Total Cholesterol… Who Cares?

By Paul Savage, MD, FAARM, ABAARM | Founder of Power2Practice

For years, I have been telling patients that I don’t care what their total cholesterol is.

It’s like asking the question, “How much do you weigh?” I don’t care! What I do care about is what their body fat percentage is—not weight. I know a 160-pound woman who is in shape, and I know a 160-pound woman who is overweight. So, it’s not about the total weight; it’s the percentage of body fat that really matters.

Beyond Good vs. Bad – Let’s Focus on Composition Using a Transportation Analogy

The same logic holds for cholesterol: We can measure the weight of cholesterol (example 200 mg/dL), but that doesn’t tell us what the composition of the cholesterol is. How much is the cholesterol transport the “bad” LDL cholesterol, and how much is the reverse cholesterol transport the “good” HDL cholesterol?

More importantly, “What is the composition of the “bad” LDL cholesterol?” When we measure LDL cholesterol, we are basically straining 100mL of blood for all the “bad” LDL and weighing that amount. We get a measurement like 140mg/dL. It’s simply a weight of “bad” LDL cholesterol. The composition of the “bad” LDL cholesterol is much more important.

Are patients packaging the “bad” LDL cholesterol into a few large particles that carry the majority of this cholesterol, or are they packaging the “bad” LDL cholesterol into many small particles?

For example: Are you are transporting 100 people on a single bus, or are you transporting 100 people in 100 cars? The numbers matter. The more vehicles you have on the road, the more the congestion. Also, the more vehicles you have on the road (like cars) which are smaller than buses, the more chance these small cars can get stuck in nooks and crannies, such as found in arterial walls.

ApoB – the Drunk Drivers of Cholesterol Transport

Additionally, are these vehicles driven by “drunk drivers?” You see, the cholesterol transport vehicles (especially the small vehicles) are often coupled with impaired drivers called ApoB. These ApoB are proteins which sit on top of the cholesterol particle and steer these particles into the walls of the artery (not good).

sdLDL – Tightly-packed and Prone to “Road Rage”

Finally, are the small vehicles (which are dangerous to begin with) packed tightly? We call these small dense LDL particles sdLDLs. The body attacks these small, densely packed “bad” cholesterol vehicles because they have managed to get into the vessel wall. When attacked, they explode and release a large amount of “bad” cholesterol into this space, prompting immune system activation.

In closing, don’t ask patients what their Total Cholesterol is, because it matters very little in the discussion. What matters more is “Are these ‘bad’ LDL cholesterol small, dense, and numerous?”

There are now many labs which offer patients the ability to evaluate their cholesterol much more in depth. One of the companies I am fond of is HDL Laboratories (

This company offers a unique plan in which patients can obtain from their doctor a full testing panel including cholesterol comprehensive evaluation, genetic markers, inflammation markers, Omega 3-6-9 evaluation, hormones, and much more. The wonderful thing about HDL is that they bill insurance for the cost of the labs, and there is little-to-no expense incurred by the patient themselves.

And yes, there are many options opened to treat these numbers, including nutrition, exercise, sleep and supplements!


Written by Paul Savage, MD, FAARM, ABAARM | Founder and Chief Medical Officer at Power2Practice

Dr. Savage founded Power2Practice in 2011 and is currently the Chief Medical Officer. He graduated from the University of Michigan Medical School in Emergency Medicine and later earned his board certification in Integrative Medicine at George Washington University. Since 2004, he has practiced integrative medicine exclusively and is considered by many as one of the world’s foremost authorities in the area of integrative metabolic medicine (IMM), including bioidentical hormone therapy. Dr. Savage is currently Founder and President of Chicago Integrative Care where he practices medicine. He continues to lecture worldwide and frequently provides expert insights on hormone therapy to major news media.

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