Can Cholesterol Be Too Low?

By Stephen T. Sinatra, M.D., F.A.C.C., F.A.C.N., C.N.S., C.B.T.

When I was a young cardiologist, I lectured on behalf of pharmaceutical companies, praising statin drugs and earning myself the nickname of “cholesterol choirboy.” Several years later, I discovered the dark side of statins – that they cause coenzyme Q10 depletion – and changed my tune.

Coenzyme Q10, you see, is absolutely essential for health – we need it to make cellular energy (also known as adenosine triphosphate, or ATP). A heart without enough energy eventually fails. So, any drug that prevents the body from making the energy it needs to stay healthy is not a good primary prevention therapy in my book.

But there’s another dark side to statins – they can lower cholesterol too much.

The Great Cholesterol Myth – Why Statins Are Not the Preventative Answer

Through extensive research, I discovered that cholesterol is not the primary cause of heart disease– as we’d all been led to believe, and eventually coauthored a book about it, The Great Cholesterol Myth (our newly revised and expanded version just hit the shelves in Oct. 2o20). In a nutshell, cholesterol is, at best, a minor contributor to heart disease – it’s found at the scene of the crime, but isn’t the perpetrator. The real smoking gun – the one we really need to hone in on – is inflammation.

And, despite the fact that doctors have been prescribing statins like candy, cardiovascular disease has steadily maintained its position as the number one killer of adults in their 40s, 50s and 60s. Should some Baby Boomers and Generation Xers be on statins? Sure – statins are highly effective anti-inflammatories, and I’d still prescribe them for middle-aged men with documented arterial disease and for very high risk women.

So you might be scratching your head now, wondering, “if statins are anti-inflammatory, and inflammation is the true cause of heart disease, aren’t statins the best solution?”

No – with statins come too many negative side effects. Besides coQ10 depletion, cholesterol levels can drop too low.

Is Having Too Low Cholesterol Dangerous?

In short, yes. There’s a reason your body makes cholesterol. You need it to maintain equilibrium in your body and stay healthy.

Cholesterol is a vital component found in every cell in our bodies. We need it to produce cell membranes, hormones, vitamin D and for overall nerve function. When our cholesterol levels are too low, our bodies and brain pay the price. As the authors of this Psychology Today article so succinctly put it:

Low serum cholesterol has been linked in numerous scientific papers to suicide, accidents, and violence…and depleting the ability of the brain and body to make cholesterol through aggressive cholesterol-lowering medication could cause a change in how the brain works.”

Your brain is made mostly of fat, and needs cholesterol to regulate your mood and help you think. Memory loss is another frequent side effect of statin use, most likely due to cholesterol levels being to low.

I don’t know about you, but I’d take higher cholesterol over cognitive decline any day.

What is Considered Low Cholesterol?

Many conventional medical doctors will tell you that your total cholesterol should be less than 200 mg/dL. I strongly disagree, and wouldn’t worry about your total cholesterol unless it’s nearing 300 (at which point your risk of stroke increases). I also wouldn’t worry about an LDL number that is less than 130 mg/dL.

What you really need to know about LDL, is what LDL subtype patterns you’re dealing with. Since LDL is only dangerous when it oxidizes, what you really want to know is if you have an LDL subtype pattern that is more prone to oxidation. Standard cholesterol testing won’t give you this information. You need to have cholesterol particle size testing done, something doctors don’t usually do.

And many doctors are still following the advice of the American Heart Association (AHA), which in 2004, updated its LDL guidelines, and lowered the recommended level of LDL cholesterol from 130 to less than 100, and regardless of LDL subtype.

Oh boy, this is one of those instances that really makes me question the direction Western medicine is moving in…

Types of Cholesterol

Normal Cholesterol Levels

I believe heart-healthy, normal cholesterol levels should fall within these ranges:

  • Total cholesterol – 180–240 mg/dL
  • LDL cholesterol – 80–130 mg/dL
  • HDL cholesterol – 40–90 mg/dL for women; 35–90 mg/dL for men.

At what point is cholesterol too low?  I would say when your LDL gets below 80 mg/dL, you’re entering abnormally low cholesterol territory. It’s important to also note that very high HDL over 90 can be dysfunctional. And if your total cholesterol is less than 120 mg/dL, it could indicate a problem with your metabolism; definitely check with your doctor if this is the case.

If your LDL is somewhere between 130 and 160 mg/dL, try weight loss and other anti-inflammatory lifestyle interventions like moderate, regular exercise, and targeted nutritional supports (see below).

Trigyceride-to-HDL Ratio: A Better Risk Indicator than Cholesterol Levels

Even though I don’t focus on cholesterol numbers unless they’re extreme, I wouldn’t forgo the standard blood tests your doctor orders. There are two numbers you can get from standard testing that are very important to know: your triglyceride (blood fat) and HDL cholesterol numbers. The ratio of these two is a much better indicator of cardiovascular risk than standard HDL and LDL cholesterol levels. Twenty years ago, a Harvard study showed that people with the highest triglyceride/HDL ratios had sixteen times the risk of developing heart disease, than those with the lowest ratios! To get your triglyceride to HDL ratio, you just divide your triglyceride number by your total HDL number. For example:

  • If your triglycerides are 200 and your HDL is 50, your ratio is 4
  • If your triglycerides are 100 and your HDL is 50,  your ratio is 2

If your ratio is 2, you’re probably just fine, no matter what your cholesterol numbers are. A ratio of 5 is problematic, and you really need to start making some changes in the way you live.

Anti-Inflammatory Lifestyle – A Better Heart Disease Prevention Plan

Adopting an anti-inflammatory lifestyle is the key to heart disease prevention (or reversal!) – here are some of the major areas you want to cover:

Eat the PAMM (Pan-Asian Modified Mediterranean) way!

We all gotta eat, and a healthy diet is one of the easiest, most effective ways to combat inflammation. PAMM combines the best foods from traditional Japanese and Mediterranean cultures, both known for their health and longevity. And, yes, moderate amounts of saturated fat – the kind that is linked to higher cholesterol – are allowed. Eating the PAMM way is anti-inflammatory because: (1) insulin response is limited, (2) free radical activity in the body is minimized, and (3) you get lots of fiber to help quickly move toxins and food through your digestive tract. Get the details on PAMM here.

Regularly engage in moderate (not strenuous) exercise

Just 20 to 30 minutes a day of something you enjoy will boost your heart health in so many ways: walking the dog, dancing, playing with the kids, not-too competitive sports – whatever you do, do it for you!

Keep your stress levels down / effectively manage your stress

Like bad fats, toxins, and sugar (what I call “the Villains In Your Body”), emotional stress inflames your arteries, through constant stress hormone release. Managing stress is such a huge part of an anti-inflammatory lifestyle, I’ve dedicated a whole section at HeartMD to it – you can read all sorts of articles about the effects of stress and how to manage it here, or download my ebook about stress.


As with Stress, I cannot underestimate the importance of detoxification to keep inflammation at bay: avoid toxins and detoxify through the foods you eat, exercise, sweating and other methods – learn more about detox here.

Targeted Nutritional Supports

Bolstering a healthy, anti-inflammatory diet with targeted nutritional supplements is a knockout punch against inflammation. Here are my top 6 recommendations.

Earthing, or Grounding

It’s so simple, but somehow we’ve lost touch with it – direct connection with the Earth. Walking or standing barefoot on the Earth’s surface – grass, sand, in the ocean, and even on stone or unpainted concrete – plugs us back in to the Earth’s healing energy, which has a normalizing effect on our nervous systems (and also helps us counteract the inflammatory effects of stress).

Together, all these lifestyle habits can help you prevent or reverse heart disease because you’re tackling the true cause – inflammation.

And if your doctor insists that you take a statin to treat your “high” cholesterol, I would ask for a cholesterol particle size test like the VAP test. Without knowing what subtypes of cholesterol you’re dealing with, statin therapy is a shot in the dark. Think about it…are the side effects of abnormally low cholesterol worth it?


© Stephen Sinatra, MD. All rights reserved.

Leave a Reply


  1. Ginny

    on April 21, 2018 at 11:22 am

    I recently had a Boston Heart test done and it said I have non-HDL-C level of 214. I’m reading your book The Great Cholesterol Myth and don’t see non-HDL-C mentioned. Can you tell me what this is?
    Thank you.

  2. DAVID W.

    on July 13, 2018 at 1:33 pm

    Five months ago in March 2018 I experienced A-Fib which resulted in no symptoms. therefore I do not know when the A-Fib
    occurred at its onset. The discovery was at my Primary Dr.s Intake visit for myself new patient. She sent me to the E.R. and
    the E.R ran test and released me to a Cardiologist that ran three test. E.K.G. Ego-Gram, P.E.T. Stress, and ultimately an
    Angio-Gram. The final test showed I.H.D. in the Branch Arteries. An Internal medicine was started immediately which consisted
    of Eliquis 5mg twice daily, 81 mg aspirin enteric coated once a day, Lipitor 80mg once a day, B/P medicine . My heart Converted on its
    own about one month post the initial discovery. I have since been stabilized. I read your book about four years ago. So I refused the
    Lipitor, and the B/P medicine. I currently do not know of any side effects. My Cardiologist got upset at my disclosure. He stated that
    I will be on Eliquis for the rest of my life. I would like to wean myself off of this drug. Any Ideas or suggestions?

  3. JRStern

    on November 7, 2018 at 6:53 pm

    Thanks for the overview.
    Would you have anything to add for diabetics – my PCP says “standard of care is statins for all diabetics”, period.
    But what if you have just “a little diabetes”, taking metformin and getting A1C of 5.8?
    Assuming all other lipids and such are in good shape.

  4. K Whalan

    on February 24, 2019 at 1:11 am

    Good Afternoon
    My cholestrol is naturally very low – but i can not get anyone to take this seriously. But i believe it is the cause of aggression / mood swings / joint pain.
    Total =108mg/dl
    HDL = 69mg/dl
    LDL = 35mg / dl
    Trig = 18mg/dl
    How can work on my body producing more.
    i follow a paleo diet. I exercise / ive changed jobs to remove stress / I have just completed a 6 month detox and rebuilding my buy lining program.
    The only information i have read is drink 1 tablespoon of cocnut oil 3 times a day.

    Please any knowledge, insight or recommendations ia m open and willing to try.
    thank you for your time today

  5. Anitha

    on February 24, 2020 at 4:47 pm

    My husband is 50 years old. His recent blood work results came back with with high LDL cholesterol, over 240. We are reluctant to follow his primary doctor’s advice to start on statins, Triglycerides are at 65 and HDL is 47. No BP, blood sugar is normal.
    We asked for referral to a cardiologist and additional testing. Of the tests recommended in your book, the doctor ordered NMR lipopfile, C reactive, Lp(a) and calcium CT scan.
    The results of the additional testing indicate that LDL particle size is acceptable, Lp(a) is well below 30 mg/dL and the C reactive protein is low risk. However, the number of LDL particles is very high (ove r 2400). Also, the calcium CT scan came back with an alarmingly high number. As expected, the cardiologist insists on statins as the best course of action. What would your recommendation be?

  6. HeartMD Editor

    on March 13, 2020 at 6:32 pm

    Hi Anitha, Dr. Sinatra says, “here are a few things I would recommend to help your husband if he were my patient:
    1. Read book I wrote with Dr Roberts and M. Zuzker: Reverse Heart Disease Now for details:
    2. A low dose statin is in order. Take Coenzyme Q10 100mg daily to offset side effects:
    3. MK-7 300 mcg daily:
    Best wishes

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