The LDL Chart Fueling Confusion Online - And What It Misses

I recently came across a graph on our Facebook page that seemed to suggest LDL cholesterol isn't a major player in heart disease. The gist of the accompanying comment was bold: “LDL might not be all that important.”

Here is that chart:

At first glance, the data looks convincing that the commenter is indeed correct! But before you disregard your cholesterol numbers, let’s look at why this specific chart is a classic example of how data can be used to lead you astray.

The Trap: Prevalence vs. Pathophysiology

On its face, the graph suggests that an LDL between 190 and 220 mg/dL is "protective" against experiencing a heart attack—even more so than an LDL under 40!  After all, only a tiny number of patients with very high cholesterol are impacted by heart disease.

If we followed that logic, we would ignore patients with Familial Hypercholesterolemia (FH) (LDL >190), who we KNOW experience early, aggressive heart disease. We would also ignore the fact that people with Familial Hypobetalipoproteinemia (lifelong LDL under 40) virtually never develop atherosclerosis.

So, is the graph fake? No. It’s just missing context. The graph fails to account for PREVALENCE. It measures how many total heart attacks happen at each LDL level, rather than the risk for an individual at that level.

• The "Protective" High LDL: Only about 0.4% of Americans (1 in 250) have genetically driven LDL levels >190. Even if every single one of them had a heart attack, they still wouldn't make a large dent in the total number of heart attacks nationwide.  There are simply too few of them.

• Hypobetalipoproteinemia is also extremely rare. But given the very low risk of heart events in this group, it’s not surprising that they account for very few heart-related hospitalizations. 
  

• The "Dangerous" Mid-Range: Most heart attacks occur in the 80–130 mg/dL range because that is where the vast majority of the population lives. When you have millions of people in the middle and only a few thousand at the extremes, the middle will always "account" for more events—but that doesn't mean the middle is higher risk. Or that highcholesterol extremes have no impact.
  

A Better Way to Look at Risk

To understand your actual risk, we need to look at data irrespective of frequency. We need to ask: "If I have 1,000 people with low LDL and 1,000 people with high LDL, who survives longer?"

When we look at the data this way, the "spin" disappears and the biology becomes clear:

This chart represents decades of study and thousands upon thousands of patients. And the trend is unmistakable: The lower the LDL, the lower the risk of a cardiac event. It is a proportional, consistent relationship.

How to Use This Information

The message isn't just "take more drugs." The message is that lowering your LDL works.  What I would add is that how you get there is also important and matters for your long-term well-being.

1. Lowering LDL naturally pays dividends: Whether you are on medication or not, dietary interventions and lifestyle changes that lower LDL allow you to reach your cholesterol goals with lower doses of medications.

2. Dose and Duration matter: The "side effects" of statins are often dependent on how high the dose is and how many decades you take them. By lowering your baseline LDL through Step One or other lifestyle shifts, you reduce the "pharmacological load" on your body.

3. Don't be distracted by the spin: Whether you use lifestyle changes, medications, or a combination of both, reducing your LDL reduces your risk.

The Bottom Line: Don't let a statistical quirk lull you into ignoring a biological reality. Your heart will thank you for keeping those LDL numbers low.