Understanding non-HDL cholesterol: The “other” bad cholesterol explained
Non-HDL cholesterol is essentially the total of all the “bad” cholesterols in your blood. It includes low-density lipoprotein (LDL), very-low-density lipoprotein (VLDL), intermediate-density lipoprotein (IDL), and lipoprotein(a) – all the particles that can contribute to plaque buildup in arteries. In a standard cholesterol test (lipid panel), non-HDL is not measured directly but calculated by subtracting your HDL (high-density lipoprotein) – the “good” cholesterol – from your total cholesterol. This simple calculation captures all the cholesterol that can clog arteries (total minus HDL), giving doctors a more complete picture of “bad” cholesterol than LDL alone.1
LDL vs. HDL vs. Non-HDL: LDL cholesterol is often called the “bad” cholesterol because high levels of LDL can lead to plaque buildup in your artery walls, a condition called atherosclerosis. HDL cholesterol, on the other hand, is the “good” cholesterol that helps carry excess cholesterol away from arteries to the liver for removal. Total cholesterol is the sum of all cholesterol in your blood (including LDL and HDL). Non-HDL cholesterol effectively represents all the bad cholesterol particles (LDL, VLDL, IDL, etc.) combined, excluding the good HDL. Unlike LDL alone, non-HDL gives a broader measure of the cholesterol that can raise your heart risk.1
Why non-HDL cholesterol matters for your heart
Monitoring non-HDL cholesterol is important because it strongly predicts your risk of heart disease. Although current cholesterol management guidelines emphasize LDL targets, some experts believe non-HDL is a better predictor of heart disease risk than LDL and cholesterol ratios.1 Research has found that non-HDL cholesterol levels correlate with cardiovascular events even when LDL levels appear “normal.” For example, one study noted that people with elevated non-HDL had a significantly higher risk of major cardiac events, whereas LDL alone was not as strongly associated with risk.2 In other words, non-HDL cholesterol may be a better indicator of heart health risk than LDL cholesterol by itself.2 This is because non-HDL captures all the cholesterol-containing particles that can harm your arteries, including those related to high triglycerides, which LDL alone might miss.
Cardiologists and health experts are paying more attention to non-HDL cholesterol for a couple of reasons. First, you don’t need to fast to measure non-HDL cholesterol, since it’s a simple calculation that isn’t affected by food the way LDL calculation can be.3,4 Most cholesterol tests traditionally required fasting because LDL is often calculated using a formula that involves triglycerides (which rise after eating). Non-HDL can be checked anytime – its value is accurate whether you’re fasting or not. Second, association between non-HDL-C and cardiovascular risk is at least as strong as that of LDL-C. Essentially, non-HDL-C levels provide the same information as apolipoprotein measurements.4 It includes LDL plus other atherogenic (artery-clogging) particles like VLDL/IDL, providing a more comprehensive risk measure.5 Indeed, many experts now consider non-HDL a more robust marker of cardiovascular risk, and its routine inclusion in lipid panels and its incorporation in cardiovascular risk assessment guidelines are essential steps toward improving patient outcomes, guiding treatment decisions, and advancing our collective efforts in the fight against heart disease.5
The European Society of Cardiology (ESC) guidelines on cardiovascular disease prevention suggest non-HDL-C as a reasonable alternative treatment goal for all patients, particularly for those with hypertriglyceridemia or diabetes mellitus.4 Bottom line – non-HDL cholesterol matters because it gives a fuller picture of “bad” cholesterol and is strongly linked to heart health outcomes. Keeping it in check can significantly lower your chances of cardiovascular problems.2
How is non-HDL cholesterol tested?
The good news is you don’t need a special test for non-HDL cholesterol. It’s part of the standard lipid panel that measures your total cholesterol, LDL, HDL, and triglycerides. Most lab reports now may list non-HDL cholesterol automatically, but if not, you or your doctor can calculate it easily: total cholesterol minus HDL cholesterol. For example, if your total cholesterol is 240 mg/dL and your HDL is 40 mg/dL, your non-HDL would be 200 mg/dL.1
To get your non-HDL cholesterol, you’ll undergo a routine blood draw (often from your arm) as part of a cholesterol test. The lab measures your total cholesterol and HDL and may calculate LDL from triglycerides. Non-HDL is then determined by subtracting the HDL value from the total cholesterol.5 If your lab report doesn’t explicitly show “non-HDL,” don’t worry – you can figure it out from the other numbers or ask your doctor to do the math. Since it’s derived from standard measurements, there’s no additional cost or complexity to knowing your non-HDL cholesterol.
What are healthy non-HDL cholesterol levels?
Just like LDL and total cholesterol, lower non-HDL cholesterol is generally better for your heart.1 For most adults, a healthy non-HDL cholesterol level is below about 130 mg/dL (milligrams per deciliter) — this is roughly equivalent to 3.4 mmol/L (millimoles per liter) in the units used in many countries. Doctors consider non-HDL <130 mg/dL as an optimal range for adults with average risk. If your non-HDL is at 130 mg/dL or less, that’s a good sign.1,4 Levels higher than this start to raise concern: for instance, non-HDL in the 130–159 mg/dL range might be considered borderline high, and 160 mg/dL and above would be high, indicating a greater risk of heart disease (similar thresholds to LDL classifications).6
However, “healthy” targets can vary depending on your overall risk profile. Guidelines differ slightly between regions and risk categories. In general, if you have higher risk factors or existing heart disease, doctors recommend aiming for an even lower non-HDL number.7 For example, European guidelines (ESC/EAS) suggest that people at high cardiovascular risk keep non-HDL under ~3.3 mmol/L (130 mg/dL), and those at very high risk (such as patients with prior heart attacks) aim for under 2.6 mmol/L (100 mg/dL).4,7 Some expert recommendations go even further for the highest-risk patients, targeting non-HDL <2.2 mmol/L (about 85 mg/dL) in certain cases.4,7
In the United States, treatment guidelines historically focused on LDL targets, but non-HDL goals align with the same principle. A common rule of thumb is that your non-HDL cholesterol should be no more than 30 mg/dL higher than your LDL cholesterol goal. For instance, if your LDL target is 100 mg/dL, then your non-HDL should be 130 mg/dL or less. If you’re aiming for an LDL under 70 mg/dL (often the case for those with heart disease or diabetes), the corresponding non-HDL goal would be under 100 mg/dL.3
It’s important to note that ideal cholesterol numbers can vary person to person. Your healthcare provider will interpret your non-HDL level in context – considering factors like your age, blood pressure, diabetes status, family history, and whether you already have cardiovascular disease.1 In general, though, lower non-HDL is better. Studies have shown that the lower your non-HDL cholesterol, the lower your chance of plaque buildup and future heart problems.1 If your non-HDL is high, your doctor may set a personalized target for you and work with you on steps to reach it.1
(For reference, non-HDL cholesterol under 130 mg/dL is broadly “normal” for a healthy adult. If you’re a heart patient or at high risk, your doctor might want it considerably lower – sometimes around 100 mg/dL or below. Always consult your physician for the goal that’s right for you.6)
How to improve your non-HDL cholesterol
Although higher levels of HDL cholesterol have links with a decreased cardiovascular risk, clinical trials that raise HDL levels have not shown results in reducing this risk. It may be that the ratio of HDL to LDL cholesterol is more important, as HDL cholesterol can only transport so much cholesterol to the liver. The American Heart Association notes that HDL cholesterol only carries about a third to a fourth of blood cholesterol. This is why interventions for issues with cholesterol typically involve methods to lower LDL cholesterol first. This may improve the balance between HDL and LDL cholesterol in the body.8 Ways to reduce cholesterol include:
Eat a heart-healthy diet:
Focus on foods that improve your cholesterol profile. Emphasize vegetables, fruits, whole grains, legumes (beans), nuts, and lean protein (such as fish and skinless poultry). These foods help lower “bad” cholesterol. Limit foods high in unhealthy fats – especially saturated fats and trans fats, which raise LDL and non-HDL levels.9 Choose healthier fats like olive oil, avocado, and omega-3-rich fish.10 Reduce added sugars, sugary beverages, sodium, highly processed foods, refined carbohydrates, saturated fats, and fatty or processed meats. A diet similar to the Mediterranean diet or DASH diet – rich in plants and healthy fats – is also recommended by American Heart Association as a healthy diet.10
Exercise regularly:
Physical activity can significantly improve your cholesterol levels. Regular exercise helps lower bad cholesterol (non-HDL) and raise good HDL cholesterol.9,11 Aim for at least 150 minutes of moderate aerobic exercise per week (such as brisk walking, cycling, or swimming), or about 30 minutes most days. 9 Adding physical activities, even in short intervals several times a day, can help you begin losing weight. Consider activities like fast-paced walking, bicycling or playing. Exercise stimulates your body to move “bad” cholesterol out of the bloodstream and steadily lowering your bad cholesterol. Exercise can improve cholesterol. Moderate physical activity can help raise high-density cholesterol. Even simple activities – taking the stairs, doing housework, or short walks throughout the day – can contribute. Incorporate more activity into your daily routine, such as climbing stairs. If you’re new to exercise, start gently and build up duration.8
Maintain a healthy weight:
Achieving or maintaining a healthy body weight is key to optimal cholesterol. If you are overweight, losing even 5-10% of your body weight can lead to noticeable improvements in cholesterol levels.11 Weight loss helps reduce LDL and VLDL (which carry triglycerides), thus lowering your non-HDL cholesterol.11 Fat tissue produces substances that can affect how your liver handles cholesterol and fats; by reducing excess weight, you ease that burden. Combine a nutritious diet with regular exercise to shed extra pounds gradually. Even moderate weight loss reduces “bad” cholesterol and triglycerides, so every little bit helps.13 And remember to limit excess alcohol, since alcohol is calorie-dense.8
Quit smoking:
If you smoke, make quitting a top priority for heart health. Smoking doesn’t directly raise non-HDL cholesterol, but it lowers your HDL (“good”) cholesterol and damages your blood vessels, which accelerates plaque buildup. Quitting smoking can improve your HDL level and reduce inflammation, helping your arteries recover. Over time, a higher HDL from quitting will mean a lower non-HDL (since total – HDL = non-HDL). Plus, the cardiovascular benefits of quitting smoking are enormous – within a year of quitting, your heart disease risk drops substantially. Seek support from your healthcare provider or smoking cessation programs to help you quit successfully.9
Consider medication if needed:
Lifestyle measures are the foundation, but if your cholesterol remains high, medications can help. The most common are statins, which reduces the amount of cholesterol the liver makes, thus helping the liver remove excess cholesterol.12 Other medications like ezetimibe, Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, fibrates, or high-dose omega-3 fatty acids (fish oil) may be used in specific situations (for example, if triglycerides are very high or if additional lowering is needed on top of a statin). Your doctor will determine if medication is necessary based on your overall risk and your cholesterol numbers.12 Always pair medications with healthy habits – drugs work best in conjunction with diet and exercise, not as replacements.14 If prescribed, take your medication as directed and have your levels rechecked as recommended to make sure you’re hitting your non-HDL goal.
By following these steps, you can effectively lower your non-HDL cholesterol and improve your heart health. Many experts indeed view non-HDL as a more reliable indicator of heart risk, so improving this number is a positive sign that you’re reducing your risk of cardiovascular disease.1 Remember that cholesterol changes happen gradually – you might see improvements in a few months of sustained lifestyle changes. Work closely with your healthcare provider, who can monitor your progress and adjust your plan (or medications) as needed.
Takeaway:
Non-HDL cholesterol is a valuable measure of all the bad cholesterols that can harm your heart. Keeping it low through diet, exercise, and (if needed) medication can significantly cut your risk of heart attacks and strokes. It’s one more tool – alongside LDL, HDL, and triglycerides – to understand and manage your cardiovascular risk. By learning about non-HDL and how to control it, you’re taking an active role in protecting your heart for the long run.
This article was written with the assistance of generative AI technology and reviewed for accuracy.
