As an NSCA-Certified and UESCA-Certified Endurance Nutrition Coach, I work with many runners and endurance athletes on their nutrition, aiming to find a diet that supports their exercise performance while promoting health.
For this reason, many people are surprised that many of the nutrition questions and goals I work on with athletes are no different than for the general public.
Just because you are a runner or workout consistently doesn’t mean that you don’t struggle with following a healthy diet or have other health issues.
High cholesterol is quite a common problem, and trying to maintain optimal cholesterol levels can be challenging, particularly if you have a genetic predisposition for high cholesterol.
Furthermore, while routine cholesterol tests like your LDL and HDL cholesterol levels can provide some insight into your risk for high cholesterol, looking at whether you have a good total cholesterol to HDL ratio can also be helpful.
In this guide, we spoke with Dr. Gil Blander, Ph.D., for the best advice on optimal cholesterol levels and a good total cholesterol to HDL ratio.
Let’s get started!
What Are Good LDL and HDL Cholesterol Levels?
Dr. Gil Blander, Ph.D., Founder and Chief Scientific Officer at InsideTracker, explains that LDL cholesterol, also known as low-density lipoprotein cholesterol, is a type of cholesterol that can be harmful if it builds up in your arteries.
“[LDL cholesterol] is often referred to as ‘bad cholesterol’ because high levels of LDL can lead to blood vessel damage, restricted blood flow, and blockages, increasing the risk of heart attacks, strokes, and heart disease,” explains Dr. Blander.
“It is important to monitor and manage LDL cholesterol levels for optimal heart health.”
The counterpart of LDL cholesterol is HDL cholesterol, which is high-density lipoprotein cholesterol. HDL cholesterol is often referred to as “good cholesterol.”
“HDL cholesterol helps remove excess bad cholesterol from the bloodstream and returns it to the liver, where it can be broken down and eliminated from the body,” explains Dr. Blander.
“Having high levels of HDL cholesterol is beneficial because it helps protect against heart disease by reducing the buildup of plaque in the arteries and promoting better cardiovascular health.”
According to the Centers for Disease Control and Prevention (CDC), normal cholesterol test results are as follows:1CDC. (2021, April 15). How and When to Have Your Cholesterol Checked | cdc.gov. Centers for Disease Control and Prevention.
|Less than 200 mg/dL
|LDL or “bad” cholesterol
|Less than 100 mg/dL
|HDL or “good” cholesterol
|40 mg/dL or higher
|Less than 150 mg/dL
What’s A Good Total Cholesterol To HDL Ratio?
In addition to looking at your LDL cholesterol and HDL cholesterol as standalone metrics, there is also value in looking at your LDL/HDL cholesterol ratio, or more commonly, your total cholesterol to your HDL cholesterol.
According to the American Heart Association, total cholesterol refers to your serum LDL cholesterol level plus your HDL cholesterol level plus 20% of your serum triglycerides.2American Heart Association. (2017). What Your Cholesterol Levels Mean. Www.heart.org. https://www.heart.org/en/health-topics/cholesterol/about-cholesterol/what-your-cholesterol-levels-mean
Total cholesterol: LDL + HDL + (0.2 x triglycerides)
Looking at your total cholesterol can be misleading because while you want a low LDL cholesterol level, you want a high HDL cholesterol level.
Therefore, you could get “punished“ by your total cholesterol value if you have a high HDL cholesterol, even if your LDL cholesterol level is within the normal range.
This is why looking at the ratio of total cholesterol to HDL cholesterol levels is more meaningful.
Your total cholesterol divided by your HDL cholesterol is known as your “cholesterol ratio.”
For example, if your total cholesterol is 190 milligrams per deciliter (mg/dL) of blood and your HDL is 50 mg/dL, your cholesterol ratio is 3.8.
“The total cholesterol to HDL ratio is a measure of the balance between total cholesterol and HDL cholesterol (good cholesterol) in the bloodstream,” says Dr. Blander. “A lower ratio is generally considered more favorable for heart health.”
This makes sense because a lower ratio means that your HDL cholesterol—the good cholesterol—is a higher relative percentage of your total cholesterol, which, in turn, also means that your “bad” cholesterol (the LDL cholesterol) isn’t as “unchecked” or composing as much of your total cholesterol.
So, what is good total cholesterol to HDL cholesterol ratio?
“A good total cholesterol to HDL ratio is typically less than 3.5,” shares Dr. Blander. “This means that the level of total cholesterol is less than 3.5 times the level of HDL cholesterol.”
Average Cholesterol Ratios By Age, Dietary Habits, and Cardiovascular Health
Dr. Blander says that women tend to have higher HDL cholesterol levels than men.
“This is partially due to hormonal differences between the sexes,” shares Dr. Blander. “Estrogen, a hormone found in higher levels in women, has been shown to increase HDL cholesterol levels, so there’s a slight difference detected there on a population level.”
This can potentially influence what is considered a “good“ total cholesterol to HDL cholesterol ratio for females vs males, as it would be expected that the HDL level for females is higher.
Thus, you would also hope to see a lower total cholesterol to HDL cholesterol ratio for females vs males in order for this biometric to be considered a “good“ cholesterol ratio for women.
Dr. Blander says that age can also influence what is considered a good total cholesterol to HDL cholesterol ratio.
“Bad cholesterol levels also do tend to increase in some people over time, which is why it’s important to increasingly monitor as you age,” he advises.
However, just because there is a trend towards increasing LDL levels in older adults does not mean that this is healthy or optimal.
Plus, Dr. Blander says that your total cholesterol to HDL ratio is just one factor to consider when assessing your risk of cardiovascular disease.
“Other factors such as LDL levels, triglyceride levels, ApoB, and individual health history should also be taken into account.”
Dr. Blander’s recommendations for a good cholesterol ratio are similar to those offered by the National Institutes of Health, which suggest that you should aim to keep your cholesterol ratio below five but that a good cholesterol ratio is closer to 3.5.3Bailey, A., & Mohiuddin, S. (2021). Biochemistry, High Density Lipoprotein. StatPearls. https://www.statpearls.com/ArticleLibrary/viewarticle/22879
Because of the difference in the cutoffs for what is considered a good HDL cholesterol for women vs men (at least 50 mg/dL for HDL for women versus at least 40 mg/dL for men), a good cholesterol ratio varies by sex.
If we use the maximum healthy total cholesterol level (200 mg/dL) as our total cholesterol level and then compare it to the HDL cholesterol level for men vs women for setting healthy cholesterol ratio values, the following occurs:
Healthy Cholesterol Ratio for Men: Total Cholesterol / HDL Cholesterol = 200 mg/dL / 40 mg/dL = 5
Healthy Cholesterol Ratio for Women: Total Cholesterol / HDL Cholesterol = 200 mg/dL / 50 mg/dL = 4
Thus, a healthy cholesterol ratio for women is lower than for men.
Keep in mind that these would be the upper bounds of what would be considered healthy because we are using the maximum normal total cholesterol level and lowest HDL cholesterol level rather than a “good” total cholesterol level and a “good” HDL cholesterol level.
Therefore, to actually be considered a good total cholesterol/HDL cholesterol ratio, you would want to have a lower number than 5 for men and 4 for women, respectively.
Lower, because ideally, the numerator would be smaller than 200 mg/dL of total cholesterol and more than 40 or 50 mg/dL of HDL cholesterol.
Indeed, research that has looked at the relative risk of myocardial infarction (heart attack) based on cholesterol ratio has found that a lower cholesterol ratio is better and more protective for heart health than these values.4Calling, S., Johansson, S.-E., Wolff, M., Sundquist, J., & Sundquist, K. (2019). The ratio of total cholesterol to high density lipoprotein cholesterol and myocardial infarction in Women’s health in the Lund area (WHILA): a 17-year follow-up cohort study. BMC Cardiovascular Disorders, 19(1). https://doi.org/10.1186/s12872-019-1228-7
For example, one study that investigated the association between cholesterol ratio and the relative risk of having a heart attack for women tracked women in their 50s in Sweden for five years (1995 to 2000).
Results revealed that women who had a cholesterol ratio below 3.5 had the lowest risk of acute myocardial infarction.
There was a relationship between the relative risk of experiencing a heart attack over the five-year study period and the average total cholesterol to HDL cholesterol ratio.
This health risk grew exponentially, not linearly, as the cholesterol ratio increased from 3.5 to 5 and over 5 as follows:
- Women with a cholesterol ratio between 3.5 and 4.0 were 14 percent more likely to experience a heart attack than women with a cholesterol ratio below 3.5.
- Women with a cholesterol ratio between 4.0 and 5.0 were 46 percent more likely to experience a heart attack than women with a cholesterol ratio below 3.5.
- Women with a cholesterol ratio above 5 were 89 percent more likely to experience a heart attack than women with a cholesterol ratio below 3.5.
Can You Improve Your Cholesterol Ratio?
Research indicates several factors can influence your LDL cholesterol, HDL cholesterol, and lipid profile in general.5National Heart, Lung, and Blood Institute. (2022, March 24). Blood Cholesterol – Causes and Risk Factors | NHLBI, NIH. Www.nhlbi.nih.gov. https://www.nhlbi.nih.gov/health/blood-cholesterol/causes
For example, research suggests genetics can play a role in high cholesterol.
Unfortunately, your genetic predisposition to high cholesterol isn’t a modifiable risk factor for high cholesterol levels or a bad total cholesterol to HDL cholesterol ratio.
However, lifestyle factors and behaviors can increase good cholesterol levels and decrease bad cholesterol levels and vice versa. These risk factors are modifiable based on your consistent health practices and behaviors.
Dr. Blander says that lifestyle risk factors that contribute to a poor LDL/HDL cholesterol ratio include smoking, drinking alcohol, consuming a diet high in saturated fats, and not engaging in sufficient exercise.
“To combat some of these habits, people should consider incorporating more foods with unsaturated fats like avocados, olive oil, nuts, seeds, and fish, and reducing intake of red meat and other highly processed foods,” he advises.
“High-fiber foods also lower the risk of bad cholesterol entering the bloodstream and traveling to other parts of the body.”
“Ultimately, everyone’s cause of high cholesterol is different, so each individual should take a unique approach when it comes to leveling out the ratio and setting people on a path for better heart health,” advises Dr. Blander.
“In some cases, diet may be the culprit, while others might need to adjust their exercise regimens or consider supplements.”
Ultimately, medications to lower cholesterol may be necessary in cases where lifestyle factors aren’t the only driving factor underlying high cholesterol.
As Dr. Blander says, “For people experiencing high cholesterol mainly because of advanced age or family history, medication might be the most effective option.”
How Can You Measure Your Total Cholesterol to HDL Ratio?
Managing your cholesterol levels is quite important, but it is equally important to routinely assess your cholesterol levels with a lipid panel (blood tests).
Cholesterol blood tests will give you quantifiable numbers to know whether your cholesterol levels are healthy and whether any steps you are taking to lower your total cholesterol to HDL cholesterol ratio or increase your HDL cholesterol levels are working.
You can work with your doctor to get cholesterol screenings with routine lab work or take a deeper dive into your health with home lab tests.
The InsideTracker Ultimate plan measures up to 48 biomarkers (including HDL, LDL, total cholesterol, triglycerides, and ApoB).
Plus, you have the option to schedule either a mobile blood draw right at your home or go to a Quest lab.
“Our members receive a detailed look at their biomarkers, as well as individually tailored recommendations to help them improve any deficiencies and meet their goals,” explains Dr. Blander.
He adds that at InsideTracker, the goal is to help individuals take control of their health and get actionable advice.
“Current medical guidelines recommend that people between the ages of 21-46 get their cholesterol checked every 4-6 years, with that number increasing to every 1-2 years up to 65, and then annually thereafter,” says Dr. Blander.
“However, we find that it takes people about three to six months to notice significant changes in their biomarkers through lifestyle adjustments.”
For this reason, InsideTracker encourages members with high cholesterol to get their cholesterol levels retested more frequently than the recommended minimum checkups to see accurately how their habits impact their heart health in real-time.
- 1CDC. (2021, April 15). How and When to Have Your Cholesterol Checked | cdc.gov. Centers for Disease Control and Prevention.
- 2American Heart Association. (2017). What Your Cholesterol Levels Mean. Www.heart.org. https://www.heart.org/en/health-topics/cholesterol/about-cholesterol/what-your-cholesterol-levels-mean
- 3Bailey, A., & Mohiuddin, S. (2021). Biochemistry, High Density Lipoprotein. StatPearls. https://www.statpearls.com/ArticleLibrary/viewarticle/22879
- 4Calling, S., Johansson, S.-E., Wolff, M., Sundquist, J., & Sundquist, K. (2019). The ratio of total cholesterol to high density lipoprotein cholesterol and myocardial infarction in Women’s health in the Lund area (WHILA): a 17-year follow-up cohort study. BMC Cardiovascular Disorders, 19(1). https://doi.org/10.1186/s12872-019-1228-7
- 5National Heart, Lung, and Blood Institute. (2022, March 24). Blood Cholesterol – Causes and Risk Factors | NHLBI, NIH. Www.nhlbi.nih.gov. https://www.nhlbi.nih.gov/health/blood-cholesterol/causes