Neto, J. R., Jr, Lemos, P., & Chagas, A. C. (2008). High ratio of triglycerides to HDL-cholesterol predicts extensive coronary disease. Clinics (Sao Paulo, Brazil), 63(4), 427–432. https://doi.org/10.1590/s1807-59322008000400003

 

Small, dense LDL is significantly more atherogenic (plaque-forming) than large LDL, making it a much more relevant marker for cardiovascular risk. Unfortunately, most routine lipid panels don’t measure LDL particle size, so deeper testing is often needed to get a clearer picture.

 

3. HDL (High-Density Lipoprotein):  HDL is often called ‘good cholesterol’, and for a good reason, it helps maintain balance in the bloodstream. HDL acts like a cleanup crew, picking up excess LDL and transporting it back to the liver, where it is broken down and removed from the body.

Beyond just removing LDL, HDL also has anti-inflammatory properties. It helps protect the inner lining of blood vessels, preventing damage that could lead to plaque formation and blockages. Higher HDL levels are generally protective, but more HDL is not always better. Extremely high levels of dysfunctional HDL, seen in some rare cases, may not provide the same benefits. This is why HDL should be viewed in context with other lipid markers, rather than in isolation.

4. Triglycerides:These are the hidden markers of metabolic dysfunction. They are the most common type of fat in the blood, stored in fat cells and used for energy between meals. Unlike cholesterol, which is a structural component of cells, triglycerides serve purely as an energy source. Elevated triglycerides indicate that your body is struggling to process fats effectively, often due to insulin resistance or excess carbohydrate intake.

Therefore, by looking at the ratio between the two markers (triglycerides and HDL), we can determine whether your body is effectively processing fats or whether it is struggling with insulin resistance and inflammation; two major precursors to cardiovascular disease and metabolic disorders like type 2 diabetes.

 

The Shocking Truth About Cholesterol—Why This Ratio is More Important Than LDL
Source: Kosmas, C. E., Rodriguez Polanco, S., Bousvarou, M. D., Papakonstantinou, E. J., Peña Genao, E., Guzman, E., & Kostara, C. E. (2023). The Triglyceride/High-Density Lipoprotein Cholesterol (TG/HDL-C) Ratio as a Risk Marker for Metabolic Syndrome and Cardiovascular Disease. Diagnostics (Basel, Switzerland), 13(5), 929. https://doi.org/10.3390/diagnostics13050929

Why the Triglyceride-to-HDL Ratio is a Game-Changer and What Makes This Ratio So Important?

The triglyceride-to-HDL ratio is not just another number—it gives insight into:

  • Fat Metabolism: A high triglyceride-to-HDL ratio suggests inefficient fat clearance, leading to excess fat storage and metabolic imbalance.
  • Insulin Resistance: An elevated ratio indicates reduced insulin sensitivity, making it harder for cells to absorb glucose, which increases diabetes and heart disease risk.
  • Inflammation: Higher ratios are linked to chronic inflammation, which damages blood vessels and accelerates plaque buildup, raising the likelihood of cardiovascular events.

While LDL tells us how much cholesterol is being carried in the blood, the triglyceride-to-HDL ratio helps determine whether the body is efficiently processing fats or struggling with metabolic dysfunction.

  • High triglycerides often indicate that the body is struggling to clear fats from the bloodstream, which is common in insulin resistance and metabolic syndrome.
  • Low HDL levels suggest reduced anti-inflammatory and cholesterol-clearing capacity, increasing the risk of plaque buildup in the arteries.

Therefore, this ratio essentially serves as an early warning system for metabolic dysfunction. In fact, research also found that individuals with a high triglyceride-to-HDL ratio were significantly more likely to develop type 2 diabetes and cardiovascular disease, even if their LDL was normal.

 

The Shocking Truth About Cholesterol—Why This Ratio is More Important Than LDL
Source: Source: Kosmas, C. E., Rodriguez Polanco, S., Bousvarou, M. D., Papakonstantinou, E. J., Peña Genao, E., Guzman, E., & Kostara, C. E. (2023). The Triglyceride/High-Density Lipoprotein Cholesterol (TG/HDL-C) Ratio as a Risk Marker for Metabolic Syndrome and Cardiovascular Disease. Diagnostics (Basel, Switzerland), 13(5), 929. https://doi.org/10.3390/diagnostics13050929

 

According to research published in the American Journal of Cardiology, a high triglyceride-to-HDL ratio is strongly linked to insulin resistance and cardiovascular disease, making it one of the best markers for assessing heart risk beyond LDL levels alone.

 

The Shocking Truth About Cholesterol—Why This Ratio is More Important Than LDL
Source: Source: Kosmas, C. E., Rodriguez Polanco, S., Bousvarou, M. D., Papakonstantinou, E. J., Peña Genao, E., Guzman, E., & Kostara, C. E. (2023). The Triglyceride/High-Density Lipoprotein Cholesterol (TG/HDL-C) Ratio as a Risk Marker for Metabolic Syndrome and Cardiovascular Disease. Diagnostics (Basel, Switzerland), 13(5), 929. https://doi.org/10.3390/diagnostics13050929

 

This is why it’s time to move away from the outdated ‘LDL = bad, HDL = good’ narrative and embrace a more nuanced, science-backed approach. By focusing on triglyceride-to-HDL ratio, LDL particle size, and overall metabolic health, we get a clearer, more accurate picture of cardiovascular risk—and a better chance at preventing disease before it starts.

 

What Influences Your Lipid Profile?

When it comes to heart health, many people believe that cholesterol levels are solely dictated by food we eat. But in reality, multiple factors, like: 

1. Genetics: The Inherited Influence on Cholesterol

For some, high cholesterol isn’t just about what’s on the plate, it’s in the genes. Familial hypercholesterolemia (FH) is a genetic condition that affects an estimated 1 in 250 people worldwide. People with FH have a mutation that prevents their liver from effectively clearing LDL cholesterol from the blood, leading to persistently high levels from an early age. If left unmanaged, FH significantly increases the risk of premature heart disease.

 

The Shocking Truth About Cholesterol—Why This Ratio is More Important Than LDL
Source: Sawhney, J. P. S., & Madan, K. (2024). Familial hypercholesterolemia. Indian Heart Journal, 76, S108–S112. https://doi.org/10.1016/j.ihj.2023.12.002

 

Another genetic factor is Lipoprotein(a) [LPA], a highly atherogenic (plaque-forming) lipoprotein. Unlike LDL, which can be influenced by food habits and lifestyle, LPA levels are mostly determined by genetics and remain relatively stable throughout life. High LPA is associated with a sixfold increase in cardiovascular risk, yet it is rarely tested in standard lipid panels.

 

The Shocking Truth About Cholesterol—Why This Ratio is More Important Than LDL
Source: Kosmas, C. E., Rodriguez Polanco, S., Bousvarou, M. D., Papakonstantinou, E. J., Peña Genao, E., Guzman, E., & Kostara, C. E. (2023). The Triglyceride/High-Density Lipoprotein Cholesterol (TG/HDL-C) Ratio as a Risk Marker for Metabolic Syndrome and Cardiovascular Disease. Diagnostics (Basel, Switzerland), 13(5), 929. https://doi.org/10.3390/diagnostics13050929

 

While genetics may predispose an individual to higher cholesterol and cardiovascular risk, they do not determine the outcome. Epigenetics, which refers to how environmental and lifestyle factors influence gene expression, plays a crucial role in the manifestation of genetic traits. Nutrition, movement, stress management, and overall metabolic health can positively or negatively impact how your body processes cholesterol and inflammation. Taking proactive steps can help counteract genetic predispositions and significantly reduce long-term cardiovascular risk. 

 

2. Food Habits and Nutrition: More Than Just Avoiding Cholesterol

For years, cholesterol from food sources was blamed for high LDL levels, leading to the widespread fear of eggs, dairy, ghee and other cholesterol-rich foods. However, modern research has debunked this myth, showing that the cholesterol we eat has little impact on blood cholesterol for most people. Instead, what matters more is the type of fats we consume.

  • Saturated and trans fats (found in processed foods, fried items, and certain animal products) stimulate the liver to produce more LDL cholesterol, particularly the harmful small dense LDL.
  • Unsaturated fats (from sources like fish, nuts, seeds, and olive oil) help reduce LDL oxidation and increase HDL levels, supporting heart health.
  • Fiber-rich foods, especially soluble fiber from oats, beans, flaxseeds, and vegetables, bind to cholesterol in the gut, reducing its absorption and lowering LDL levels naturally.
The Shocking Truth About Cholesterol—Why This Ratio is More Important Than LDL
Image Credits: Freepik

 

In my conversation with Dr. Sudhir Pillai, a leading Cardiologist, also pointed out that not all LDL elevation from food is harmful. For active individuals with a good triglyceride-to-HDL ratio, a slightly elevated LDL may not be a concern. This highlights the need to look at the full picture rather than focusing on LDL alone.

 

3. Exercise and Lifestyle: How Daily Habits Shape Your Lipid Profile

Lifestyle plays a huge role in cholesterol management. Unlike genetics, which you can’t change, your daily habits can significantly impact LDL, HDL, and triglycerides.

  • Exercise: Regular aerobic and resistance training has been shown to increase HDL and reduce small dense LDL particles. Studies suggest that even 30 minutes of moderate exercise, five times a week, can improve lipid levels and reduce cardiovascular risk.

    The Shocking Truth About Cholesterol—Why This Ratio is More Important Than LDL
    Image Credits: Freepik

  • Smart Fasting: It helps lower triglycerides, improve insulin sensitivity, and promote fat metabolism. This is why smart fasting is often recommended for individuals with high triglycerides and metabolic syndrome under expert guidance.
  • Smoking: Cigarette smoke oxidizes LDL, making it more likely to cause inflammation and plaque buildup in arteries. Quitting not only improves HDL levels but also significantly lowers cardiovascular risk over time 

 

In a nutshell, instead of relying on LDL alone, a more comprehensive blood test approach includes:

  1. Triglyceride-to-HDL Ratio: One of the strongest predictors of cardiovascular risk and insulin resistance. A high ratio suggests metabolic dysfunction, while a low ratio indicates better fat metabolism and cardiovascular protection.
  2. LDL Particle Size: Not all LDL is harmful. Small, dense LDL is more prone to oxidation and plaque formation, while large, smooth LDL is less atherogenic. Standard lipid tests don’t differentiate between the two, but advanced testing can provide better insights.
  3. Lipoprotein(a) [LPA]: A genetic risk factor for heart disease. People with high LPA levels may require more personalized interventions.
  4. Signs of Insulin Resistance: High fasting insulin, elevated HbA1c, and poor triglyceride-to-HDL ratios are early indicators of metabolic dysfunction that can increase cardiovascular risk, even in those with normal LDL. Addressing insulin resistance through food, exercise, and lifestyle changes is key to long-term heart health.
The Shocking Truth About Cholesterol—Why This Ratio is More Important Than LDL
Image Credits: Freepik

Moving Beyond Cholesterol Myths

If there’s one takeaway from this, it’s that heart disease prevention is not just about lowering LDL—it’s about optimizing the entire lipid profile and addressing the root causes of metabolic dysfunction.

Rather than fixating on LDL numbers, a more informed approach looks at the bigger picture, balancing lipoproteins, managing insulin resistance, and optimizing metabolic health. It is far more effective and sustainable than simply chasing numbers on a lab report.

 

Watch my whole conversation with Dr Sudhir Pillai,

 

Disclaimer: This blog is for informational and educational purposes only and is not intended as medical advice. Individual health conditions vary. Always consult with a qualified healthcare professional before making any changes to your nutrition, lifestyle, or medication. Additionally, cholesterol management and cardiovascular risk assessment should be personalized, taking into account genetics, lifestyle, and overall metabolic health. If you have a history of heart disease, high cholesterol, or metabolic disorders, seek medical advice from a qualified doctor for tailored recommendations and appropriate testing.

 


 

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