What is a “good” cholesterol level?

If I were to echo conventional advice, I would refer you to the guidelines provided by ATP-III, then say "Discuss it with your doctor." You and your doctor would then be taking notes from the same page.

But I won't.

Though, in my view, the guidelines provided by ATP-III are helpful as a starting point for crude advice on cholesterol, for truly effective advice on how to gain control over heart health, you need to go further.

First of all, let's dismiss the value of total cholesterol. Total cholesterol is the combination of LDL ("bad") cholesterol, HDL ("good") cholesterol, and triglycerides (another "bad" blood fat), all lumped together. Total cholesterol is therefore a mixture of both good and bad factors and can yield confusing, often misleading, information. If, for instance, HDL goes way up (a good thing), so does total cholesterol (an apparently bad thing). That makes no sense. Yes, total cholesterol can serve to predict heart disease on a broad statistical basis in a large population. But you're just one person, not thousands. You require information that applies to you.

Two, the LDL cholesterol number provided by your doctor is not actually measured, but calculated. It is calculated from the three other measured values (total cholesterol, HDL, triglycerides) by a nearly 50-year old equation, known as "the Friedewald equation". Dr William Friedewald developed this equation years ago, when measured LDL cholesterol values were not widely available and the equation was a necessity. When measured more precisely, calculated LDL is commonly 20, 40, 50% or more inaccurate. It can be higher, it can be lower, but you and your doctor can't tell which just by looking at the calculated LDL.

Calculated LDL cholesterol by the Friedewald equation has about much remaining value as tie-dye T-shirts and hippie haircuts. It was relevant for its time, but it is starting to get faded and worn. More recent analyses have suggested that, while the higher LDL cholesterol is, the greater the risk for heart disease, many people with low cholesterols can also have substantial risk and that not everybody with high cholesterol does indeed face increased risk. How to make sense out of this jumble? No wonder it's not clear what exactly is a "high" cholesterol!

Fast forward 50 years from Dr. Friedewald's day and LDL cholesterol is now widely available as a measured value. Even better, it is available as a superior measure, one that possesses superior power to predict whether heart disease is in your future or not.

Allow me to make a set of bold predictions for the future:

One: Total cholesterol will join 8-track tape players in the junk heap of technology, and you will no longer see it on your standard cholesterol panel.

Two: Calculated LDL cholesterol will become less and less the number used to gauge risk from cholesterol issues. More accurate measures like measured LDL, apoprotein B, and my favorite, LDL particle number (obtained through a more sophisticated though highly accurate test called the NMR LipoProfile, Liposcience), will replace this rusty old model-T called calculated LDL. Measured LDL and apoprotein B are already available in most modern laboratories; the NMR and other lipoprotein tests are also available, but must be specified by your doctor.