What is non-HDL cholesterol: the level in your blood, what it tells you, what level is good and when to see your GP

In this article you will find the answer to the question what is non-HDL cholesterol, how the level in your blood is calculated, which level counts as good and what a higher level means over the years. That matters, because high cholesterol causes no symptoms, while years of cholesterol that is too high raise the risk of a heart attack or a stroke.⁠⁴ Many people see non-HDL cholesterol on a lab result and get no answer to the question ‘what is non-HDL cholesterol’. BioProfile’s heart and blood vessel scan gives you an indication of where you stand today in this area, as one of the 11 health areas the full scan assesses. The scan is self-insight. The scan shows where you stand today and helps you make better choices in your diet and lifestyle. The scan is not a diagnosis. Only a doctor can judge what your blood values mean for you.

Non-HDL cholesterol: what is it?

Cholesterol is a fat-like substance that your body makes in the liver and also takes in from food. Your body uses cholesterol to make cells, hormones and bile.⁠⁴ Non-HDL cholesterol is all the cholesterol in your blood except HDL cholesterol. That number is the sum of the harmful cholesterol particles: LDL plus VLDL, IDL, remnant particles and Lp(a).⁠¹ The calculation itself is simple: total cholesterol minus HDL cholesterol.⁠²

In plain words: LDL cholesterol counts one type of harmful particle, and non-HDL cholesterol counts all types together.⁠¹

What is non-HDL cholesterol in the blood: what the value tells you

Non-HDL cholesterol needs no extra measurement. The lab already measures total and HDL cholesterol, so the number comes at no extra cost. The number also stays usable when triglycerides are very high (above 4.5 mmol/l), where a calculated LDL cholesterol becomes unreliable.⁠²

A large analysis of 302 430 people from 68 long-running studies, mainly in Europe and North America, found that the link between blood fats and heart disease was at least as strong in people who had not fasted as in people who had. The researchers concluded that a check of your blood fats can be simplified to total and HDL cholesterol, without the need to fast.⁠⁵ For you, that means blood taken without fasting also gives a useful value.

A second analysis brought together 12 reports covering 233 455 people and compared three blood markers. Non-HDL cholesterol tracked the risk of heart and blood vessel events slightly better than LDL cholesterol, and a third marker, apolipoprotein B (apoB), did slightly better again. In a model for adults in the United States, an approach based on non-HDL cholesterol would avoid an estimated 300 000 more events over ten years than an approach based on LDL cholesterol.⁠⁶ Put simply: the number that appears free of charge on your lab result says a little more about risk than the better-known LDL value. Cholesterol is one heart number among several, and knowing what a normal heart rate is also helps.

What value is good

The Hartstichting considers a non-HDL cholesterol below 3.8 mmol/l normal. The Hartstichting also considers a total cholesterol below 5 mmol/l normal, with an LDL target below 3 mmol/l, depending on your risk group.⁠¹ Thuisarts gives values for adults in good health, in mmol/l: total cholesterol below 5 is usually good and above 8 is very high, LDL below 3 is usually good, HDL above 1 is good and triglycerides below 2 are good.⁠⁴

When a doctor sets a target, the Dutch guideline on cardiovascular risk management links the two values to each other. An LDL of 1.8 mmol/l goes with a non-HDL cholesterol of 2.6 mmol/l, and an LDL of 2.6 goes with a non-HDL of 3.4.⁠² So what counts as a good level differs from person to person. Below 3.8 is considered normal, and if your risk is higher, you work towards a lower number.⁠^1,2

Values also shift with age. Among 133 450 Dutch participants in Lifelines, LDL cholesterol in men rose by 64% between 20 and 49, and triglycerides almost doubled. In women, LDL cholesterol stayed the same between 18 and 35, then rose by 42% up to 59.⁠⁷ In plain language: a value that looked fine when you were 25 can be clearly higher when you are 50.

What a higher value means over the years

The largest study of non-HDL cholesterol followed 398 846 adults from 38 cohorts in 19 countries. At the start, nobody had heart or blood vessel disease, and half were followed for more than 13.5 years. The share who had a heart or blood vessel event within 30 years rose step by step with non-HDL cholesterol. In women, the share went from 7.7% at less than 2.6 mmol/l to 33.7% at 5.7 mmol/l or higher, and in men from 12.8% to 43.6%. Even after taking other risk factors into account, the highest group had about twice the risk of the lowest.⁠³ Put simply: about one in three women with the highest values had an event within 30 years, compared with fewer than one in ten women with the lowest. For women who want to know which symptoms deserve attention, heart symptoms in women goes into this in more depth.

In the 68 studies above, coronary heart disease was almost three times as common in the third of people with the highest non-HDL cholesterol as in the third with the lowest. The link with a stroke caused by a blocked blood vessel was weaker.⁠⁵ What this means for you: a higher level is a long-term risk signal, and it is the years of cholesterol that is too high that count.⁠⁴

How to lower your non-HDL cholesterol

In the large study of almost 400 000 adults, a model suggested that a non-HDL cholesterol 50% lower was linked to a lower risk of an event before you turn 75. The earlier the lower level began, the greater the gain.⁠³ In plain words: lower is better, and sooner is better than later.

For high cholesterol, the Voedingscentrum gives this dietary advice: a handful of unsalted nuts every day (30 grams), oily fish once a week (1 to 2 times a week if you have heart or vascular disease), and no more than 300 grams of meat a week, of which at most 100 grams is red meat. Plant sterols, 1.5 to 3 grams a day, can lower LDL cholesterol by 7 to 11%. The advice also says: move for at least 2.5 hours a week, plus exercises for your bones and muscles at least twice a week.⁠⁸ What sitting still does to the rest of your body is covered in what too little movement does to your body. In practice, these are small habits you can keep up week after week.

When to see your GP

High cholesterol causes no symptoms, so a high level only comes to light through a blood test.⁠⁴ Thuisarts lists signs of inherited high cholesterol, familial hypercholesterolaemia (FH), to discuss with your GP: very high cholesterol, thickened patches on tendons (especially the Achilles tendon), a yellowish ring around the coloured part of the eye before you are 45, yellow bumps around the eyes, heart or blood vessel disease of your own before you are 60, or known or suspected FH in a parent, child, brother or sister. Your GP can then talk with you about a DNA test. With FH, brothers, sisters and children have a 1 in 2 chance of carrying the same gene fault.⁠⁹ If one of these signs applies to you or your family, a visit to your GP is worthwhile, even if you have no symptoms.

In summary

Non-HDL cholesterol is total cholesterol minus HDL cholesterol: all the harmful cholesterol particles in one number.⁠¹ The number comes free with a standard blood lipid test, is usable without fasting and says a little more about risk than LDL cholesterol.⁠^2,5,6 Below 3.8 mmol/l counts as normal.⁠¹ A higher level goes with more heart and vascular disease over the years, and the eating and exercise advice of the Voedingscentrum is the place to start.⁠^3,8 Signs of inherited high cholesterol are a reason to see your GP.⁠⁹