What’s the latest-greatest heart-health indicator?
For decades the medical establishment focused on total cholesterol as the main indicator of cardiovascular and heart health. This despite the fact that it’s relatively ineffective as a predictor — half of people with high cholesterol never have a heart attack, and half of people who die of heart attacks don’t have high cholesterol.
Over the years this morphed into a focus on good and bad cholesterol — HDL and LDL — and then the ratio between HDL and the total. This eventually gave way to a spotlight on the LDL particle size — the vLDL — which was deemed to be very bad, and also contained another blood fat, triglyceride.
The truth is none of these numbers give a clear and simple picture of heart health. However, studies have increasingly demonstrated a better, more stable and balanced view of an important single number that can replace the old ones. This is the ratio of triglycerides (TG) to HDL.
Most importantly, these two measures correspond to two of the strongest lifestyle habits — the effects of both aerobic exercise and a healthy diet. Both TG and HDL influence the balance of cholesterol and the health of arteries, including those in the brain and heart and the rest of the body.
The ratio of these two numbers — TG divided by HDL — is one everyone should know and monitor. Both high TG and low HDL separately can significantly increase the risk of illness and disease, although many people with high TG also have low HDL; a high ratio.
When the TG/HDL ratio is too high, health risks rise significantly. Fortunately, lowering it is relatively easy, but it’s important to measure both fats, which are part of the basic blood testing most people obtain during regular checkups.
Not only does a higher ratio predict the risk of cardiovascular disease, but also may indicate blood sugar-related conditions like diabetes, metabolic syndrome and carbohydrate intolerance (insulin resistance). This combined cardiovascular and metabolic risk, referred to as cardiometabolic, is typically associated with being overfat, which also promotes chronic inflammation, another key risk factor. The overfat pandemic underlies most common causes of global morbidity and mortality.
- TG reflects the fats in the blood that typically elevate after a meal, especially one that’s higher in carbohydrates. It also increases with age (which increases insulin resistance), and in women after menopause (due to aging and reduced estrogens). Excess calories and alcohol (more than two drinks daily for men and one for women) can also increase TG. And, the easiest way to lower VLDL is by reducing TG. While traditional recommended blood levels are still stuck at 150, I prefer them to be under 100 (mine is usually less than 75).
- HDL generally reflects physical activity, especially aerobic fat-burning exercise. While a level of 60 or above is associated with lower risk of heart disease, and below 40 reflects high risk, I like seeing HDL over 70 (mine is usually around 90).
In addition, the TG/HDL ratio can predict LDL particle size. While LDL particle size is a valuable number to know, it’s a specialized, costly test, while TG and HDL are not and regularly measured in standard testing. Most people who have a regular blood test have both numbers (although the ratio may not be listed).
While poor health can be predicted by a TG/HDL ratio above 3.0, some studies show the optimal cut-off values are about 3 in men and 2 in women; but others show even lower numbers are better, which appear to correspond with clinical observations.
So, if your TG/HDL ratio is lower than these numbers, especially if closer to 1.0 or less, among the best number in many studies, you may be at the lowest health risk.
The lowest risk numbers are the typical outcomes of those who have eliminated sugar and other refined carbs, and exercise aerobically with a heart rate monitor, thereby increasing fat-burning and maintaining normal body fat. But when the ratio is too high, this lifestyle approach becomes the first, go-to treatment.
For decades, lifestyle modifications have been the first treatment of choice in those with high risk for cardiometabolic conditions. Unfortunately, too many patients are not treated as individuals, often just told to lose weight or exercise — but without any specific guidelines. Or, an off-the-shelf diet is given, which is typically unsuccessful. Worse, outdated blood test numbers guide a practitioner’s use of medications instead of first recommending lifestyle modification. (If food and exercise is not a practitioner’s area of expertise, the patient should be referred to an expert.)
While specific individualized lifestyle changes are key, they must also be accompanied by a long-term TG/HDL ratio that demonstrates success.
Be aware that short-term single blood or other tests may reflect a transition process, once the body adapts to a healthier lifestyle ongoing healthy TG and HDL levels are maintained.
And, when the appropriate dietary changes are made, especially by eliminating sugar and other refined carbohydrates, TG will be the first to change. It can measurably reduce significantly — often normalizing in a week. With effective aerobic exercise, HDL typically improves slower over time, but it eventually does. The most important factor to consider is that individuals strictly monitor their food intake to eat consistently healthy for two, three or more tests to encompass all the changes that are to come.
These changes also can include other important factors such as blood sugar, weight and body fat, blood pressure, and other tests, in addition to those associated with mental-emotional function such as memory, learning and cognition.
Dong T, et al. The effects of low-carbohydrate diets on cardiovascular risk factors: A meta-analysis. PLoS One. 2020;15(1):e0225348. doi: 10.1371/journal.pone.0225348.
Wakabayashi I, Daimon T. Comparison of discrimination for cardio-metabolic risk by different cut-off values of the ratio of triglycerides to HDL cholesterol. Lipids Health Dis. 2019. 18, 156. doi.org/10.1186/s12944-019-1098-0.
Hajian-Tilaki K, et al. Triglyceride to high-density lipoprotein cholesterol and low-density lipoprotein cholesterol to high-density lipoprotein cholesterol ratios are predictors of cardiovascular risk in Iranian adults: Evidence from a population-based cross-sectional study. Caspian J Intern Med. 2020;11(1). doi:10.22088/cjim.11.1.53.