Blood cholesterol has become one of the most hotly debated topics in preventive health.
Dr. Jason Fung, a physician known for his work on diabetes and obesity, recently made waves with a bold claim: cholesterol levels just aren’t that important when it comes to heart disease risk.
His argument comes backed with research from a massive study involving over 6 million people, making it seem like an open-and-shut case.
But when health educator Nicholas from Physionic took a closer look at the same evidence, he uncovered some critical context that changes everything about how we should interpret these findings.
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The Central Claim: Cholesterol Doesn’t Matter Much
Dr. Fung’s position is straightforward and provocative.
As a risk factor for heart disease, cholesterol is just not that important. But by the way people go on and on about cholesterol, you think that it was super super super important, but it’s not.
He points to the American Heart Association’s PREVENT calculator, which analyzed data from 45 studies covering more than 6 million patients. This tool attempts to predict 10-year cardiovascular risk by comparing various factors like diabetes, high blood pressure, and smoking against cholesterol levels.
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According to Dr. Fung’s interpretation, the data shows cholesterol barely registers as a risk factor compared to these other health markers.
The Non-HDL Cholesterol Issue
Dr. Fung raises an interesting technical point about the study’s methodology.
Instead of measuring just LDL cholesterol—the so-called “bad cholesterol”—the researchers used something called non-HDL cholesterol. This measurement includes LDL plus other cholesterol-carrying particles like very low-density lipoproteins and remnant particles.
They cheated a little bit because they used something called the non-HDL. So, by using instead of LDL, they’re using this non-HDL, they’re sneaking in the triglycerides in there.
His concern is that this approach muddies the waters by including triglycerides, which respond to dietary carbohydrates rather than cholesterol itself.
But here’s where the critique gets complicated. If we’re evaluating whether blood cholesterol overall matters—not just LDL in isolation—then using non-HDL cholesterol actually makes perfect sense. It captures a more complete picture of cholesterol-carrying particles in the bloodstream.
Plus, triglycerides aren’t technically included in non-HDL cholesterol measurements, contrary to the implication.
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The Hazard Ratio Breakdown
Dr. Fung’s strongest argument centers on something called hazard ratios—essentially a measure of how much a risk factor increases your chances of developing disease.
A hazard ratio of 1.0 means no effect. A ratio of 2.0 means double the risk.
When looking at the PREVENT study data, Dr. Fung highlights some striking comparisons:
- Diabetes: 65% increased risk (hazard ratio 1.65)
- Smoking: 60% increased risk
- High blood pressure: 36% increased risk
- Non-HDL cholesterol in women: No increased risk (hazard ratio 1.0)
- Non-HDL cholesterol in men: 5% increased risk
According to the development of the American Heart Association’s own 10-year risk calculator, every time you raise your non-HDL, your risk of heart disease in women doesn’t go up at all. And for men, it’s a 5% risk.
On the surface, this seems damning. Cholesterol appears almost irrelevant compared to other risk factors.
The Critical Context That Changes Everything
Nicholas’s analysis reveals several major issues with how these numbers are being interpreted.
Wrong Outcome, Wrong Story
The most significant problem is that Dr. Fung focused on total cardiovascular disease data, which combines both plaque-related heart disease and non-plaque-related conditions like heart failure.
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Cholesterol’s role is specifically tied to atherosclerotic cardiovascular disease (ASCVD)—the plaque-building process that clogs arteries. When you look at ASCVD data specifically in the same study, the picture transforms completely.
For ASCVD outcomes, both women and men show significantly increased risk with higher non-HDL cholesterol levels. The association that seemed to disappear suddenly reappears when examining the appropriate outcome.
It’s like judging a fire extinguisher’s effectiveness by whether it prevents floods. You have to measure the right outcome.
Study Design Limitations
The PREVENT study followed participants for less than five years on average. Cholesterol’s impact on arterial plaque typically unfolds over decades, not a handful of years.
Additionally, all participants started without known cardiovascular disease. In a relatively healthy population tracked for such a short period, you’d expect weaker associations regardless of how important cholesterol truly is over a lifetime.
The study also adjusted for statin use but not for participants’ prior cholesterol exposure. Two people might have identical current cholesterol levels but vastly different histories—one may have had elevated levels for decades before treatment.
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The Diabetes Comparison
Dr. Fung makes another compelling point: diabetes increases cardiovascular risk far more dramatically than cholesterol does.
5% risk compared to a 60% risk for smoking or diabetes, that means smoking or diabetes would be somewhere around 10 to 12 times more important than the cholesterol.
This is absolutely true. Diabetes is a more powerful predictor of heart disease than cholesterol levels alone.
But here’s the thing: no one disputes this. Medical guidelines already prioritize diabetes management. The question isn’t whether diabetes matters more—it’s whether cholesterol matters at all.
Comparing Trucks to Truck Lots
Nicholas offers a helpful analogy. Comparing cholesterol to diabetes is like comparing a single truck to an entire truck lot.
Diabetes affects multiple organ systems simultaneously—blood sugar regulation, insulin resistance, inflammation, visceral fat accumulation, and cholesterol levels. It’s a systemic metabolic disorder.
Cholesterol is one component within that larger metabolic picture. Of course the comprehensive disease shows stronger associations than a single biomarker.
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The relevant comparison isn’t cholesterol versus diabetes. It’s high cholesterol versus low cholesterol—and there, the evidence still shows meaningful differences in cardiovascular risk.
What the Guidelines Actually Say
It’s worth noting that the American Heart Association guidelines Dr. Fung critiques aren’t based solely on the PREVENT calculator study.
The position statement includes over 600 unique studies, creating a comprehensive evidence base rather than relying on any single piece of research.
The recommendation to lower LDL targets to 55 mg/dL applies specifically to people at high risk of atherosclerotic cardiovascular disease—not the general population.
Additionally, the committee members who authored the guidelines largely had no industry affiliations, addressing common concerns about conflicts of interest in medical recommendations.
Where Dr. Fung Is Right
Despite the critiques of his analysis, Dr. Fung makes valid points worth acknowledging.
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Cholesterol isn’t everything. Focusing obsessively on cholesterol numbers while ignoring diabetes, blood pressure, smoking, and overall metabolic health makes little sense.
Metabolic health matters more. Addressing insulin resistance, maintaining healthy body composition, and preventing diabetes should take priority over isolated cholesterol management.
Context matters tremendously. A person with excellent metabolic health but slightly elevated LDL is in a fundamentally different situation than someone with metabolic syndrome and the same LDL level.
The Balanced Take
So where does this leave us?
Cholesterol does matter for cardiovascular disease risk, particularly atherosclerotic disease. The evidence supporting this remains robust, even when examining the very studies cited to dismiss its importance.
However, cholesterol is likely less important than overall metabolic health. Diabetes, insulin resistance, chronic inflammation, and obesity carry greater risk and deserve primary attention.
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For someone who is metabolically healthy, physically active, maintains healthy body composition, doesn’t smoke, and manages stress—slightly elevated cholesterol may be a lower priority concern.
For someone unable or unwilling to make comprehensive lifestyle changes, or for those already at high cardiovascular risk, targeted cholesterol reduction through medication becomes a reasonable evidence-based intervention.
The Real Lesson
This deep dive illustrates something crucial about health information: the devil truly lives in the details.
The same study can tell completely different stories depending on which outcomes you examine, how you frame the comparisons, and what context you provide.
Dr. Fung’s message that we shouldn’t obsess over cholesterol alone is valuable. But the conclusion that cholesterol “just isn’t that important” oversimplifies a nuanced body of evidence.
Health optimization isn’t about finding the one thing that matters most. It’s about understanding how multiple factors interact and addressing the ones most relevant to your individual situation.
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- Full-body training with one weight using swings, squats, and presses
- Solid cast iron build that feels stable and lasts for years
- Comfortable grip that makes high-rep workouts easier to handle
For most people, that means prioritizing metabolic health through diet, exercise, sleep, and stress management—while keeping an eye on cholesterol as one piece of a larger puzzle.
Neither dismissing cholesterol entirely nor fixating on it exclusively serves your long-term health interests.
