The critical issue is how cholesterol is carried in the blood, not just the sum total.

Total cholesterol simply adds HDL and LDL together, so two people with the same total can have very different health risks.

In fact, studies show that particle patterns and ratios predict risk far better than total cholesterol. 3

For example, the number and size of LDL particles really matter: many small, dense LDL particles greatly increase risk, while larger LDL particles are more protective

Likewise, having lots of HDL particles (high HDL) lowers risk. 4

Because of this, newer tests measure LDL particle count or apoB (each atherogenic particle) and non-HDL cholesterol (total minus HDL) – and these outperform LDL-C alone in predicting heart disease 

Important Cholesterol Ratios and Markers

Rather than total cholesterol, clinicians now emphasize specific ratios and lipid markers. Key ones include:

1. HDL/Total Cholesterol Ratio: 

This tells you what portion of your cholesterol is HDL (the “good” kind).

A higher ratio (e.g. HDL/Total ≈25–30%) is protective.

Studies found that people with high total cholesterol lived longer because much of it was HDL. 5

In practice, a high HDL/total ratio means most of your cholesterol is the good kind.

2.Triglyceride/HDL Ratio: 

A high TG/HDL ratio is a red flag for metabolic trouble.

Elevated triglycerides with low HDL are classic signs of insulin resistance and metabolic syndrome.

A recent 2023 review notes that the TG/HDL- C ratio is ‘closely related to insulin resistance and central obesity’ and is an ‘excellent novel risk marker’ for metabolic syndrome and all forms of CVD. 6

In plain language, a high TG/HDL ratio (often above 2–3) means much higher heart risk, even if total cholesterol looks okay.

3.LDL Particle Size / ApoB: 

We already mentioned LDL particles above. In practice, apoB or direct LDL-P tests count those particles.

A meta-analysis showed apoB was the strongest predictor of cardiovascular events, and LDL-C was the weakest. 7

Non-HDL cholesterol (total minus HD L) is also a better predictor than LDL-C. 8

This is why guidelines now often use non-HDL-C and apoB to assess risk: they capture all the ‘bad’ particles rather than just the cholesterol they carry.

In summary, don’t panic over a total cholesterol number alone.

The balance and quality of your lipids matter more.

For example, someone with total cholesterol 220 mg/dL could be low-risk if their HDL is high and TG is low, while someone with total 180 but high TG/HDL ratio and many small LDL particles is at high risk.

Total cholesterol as a lone metric is the least predictive compared to these ratios and particle measures.

Focus on the whole picture:

Ask your doctor for HDL, triglycerides, and if needed apoB/LDL-P.

Aim for healthy markers like high HDL, low TG, and favorable ratios (for example, TG/HDL below ~2–3).

These give a much clearer readout of metabolic and heart health.

In the end, it’s the patterns and ratios of your lipids, not just the total number, that best tell whether your cholesterol profile is healthy. 9