Risk Assessment:
What Is A Normal Cholesterol Level?

Is There Any Such Thing As A Normal Cholesterol Level?

Yes and No. Don’t you love political answers?

Determining a normal cholesterol level is a continuing project for scientific research.

Should my LDL cholesterol be below 100 mg/dL? Yes. It is best for optimal heart health.

But for treatment purposes reaching that goal becomes much more important for certain risk groups.

Should I worry if my LDL cholesterol is over 100 mg/dL? The answer depends on the risk group I find myself in.

Risk assessment for coronary heart disease (CHD) has evolved over the years as advancements in research have provided more detailed information. Determining your risk for developing CHD is not as simple as looking at a total cholesterol chart and comparing the results of your cholesterol test with what is considered a normal cholesterol level.

There are many factors which your doctor can take into consideration when determining the likelihood of you having a cardiac event within the next ten years. (Ten years is considered long-term risk) The combination of several studies has provided us with a detailed model for heart disease prediction.

This page provides a summary of why we know what we know. It helps us understand how doctors assess risk for heart disease. Depending on the degree of risk, doctors will set different cholesterol goals for different patients.

Of course we all would like to have optimal cholesterol levels. However, for the purposes of treatment, cholesterol goals do differ depending on the level of long-term risk for coronary heart disease (CHD).

How the Framingham Heart Study Helps Determine High Cholesterol Risk

Perhaps chief among these studies is the Framingham Heart Study. Begun in 1948 by the United States Public Health Service, this study has involved thousands of participants from three generations in its extensive data collection efforts. As a result heart disease research has taken a huge leap forward.

Not only has heart health research greatly benefited from the study, but the broader environment of medical science has profited as well. Health concerns such as…

  • stroke
  • dementia
  • osteoporosis
  • arthritis
  • diabetes
  • eye disease
  • cancer
  • the genetic patterns of many common diseases…

… have also come into sharper focus. 

For more detail on the Framingham Heart Study please click here.


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Adult Treatment Panel

Among the many reports that have been spawned by the Framingham Heart Study are three in particular that focus primarily on cholesterol. These three reports have resulted due to the efforts of the National Cholesterol Education Program’s (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. They are known as…

  • Adult Treatment Panel I (ATP I)
  • Adult Treatment Panel II (ATP II)
  • Adult Treatment Panel III (ATP III)

ATP I was primarily concerned with high LDL cholesterol levels (>= 160 mg/dL). It therefore outlined a strategy for preventing CHD in patients with high LDL cholesterol.

ATP I also recommended strategies for treating patients with borderline high LDL cholesterol (130 -159 mg/dL) who exhibit at least two other CHD risk factors. 

With ATP II the standard for a normal cholesterol level shifted a bit. Why? Because it identified that people with established coronary heart disease were at higher risk. Therefore it added a more intensive LDL lowering effort for patients with established CHD. The LDL goal for ATP II for these patients is <=100 mg/dL.

ATP III upheld the recommendations of ATP II and outlined even more intensive goals for LDL lowering in patients with certain high risk conditions such as diabetes and metabolic syndrome.

New Discoveries That Aid in Proper CHD Risk Assessment

Proper risk assessment for coronary heart disease must include a consideration of multiple risk factors as hinted above. These risk factors were the focus of ATP III. To help us see this it is useful to list the features added to ATP III that were not considered in its predecessors.

ATP III and Multiple Risk Factors

ATP III first focuses on multiple risk factors. For example...

A person with diabetes and with no coronary heart disease is now considered to have the same risk for a heart episode as a person with documented CHD.

Part of the reason for this is that people with diabetes also exhibit other multiple risk factors.

Further, ATP III recommends using the Framingham Point Scores to identify patients with a high likelihood of having a CHD event within the next ten years. The purpose of identification is so that these patients may receive more intensive treatment.

ATP III also recommends identifying patients with Metabolic Syndrome for more intensive therapeutic lifestyle changes.

If you want to read more about Metabolic Syndrome you can click here.

ATP III and New Cholesterol Goals

The second focus of ATP III is to modify lipid and lipoprotein classifications. That means we reconsider what a normal cholesterol level is.

The researchers involved in ATP III identified LDL cholesterol levels below 100 mg/dL as optimal.

HDL cholesterol below 35 mg/dl was previously considered low. That level was reset to anything less than 40 mg/dL. Remember HDL cholesterol is the healthy kind.

ATP III determined that healthy levels of HDL should be higher than previously thought. In addition to this...

Triglycerides are now considered a more important risk factor.

Moderate levels of triglycerides received more attention after ATP III. Perhaps that is why so many more people are concerned with their triglycerides.

ATP III and More Thorough Testing

Thirdly, ATP III made adjustments for testing and treatment. Formerly the recommended screening only included total cholesterol and HDL cholesterol. Determining a normal cholesterol level is no longer considered sufficient.

Now a complete lipoprotein profile is recommended including…

  • Total cholesterol
  • LDL cholesterol
  • HDL cholesterol
  • Triglycerides

ATP III also encourages the use of plant stanols/sterols and soluble fiber as dietary treatment options for lowering LDL cholesterol. This is good news because this can encourage a shift away from dependence on prescription drugs.

ATP III also recommended more aggressive lowering of LDL cholesterol for patients with triglycerides =>200 mg/dL.

What Is The Big Deal About These Shifts In Research?

Why is all this important? Because it demonstrates that heart health maintenance is a much more complex endeavor than previously thought. It is not enough to accept higher blood pressure and a higher than normal cholesterol level simply because we are getting older.

It also hints at the great importance of aggressively controlling those factors which damage our hearts and set us up for disaster.

Finally it gives us hope that doctors are progressively more able to predict and prevent heart disease. Keep in mind, however, much of our doctors’ success depends on us. You and I are responsible to do our part in pursuing optimal heart health.

One thing should be kept in mind. Though there are many factors to consider such as different types of cholesterol, triglycerides and blood pressure, etc the current focus in treatment is to lower LDL cholesterol. HDL can be affected to a lesser degree.

However, when all the factors are considered the primary focus of treatment is the lowering of LDL cholesterol. Such is the attitude of ATP III.

Proper Risk Assessment Takes Center Stage

Proper risk assessment, then, takes the spotlight as the first step of risk management. Before we can receive treatment it is important to know how high our risk is for coronary heart disease.

The intensity of therapy to reduce risk can not be determined until a patient’s absolute risk is determined. Absolute risk is determined by a measurement of a patient’s LDL cholesterol in addition to other risk factors which are spelled out by the Framingham point scores.

What Should We Do?

For the moment, however, let’s look at the generalities. ATP III recommends that every adult at least 20 years of age get a fasting lipoprotein profile every five years. A complete lipoprotein profile includes…

  • Total cholesterol
  • High density lipoprotein (HDL)
  • Low density lipoprotein (LDL)
  • Triglycerides

If a nonfasting lipoprotein profile is taken then only total cholesterol and HDL cholesterol can be used in this scenario. In the latter case a more detailed follow-up profile is recommended if total cholesterol is at least 200 mg/dL or HDL is < 40 mg/dL. This is perhaps more clear in outline form. The data below reflect the cholesterol classification accepted by ATP III. 

Total Cholesterol

  • <200 - Desirable
  • 200-239 - Borderline
  • >=240 - High

LDL Cholesterol

  • <100 - Optimal
  • 100-129 - Near Optimal
  • 130-159 - Borderline
  • 160-189 - High
  • 190 or above - Very High

HDL Cholesterol

  • Less than 40 - Low
  • At Least 60 - High

To Sum Up

The profile standard mentioned above along with such risk factors as…

  • high triglycerides
  • smoking
  • diabetes
  • metabolic syndrome

… as well as others provide doctors and researchers with a strong tool for predicting the likelihood of coronary heart disease as well as other cardiac events. 

However, it should give us a hint too. At the very least I may suppose from the partial list above that I should not smoke. I also need to keep my triglycerides low. I could also safely assume that if I have diabetes or metabolic syndrome then I should work hard to control these conditions. They affect my heart as well.

All this detail about research shifts is interesting to someone like me. When I look at a chart that tells me what a normal cholesterol level is I know the diagnosis is not as simple as that.

As I get older I realize that avoiding heart disease is not enough. My goal – and I hope it is yours as well – is for optimal heart health. That means I am going to do my part to keep my heart in the best shape I can. For that an evaluation of what is considered a normal cholesterol level is not enough.

The ball, so to speak, is in our court. What are we going to do about it?

Please return to the main cholesterol page below and continue your research on heart health. Or perhaps you want to read other sections of this website.

If you are impatient and busy like I am you might want to go right to the section that is the most practical for our current topic. That section is called Lifestyle Therapy for Cholesterol Maintenance. You will see elsewhere in the cholesterol section that lifestyle changes are the first line of treatment. The nice thing is these are the things we can do to avoid coronary heart disease and progress toward optimal heart health.

Lifestyle Therapy for Cholesterol Maintenance

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