The many faces of LDL

Ginnie came in for an opinion about her heart scan score of 393. At age 57, this put her in the 99th percentile, a high score.

As usual, we did a lipoprotein analysis by NMR (Liposcience). Some numbers:

LDL cholesterol: 96 mg/dl
This value puts Ginnie's LDL in the most favorable 25% in the country.

LDL particle number: 2140 nmol/l
This value is in the worst 25% of the country and is the equivalent of an LDL cholesterol of 214 mg/dl (take off the zero).

In addition, over 90% of Ginnie's LDL particles fell into the small class.

Had we run some other values, how would they have turned out? These are my estimates (since we didn't actually run them in Ginnie), but having run side-by-side numbers in past, reasonable estimates would have put:

Apoprotein B somewhere in the 120 to 140 mg/dl range

Direct LDL 100-130 mg/dl range.

In other words, conventional calculated LDL is the least reliable of all the ways of examining low-density lipoprotein.

It can also go the other way: High calculated LDL, low LDL particle number or ApoB or direct LDL. And, indeed, these other measures have proven superior in their ability to predict "events" like heart attack over conventional calculated LDL.

Unfortunately, relying on conventional LDL is like a broken speedometer on your car. You really can't gauge accurately how fast you're going; sometimes you could be way off. While insurance companies and many physicians still continue to balk at this argument, the data have already been generated that show that lipoprotein analysis (my bias is NMR) is not just superior, but enormously superior for accuracy and event prediction.

In addition, lipoprotein analysis has proven a crucial tool that accounts for our extraordinary success in reducing and controlling CT heart scan scores in the Track Your Plaque program. I doubt that we could have achieved the same level of success using conventional lipids.

I'm also aware of the logistical difficulties obtaining lipoprotein testing in a world enthusiastically supportive of hospital procedures and smugly ignorant of superior prevention tools like lipoprotein analysis. I've learned just how difficult it can be in our Track Your Plaque Member Forum; I've also learned about some strategies for obtaining these tests that I hadn't been aware of, thanks to the resourcefulness of our Members.

We will be working on some solutions in the coming months.

Copyright 2007 William Davis, MD

Comments (13) -

  • kdhartt

    1/29/2008 1:11:00 PM |

    Interesting that we just need to refine the notion of "good and bad cholesterol," and it seems to be about particle size, not density. Are lp(a) small? Is there a treatment that converts small LDL to benign LDL but doesn't raise HDL?


  • Dr. Davis

    1/29/2008 1:27:00 PM |

    Lp(a) particle size tracks LDL particle size. Small, dense LDL therefore occurs with small, dense Lp(a) (referring to the LDL part of Lp(a), not the apo(a) portion).

    Small LDL responds to the same treatments that raise HDL. I do not know of any treatments that diverge on this point with the exception of alcohol, which principally raises HDL.

  • moblogs

    1/29/2008 3:14:00 PM |

    That's an eye opener. In England all we get is LDL, HDL and trigylceride reports, and even then the decision to put someone on statins varies between doctors and deviates from guidelines. It's all messed up.

    Just to deliver some more from Trevor Marshall (against vit D), what's your opinion of this article? It's a lengthy one.
    I'm guessing the reason this has shown effect is not really the reduction of vitamin D but antibiotics that mimic it's effects. Do note that the author of that author is biased because she follows Marshall.

  • Dr. Davis

    1/29/2008 5:49:00 PM |

    Every so often, a kooky idea comes along that seizes the attentions of the fringes. Linus Pauling and high-dose vitamin C to cure heart disease, cancer, and most human illnesses was this way. Nanobacteria did this. Chelation is another.

    From what I've read of the so-called Marshall Protocol, I would lump this with the above.

    The focus of this blog and the website is reduction of coronary calcium scores and regression of coronary plaque. I do not think that we need to invoke these sorts of ideas and reinvent the wheel to accommodate the rants of people like this.

    By the way, the article states that the causes of heart disease are not often revealed by conventional cholesterol values. I heartily agree with this. The answers will be found in lipoprotein analysis and associated laboratory and lifestyle examination. It is not in antibiotics.

  • onewaypockets

    1/29/2008 6:15:00 PM |

    I did find a web site that outlined the risks for someone that follows the Marshall Protocol. I should point too that Dr. Marshall is not a MD.

        *  Major risk of Addison Syndrome (5%-25% of CFS that complete the protocol)
        * Increased risk (100 300%) of Heart Attack
        * Increased risk (100+%) of Cancer (Breast, Colon and Prostate are well documented)
        * Increased risk (67+%) of Multiple Sclerosis
        * Increased risk (400+%) of Diabetes
        * Increased risk of Depression
        * Increased risk (500+%) of Osteoarthritis and Osteoporosis
        * Increased risk of nephrotic syndrome, schizophrenia and severe bipolar disorder.
        * Increased risk of Hyperparathyroidism
        * Increased risk of Crohn Disease and Sjogren's syndrome
        * Increased risk of Rheumatoid Arthritis
        * Increased risk of Systemic Lupus Erythematosus
        * May cause fetal and neonatal morbidity and death
        * Risk of Angioedema

  • Anonymous

    1/29/2008 6:51:00 PM |

    Another from the UK!  I've often wondered how cholesterol is measured in a standard lab (as described my moblogs)   If cholesterol is contained within or is a part of a lipoprotein, how on earth do they separate out the different contents of the lipoproeins and then measure them with any precision?

  • Dr. Davis

    1/29/2008 7:42:00 PM |

    Of course, LDL is NOT measured.

    The other cholesterol fractions are measured enzymatically and separated by density.

  • Anonymous

    1/29/2008 8:06:00 PM |

    I looked at the article linked by mobloogs.  At first I was surprised it didn't list his background like it did the others it mentioned, until I looked around the site and realized the whole site is just a PR piece for Marshall.  The site states Trevor Marshall, Ph.D., is a biomedical researcher.
    His site says "Prof. Marshall is currently a Director of the Autoimmunity Research Foundation, an Adjunct Professor of the School of Biological Sciences and Biotechnology, Murdoch University (Western Australia)"
    Wikipedia lists him as "Trevor Marshall received his PhD in Electrical Engineering from the University of Western Australia in 1984 [3]. He also possesses an undergraduate and a masters (1978) degree in Electrical Engineering.[4]"
    Murdoch dosn't show him on their research page

  • Anonymous

    1/29/2008 9:07:00 PM |

    Thanks Dr Davis  (anon from the UK)

  • Anonymous

    2/7/2008 4:26:00 AM |

    Dr. Davis - I have been a faithful reader of your blog for about a year and try to follow your protocol for plaque reduction even though I have not been able to afford a CT Heart Scan.   I did have a lipoprotein breakdown and believed that Vitamin D, Fish Oil, and Vitamin K are very important.   My Vit D level was 36 while taking 2,000IU of Carlson's capsules.  I doubled it to 4,000IU and my blood level went to 48.   I then decided to try to get it closer to 60, so I started taking 6,000IU back in Sept.  I have a lot of cancer in my family history, have already been diagnosed with borderline osteopenia (-2.0) and fear heart disease, so Vitamin D seemed the logical thing to supplement up to a blood level of 60-70.   Then...

    In December I came down with a c-diff infection out the blue, my immune system now seems to be in really bad shape which is a complete shock to me, a self-proclaimed health nut who strives to eat right, exercise and take multiple supplements.  I am really devastated to think I might have done this to myself.

    A few weeks ago I ran across this new study indicating that high Vitamin D doses could harm the immune system.

    Please comment on this study to ease my mind....I dropped back to 2,000IU a day of the D supplement as I'm scared to death!

  • Dr. Davis

    2/7/2008 1:02:00 PM |

    I've commented on this bit of nonsense several times, both here and in the Track Your Plaque forum. It is patent nonsense based on the rants of a single man. Yes, there is a sliver  of science in his comments, but nothing more. Vit D has nothing to do with catching an infectious bacterial disease in the gastrointestinal tract.

  • Anonymous

    2/7/2008 4:42:00 PM |

    Thank you Dr. Davis -- I felt like you would have an unbiased opinion on this.  Its just scarey to read about immunosuppression, especially when you seem to be suffering from it!   I've also had a flu-like episode and a cold since the first of Dec!  

    I feel like I am literally starving myself on (ugh) white bread, white potatoes and white rice, but thats all I can eat at this time.   Things I haven't eaten in over 5 years!

    Thanks for clarifying the Vitamin D issue.  I'll go back to my 6,000IU dose.

    Noreen (who is healing slowly)

  • buy jeans

    11/3/2010 12:32:05 PM |

    Knowing that Pam has Lp(a) can point us in an entirely different direction than just LDL cholesterol. It might mean high-dose fish oil, a more serious approach to niacin, hormonal treatments like DHEA or testosterone. It might mean more attention to warning your children about the possibility that they, too, might share this genetic trait.