Sep 10

Women: Let’s Talk Cholesterol

Note from Dave: This long-awaited installment from Siobhan is a must-read for every female interested in cholesterol and risk. Enjoy!

The First Hint

As the #LDLBounty continues, and the question of whether high LDL in isolation raises the risk of cardiovascular mortality (or all-cause mortality) in and of itself remains unanswered, there may be a group which may give one even more pause when contemplating the answer. My first hint that things weren’t exactly equal in regards to cholesterol between men and women was way back in 2015. Far before I had even thought about picking up a textbook on lipidology, I noticed there seemed to be something a little odd going on in regards to women and high cholesterol levels. For one, I had heard talk of some research that women with low cholesterol were more at risk for symptoms of depression1, 2, and while I found this interesting it was merely an association. So what if you’re less likely to become depressed if you have higher cholesterol as a woman? You’ll still be more likely to die of things like heart disease, and die more over all, anyway.


More Cholesterol, Less Death

In fact, there appears to be a bit of a difference when it comes to women and men in regards to mortality risk when it

From: doi:10.1111/j.1365-2753.2011.01767.x

comes to cholesterol. Because, while in men it appears as though there’s a U shaped risk when it comes to

cholesterol levels – meaning that rates of death are higher with lower and higher total cholesterol – with women it appears to be quite a bit more simple. As stated in the paper3, in women it appears as though when cholesterol levels are higher, death from all causes is lower.

That study didn’t appear to be a random fluke, either. As time went on I found more4, and more5 and more6 studies all showing that, specifically in women, either there was no difference in death from all causes with varying cholesterol levels, or those in the lowest cholesterol group had the highest rates of mortality. But, admittedly, this is looking at total cholesterol, so I thought that at the very least higher LDL (often considered the true bad guy in regards to cholesterol) would correlate to higher mortality rates.

More of the Same

Even after looking for studies which looked at LDL levels in regards to the rate of mortality and cardiovascular disease, the result ended up being the same with studies I encountered generally coming to similar conclusions. Some said that LDL levels in women were “not significantly related” to all-cause mortality7, while other said that LDL was not associated with Peripheral Artery Disease in women8, and yet more indicating variations of the same result.9, 10

But, clearly women aren’t bulletproof when it comes to cardiovascular disease, as they get it at about the same rates as men do, and it’s not like we’re especially good at avoiding death in general (as much as we might like to think of ourselves as invincible), either. So, it doesn’t appear as though this is a case of women being immune to cardiovascular disease, or being particularly resistant to death, so much as total cholesterol and LDL seemingly being poor predictive markers for women.

Now What?

If neither LDL nor total cholesterol is especially predictive in women, then what can we look for to determine our risk? Some studies indicate other, potentially more relevant markers for women, and luckily no additional tests need be ordered, as the information can be found on a standard lipid panel.

For example several studies found that the ratio of triglycerides to HDL were predictive of carotid plaque11, insulin resistance12, 13 (which is related to increased cardiovascular disease risk), cardiovascular mortality14 and all-cause mortality in women.15 Atherogenic Index of Plasma (AIP) also has some promise to better predict all-cause mortality among women.16 Although AIP is unlikely to show up on your lab report, you can easily calculate it via our report tool so long as you have your triglyceride and HDL levels.

While these markers do appear to predict cardiovascular and all-cause mortality risk better than Total Cholesterol or LDL this doesn’t mean that these markers are perfect. For one, both of these measures can be impacted by how long you fasted before the test, as well as issues which may raise triglycerides in isolation. Use of medication which influences HDL and triglycerides may also potentially interfere with their value as health markers, as well, so looking at multiple risk markers together may help avoid some of the pitfalls of relying on one marker alone.

Final Note From Siobhan


As always, the evaluation of personal health is a topic that, first and foremost, should be had with your doctor. Likewise, we always recommend researching all reputable sides of this debate as we do ourselves.





Horsten, Myriam, et al. “Depressive Symptoms, Social Support, and Lipid Profile in Healthy Middle-Aged Women:” Psychosomatic Medicine, vol. 59, no. 5, 1997, pp. 521–28. Crossref, doi:10.1097/00006842-199709000-00009.

Persons, Jane E., et al. “Longitudinal Study of Low Serum LDL Cholesterol and Depressive Symptom Onset in
Postmenopause.” The Journal of Clinical Psychiatry, vol. 77, no. 2, Feb. 2016, pp. 212–20. PubMed, doi:10.4088/JCP.14m09505.
Petursson, Halfdan, et al. “Is the Use of Cholesterol in Mortality Risk Algorithms in Clinical Guidelines Valid? Ten Years Prospective Data from the Norwegian HUNT 2 Study.” Journal of Evaluation in Clinical Practice, vol. 18, no. 1, Feb. 2012, pp. 159–68. PubMed, doi:10.1111/j.1365-2753.2011.01767.x.
Forette, B., et al. “Cholesterol as Risk Factor for Mortality in Elderly Women.” Lancet (London, England), vol. 1, no. 8643, Apr. 1989, pp. 868–70.
Higgins, M., and J. B. Keller. “Cholesterol, Coronary Heart Disease, and Total Mortality in Middle-Aged and Elderly Men and Women in Tecumseh.” Annals of Epidemiology, vol. 2, no. 1–2, Mar. 1992, pp. 69–76.
Choi, Ji-Sook, et al. “Serum Total Cholesterol and Mortality in Middle-Aged Korean Women.” Atherosclerosis, vol. 192, no. 2, June 2007, pp. 445–47. PubMed, doi:10.1016/j.atherosclerosis.2007.03.006.
Nilsson, Göran, et al. “Ten-Year Survival in 75-Year-Old Men and Women: Predictive Ability of Total Cholesterol, HDL-C, and LDL-C.” Current Gerontology and Geriatrics Research, 2009, p. 158425. PubMed, doi:10.1155/2009/158425.
Aday, Aaron W., et al. “Lipoprotein Particle Profiles, Standard Lipids, and Peripheral Artery Disease Incidence – Prospective Data from the Women’s Health Study.” Circulation, July 2018, p. CIRCULATIONAHA.118.035432. DataCite, doi:10.1161/circulationaha.118.035432.
Hamazaki, Tomohito, et al. “Towards a Paradigm Shift in Cholesterol Treatment. A Re-Examination of the Cholesterol Issue in Japan.” Annals of Nutrition & Metabolism, vol. 66 Suppl 4, 2015, pp. 1–116. PubMed, doi:10.1159/000381654.
10 Bass, Katherine Miller. “Plasma Lipoprotein Levels as Predictors of Cardiovascular Death in Women.” Archives of Internal Medicine, vol. 153, no. 19, Oct. 1993, p. 2209. Crossref, doi:10.1001/archinte.1993.00410190045006.
11 Masson, Walter, et al. “Association between Triglyceride/HDL Cholesterol Ratio and Carotid Atherosclerosis in Postmenopausal Middle-Aged Women.” Endocrinologia Y Nutricion: Organo De La Sociedad Espanola De Endocrinologia Y Nutricion, vol. 63, no. 7, Sept. 2016, pp. 327–32. PubMed, doi:10.1016/j.endonu.2016.04.004.
12 Murguía-Romero, Miguel, et al. “Plasma Triglyceride/HDL-Cholesterol Ratio, Insulin Resistance, and Cardiometabolic Risk in Young Adults.” Journal of Lipid Research, vol. 54, no. 10, Oct. 2013, pp. 2795–99. PubMed, doi:10.1194/jlr.M040584.
13 González-Chávez, Antonio, et al. “Elevated Triglycerides/HDL-Cholesterol Ratio Associated with Insulin Resistance.” Cirugia Y Cirujanos, vol. 79, no. 2, Apr. 2011, pp. 126–31.
14 Mazza, A., et al. “Triglycerides + High-Density-Lipoprotein-Cholesterol Dyslipidaemia, a Coronary Risk Factor in Elderly Women: The CArdiovascular STudy in the ELderly.” Internal Medicine Journal, vol. 35, no. 10, Oct. 2005, pp. 604–10. PubMed, doi:10.1111/j.1445-5994.2005.00940.x.
15 Bittner, Vera, et al. “The Triglyceride/High-Density Lipoprotein Cholesterol Ratio Predicts All-Cause Mortality in Women with Suspected Myocardial Ischemia: A Report from the Women’s Ischemia Syndrome Evaluation (WISE).” American Heart Journal, vol. 157, no. 3, Mar. 2009, pp. 548–55. PubMed, doi:10.1016/j.ahj.2008.11.014.
16 Bendzala, Matej, et al. “Atherogenic Index of Plasma Is Positively Associated with the Risk of All-Cause Death in Elderly Women : A 10-Year Follow-Up.” Wiener Klinische Wochenschrift, vol. 129, no. 21–22, Nov. 2017, pp. 793–98. PubMed, doi:10.1007/s00508-017-1264-1.

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19 Comments on "Women: Let’s Talk Cholesterol"

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Thanks for doing this important work! I have high LDL cholesterol in isolation but had a CT Scan that showed I have absolutely no evidence of coronary artery disease! I am 53 and have been doing LCHF since November 2016. I believe I am going to live a good long time!!

فروشگاه اينترنتي

There should be results for the upper and lower levels of Cholesterol and a careful and accurate examination to consider the possible risk for fat and cholesterol levels.


In your review of the literature, did you find that HDL became “good” because people were trying to determine why women’s heart disease rates were lower than men’s and came up with this idea? (This has always been my understanding, but could be — and likely am — wrong.)

Also, is there one reference study we could use (say, a meta-analysis or review) to illustrate this concept? I always say that higher TC (or even LDL) appears to be protective for women, but then I don’t have anything to back that up, other than all the people whose views I trust and who have researched this say this is the case.

And this points out yet another reason our older-male-dominated medicine fails: researchers (men) think that what applies to older men should apply to everyone else, women, children, etc., and that may or may not (in many cases, is not) true.

Adam G

Sorry to but in with a different topic but did you post your final results from the beef vs pork tests anywhere or Did the video CCW4 cover it? Thank you sorry again for interrupting

Frank Tufano

Hey Dave do you have any idea of a solely fish diet over 1-2 weeks would drastically impact cholesterol? My LDL has tested anywhere between 350 (after 2 weeks of fasting) and 220 (fasted 12 hours), I’m tempted to test it out for a week or two.

The idea was:
Normal Diet for 1 week, fast 12 hours, get blood results
Only fish/light calories/fasting for 2 weeks, fast 12 hours, get blood results
fast 1 more week, get blood results

Susan P.

Thank you for the AIP report tool. I put in my numbers and got an answer of
AIP: -0.252 >>> Lowest Risk Third Is that a truly a negative number? That seems too good to be true!


Siobhan, I am assuming these are all good? Can you confirm. I am not really familiar with AIP especially. Thank you for all you do here and on the KKAB page.

Kelle Clark

I’m preparing for my first blood testing after 6 months Keto and Carnivore for the last 4 months. I will be going to Quest Diagnostics and will be self-paying, so I want to get the most bang for my bucks 🙂 A semi-retired Naturopath has offered to call in my prescription, but is unsure what to request considering my WOE and cholesterol concerns. I have had kidney stones n the past (last bout 2 years ago) so I also want these levels checked. I was overwhelmed at the number of test available on the Quest website and wonder if you can help me out? I will be posting my results as soon as I receive them. Thanks for all your great work!



What are good studies to give your doctor when they want you to start on statins?


Most of the studies and discussion I see about cholesterol and disease is all about impact on coronary disease. What about stroke risk? and Small Vessel Disease (SVD) in the brain? can we translate effects of diet and cholesterol on the heart and it’s vascular system to the brain and it’s blood vessels?