PHILA TODAY · LIVE WELL · EAT WELL · MOVE WELL
CHOLESTEROL SERIES · ARTICLE 4 OF 12
Understanding your lipid panel
The four numbers and what they mean.
If the first three articles have done their job, you’ve either had a cholesterol test or are planning to. This article picks up where that ends. The test result lands on your phone or in your clinic file. You look at the numbers. Now what?
We are going to walk through how to read a typical South African lipid panel, what each of the four numbers tells you, the two newer numbers some clinics now report (ApoB and Lp(a)), how to spot what’s improved between visits, and what to actually ask your clinic when you see the result.
Heads up about units
South African labs report cholesterol in mmol/L (millimoles per litre). American labs use mg/dL. If you find a target online quoted as “LDL under 100”, that is American and equals roughly mmol/L 2.6. To convert American to South African, divide by 39. To convert triglycerides specifically, divide by 89.
What’s on the panel
A standard South African lipid panel reports five things:
1. Total cholesterol
2. LDL cholesterol (“bad”)
3. HDL cholesterol (“good”)
4. Triglycerides
5. Total cholesterol to HDL ratio
Many panels also calculate non-HDL cholesterol automatically (it’s just Total minus HDL — a useful single number that captures all the “bad” lipoproteins together).
1. Total cholesterol
The headline number — the sum of all the cholesterol in your blood, good and bad. Useful as a quick screen, but it hides the detail. Two people can have the same total of 5.5 mmol/L: one with high HDL (good) and moderate LDL, another with low HDL and high LDL. Same number, very different risk.
Targets:
• Under 5.0 mmol/L — optimal for most adults.
• 5.0 – 6.2 — borderline.
• Above 6.2 — high, worth investigating further.
2. LDL cholesterol — the main number
LDL is the single most important number on the panel. Almost every cholesterol treatment is aimed at bringing it down. As we covered in article 2, your LDL target depends on your overall cardiovascular risk:
Risk category LDL target Low risk under 3.0 mmol/L Moderate risk under 2.6 mmol/L High risk (diabetes, kidney disease, multiple risk factors) under 1.8 mmol/L Very high risk (previous heart attack, FH, advanced diabetes) under 1.4 mmol/L
A common confusion: most lab reports flag any LDL above 3.0 as “high”, in red ink. For a low-risk young adult, this may be fine and not warrant treatment. For a high-risk diabetic, an LDL of 2.5 — which would not be flagged in red — is too high. The number in red on the lab report is not always the number that matters for you. Read it in context.
3. HDL cholesterol — the one you want high
HDL is the only number on the panel where higher is better. It reflects how well your body is clearing cholesterol out of artery walls.
• Men: above 1.0 mmol/L is acceptable; above 1.2 is good.
• Women: above 1.2 mmol/L is acceptable; above 1.4 is good.
• Anyone under 0.9 mmol/L is concerning, regardless of LDL.
What raises HDL? Exercise (especially aerobic), moderate alcohol (one drink a day, no more), monounsaturated fats (olive oil, avocado, nuts), and stopping smoking. What lowers HDL? Smoking, sedentary lifestyle, obesity, high refined-carb intake, certain medications, and untreated diabetes.
Important nuance: very high HDL (above 2.5) is not always good news. In some genetic conditions, very high HDL particles don’t work properly. Most people will never hit this; mention it if you do.
4. Triglycerides — the third fat
Triglycerides are not cholesterol; they’re a separate kind of blood fat, mostly made from excess calories. They go up after meals, sometimes by a lot, which is why fasting tests still get done when triglycerides are the focus.
• Under 1.7 mmol/L — optimal.
• 1.7 – 2.3 — borderline; investigate lifestyle.
• 2.3 – 5.6 — high; usually needs treatment, especially if HDL is also low.
• Above 5.6 (and especially above 10) — very high; risk of pancreatitis, urgent treatment needed.
What pushes triglycerides up? Sugar, refined carbohydrates, alcohol, untreated diabetes, certain medications (steroids, some HIV drugs, certain birth-control pills), under-active thyroid, and family genetics. The good news: triglycerides respond fast to lifestyle change. Two weeks of cutting sugar and alcohol can drop them by 30 – 50%.
5. Total cholesterol / HDL ratio
Some panels report this; some don’t. It’s the total divided by the HDL — a quick way to capture the “good vs bad” balance in one number.
• Under 3.5 — excellent.
• 3.5 – 4.5 — good.
• 4.5 – 5.5 — borderline.
• Above 5.5 — high.
This is a useful single number to track over time, especially for people who want one figure to focus on.
Non-HDL cholesterol — the underused single number
Take your total cholesterol and subtract your HDL. The result is your non-HDL cholesterol. It captures everything that’s “bad” or potentially bad in one number — LDL plus VLDL plus a few smaller things — and is more reliable than LDL alone when triglycerides are high.
Targets are simple: roughly 0.8 mmol/L higher than your LDL target. So a high-risk person aiming for LDL under 1.8 should aim for non-HDL under 2.6.
If you forget everything else, watch two numbers
For most people, the two numbers worth tracking visit to visit are LDL and HDL. LDL should be coming down. HDL should be holding steady or rising. The total, triglycerides and ratio will mostly follow.
The newer markers some clinics use
If you’re seeing a cardiologist or a private GP who is particular about lipids, you may see two extra tests on your panel. They aren’t standard at public clinics but are widely available privately.
ApoB (Apolipoprotein B)
Every LDL particle carries one ApoB molecule. Counting ApoB tells you how many “bad” particles are circulating, which can be different from how much cholesterol they collectively carry. For most people, ApoB tracks LDL closely. For people with diabetes, metabolic syndrome, or high triglycerides, ApoB is often elevated even when LDL looks fine — and is a better predictor of heart attack risk.
Target: roughly under 0.9 g/L for high-risk patients, under 0.65 g/L for very high-risk. Costs around R200 – R350 privately.
Lp(a) — Lipoprotein little-a
This is a particular kind of LDL particle that’s mostly determined by your genes. Some people are born with very high Lp(a) and it’s a significant independent risk factor for heart attack and stroke — but it’s almost completely fixed; statins don’t bring it down much.
You only need to measure Lp(a) once in your lifetime — it doesn’t change. If yours is high (above 50 mg/dL or 125 nmol/L), your overall LDL target becomes more aggressive, and your family members should test theirs. Costs around R300 – R500 privately. If you have a family history of early heart attack and no other explanation, asking for an Lp(a) test once is reasonable.
To fast or not to fast?
Old advice was always to fast for 8 – 12 hours before a cholesterol test (only water allowed). Newer guidelines accept a non-fasting test for routine screening, because LDL and HDL barely change after a meal. Triglycerides do go up after eating — usually 0.3 to 0.5 mmol/L higher than fasting — so if triglycerides are the focus, fasting is still preferred.
The simple rule:
• First screening test or routine annual: fasting not required.
• Triglycerides above 2.3 on a non-fasting test: repeat fasting to confirm.
• You’re already on a statin and being monitored: non-fasting is fine.
How quickly should things change?
Once you start treatment — food, exercise, or a tablet — when can you expect to see the numbers move?
Change Expected LDL effect How long Adding oats and beans daily 5 – 10% lower 4 – 8 weeks Walking 30 min/5 days a week 3 – 5% lower 8 – 12 weeks Cutting saturated fat 5 – 15% lower 4 – 8 weeks Losing 5 – 10 kg 5 – 10% lower 3 – 6 months Starting a low-dose statin 25 – 40% lower 4 – 6 weeks Starting a higher-dose statin 40 – 55% lower 4 – 6 weeks
Most clinics will retest at 4 – 8 weeks after a major change to see if treatment is working, then every 6 – 12 months once you’re stable. Some shifts are within normal lab variation — a 0.2 mmol/L change one way or another doesn’t always mean something. Trends over multiple visits matter more than a single number.
What to ask your clinic when you get a result
Useful questions, none of which are demanding:
• “What’s my LDL target — given everything else about me?”
• “What’s my 10-year heart-disease risk percentage?”
• “Are my HDL and triglycerides where they should be too?”
• “Do I need any baseline tests — kidney, thyroid, blood sugar?”
• “What changes should I make before my next test, and when is that?”
• “If I need medication, which one and why?”
• “Is there anything in my family history that should make us consider Lp(a) or genetic testing?”
The bigger picture
A lipid panel is one of the most useful single blood tests available. It captures, in five numbers, your single largest preventable risk for the diseases in article 3. Knowing how to read it — and how to read it in the context of your overall risk — turns the test from a piece of paper into a tool you can actually use.
People who understand their own numbers tend to do better. They notice when something has slipped. They ask more useful questions. They take medication more seriously because they can see what it is doing.
The next article in the series moves to food: the 10 most affordable South African foods that lower cholesterol, and how to use them in everyday meals.
Where to get more help
Heart and Stroke Foundation South Africa — heartfoundation.co.za · 021 422 1586.
Your nearest public clinic — for free lipid panels and chronic-care follow-up.
Lipid and Atherosclerosis Society of Southern Africa — lasousa.org.
Phila Today Cholesterol Series — next: the 10 most affordable South African foods that lower cholesterol.
Phila Today · Article 4 of 12 in the Cholesterol Series