Ep. 18: Three Things to Know About Your Lipid Profile: S.O.S. Part 2 — with Dr. Regina Druz, MD, MBA, FACC, FMCP-M, integrative cardiologist

You got your bloodwork back and your cholesterol is ‘high’ — now what? In Part 2 of her Statin Overprescribing Solution series, Dr. Regina Druz goes back to basics on the standard lipid profile almost everyone already has. She explains why the old ‘good vs. bad cholesterol’ framing is outdated, what your numbers actually mean once you put them in the context of your personal risk, and — most powerfully — a simple ratio you can calculate yourself that reveals whether insulin resistance is driving your lipids. Walking through a real patient’s report, she shows how ‘normal-ish’ numbers can hide the real opportunity, and why the fix is often cardiometabolic, not just another statin. No advanced testing required — just three things to know. (This episode includes an on-screen calculator walkthrough — best watched on YouTube.)

Watch on YouTube: A video version of this episode is available on the Own Your Heart Health YouTube channel. Subscribe to be notified of new episodes.

Episode Chapters

[00:00] Introduction: Back to Basics on Your Lipid Profile
[02:00] Forget Good vs. Bad — Meet Your Lipidome
[06:00] Homework #1: Was It Fasting?
[09:00] Homework #2: Your Numbers
[13:00] The “Ugly”: What ApoB Really Measures
[16:00] It All Depends on Your Risk
[22:00] Risk Calculators: ASCVD, PREVENT & Reynolds
[26:00] A Real Patient: 59, “Normal-ish” Numbers
[30:00] Homework #3: The Triglyceride-to-HDL Ratio
[35:00] Her Real Problem Is Insulin Resistance — and How to Fix It
[38:00] Recap & Your Lipid Type
[41:00] Closing & For Clinicians

Transcript

[00:00] Introduction: Back to Basics on Your Lipid Profile

Dr. Regina Druz (00:02): Welcome to Own Your Heart Health. I’m Dr. Regina Druz, your holistic cardiologist. This week we’ll dive into common heart health concerns, uncovering root causes and unpacking scientific discoveries and controversies. The information provided does not constitute medical advice. Please contact your healthcare practitioner before making any changes that may impact your health.

Dr. Regina Druz (00:35): Welcome, everybody. Today we’re diving into one of the most common investigations we do as preventive cardiologists and primary-care physicians: your lipid profile. So you saw a doctor, or got bloodwork elsewhere, and found your cholesterol is elevated. Now what? At Holistic Heart Centers we very commonly run advanced biomarkers, advanced lipid profiles, and genetics, and pull it all together into what we call your ‘lipid type.’ But today is deliberately simpler — the basic, standard lipid profile you probably already have — because some of what’s in it is powerful enough to act on without any fancy testing. Think of this as back to basics. I’ll also walk through a real patient’s numbers using tools that are free and in the public domain, so it’s worth catching this one on YouTube.

[02:00] Forget Good vs. Bad — Meet Your Lipidome

Dr. Regina Druz (02:00): First: if cholesterol were a pure villain we could live without, evolution would have discarded it — but cholesterol is essential, manufactured by every cell, with the liver as the main production hub. People tend to be very categorical: ‘I have so much good cholesterol, so much bad cholesterol.’ I want you to forget good and bad and focus on the ugly — I’ll explain. The good/bad division is outdated. It came from population-level studies that gave us a useful framework — LDL ‘bad,’ HDL ‘good’ — but as science and genetics advanced, we learned there are many layers.

Dr. Regina Druz (03:30): Each of us has a lipidome — like the microbiome, but for lipids: the whole ecosystem of particles your body produces and repackages from food, shuttling cholesterol and triglycerides between the gut, the blood, the liver, muscle, and fat. It’s a complex, genetically driven, environment-influenced system. So ‘my cholesterol’s elevated but it’s fine because my good cholesterol is high’ isn’t really true. I want you to get a more contemporary read on the basic profile and go beyond good-versus-bad, because that framing won’t tell you where you need to go or what to do.

Dr. Regina Druz (04:30): Hi everyone, it’s Dr. Regina here. I know there are contradictory opinions about nutrition for heart health and longevity — the discussion gets heated and confusing. Some push low-fat, low-cholesterol; others are fans of a ketogenic diet; and there are many voices urging vegan or vegetarian eating. To cut through the clutter, my team and I created Holistic Heart University: on-demand courses, nutrition and lifestyle resources, and supplement guidance to make healthy choices for your heart easier to understand. I’m especially proud of our open office hours and the Q&A feature where you can put us in the hot seat. Head to the show notes for the link and use promo code OWNER20 for 20% off our annual subscription. I’ll see you in office hours.

[06:00] Homework #1: Was It Fasting?

Dr. Regina Druz (06:00): The basic lipid profile is easy to get — at a physical, an employee screening, or even direct-to-consumer online. Homework number one: look at whether it says fasting or non-fasting, and recall whether you actually fasted (at least eight hours). Why does it matter? The most common ‘elevated’ number people are told about is LDL cholesterol — low-density lipoprotein — and in basic panels LDL is usually not measured directly; it’s calculated (you may see ‘LDL-C’ or ‘calculated’ next to it).

Dr. Regina Druz (07:30): Under most circumstances the calculation closely approximates a direct measurement — but it breaks down in people with elevated triglycerides, typically above 200. And the formulas were standardized in the fasting state. Physicians often tell you to get lipids ‘any time’; I disagree, because the cutoffs we rely on came from fasting specimens. There’s literature supporting non-fasting values (especially for triglycerides), but we can’t standardize those numbers yet. So fasting removes the influence of a recent meal — particularly on triglycerides — and lets us trust what the panel is telling us about your metabolism rather than your last meal.

[09:00] Homework #2: Your Numbers

Dr. Regina Druz (09:00): Homework number two: know your numbers. A basic profile contains total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides. Some labs also report non-HDL cholesterol, and occasionally — if your doctor requested it — ApoB. Each of these is independently relevant to heart-disease risk, and they aren’t substitutes for one another; you need the whole picture, which is exactly why we talk about your lipid type. Remember, in your lipidome these aren’t separate buckets — LDL and HDL are measurable but interrelated, constantly transforming as your body processes the cholesterol and triglycerides you eat.

[13:00] The “Ugly”: What ApoB Really Measures

Dr. Regina Druz (13:00): So forget good and bad — here’s the ugly. LDL cholesterol turns out to be only a surrogate marker for the real culprit: ApoB. ApoB is essentially the sum total of all the cholesterol-carrying particles capable of damaging your arteries — a global marker of your atherogenic burden. Most of it is LDL, but it also captures very-low-density lipoprotein and chylomicrons (the big triglyceride-laden particles that ferry fat from your gut). Think of ApoB as one large basket from which various harmful particles can emerge. We’ll devote a whole future episode to ApoB and particle counts, because it’s a rich topic.

[16:00] It All Depends on Your Risk

Dr. Regina Druz (16:00): What counts as an ‘okay’ number depends entirely on your risk. For a genuinely low-risk person, most guidelines accept total cholesterol around 200 or less, LDL under 130, and non-HDL under 160 (non-HDL is simply total cholesterol minus HDL — an approximation of all the artery-damaging cholesterol). But many of us aren’t low-risk. Major risk factors include older age, diabetes, high blood pressure, chronic kidney disease, smoking, and a family history of early heart disease. Then there are ‘risk enhancers’ — obesity, a history of preeclampsia, high inflammation, and genetic markers, whether single-gene (like ApoE4) or polygenic.

Dr. Regina Druz (18:30): So in prevention we recognize levels: low, moderate, high, very high, and extreme. Roughly: at moderate risk (a couple of risk factors, 10-year risk under 10%), aim for LDL under 100, non-HDL under 130, and ApoB under 90. At high risk (diabetes or stage 3–4 kidney disease, or a 10-year risk of about 10–20%), aim for LDL under 70, non-HDL under 100, and ApoB under 80. And at extreme risk — progressive disease, recurrent events despite treatment, or strong genetic and family history — we may target LDL under 55 and ApoB under 70, because at those levels there’s literature suggesting actual plaque regression and healing. (As a rule of thumb for ‘early’ family history: a first-degree male relative under about 55, or female under about 65, with a serious cardiac event.)

[22:00] Risk Calculators: ASCVD, PREVENT & Reynolds

Dr. Regina Druz (22:00): To put your numbers in context we use risk calculators — all free and in the public domain (links in the show notes). The best known is the ASCVD (atherosclerotic cardiovascular disease) Risk Estimator, drawn largely from the 2018 American College of Cardiology cholesterol guidelines. This year, in 2025, I’ll be at the European Society of Cardiology meeting, where they’re unveiling a revamped European cholesterol guideline. There’s also a newer calculator called PREVENT, which adds kidney function, hemoglobin A1c, BMI, and even ZIP code — but it drew criticism for suggesting many people we’d thought needed statins may not, so it’s still being refined. And there’s the Reynolds Risk Score from Dr. Paul Ridker’s group, originally developed in women, which incorporates C-reactive protein and family history.

[26:00] A Real Patient: 59, “Normal-ish” Numbers

Dr. Regina Druz (26:00): Let me use a real patient. She’s 59, white, with a systolic blood pressure of 132 and diastolic of 85 — very common. Her fasting total cholesterol was 234, HDL 42, and LDL 168. She’s not diabetic, never smoked, takes blood-pressure medication, and was started on a statin plus aspirin. Plugging her into the ASCVD estimator, her current 10-year risk is about 5.9% — borderline — while her lifetime risk, as for most younger patients, is high, around 39%. If all her risk factors were optimally controlled, her 10-year risk would drop roughly threefold.

Dr. Regina Druz (28:30): Running her through the Reynolds Risk Score (with a C-reactive protein around 1.2 and no family history) gives a 10-year risk in the low single digits. So she’s not someone who obviously needs aggressive statin therapy. By the guidelines her LDL of 168 ‘should’ be under 100 for her risk level — so how do we get her there? The standard calculators won’t show you the most important clue. There’s a far more powerful variable hiding in her basic profile.

[30:00] Homework #3: The Triglyceride-to-HDL Ratio

Dr. Regina Druz (30:00): Homework number three — and this one holds the keys. Take your triglycerides and divide them by your HDL cholesterol. This is why fasting matters: a non-fasting sample inflates triglycerides and skews the ratio. For this patient, triglycerides were 119 — flagged ‘normal’ by standard labs, which use a cutoff under 150 (in functional medicine we prefer to see triglycerides in double digits). But her HDL was only 42, and for women an HDL under 50 is considered unfavorable. So 119 divided by 42 is 2.88.

Dr. Regina Druz (32:00): Why does that number matter? A triglyceride-to-HDL ratio at or above 2.4 is a strong indicator of insulin resistance. So here’s the opportunity: this 59-year-old scores low-to-intermediate risk with no risk enhancers — not diabetic, no early family history — yet if all we fixated on was her LDL, or even her ApoB, we’d miss the real story. Her ratio reveals that insulin resistance is driving her lipids.

Dr. Regina Druz (33:30): Hi everyone, it’s Dr. Regina here. Many of my colleagues and I are seeing patients arrive with self-ordered blood tests. When this trend started, I thought it would help — who doesn’t want more access to their health data? But too often self-ordered labs lead to more confusion and frustration: patients come in with a pile of results and are no better off. That’s why we created HeartWell Toolkits — a curated collection of at-home blood and genetic markers focused on heart and brain health that gives you the data you need to make informed, actionable decisions. You can order them at the shop on holisticheartcenters.com — the link is in the show notes. Use code TESTING10 for 10% off and free shipping.

[35:00] Her Real Problem Is Insulin Resistance — and How to Fix It

Dr. Regina Druz (35:00): So unless there’s another compelling reason for a statin, her path isn’t medication — it’s cardiometabolic intervention: addressing insulin resistance and the factors that drive it, like excess weight. This is a patient who could do very well with a low-glycemic Mediterranean diet, a fasting-mimicking approach, or metformin — an inexpensive, powerful insulin sensitizer with potential longevity and cancer-prevention benefits. Targeted supplement regimens can help, and GLP-1 therapies everyone’s heard about — such as tirzepatide (Zepbound) — can be useful too. Normalize the insulin resistance and her lipid profile responds, lowering not just her 10-year risk but, importantly, her lifetime risk — because her lipid type is fundamentally cardiometabolic.

[38:00] Recap & Your Lipid Type

Dr. Regina Druz (38:00): So, equipped with just your basic profile: number one, was it fasting? Then we can trust the numbers. Number two, what’s your vascular risk category — low, moderate, high, very high, or extreme — and are your numbers good enough for that category? You can look this up or simply ask your doctor. And number three, the most important: divide your triglycerides by your HDL. A ratio at or above 2.4 points to insulin resistance — a roadmap to where you can intervene, no fancy tests required.

Dr. Regina Druz (39:30): In clinical practice it’s more involved — we use the HeartWell Toolkit to measure advanced lipids and genetics, because population-level studies are great for assigning risk to a population, but an individual in front of me may not fit that population. Building your composite lipid type lets us say how much of your picture comes from metabolism, hormones, environment, and genetics — and gives you a personalized roadmap. It’s not magic or voodoo, and it’s not chasing one supplement after another; it’s using the science we already have to personalize the plan for you.

[41:00] Closing & For Clinicians

Dr. Regina Druz (41:00): This is Part 2 of our Statin Overprescribing Solution series, so check out Part 1 — and there will be Parts 3, 4, and 5, plus dedicated episodes on ApoB and lipid particles, and on vascular age and carotid intima-media thickness. The tools I mentioned are in the public domain and linked in the show notes, so go plug in your own numbers. If you have questions, message me on Instagram, Facebook, or YouTube. I’ll see you in the next episode.

Dr. Regina Druz (42:00): To the professionals listening: if you’re thinking of launching a cardiometabolic or integrative cardiology program in your practice, we can help. Holistic Heart Centers helps physicians expand into hybrid or concierge services — head to the show notes and click the application link; your intro call is entirely free. Ready to schedule a practice review? Use code DOC10 for 10% off our Practice Power Hour, a 60-minute coaching session. Thank you for tuning in to Own Your Heart Health with Dr. Regina Druz. This podcast is powered by Holistic Heart Centers. If you enjoyed the show, please rate and review us on your favorite platform, and visit holisticheartcenters.com and subscribe to our YouTube channel. See you next week.

Frequently Asked Questions

Do I need fasting bloodwork for a lipid panel?

Dr. Druz strongly prefers fasting (at least eight hours). The reason is standardization: the cutoffs and formulas we rely on were derived from fasting specimens. In a basic panel, LDL cholesterol is usually calculated rather than measured directly, and those calculations were standardized in the fasting state — they also become unreliable when triglycerides are elevated (typically above 200). A recent meal raises triglycerides, which can skew both your LDL calculation and the all-important triglyceride-to-HDL ratio. While there’s growing literature on non-fasting values (especially for triglycerides), we can’t yet standardize those numbers, so fasting lets you trust that the panel reflects your metabolism rather than your last meal. Homework step one is simply to check whether your result was taken fasting. This is educational information; discuss your testing with your own clinician.

Is “good cholesterol vs. bad cholesterol” still the right way to think about it?

No — Dr. Druz calls that framing outdated. It came from useful population-level studies (LDL ‘bad,’ HDL ‘good’), but your body actually runs a whole ‘lipidome’: an interrelated ecosystem of particles constantly repackaged as you process food. So saying ‘my cholesterol is high but it’s fine because my good cholesterol is high’ isn’t really accurate. She suggests focusing less on good versus bad and more on ‘the ugly’ — ApoB, which represents the total burden of all artery-damaging, cholesterol-carrying particles (mostly LDL, but also VLDL and chylomicrons). LDL cholesterol turns out to be largely a surrogate marker for that broader ApoB burden. The bigger point is that no single number tells the whole story; you need to see your numbers together and in the context of your personal risk. Interpret your results with a qualified clinician.

What is the triglyceride-to-HDL ratio, and why does it matter?

It’s a simple calculation you can do yourself — your (fasting) triglycerides divided by your HDL cholesterol — and Dr. Druz calls it the part of the basic profile that ‘holds the keys.’ A ratio at or above 2.4 is a strong indicator of insulin resistance, even when the individual numbers look ‘normal.’ In her real-patient example, triglycerides of 119 (flagged normal) and an HDL of 42 gave a ratio of 2.88 — revealing that insulin resistance, not simply high LDL, was driving the lipid picture. That changes the plan: instead of reaching for more statin, the path is cardiometabolic — a low-glycemic Mediterranean or fasting-mimicking diet, weight management, and sometimes metformin or GLP-1 therapy. Because fasting affects triglycerides, the ratio is only reliable on a fasting sample. This is general education, not personalized medical advice.

What LDL number should I aim for?

It depends entirely on your risk category — there’s no universal target. As a rough guide from the guidelines Dr. Druz cites: a genuinely low-risk person may be fine with LDL under 130 (total cholesterol around 200, non-HDL under 160); at moderate risk, aim for LDL under 100 (non-HDL under 130, ApoB under 90); at high risk — for example, diabetes or advanced kidney disease — aim for LDL under 70 (non-HDL under 100, ApoB under 80); and at extreme risk, targets may drop to LDL under 55 and ApoB under 70, where some evidence suggests plaque regression. The key is matching your numbers to your personal risk, which you can estimate with free tools like the ASCVD Risk Estimator or, for women, the Reynolds Risk Score — or simply ask your doctor what risk category you’re in. Decisions about targets and treatment should be individualized with your physician.

Show Notes & Resources

Host: Dr. Regina Druz, MD, FACC

Dr. Regina Druz is a board-certified holistic cardiologist and the founder and CEO of Holistic Heart Centers. With a background in cardiac imaging and nearly 25 years in practice, she blends conventional cardiology with integrative, functional, root-cause medicine. Her focus is cardiometabolic health, personalized prevention, and cardiovascular longevity — using advanced lipid testing, genetics, and vascular and biological age assessment to define each patient’s ‘lipid type’ and ‘age-proof’ their cardiovascular system. She is the host of Own Your Heart Health and the creator of Holistic Heart University, the HeartWell Toolkits, and the Statin Overprescribing Solution program.

Resources Mentioned in This Episode

ASCVD Risk Estimator Plus (American College of Cardiology) — free, online; based on the 2018 ACC/AHA cholesterol guideline
Reynolds Risk Score (Dr. Paul Ridker) — risk calculator originally developed in women; incorporates C-reactive protein
AHA PREVENT risk calculator — newer; adds kidney function, hemoglobin A1c, BMI, and ZIP code (still being refined)
2018 ACC/AHA Cholesterol Management Guideline — risk categories and LDL / non-HDL / ApoB targets
Triglyceride-to-HDL ratio — a quick, do-it-yourself insulin-resistance screen (≥2.4 is a strong indicator)
HeartWell Toolkit — advanced lipid markers and genetics to define your ‘lipid type’ (use code TESTING10 for 10% off and free shipping)
Statin Overprescribing Solution series — Part 1 (age-proofing); upcoming parts on ApoB / lipid particles and vascular age / CIMT
Cardiometabolic tools mentioned — low-glycemic Mediterranean diet, fasting-mimicking diet, metformin, and GLP-1 therapy (e.g., tirzepatide / Zepbound)
Holistic Heart University — on-demand courses and resources (use code OWNER20 for 20% off annual)
For clinicians: Practice Power Hour coaching with Holistic Heart Centers (use code DOC10 for 10% off)

Holistic Heart Centers

holisticheartcenters.com
HeartWell.ai — AI-powered cardiovascular risk assessment
Address: 55 Bryant Avenue, Suite #6, Roslyn, NY 11576
Phone: 877-511-5166
YouTube: @reginadruzmd
Instagram: @dr.reginadruz
Podcast: Own Your Heart Health — available on Apple Podcasts, Spotify, and all major platforms

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