Your total cholesterol just came back at 280 mg/dL. Your doctor wants you on statins immediately. But here's the thing: they're looking at the wrong numbers.

Total cholesterol is basically useless as a risk metric. What matters is the detailed lipid panel, particle size, and metabolic context. Your doctor is making treatment decisions based on a 1960s understanding of cardiovascular disease.

Let's fix that.

NOT A DOCTOR DISCLAIMER: I'm a health coach and researcher, not a physician. This isn't medical advice. Always work with your healthcare provider, especially for cardiovascular health decisions.

Why Total Cholesterol Doesn't Tell You Anything

Total cholesterol is like knowing the total number of vehicles on a highway without knowing if they're motorcycles or 18-wheelers. It tells you nothing about what's actually happening.

Here's what total cholesterol measures:

  • LDL cholesterol (the "bad" one)
  • HDL cholesterol (the "good" one)
  • VLDL (very low-density lipoprotein)
  • IDL (intermediate-density lipoprotein)

You can have a total cholesterol of 280 and be metabolically healthy. You can have 180 and be on your way to a heart attack. The number itself is meaningless without context.

The Numbers That Actually Matter

When you go carnivore, you need to stop obsessing over total cholesterol and start tracking these instead:

1. Triglycerides (should be < 100 mg/dL, ideally < 70)

This is your most important number. High triglycerides mean you're storing excess energy as fat and your liver is converting carbohydrates into triglycerides. Low triglycerides (which carnivore typically produces) indicate efficient fat metabolism.

Most carnivores see triglycerides drop to 40-60 mg/dL within 3-6 months.

2. HDL Cholesterol (should be > 50 mg/dL, ideally > 60)

HDL is your cleanup crew. It removes excess cholesterol from arteries and transports it back to the liver. Higher HDL is strongly protective against cardiovascular disease.

Carnivore tends to raise HDL significantly. Increases of 10-20 points are common within 6 months.

3. Triglyceride-to-HDL Ratio (should be < 2.0, ideally < 1.0)

This is the single best predictor of insulin resistance and cardiovascular risk available on a standard lipid panel.

Calculate it: Triglycerides ÷ HDL

  • Ratio < 1.0: Excellent metabolic health
  • Ratio 1.0-2.0: Good
  • Ratio 2.0-3.0: Concerning
  • Ratio > 3.0: High risk

Example: Triglycerides 60, HDL 70 = Ratio 0.86 (excellent)

Most carnivores achieve ratios under 1.0 within 6 months, even if total cholesterol rises.

4. LDL Particle Number (LDL-P) or ApoB

LDL cholesterol is not one thing. It's a mix of large, fluffy LDL particles (mostly harmless) and small, dense LDL particles (atherogenic).

Standard lipid panels measure LDL-C (LDL cholesterol concentration). What you actually need is:

  • LDL-P: Total number of LDL particles (NMR LipoProfile test)
  • ApoB: Apolipoprotein B, which tags each atherogenic particle

These tests cost $100-200 out-of-pocket but give you actual cardiovascular risk data.

Target ranges:

  • LDL-P: < 1000 nmol/L (optimal), < 1300 (acceptable)
  • ApoB: < 90 mg/dL (optimal), < 100 (acceptable)

What Happens to Cholesterol on Carnivore?

Most people see one of three patterns:

Pattern 1: LDL Stays Normal or Drops (60% of carnivores)
  • Total cholesterol: 180-220 mg/dL
  • LDL: 100-140 mg/dL
  • HDL: 60-80 mg/dL
  • Triglycerides: 40-70 mg/dL
  • Trig/HDL ratio: < 1.0

This is the "dream result." Your doctor won't complain, and your metabolic health is excellent.

Pattern 2: LDL Rises Moderately (30% of carnivores)
  • Total cholesterol: 240-300 mg/dL
  • LDL: 160-200 mg/dL
  • HDL: 70-90 mg/dL
  • Triglycerides: 50-80 mg/dL
  • Trig/HDL ratio: < 1.0

This is the "Lean Mass Hyper-Responder" pattern. Your LDL is elevated, but your triglycerides are low and HDL is high. Research suggests this pattern is not atherogenic when triglycerides are low.

Pattern 3: Everything Rises (10% of carnivores)
  • Total cholesterol: 300+ mg/dL
  • LDL: 220+ mg/dL
  • Triglycerides: 100+ mg/dL
  • Trig/HDL ratio: > 1.5

This pattern needs investigation. High LDL + high triglycerides suggests metabolic dysfunction. Possible causes:

  • Not actually carnivore (hidden carbs, seed oils)
  • Thyroid dysfunction (get TSH, Free T3, Free T4)
  • Genetic hypercholesterolemia (FH)
  • Chronic stress or sleep deprivation

The Lean Mass Hyper-Responder Phenomenon

If you're lean (BMI < 25), active, and eating carnivore, you might see LDL spike to 200-250 mg/dL while triglycerides drop to 40-60 mg/dL.

This is called the Lean Mass Hyper-Responder (LMHR) phenotype. Research by Dave Feldman and the Lipid Energy Model suggests this is an adaptive response: your body is efficiently transporting energy as lipoproteins instead of storing it as triglycerides.

Key LMHR criteria:

  • LDL-C ≥ 200 mg/dL
  • HDL-C ≥ 80 mg/dL
  • Triglycerides ≤ 70 mg/dL

If you meet these criteria, your elevated LDL is likely not a cardiovascular risk. That said, get an advanced lipid panel (LDL-P or ApoB) to confirm particle count is normal.

Research: The LMHR phenotype is being studied in the ongoing "Lean & Low-Carb Study" by the Lundquist Institute. Preliminary findings suggest normal coronary artery calcium scores despite high LDL-C.

What to Do If Your Doctor Freaks Out

Your doctor sees "Total cholesterol: 280" and immediately reaches for the statin prescription pad. Here's how to have a productive conversation:

1. Request an advanced lipid panel
  • NMR LipoProfile (LabCorp or Quest)
  • CardioIQ Advanced Lipid Panel (Quest)
  • Boston Heart Diagnostics
2. Show your triglyceride-to-HDL ratio

If it's < 1.0, you have excellent metabolic health regardless of total cholesterol. Print out studies showing trig/HDL ratio as a superior predictor of CVD risk.

3. Ask for a coronary artery calcium (CAC) score

This is a CT scan that measures actual arterial calcification. It's the gold standard for cardiovascular risk assessment.

  • CAC score 0: No plaque, minimal risk
  • CAC score 1-100: Mild plaque
  • CAC score 100+: Significant plaque, consider intervention

If your CAC score is 0 and your trig/HDL ratio is < 1.0, there's no justification for statins.

4. Monitor over time, not a single snapshot

Cholesterol fluctuates. A single elevated reading means nothing. Track quarterly for 6-12 months to see the trend.

When Should You Actually Worry?

You should investigate further if:

  • Triglycerides stay > 100 mg/dL after 6 months on carnivore
  • Trig/HDL ratio > 2.0
  • LDL-P > 1500 nmol/L or ApoB > 120 mg/dL
  • CAC score rising year-over-year
  • Family history of early heart disease (< age 55)

In these cases, work with a lipid specialist (not just a GP). Consider:

  • Thyroid function testing
  • Genetic testing for FH (familial hypercholesterolemia)
  • APOE genotype testing
  • Insulin resistance testing (HOMA-IR, fasting insulin)

The Bottom Line

Total cholesterol is a useless metric. Your doctor's panic over 280 mg/dL is based on outdated guidelines.

What matters:

  • Low triglycerides (< 70 mg/dL)
  • High HDL (> 60 mg/dL)
  • Trig/HDL ratio < 1.0
  • LDL-P or ApoB in normal range
  • CAC score 0 or stable

If you hit these targets, your cardiovascular risk is low, regardless of what your total cholesterol says.

Get the right tests. Ignore the wrong ones. And don't let a GP bully you into statins based on a single number that tells you nothing about your actual health.

---

References:
  • Krauss RM. Lipoprotein subfractions and cardiovascular disease risk. Curr Opin Lipidol. 2010.
  • Feldman D et al. The Lean Mass Hyper-Responder phenotype. Metabolites. 2020.
  • Harcombe Z et al. Evidence from randomised controlled trials does not support current dietary fat guidelines. Br J Sports Med. 2017.
  • Varbo A, Nordestgaard BG. Remnant cholesterol and triglyceride-rich lipoproteins in atherosclerosis progression and cardiovascular disease. Arterioscler Thromb Vasc Biol. 2016.