Old habits die hard.

For several decades, doctors have focused on low-density liprotein (LDL), the so-called “bad cholesterol,” as a key indicator of a person’s risk for heart disease.

But another readily available measurement usually ignored by doctors is much better—the ratio of triglycerides, a kind of fat found in the blood, to high-density lipoprotein (HDL), the “good” cholesterol. The lower the ratio, the better.

And now a new study has confirmed that the triglyceride/HDL ratio, as opposed to LDL levels, is far more predictive of heart disease risk.

That would be bad enough if it meant that many doctors are missing a prime driver of heart disease in their patients. But the real effects actually are much worse—they’re missing the right prescription for heart disease prevention and often prescribing the wrong one…statins.

To find out about the latest study—and the very different approach to heart disease prevention that it supports, we spoke with cardiologist Stephen Sinatra, MD, an assistant clinical professor of medicine at University of Connecticut School of Medicine and coauthor of The Great Cholesterol Myth.


The triglyceride/HDL ratio has shown up as a big risk factor in small studies, so researchers at Kaiser Permanente Northern California, one of the country’s largest health-care providers, analyzed data from more than 100,000 healthy men and women between ages 50 and 75 over about eight years to see which ones developed ischemic heart disease. That’s the most common form of heart disease, caused by narrowing of the arteries.

The researchers checked these outcomes against lab values available in the typical “lipid profile.” For LDL, they looked at people with levels above 160 mg/dL, which is officially “high” according to national guidelines. For the triglyceride/HDL ratio, they looked at people within the top third of trigylcerides and the bottom third of HDL levels.

Here’s what they found…

• Those with high LDL cholesterol were 19% more likely to develop heart disease.

• Those with high triglyceride/HDL ratios were 68% more likely to develop heart disease—more than triple the risk of those with high LDL.

The new research strengthens the growing body of evidence that LDL cholesterol levels aren’t the main drivers of heart disease. Here’s the big concern—one in four Americans is currently taking cholesterol-lowering prescription medication, primarily statins, which reliably lower LDL levels but do little or nothing to prevent a first heart attack. (To learn more, see Bottom Line’s The Ugly Truth About Statins.)

The triglyceride/HDL ratio, on the other hand, can indicate something completely different—potential insulin resistance, the ability of the body to metabolize carbohydrates. Insulin resistance, Dr. Sinatra explains, a well-known risk factor of type 2 diabetes, also is a main driver of metabolic syndrome—a constellation of risk factors that may include high blood pressure and being overweight, especially with a big belly, that greatly increases heart disease risk.

“If you have insulin resistance and you cannot metabolize sugar effectively, the calories are not burned up but stored as fat in the form of triglycerides,” Dr. Sinatra explains. “If you look at love handles on men and women, that’s a visual of triglycerides,” he says. “Visceral belly-fat tissue is a hotbed of inflammatory chemicals, and studies show that inflammation is a key cause of plaque buildup in blood vessels.”

Paying attention to the more significant triglyceride/HDL ratio leads to a very different treatment plan—lose weight, increase exercise and change your diet. Instead of statins, says Dr. Sinatra, “What these patients really need is to treat the insulin resistance with a low-carbohydrate, low-sugar diet and exercise.”


To find your ratio, divide your triglyceride level by your HDL level. For instance, if your triglyceride level is 150 and your HDL is 50, your ratio is 150/50 or 3. A ratio of 2 or less is considered ideal. In the Kaiser study, the cut-off for being in the top third of trigylcerides and lower third of HDL turned out to be 2.7.

“Anything over 3, I tend to get a little concerned about,” says Sinatra. “If you’re 5 or over, I’m very aggressive at reducing it.” To improve your ratio, he recommends…

• Reducing your intake of sugar and processed carbohydrates, which break down quickly into blood sugar and raise triglyercides.

• Adding healthy fats including olive oil, coconut oil and avocados.

• Including foods rich in omega-3s, such as fish and fish oil, flaxseed, walnuts and fermented soy. (He often recommends squid or fish oil supplements to his patients with poor ratios.)

• Getting regular exercise, which helps boost HDL among many other heart benefits.

Simply cutting out refined carbs and sugars, says Dr. Sinatra, goes a long way toward losing weight, especially around the middle. Consider a typical breakfast of a bagel, a donut or a sugary cereal and skim milk. It contains lots of refined carbs and sugar but very little protein or fat. “That causes a surge in insulin, which leads to higher triglycerides,” he says. Better breakfast ideas: Scrambled eggs with spinach, or granola made with whole oats and rye flakes, nuts, seeds and dried fruit.

To learn more about weight loss, see Bottom Line’s Guide to Keeping Weight Off—for Good!