How to interpret a lipid panel

As the time doctors spend with us becomes more limited, I think everyone should be able to look at their own lipid panels and perform a basic interpretation of the results. All one has to do is look at a few numbers and calculate a ratio.

A typical lipid panel consists of a measurement of fasting triglycerides, total cholesterol, LDL cholesterol (LDL-C), and HDL cholesterol (HDL-C). Even though several ratios can be assessed from the lipid panel, the ratio of triglycerides to HDL-C is the most telling part of the test.

The traditional lipid panel does have its limitations. It provides a look at triglyceride levels, which is important, but does not show the size and number of the lipoproteins traveling in the blood. LDL and HDL are lipoproteins that shuttle a variety of fats. The lipid panel only measures the amount of cholesterol they contain.There are sophisticated lipoprotein tests like the NMR lipid profile test that are much more extensive in this regard.

I would like the get an NMR test at some point, but the standard lipid panel has still proven useful to me, and is also quite cheap to have done at a direct lab service.

Let’s take a look at my blood work compared to the criteria for metabolic syndrome back in late 2010 when I was about 215 pounds at 5’5.”

  • Fasting glucose greater than or equal to 100 mg/dL              104 mg/dL
  • Blood pressure greater than or equal to 130/85 mmHg          136/90 mmHg
  • Triglycerides greater than or equal to 150 mg/dL                   189 mg/dL
  • HDL-C less than 40 mg/dL in men, less than 50 mg/dL in women 37 mg/dL
  • Waist circumference greater than 40 inches in men 35 inches in women
    • I don’t remember the number but at that weight my waist circumference definitely exceeded 35 inches.

Metabolic syndrome (Insulin resistance syndrome) — a condition that waves the red flag for the development of chronic conditions like type II diabetes, heart disease, certain cancers and neurodegenerative diseases —  is diagnosed when a patient has at least 3 out 5 of the above conditions.

That was 5 out of 5 for me. Plus my liver function tests (LFTs) showed elevated liver enzymes — a sign of liver malfunction — and an abdominal ultrasound showed fatty liver, supporting evidence for the elevation in liver enzymes. Both consequences of an insulin dependent abdominal weight gain pattern.

Here is my complete lipid panel from that same day, with the normal ranges/numbers in parentheses, as dictated by the print out from my doctor’s office:

  • Triglycerides 189 mg/dL (should be under 150 mg/dL, ideally under 100 mg/dL)
  • HDL-C 37 mg/dL (Should be greater than 50 mg/dL, but for optimal heart health greater than 60 mg/dL)
  • LDL-C 83 mg/dL (less than 130 mg/dL)
  • Total cholesterol 155 (125-200 mg/dL)

Notice that total cholesterol and LDL-C are not included in the diagnosis for metabolic syndrome, and my values for these two measurements were not out of range. LDL-C levels can be deceptive, they can be high or low and be dangerous or healthy. It’s the size and quantity of the particles that matter.

In fact, people with high LDL-C as shown on the standard lipid panel, might be put on statins when they don’t need to be. They could have high LDL-C but might not have many LDL particles and a very small portion or none of it may be small and dense. A low number of large, buoyant LDL particles is the composition to strive for. Patients like these should get NMR lipid testing so that their LDL can be accurately assessed.

If you have a lot of small dense ones then you’re in trouble. They’re the bad guys that build up inside artery walls, leading to massive problems like strokes and heart attacks.

There’s no way to tell the size and number of LDL particles from a typical lipid panel, but, simply divide the triglyceride number by the HDL-C number and you can get an idea of where you’re at. I wrote about the relationship between high triglycerides, low HDL-C and small dense LDL particles a previous post “Why Insulin Resistance Gives you Heart Disease.” It is high triglycerides that must be brought down for heart health. High triglycerides force HDL-C levels down and cause small LDL particles to be produced in large numbers.

Let’s look at what my ratio was:  189/37= 5.11. Not good. The ratio should be less than 2. Actually, in people with very healthy cardiovascular systems, HDL-C can even reach the 90s and the triglyceride/HDL-C ratio can drop below 1. Many centenarians have values like these. HDL-C should be over 60 mg/dL for both men and women for optimal heart health.

My ratio, 5.11, tells me that even though my LDL-C was only 83 mg/dL, it probably consisted of a large number of small dense particles.

My doctor never went over these tests with me. All he said was, “lose some weight and exercise.” I’ll be polite and say I couldn’t blame him for his brevity. After all, he had about ten minutes with me.

I struggled for over a year on a high carb diet, still eating refined carbohydrates like pasta while curbing my caloric intake. Cutting calories to a minimum, that’s the way to lose weight, I thought.

I came across the documentary Earthlings, a movie that shows inside footage of factory farming and adopted a vegan lifestyle a group of doctors were touting for heart health. I switched to a low-fat vegan diet free of processed carbohydrates and full of fruits, vegetables and whole grains. I stopped counting calories too, a practice that was making me suicidal.

After about two years of following this vegan diet insulin resistance was obviously much improved, though I can’t say gone, and I got down to 155 pounds. My fasting blood sugar was at 70 mg/dL, my blood pressure 120/70, my liver function test was normal, fatty liver was cleared. But, I was not completely impressed with the results of my lipid panel:

  • Triglycerides 79 mg/dL
  • HDL-C 32 mg/dL
  • LDL-C 47 mg/dL
  • Total cholesterol 95 mg/dL

It was great to see my triglyceride levels drop to 79 mg/dL, but I was upset to see my HDL-C levels go down even more! The ratio between triglycerides and HDL-C was now 2.5. Still not there.

Another year went by and my HDL-C levels barely budged. While it’s true that HDL-C can take a while to rebound after weight loss, that was not happening for me on a low-fat diet. I had even given up eating extra virgin olive oil, a food I had grown up with in a Mediterranean family.

My weight loss had stagnated, and frankly eating low-fat and vegan was not satisfying, especially the low-fat part. I was also very tired all the time. And weight loss wasn’t as important to me anymore as what was going on inside me.

A consistently low HDL-C level told me insulin resistance was never fully going to go away if I stayed on a diet like this. Eating a lot of fruit, grains, and legumes might work for others who have better glucose tolerance so I don’t want to completely knock it down, but it was not working for me.

Studies show dietary fats, including saturated fats, do not contribute to heart disease. Despite this, low fat, high carbohydrate diets are still being recommended as a primary way to reduce the risk of heart disease.

Fat is tasty, filling, and healthy. We need dietary fats to keep our brains functioning properly, to make hormones, form cell membranes, absorb certain vitamins, and keep our blood sugars in check, just to name a few things. Doctors won’t usually tell us that high triglycerides result from a diet high in sugars and carbohydrates, not directly from dietary fats.

In the last year I started adding fats into my diet. Here’s what my latest lipid panel looks like:

  • Triglycerides 80 mg/dL
  • HDL-C 46 mg/dL
  • LDL-C 55 mg/dL
  • Total cholesterol 117 mg/dL

Adding saturated fats into my diet did not radically raise my LDL-C, it only went up a bit, and is still quite low because I eat a primarily plant based diet. I expect it to move up more along with the HDL-C. The HDL-C levels are in the process of climbing. My triglyceride/HDL-C ratio is now 80/46 = 1.73. Finally under 2.

At the time of this lipid panel taken about two months ago, I wasn’t eating particularly low carb, it was reduced carb. I was avoiding processed carbohydrates and wheat due to their high glycemic indexes, but I had still been consuming whole grains like brown rice a few times per week and eating several fruits per day.

I am confident that my HDL levels will rise more and my triglycerides will drop as I modify my diet. I want to get my HDL levels above 60 mg/dL and my triglycerides below 60 mg/dL and so I have been cutting my carbohydrate intake more to do so.

Here is a look at what I currently stick to eating, and I have to say I feel great. I can tell that it has helped even more with my blood sugar levels because I don’t get ravenously hungry if I go without eating for a few hours. I have also lost fifteen more pounds. And, I’m actually looking forward to getting a lipid panel done in the near future to see how I’ve improved.

  • I eat vegetables at every meal, mainly leafy greens which are high in fiber, a carbohydrate that for the most part doesn’t even get processed by the digestive tract. The fiber also mitigates blood sugar rises after a meal.
  • I eat fat at every meal. Usually I’ll saute vegetables in a bit of olive or coconut oil, sometimes butter. I put extra virgin olive oil on salads.
  • I eat eggs almost every morning, and meat or full fat dairy once or twice a week, sometimes less than that. I don’t eat any animal products that have been industrially produced. I buy them from local small farmers here in Maine.
  • I love making my own fermented foods like sauerkraut and kimchi and I’ll eat that with meals or between meals. Doing this myself saves a ton of money as well.
  • I eat about two to four servings of fatty fish every week. I like sardines and they are cheap, I just make sure they are canned in water or extra virgin olive oil.
  • Occasionally, here in Maine, I’ll eat other seafood like lobster, oysters, mussels, and clams when the prices are affordable.
  • I haven’t been eating grains or legumes at all, but I haven’t completely ruled them out. I’ll probably eat them every once in a while because I grew up eating some of them, like stewed lentils and chickpeas in dishes such as hummus.
  • Having said all this, I don’t think vegetarianism isn’t at all incompatible with what I do because I’m pretty close to it anyways. You could take out the meat and fish and still get plenty of good fats in. If you are vegan you can eat more foods like olives, coconut, avocados, seeds, and nuts.  


Here’s an example of a typical day for me:

Breakfast:

Two eggs and a plate of sauteed vegetables like mushrooms or greens with coffee, black or with full fat coconut milk. On occasion I’ll have coffee with cream because it has no sugar, but it’s not something I keep in the house.

Lunch:

A big bowl of salad — I mean like large mixing bowl size, a size that might make someone say, “you’re going to eat all that salad?” I’ve really been enjoying caesar salads lately, without croutons of course. I like to slice up a whole avocado and add it in and have a serving of fatty fish with it.

Dinner:

A whole, large eggplant cut into pieces and sauteed in coconut oil with tofu, onions, a leafy green like bok choy, and soy sauce.

Depending on my activity level on a given day, if I get hungry in between meals I eat vegetables, nuts, seeds, and olives. I have limited my intake of fruits due to their sugar content, but enjoy a serving of high fiber fruits like berries and apples no more than once per day.

Lastly, I won’t pretend to be perfect. I will eat processed foods like cake or ice cream, but I reserve those foods for special occasions.