LDL-P
Counseling patients on the role of different fats, and their association with the risk of cardiovascular disease (CVD) can be a difficult task. There are many types and subtypes of fats and, most of them play an important role for bodily functions. Furthermore, a correlation between plasma measurements of different subtypes of fats or lipoproteins and the risk for heart disease, does not have to imply a causative relationship. Cholesterol is the type of fat that most often is associated with the risk of heart disease. High blood levels of cholesterol, low density lipoprotein cholesterol (LDL-C) in particular, have been associated with increased risk. Although disputed by many, it has been proposed that cholesterol may play a causative role in CVD. Lowering blood levels of LDL-C is generally recommended to reduce the risk of CVD.
Large and small LDL particles
Triglycerides are the largest category of lipids in the human body and in our diet. About two percent of dietary lipids are phospholipids. Only a small percent of our dietary lipids are sterols. The most common animal sterol is cholesterol. To be able to travel outside cells and in the circulation, cholesterol molecules are bound to different types of proteins. The term lipoprotein describes these combinations of fats and protein.
Most people are aware that there are two types of cholesterol, depending on the types of proteins that carry the cholesterol molecules. High density lipoprotein cholesterol (HDL-C) is often termed the “good” cholesterol while LDL-C is usually termed the ”bad” cholesterol. HDL and LDL are two of five major lipoproteins that enable transport of different fat molecules, including cholesterol. The other lipoproteins are chylomicrons, IDL (intermediate density lipoprotein) and VLDL (very low density lipoprotein, mainly triglycerides).
LDL is the lipoprotein particle that is mostly involved in atherosclerosis. LDL particles exist in different sizes. On one hand there are the large, fluffy, cotton-ball like molecules, and on the other hand the small dense molecules. Many recent studies have looked into the importance of LDL-particle size. Studies show that people whose LDL particles are predominantly small and dense, have a threefold greater risk of coronary heart disease. Furthermore, the large and fluffy type of LDL may be protective. However, it is possible that the association between small LDL and heart disease reflects an increased number of LDL particles in patients with small particles. Therefore, the number of LDL particles could be more important in terms of risk than particle size in itself.
There is an inverse correlation between blood levels of triglycerides and particle size. Thus, the higher your triglycerides, the higher the number of small LDL particles. Conversely, the lower your triglycerides, the higher the number of large, fluffy LDL particles.
What is LDL-P and why is it important?
LDL-C is usually calculated using the Friedewald equation. However, this measure can underestimate LDL-C level as triglycerides increase. Direct LDL-C measurements are also available and better reveal individual issues, but are less often promoted or done due to slightly higher costs. LDL-C reflects the total content or concentration of cholesterol within LDL-C particles in mg/ml or mmol/L. Since the amount of cholesterol in each particle may vary, measuring LDL-C does not necessarily reflect the actual number of particles.
LDL-P (LDL particle number) measures the actual number of LDL particles (particle concentration, nmol/L). It appears that LDL-P may be a stronger predictor of cardiovascular events than LDL-C. Low LDL-P is a much stronger predictor of low risk than low LDL-C. In fact, about 30 – 40% of those with low LDL-C may have elevated LDL-P. Therefore you can have low LDL-C but still be at risk for CVD, particularly if your LDL-P is elevated. Discordance is when LDL-C differs from LDL-P.
Lipoproteins play an essential role for the initiation and progression of atherosclerosis. Therefore it is very important for us to understand what regulates the production and clearance of atherogenic lipoprotein particles and how these mechanisms may be influenced. LDL-C is only a measure of the cholesterol mass within LDL-particles. Thus, LDL-C only indirectly reflects the atherogenic potential of LDL particles. Apolipoprotein B (apoB) and LDL-P on the other hand reflect the number of atherogenic particles, with no mention of cholesterol mass. Therefore apoB and LDL-P are believed to be better risk predictors than LDL-C.
In a consensus statement from 2008 on lipoprotein management in patients with cardiometabolic risk, the American College of Cardiology and the American Diabetes Association recommended more prominent roles of apoB and LDL-P as target of therapy
Some patients with low LDL-C may have elevated LDL-P and the other way around. This may explain why so many patients who suffer a heart attack do not have elevated levels of LDL-C.
LDL-P is measured by a so-called NMR lipid profile test. A value of less than 1.000 is considered ideal. Above 2.000 is considered very high.
How to lower LDL-P
Much has been written about how to lower LDL-C. Most doctors will recommend eating less fat and cholesterol from meat and dairy products. Statin therapy significantly lowers LDL-C. However, therapies may affect LDL-P differently. Interventions that will lower LDL-C more than LDL-P include statins, estrogen replacement therapy, some antiretrovirals, and a low-fat, high-carbohydrate diet. Interventions that lower LDL-P more than LDL-C include fibrates, niacin, pioglitazone, omega-3 fatty acids, exercise and Mediterranean, low carbohydrate diet. Although statins lower LDL-P, they may leave a significant number of patients above the LDL-P target.
Patients with high levels of triglycerides and low HDL-C are likely to have high LDL-P despite normal or low LDL-C. Such a lipid profile is typical for individuals with the metabolic syndrome. Studies indicate that these patients may benefit most from low carbohydrate diets and that carbohydrate restriction reduces LDL-P.
Dr. Thomas Dayspring MD gives a fantastic explanation of LDL particle number in CVD.
LDL-C and total cholesterol have never been particularly good predictors of who will develop clogged arteries. However, total cholesterol strongly correlates with all cause mortality risk. For example, as total cholesterol rises above 240, there appears to be some increased risk for cardiovascular disease. As total cholesterol drops below 200 there is a steep rise in mortality from infections, parasites, and cancers and increased risk of violent death. http://perfecthealthdiet.com/wp/wp-content/uploads/2011/06/O-Primitivo-Cholesterol.jpg
Unfortunately, last I heard, the American Heart Association was still recommending that total cholesterol be artificially depressed below 200 to decrease risk of heart attack. http://www.theheart.org/article/1371059.do
Yet researchers at Texas A&M university found that higher LDL levels predicted greater gains in muscle mass in a strength training study involving 60 to 69-year-old males. http://www.eurekalert.org/pub_releases/2011-05/tau-cn050511.php
Hopefully, the LDL particle size issue will help exonerate total cholesterol and get saturated fats off the hook for heart disease. http://www.meandmydiabetes.com/2010/03/26/ldl-cholesterol-ron-krauss-md/ After all, saturated fats have very little effect on total cholesterol compared to other dietary factors. http://www.theheart.org/article/1267163.do
Are you seriously trying to imply that low cholesterol causes infections, parasites, cancer, and violent behavior? If you look at that graph, it’s obvious that the countries with low cholesterol are Third World Nations with poor sanitation, disease epidemics, civil war, etc. Do you think you could protect yourself from HIV by eating enough butter, sir?
I found out 2 days ago I have High Small LDL-P levels 1455 High Triglycerides 160 Low HDL-C 36 Low HDL-P (Total)24.2 High Cholesterol,
Total 210. Im scard to death. Doctor wants to put me on Statin drug. Husband says its hype mother says eat oats. Im afraid of side effects . And afraid of CVD. Im 47 woman . Father died of CVD at age 35 . Mother says it was Lymes disease. I’m afraid to take statin and afraid not to. I dont know what to do. Help please
Hi Jane. Thanks for your post.
A TG/HDL ratio above 4 (in your case 4.6) may sometimes indicate high insulin levels (hyperinsulinemia). I don’t know if you are overweight, but if you are, a low carbohydrate, high fat diet may indeed increase your HDL-C and lower your triglycerides which is probably a good thing. Furthermore, it might improve particle size and particle number.
Your lipid profile in general, with high TG and low HDL, is compatible with the metabolic syndrome. Therefore it is important to know whether you are overweight or not.
Furthermore, it is important to look at your total risk. Do you smoke? Do you have high blood pressure? In Europe, LDL particle number (LDL-P), total, small or large, is seldom used for risk stratification in clinical practice. Your total cholesterol is not very high, I don’t know about your LDL- C.
Personally, I generally I do not recommend statin therapy for this lipid profile alone. However, if your total risk score is high, for example if you smoke, have high blood pressure and prediabetes or diabetes, it can be argued that statins will reduce your risk of CVD.
Finally, let me just repeat that studies have shown that low carb high fat (LCHF) diets may improve a lipid profile like yours, not least if you are overweight or obese.
Saturated fats, in conjunction with adequate supportive nutrition, can lower triglycerides and raise HDL-C. The important thing is to restrict added sugars.
Optimum total cholesterol seems to lie in the 200 to 240 range. http://perfecthealthdiet.com/wp/wp-content/uploads/2011/06/O-Primitivo-Cholesterol.jpg
Thanks for the reply I am 5’3 and 153 # I do smoke.
do you mean unsaturated fats and are you saying no sugar because it turns in carbohydrates. What about omega 3 oats nuts avacado fish oil walnuts fresh fruit vegtables oats . If i eat this diet do you think it will lower ldl-p?
@ Jane Bateman, A person does not necessarily need to eliminate added sugars or omega-6s
from the diet. Just keep them to safe levels. A diet of whole, natural foods such as you listed will naturally limit added sugars and omega-6s without much effort but it may not lower LDL-P.
As for smoking, I suggest you read about the Kitava Study:
http://www.staffanlindeberg.com/TheKitavaStudy.html
http://wholehealthsource.blogspot.com/2008/08/cardiovascular-risk-factors-on-kitava_17.html
My doctor wants to put me on statins because of elevated LDL-P. In May, it was 1578. Now:
LDL-P – 1348
LDL-C = 105
HDL-C = 44
Triglycerides = 73
Cholesterol Total = 164
LDL & HDL Particles
HDL-P (total) = 29.7
Small LDL-P = 513
LDL Size = 21.6
I am 53, never smoked, both parents died from heart disease, I’m 141# (have lost 30 lbs this year). I had bile duct surgery a month ago with elevated liver enzymes and I hate to take medication that will bother my liver. For the last 3 months, I haven’t eaten grains or process foods. The only sugar I eat is fresh fruit. Are statins really necessary in my situation. My doc is more concerned with the LDL-P number and my family history. He feels the family history alone is worth putting me on statins. I don’t have high blood pressure (it was 100/73 today).
Maribeth. Thanks for sharing your thoughts. It would be irresponsible of me to give advice on individual cases. This is certainly a situation where some doctors may want to prescribe statins and some would recommend against it. The decision to prescribe statin therapy in primary prevention is often quite difficult. The clinical guidelines generally recommend looking at total risk, taking into account all risk factors, not only lipids. In your case the total risk is propably rather low, considering that you have never smoked and don´t have hypertension or diabetes. One could certainly wonder, looking at your family history and LDL-P number, whether statin therapy might reduce your risk of cardiovascular disease. However, taking into account the low total risk, your liver enzymes and other possible side effects, I guess many doctors would not recommend statin therapy.
If we reduce carbs in our diet, I think we can assume that food will be replaced with fats and proteins. The additional fats and proteins will increase LDL-C, right? Will it also increase LDL-P? I understand that LDL-P is what we need to be concerned about. Thanks.
Ed. Some studies indicate that low carbohydrate diets may increase LDL-C as you suggest. However, HDL-C seems to increase as well and triglycerides usually go down, which is positive. Furthermore, LDL-particle size appears to increase on low carb, and LDL particle number (LDL-P) decreases. Thus, discordance (between LDL-C and LDL-P) appears to become more prominent.
Hi! I am 36 years old, 5’3, weigh 113lbs. I eat relatively healthy and excerise 6 days a week. I do not smoke. My dad died of congestive heart failure at 53, his identical twin died at 46 from a massive heart attack and their dad died at 53 from heart disease. All 3 smoked. Dad had his first heart at 37. I just had extensive blood work done and here are the results. My doctor wants me to take a baby aspirin daily and retest in 3 months. I would love your thoughts on this. I am not sure about taking the baby aspirin daily.
Thank you so much!
HDL: 97
LDL: 103
Triglycerides:59
total Cholesterol:97
LDL-P: 1101
APO B: 82
APO A-1: 181
I have a ton of other numbers. Please let me know if you need to see all of them
Krstina. I understand your family history is a cause for concern. Remember however that your dad, his brother and your grandad were all smoking males. You being a nonsmoking woman is quite different. The regular exercise, and I am assuming a normal blood pressure is also positive when assessing your total risk. I think your lipid numbers are indeed quite good as well, apart from the LDL-P. The goal for LDL-p is less than 1.000. 1300-1600 is generally considered moderate risk and above 1600 is high risk. However considering that all other measures are very good, I don´t think you need to worry that much. Apo B and Apo A-1 values are fine. Total cholesterol (assuming the number is 197), LDL-C, HDL-C and triglycerides are all quite good numbers. TG/HDLratio is also low which is positive.
If we use the traditional algorithms, your total risk is indeed very low, despite the family history. I am not aware of any scientific studies showing a clear positive effect of baby aspirin under similar circumstances, which is the reason why I would not prescribe it if you were my patient. I do not think it will affect your lipid numbers. I would not give a cholesterol lowering drug either under these circumstances. Continuing the healthy lifestyle, healthy eating and exercise, definitively, in my opinion is the best thing you can do.
Thanks for the post.
Thank you do much for your quick response! The total cholesterol is 206. ( 3 little ones running circles around me while typing). Also, my Lp-PLA2 is 236. This has to do with inflammation? What are your thoughts regarding that number? I am told this is a high risk number for me. Thank you do much!
Kristina. There is still some uncertainty about the value of Lp-PLA2 measurements. There seems to be a positive association between Lp-PLA2 levels and vascular and nonvascular outcomes in many studies, but these are observational studies and can´t establish causality. http://www.theheart.org/article/1071965.do
High sensitivity CRP (hs-CRP) is probably the most commonly used marker of inflammation. Some studies have raised the possibility that hs-CRP could be used to target high-risk patients who may benefit from statin use. http://ukpmc.ac.uk/abstract/MED/16442935
I just had my labs done due to feeling fatigued and tired all the time as well as headaches. My LDL-P was 2051, LDL-C 131, Triglycerides 147, Cholesterol 212. My small LDL-P is 787. Also, my LP-IR score is 50. I am so confused about all the information about diets and the fact that my LP-IR is high. Now I’m confused about diabetes and insulin resistance. I am overweight, 185 and 5’2″. My Vit D is also low at 27.1. I know I need to maintain a diet and decrease weight, but the proper diet, what to eat and what not to eat, is totally confusing to me. Looking for suggestions! Thanks so much!
Rebecca. Please discuss your symptoms and lab results with your doctor and get his advice.
What concerns me with your lab results is the elevated LDL-P and small LDL-P. Triglycverides are also borderline high. Total cholesterol and LDL-C are not that bad numbers. Your BMI is 33.8. Your LP-IR certainly indicates some insulin resistance.
Lipid problems, including higher triglycerides, decreased HDL levels, and increased small, dense LDL particles, have been shown to be atherogenic. In obesity, these lipid disorders seem to be closely related to insulin resistance. Weight loss and exercise, even if they do not result in normalization of body weight, can improve lipid profile and thus reduce the risk of heart disease. Therefore, weight loss is extremely important. http://www.ncbi.nlm.nih.gov/pubmed/14711065?dopt=Abstract
Furthermore, evidence suggests that carbohydrate restriction, positively influences the aforementioned lipid problems. http://www.nutritionandmetabolism.com/content/3/1/24#B1.
So, for an individual with obesity, insulin resistance, elevated LDL-P and triglycerides, carbohydrate restriction is certainly something I would suggest. It usually helps inducing weight loss and will likely improve lipid profile.
I went LCHF Paleo in 2011 and my cholesterol numbers have worsened considerably. I am worried that I might have familial hypercholesterolemia.
I am a 49 year old female, non-smoker, low-normal blood pressure, low (but treated) thyroid, BMI of 23.
Now (pre-Paleo)
Total Chol. 298 (195)
LDL-C 136 (98)
HDL-C 134 (85)
VLDL 28 (9)
Trigl. 140 (61)
CRP 0.9 (1.6)
My doctor wants to prescribe statins and is unwilling to order an NMR (I’m in Massachusetts where it is illegal to get any blood tests without a doctor’s order – even online). I think I can, however, drive out of state for a heart (calcium) scan which I can schedule myself. If the heart scan is good, should I still try to find a way to get the NMR? Many thanks!
Thanks for the post Dottie. I find your experience interesting. It surprises me a little bit that your Total Chol and LDL-C have gone up this much. It surprises me even more that your TG have gone up as well, which is uncommon on Paleo and other low carbohydrate diets. However, your HDL-C has gone up considerably which is very positive. Therefore, your TG/HDL-C ratio has only gone up a little bit. I see from the numbers that your LDL-C is calculated (not measured) using the Friedewald equation, but it should be reliable anyway in your case.
There appears to be some inconsistency in how a Paleo type diets affects blood lipids. In one study this type of diet appeared to lower Total Chol and LDL-C as well as TG. http://naturetherapies.com.au/wp-content/uploads/2012/04/Paleo-diet-Study-Frssseto09.pdf
In another study a Paloelithic diet appeared to elevate LDL-cholesterol in diabetic individuals.http://www.biomedcentral.com/content/pdf/1475-2840-8-35.pdf
Clinical experience and individual reports indicate that elevation of Total Chol and LDL-cholesterol is not uncommon on a Paleolithic Diet. However, HDL-cholesterol seems to rise as well and triglycerides usually drop. Many of the Paleo followers believe that the elevation of Total Chol and LDL-C is nothing to worry about because they consider cholesterol in itself not dangerous and they don´t believe it is a causative factor in cardiovascular disease. However, I don´t think there is available evidence for us to believe that. There is so much evidence indicating that LDL-C is associated with cardiovascular risk. However, maybe an elevation of HDL and a drop in TG on Paleo, might counteract the effects of elevation of LDL-cholesterol. It appears that the TG/HDL-C ratio is an important predictor of risk. This ratio is highly associated with insulin resistance. In your case this ratio is just above one (on Paleo) which is relatively low. A cutoff of 3.5 has been suggested to identify patients at most risk for cardiovascular disease.
Although your LDL-C has gone up on Paleo, it is possible that your LDL-P has not (discordance). That is what an NMR might reveal.
Your CRP has gone down which is generally considered positive.
I doubt that you have familial hypercholesterolemia (FH), considering your Total Chol and LDL-C before Paleo.
These are the main symptoms of FH:
•High levels of total cholesterol and LDL cholesterol.
•A strong family history of high levels of total and LDL cholesterol and/or early heart attack.
•Elevated and therapy-resistant levels of LDL in either or both parents.
•Xanthomas (waxy deposits of cholesterol in the skin or tendons).
•Xanthelasmas (cholesterol deposits in the eyelids).
•Corneal arcus (cholesterol deposit around the cornea of the eye).
Personally I am usually a bit conservative when prescribing statins in primary prevention. I do not only look at the lipids. I usually look at other risk factors as well such as familiy history, smoking, blood pressure, diabetes etc. Of course, if you have FH, you should have statin treatment.
I also wonder what your diet was before Paleo and why you decided to change…
Hello Doc, I have been watching your video and reading your articles, and I just received my results from an NMR and VAP cholesterol test. Below are my NMR results and I am very concerned and hoping you can give me some advice for area of my diet and exercise to explore.
My results:
LDL-C 217
HDL 68
VLDL 16
Cholesterol Total – 301
Trigs 66
LDL+VLDL 233
LDL-R (Real) 190
Lp(a) 16
LDL-P 1812
LDL Density Pattern: A
I weigh 170 lbs, 5’10″, male. My diet is generally low carb, low grains. I eat eggs, steak, chicken a few times per week each. Not much milk and I exercise 5-6 times per week, which includes 3-4x weights, 4-5x cardio.
Any thoughts? Thank you!
Hi Dave. As you probably know genetic factors highly influence our blood lipid pattern. I presume you have a family history of high cholesterol, correct me if I am wrong. You seem to live a healthy lifestyle, BMI is normal, lots of exercise and a relatively healthy diet.
Total Chol and LDL-C are quite high and so is LDL-P. The positives are a relatively high HDL for a male and relatively low levels of TG. TG/HDL-C is close to 1 which is fine. LDL density Pattern A suggests that large particles dominate which is positive. Lp (a) is not that bad.
It is very often hard to predict how diet affects our lipid pattern and there is a lot of individual variation. I would certainly be curious to know whether you could lower your LDL-C and LDL-P by cutting down on the consumption of cholesterol and saturated fat, as indeed recommended by the American Heart Association and the European Society of Cardiology. You could even choose a Mediterranean style diet, or DASH, increasing the consumption of whole corn, fish, olive oil and eat lots of vegetables and fruit.
Considering your BMI and lipid pattern, there are no signs of the metabolic syndrome. Therefore you probably don´t have any insulin resistance and no carbohydrate intolerance. So, in my mind there is no need for you to avoid healthy carbohydrates and starchy food unless you prefer to do so yourself. However, by all means, stay away from simple refined sugars and junk food.
I guess many doctors will suggest statin therapy when looking at your lipid pattern. Many specialists consider an LDL-C level above 190 to be a clear indication for drug therapy, no matter what else you find. This decision may however have to take into account your age, previous disease history ( I am indeed assuming you are healthy) family history and other risk factors.
Good luck Dave. Will be happy to hear about your progress.
Thank you, Doc, for your comment. Yes, I am healthy, have no risk factors and do not have a history of high cholesterol in my family. I am going to take your advice and add carbs to my diet, probably sweet potatoes and white rice, and more nuts, and then retest in a month, unless you think this is not enough time.
Also, I was wondering what your thoughts are on low-carb eating and the effect of T3 or rT3. Could low thyroid function be the cause of high LDL-P? I was considering getting tested for thyroid function and testosterone if I test in one month. Thoughts?
Thank you for your help.
Low thyroid function has been associated with elevated levels of blood cholesterol. Thyroid hormones seem to be involved in LDL and HDL metabolism, although the mechanisms are still a bit unclear. I agree that you should have your thyroid function tested. There is a recent publication indicating that hypothyroidism (TSH levels over 10 mIU/l) is associated with a significant reduction in LDL particle size and a higher prevalence of atherogenic pattern B. http://www.ncbi.nlm.nih.gov/pubmed/23039873
One month may be a little to short to evaluate the effects of diet changes on blood lipids, but you might see some trend. I often recommend reevaluation in six months following a change in lifestyle and/or dietary habits.
Thanks, Doc. As it is easy to overdo these tests, which test do you recommend for Thyroid?
Here is a site I have been using: https://www.accesalabs.com/thyroid
Thanks.
Measuring TSH is usually enough to test for hypothyroidism (low thyroid function). If hypothyroidism is present, TSH will be elevated. If hyperthyroidism (overactivity of the thyroid gland) is suspected Free T4 is ofte measured as well. Other tests are seldom needed.
Thank you, Doc, for your informative reply. Regarding FH, I tend to agree that it would likely have shown up earlier in life. Prior to Paleo, I had been on a SAD/ Weight Watchers diet for 10 years. My diet was chronically calorie-restricted, VLF, and nutrient sparse (I believe that may have caused the hypothyroid). I have read that FH can be hidden by a low-fat diet, so, I am going to find a way to get an NMR.
On a positive note, I’ve just learned from 23andme that I don’t carry the ApoE ε4 variant. So, I’m now thinking the low thyroid function may be the cause of the high LDL and TG (that darn TG really should have gone down on VLC!). Thus, I wonder if the VLC diet is suppressing my thyroid and thus interfering with cholesterol metabolism… (ah, so many variables). I wish my GP knew as much as I do about this. Better yet, I wish more doctors were as up on the research as you. Anyway, if it would be of interest to you or your readers, I’ll post again once/if I figure it out.
Thanks for sharing your thoughts Dottie. I will be very happy to hear about your progress.
Hi Doc! Went to the doc yesterday to talk about Cholesterol & labs and got scared out of mind!! Here are the results of my labs:
Total Chol-209
LDL-C-148
HDL-C-37
TRIGLYCERIDES-60
NON HDL C-172
APO B-128
LDL-P-2430
LP MASS-20
HS-CRP-25.7
I am overweight but I am dieting right now and have been successfully for about a month. I have lost 13 lbs since these labs were drawn. At the same time these labs were drawn I was also being checked for a UTI that did come up positive. Was wondering if the UTI caused the high hs-CRP? I am 33 yrs old, I do smoke and now weigh 187 down from 199. My blood pressure is normal now because of the weight loss and my doc said I would probably get to come off of my bp meds sooner than later because the weight loss seems to be bringing it down. At least I got some good news. Also, heart disease runs in my family through my grandparents. My doc wants to put me on Lipitor and Niaspan 500 mg & 1 coated asprin a day. Mixed advise given to me about Statins and Niacin. Would like to know what you think. Confused and scared I am going to drop dead from a heart attack at anytime. Thank you and any info would be greatly appreciated!!! Amanda
@ Amanada. UTI can definitively raise hs-CRP. Measuring hs-CRP when you have an active infection can therefore be misleading. There appears to be a lot you can do to reduce your risk for heart disease. Quitting smoking is extremely important. If you continue losing weight, your LDL-P and APO B will probably improve. You may have insulin resistance so limiting sugar and carbohydrates might be helpful. I think you should discuss with your doctor the possible advantages and disadvantages of medical therapy.
I am 31 yr old female. I weigh 120 lb and am 5’3 inches. I eat relatively healthy, including whole grains, fruits, vegetables, lean meats, and dairy into my diet. I don’t eat a lot of fat, but when I do I try to use healthy fats like olive oil or Smart Balance spread which is supposed to help maintain healthy cholesterol. I usually don’t eat a lot of junk, but I would usually bake something sweet about twice a month. My doctor did a full array of blood tests for me in February, where I had some parts of my cholesterol that were too high. I kind of thought it was a fluke, so didn’t think too much about it until I got retested this month. My LDL-P is 2153, My LDL-C is 125, My HDL-C is 47, my Triglycerides are 144, My total Cholesterol is 201, My small LDL-P is 1575, and my LP-IR score is 55. I was pretty surprised when my doctor stressed how poor my scores were since I do traditionally abstain from junk, I don’t smoke or drink, I’m not over 50, and I’m not overweight. Though my parents and grandparents have not died of heart disease I have learned that one of my grandmas had heart problems and that her brothers died of heart attacks, both after shortly being told by a doctor they looked healthy.
I would like some advice how to get my numbers to look better. I’ve started working out more vigorously than before (though I was never sedantary) and I’ve eliminated sweets (definitely starting to miss the baking), and I’m taking niacin daily. What else can I do? My doctor mentioned that if my blood work in February doesn’t look better she would consider putting me on medication. I really feel too young to be taking cholesterol meds.
@ Katie. This is a difficult situation as you seem to eat healthy, have no overweight and do a lot of exercise. Your genetic predisposition does not appear strong either. The TG/LDL ratio and the LP-IR score may indicate you have some insulin resistance. LDL-P and small LDL-P are high as you are aware of. If you look into the scientific literature, a low carb high fat diet is probably more likely than a low fat diet to raise your HDL and lower your TG, LDLP and small LDL-P.
Hi Doc! I’ve just got my results, and I’m a little concerned with the numbers. I never smoked, drink only socially, don’t exercise, love sweets (ice cream, chocolate, cakes, etc), a little overweight, but accumulate fat basically in my stomach. My energy levels change, my sleep pattern is crazy. Please, help me to figure out what I need to do. Today I tried not to eat sweet and I must tell you. It’s hard. My mouth waters when I see it, and I get a little upset because of that. AST(SGOT) high – 49; ALT (SGPT) high – 74; Vitamin D, 25-Hydroxy low – 16.9; LDL-P high – 2123; LDL-C high – 107; Triglycerides (high) – 211; Small LDL-P (high) – 1317; LDL size (low) – 20.3; LP-IR Score (high) 79. I don’t have any family history. I’d prefer not taking drugs if it’s all possible.
Hi Marcia. The liver enzymes, AST (GOT) and ALT (GPT) are only marginally elevated. There appears do be a typical discordance between LDL-C and LDL-P; LDL-C is not that bad, but LDL-P is high. Triglycerides are high, so is small LDL-P. LP-IR score is elevated suggesting insulin resistance. This is a lipid profile you would expect to see in an individual with the metabolic syndrome.
I would focus on two things, both important.
1) Try as much as you can to stop gaining weight. I know it sounds easy, but I have to emphasize it. I don´t know about your age: you look young in the picture by the way. Sometimes weight gain occurs very easily over a short time, so stay alert.
2) I hate to tell you this, but I think it is very important for you to avoid sugars. I know it can be though, but I know that you know how important it is. I´m not necessarily suggesting that you avoid carbs altogether, but definitively sugar. Maybe you should study glycemic index (GI) and select carbs with a low GI. Have you studied the GI-diet which is quite popular these days?
Good luck and thanks for the post.
I am an almost 63 year old female, low blood pressure, get lots of exercise (walk almost every day at least 4-5+ miles and do Pilates 2-4+ times/week), eat a mostly plant –based diet w/lots of greens, onions, garlic, mushrooms, raw nuts, some fruit, etc. plus wild Alaska salmon almost every day. (Started eating fish regularly when I started taking my ldl seriously around June of this year.) Take one fish oil tablet usually every day (EPA 360mg/DHA 240 mg). I am about 5’ 1” and weigh about 116. (Have been bringing down my weight by strictly eating a high-density diet.) My mother had congestive heart failure, but smoked and took terrible care of herself. My father, born in 1925, had a mild heart attack, but has taken such good care of himself that 15-20 years post-bypass his arteries are free and clear. (He does take statins.) He smoked until he was about 35, I believe.
I took an exercise stress test and was told I performed at an active 23-25 year old level.
When a cardiologist saw that my ldl was 196, he said that based on my family history, he didn’t think I could bring it down with diet, so he wanted to put me on statins. That made me mad so I set about doing just that. After the first 6 weeks I brought it down to 160. After another 6 weeks to 129. But then it crept up to 147 and then basically stayed there the next time. I was eating dark chocolate with caramel, however, plus other chocolate during this time.
I had gestational diabetes (in 1986), but have avoided diabetes. I may qualify as having pre-diabetes, however. I do try to include protein whenever I eat, but am not as good about this as I should be.
My hs-CRP was last 0.05 on a 0.00-0.30 scale and has been around that for quite some time.
My last two lipid studies were as follows (the most recent one first):
Cholesterol 243 244
Triglycerides 109 87
HDL 55 62
LDL, direct 146 147
The really scary part, though, is my LDL-P = 2301.
Other results follow (taken the same day that my cholesterol was measured at 160 at another lab):
LDL-C 176
HDL-C 58
HDL-P (total) 35.2
Small LDL-P 778
LDL size 21.6
Large VLDL-P <0.7
Large HDL-P 5.6
HDL size 8.8
LP-IR score 26 (fasting)
I have probably left out something important, but imagine you will ask.
Hi Sandy. Your BMI, blood pressure, lots of exercise, no-smoking certainly indicates you are taking good care of your self. You do have family history of CAD and your blood lipids have caused some concern. However, considering the usual algoritms, your total risk is probably not very high. LP-IR score indicates no insulin resistance. Most doctors recommend statins if LDL-C is above 190, so I understand your doctor very well when he recommended drug therapy, when your LDL-C was >190. However, you managed to lower your LDL-C which is great. The high LDL-P worries me a little bit. You can argue for and against drug therapy in your case but the effect of statin treatment in primary prevention, if total risk is low, is quite small.
There are two options.
1) Continue taking good care of yourself, exercise and eat healthy. Have your lipids tested again in 6-12 months.
2) Start statin therapy which will probably lower both your LDL-C and LDL-P signficantly. However, there is always a possibility of side effects although these drugs are generally well tolerated.
If you ask 100 cardiologsits which way to go, 50 percent will probably say 1) and 50 percent will say 2). So, there is really no right answer, there is no truth. If you are properly informed you might even want to make this decision yourself. I would probably go for number 1).
PS I forgot to mention (at least) a few things. First, I very much want to avoid taking drugs, if at all possible, and have the discipline to do what is necessary, I believe, assuming it can be done. Second, I have Hashimoto’s, which last time measured at 1204. And, for what it’s worth, I have acquired angioedema triggered by NSAIDs.
Hi Doc,
I am 51 6’2 203lb male. I was diagnosed with celiac disease 2 years ago and soon after my weight went
up to 220 after plummeting to 190. Blood Pressure was controlled by norvasc 5mg and cardiologist insisted on taking simvastatin, to which I have resisted until now. Father and both grandfathers died from heart attacks. Mother’s side has history of diabetes and high cholesterol.
NMR profile:
LDL-P 2333
LDL-C 163
HDL-C 35
triglycerides: 116
Total Cholesterol: 220
HDL-P 23.2
Small LDL-P 1561
LDL size 20.1
LP-IR score 64
I do moderate cardio exercise with weight training. I try to stay low carb as much as possible but have a major weakness for potato chips which I usually can resist. I mostly eat mixed greens, chicken, vegetables, and nuts.
I only drink milk with coffee. I am going back on bp meds as my pressure started to creep up again after a nice hiatus from having to take them. any words of advice would help. I
Hi John. Thanks for the post. The high LDL-P certainly put you at higher risk. Considering your BMI and LP-IR score it is likely that you have insulin resistance. Losing weight is very important in this situation. I definitively agree that carbohydrate restriction is sensible. Under these circumstances, considering the lipoprofile, high blood pressure and family history of coronary artery disease, I usually recommend statin therapy unless there are contraindications for such treatment.
Dear Dr. Sigurdsson, I am a 71 yr. old male and have been lucky not to have hight blood pressure, and no Diabetes,but both of my parents did have it. I have total body weight of 146 lbs. On my recent visit to my Dr. My test Total cholesterol is 170. Triglycerides 55, Hdl 68, Ldl (direct)82, and vldl 11, also HDL risk factor is 2.5, which is low. Fasting Glucose is 91 and Hemoglobin A1C is 5.6 four months ago but as of this new test date is 5.9. The cause for my question to you is that I have had in the past a up and down results for this one test named LDL-P which now is at 1087. back in 2010 it was 1036, and in 2011 it was 1030, and in 2011 it was 1009, and in April of this year it was 1006. This most current test is dated 11-16-2012 and is 1087. also the result for LDL size is 21.1. My Dr. who I dearly respect wants me to take Creastor 5mg. 3 times a week to get this number down. Honestly I do not want to take this Med. I would like to try whatever for the next three months before he re tests my blood. I do not smoke as I quit that over 40 years ago. I drink 2 bottles of beer a week and do drink any hard suff at all. Maybe a glass of red wine on the weekend at dinner. All of theses Tests are done buy NMR Lipo Profile. Test for the Lab known as Health Diagnostic Labs Inc. This LDL-P Particle size test shows that I may have of I am prone to have atery problems as well as plack problems ???. It is enough to make me crazy. Not to put you on the spot as I have read some of your comments to other Posts could you give me your thoughts. God Bless you for your caring as you do about us Folks. And happy Holidays to you and Yours.
@ Anthony. Thank you for your post and all the kind words.
As you know I do have to be careful when it comes to individual recommendations. Your doctor will surely know much better than I what´s best for you. I can only reflect on what you have written in very general terms. In general, your risk profile appears to be low; no smoking, no hypertension, no obesity, no diabetes. There is family history of hight blood pressure and diabetes but no history, as it appears on premature coronary events. Your general lipid profile does not cause much concern, total cholesterol and LDL-cholesterol are not elevated. LDL-P repeatedly just above 1000 which is not all that bad. For a low or moderate risk individual an LDL-P less than 1300 is considered optimal.
In my opinion a lipid profile like yours does not cause that much concern. Furthermore, your total risk appears low. Considering that you have no previous history of cardiovascular events, statin therapy certainly might sound a little aggressive. However, I certainly don´t know all the details of your history. Ask your doctor why he considers your risk to be high and ask him to explain why he wants to put you on statin therapy. There may be reasons that I´m not aware of.
Dear Doctor, Its Anthony again and a sincere Thank you for your response. What I will do is not take the Creastor as My Dr. suggested , but I will excirse more , Walk more and stop eating Cheese, and Potato chips that I adore. I have read and read about diets , and a question I ask you now is what diet helps to lower LDL-p and is the most Heart Healthy diet to live by. I eat chicken, fish, and red meat only once a week. I do drink 4 cups of coffee in the am with oat meal and bannans. 5 prunes, and 3 tablespoons of blueberries in the hot oat meal with shim milk fat free. Ice Cream 1x per week. Is it what I am eating that makes the ldl-p numbers seen high as My doctor said the new target numbers are at 750 now not 1300, as the testing Lab says is opitmal. What I am trying to do is really to live as healthy as my Grandmother who made it to 97. Her Mother made it to 103. and would you believe her sister made it to 105 years old. That is some track record, but they all lived in different times. By the way I am a hyper person and I have a Person type you would call the ” A ” type. If their is any book written about the diets that help to keep this LDL-p in check please advise and any further comment from you is so much appreciated. Gratefully Yours. Anthony
Greetings Doc – I have studied your previous responses but am still confused about my direction.
I am 43, male, 5 ft. 10 in., non smoker, normal blood pressure and light exerciser (walking about 3 times per week). No family heart problems in the past.
I started a Paleolithic diet after a lipid profile I received last year.
I also began supplementation as follows:
Vitamin D at 3000 IU daily (2011: 21.2 ng/mL 2012: 66.6 ng/mL)
FISH OIL at about 2 grams daily
Here’s the before and after:
PRE- PALEO November 2011
1784 LDL-P
115 LDL-C
54 HDL-C
315 Triglycerides
232 Cholesterol, Total
31,9 HDL-P (Total)
971 Small LDL-P
21.1 LDL Size
83 LP-IR Score
185 Weight
POST – PALEO November 2012
2272 LDL-P
199 LDL-C
57 HDL-C
93 Triglycerides
275 Cholesterol, Total
35.6 HDL-P (Total)
639 Small LDL-P
21.6 LDL Size
31 LP-IR Score
168 Weight
I basically cut out 80% of my carbs by avoiding wheat and sugar as much as possible.
I still eat them sometimes (pizza and ice cream on weekends). I eat eggs everyday for breakfast.
So I improved in certain areas and reduced my insulin resistance, but did I increase my risk for heart problems?
Might a further reduction in carbs make a difference? DOes high dose fish oil affect the results?
I suspect it is all interrelated but I’m concerned about such a high LDL-P.
Thanks so much for your efforts on this website. Your opinion is greatly appreciated!
Thank´s for the post Charles. I understand your confusion. Your lipid profiles pre – and post Paleo show very well how difficult it is to predict how our lipid numbers react to different diets. The fact that your total cholesterol (TC) and LDL-cholesterol (LDL-C) go up on Paleo is not surprising. Generally, carbohydrate restriction with increased consumption of fat elevates TC and LDL-C. However, more than 50 percent elevation of LDL-C on Paleo is more than I usually see.
The lowering of TG and insulin resistance (LP-IR score) is something you would expect on Paleo. However, I would have expected HDL-C to rise a little bit more. Indeed HDL-P goes up a little bit.
Generally, cholesterol rich foods, like eggs don´t elevate TC and LDL-C very much. However, studies have shown and I have also seen in my practice, that a small percentage of people who eat a lot of eggs elevate their TC and LDL-C quite much although this is not the general rule. Maybe you are just one of those individuals. However, it surprises me a bit that LDL-P goes up at the same time as the number of small LDL-P decreases. The Paleo theoretics might say to you: “Don´t worry about TC and LDL-C, it is all about LDL-particle size. You have a lot of large particles and should not have to worry”.
I have seen a lipid response like yours a few times among people on low carb high fat diets. I am not ready to ignore LDL-C as a risk factor. Clinical guidelines recommend LDL-C as the main target for treatment with lipid lowering drugs. An LDL-C above 190 is something that most cardiologists want to treat with a statin drug, no matter what. Remember that your LDL-P is also very high. When I see a lipid response like yours I always recommend my patients to reduce the consumption of cholesterol and saturated fat. This involves eating less eggs and animal and less dairy fat. I usually urge them to eat mono-and unsaturated fats including fish oils and Omega-3. In my opinion a Mediterranean type diet is very sensible under these circumstances.
Wish you all the best.
My personal anecdotal experience — starting as a prototypical metabolic syndrome case whose good numbers were all low and whose bad numbers were all high: Eating low-carb high-fat paleo significantly reduced my triglycerides and raised my HDL; and then going on a statin and naicin massively brought down the TC, LDL-C, and LDL-P. Those two approaches seem to be working great for me.
I didn’t get a lipid profile done just prior to converting to a LCHF diet early this year (unfortunately!). Hadn’t had cholesterol checked in a couple years — so I can’t say for sure exactly what the diet alone did. 6 months into the diet, and not under influence of drugs yet, I tested TC 280, LDL 190, and LDL-P at over 2800! That’s pretty bad. But the good was that my HDL had increased to 40 (from 32 two years ago) and TG was down to 180 (from nearly 500 two years ago … even 20 years ago in my mid-20s, I had tested in the 300s on TG).
So my Doc put me on simvastatin and Niaspan. He advised that low-carb was OK but I should minimize red meat and saturated fat (ie, a low-carb Mediterranean or South Beach kind of diet). I took the drugs and ignored his diet advice, kept eating all the bacon, eggs, cheese, and beef I wanted, with whipping cream in my coffee, all 5 cups a day. After 4 months on the drugs, I’ve just tested at … TC 126, LDL-C 52, LDL-P about 1280. HDL up to 45 and TG down to 140. I clearly remain a met syn case, hence still have somewhat high TGs and LDL-P that’s above ideal (though better than 50th percentile I do believe). But have to say the drugs clearly had quite an impact. I personally suspect that if I did anything other than a low-carb high fat diet my triglycerides would explode again, and probably the LDL-P along with it.
Dr Sigurdsson,
I would like to start by saying that I just came across your website and have been quite impressed. I too am one of those people on “lowish” carb Paleo with elevated LDL-C/P. It is quite difficult to find good data that combines the principles of a low carb approach to looking at lipids(i.e. high HDL, LDL size, low TG/HDL ratios) and the reality of LDL particle numbers. Some of the comments you have made above have been quite insightful and on the money. As a physician (anesthesiologist) I appreciate that. In my personal lipid situation I have spoken with many physicians and frankly the majority had never even heard of LDL-P. The recommendations I have received are quite varied and often just based on LDL-C number.
From my reading of low carb and Paleo blogs, I believe my situation is fairly common and we all could use your insight. I would truly love to hear your opinion on my situation. I am not asking for specific medical recommendations but more of a way to look at the situation or any suggestions about specific reading.
My father and paternal grandfather were diagnosed with coronary disease in their mid 60′s. In 2003 (age 40) I had a cholesterol of 220 and an LDL 160. I was started me on simvastatin initially at 10 or 20 mg but ultimately up to 40mg/day.
Date (Total Cholesterol/HDL/LDL/TG)
2003 Statins started
2004 140/63/61/79
04/2009: started to decrease processed carbohydrates
10/2009 166/72/82/44
07/2010: started low carbohydrate “Paleo” diet, higher in saturated fat, with no wheat minimal grains and no seed oils.
12/2010 218/98/93/53
Calcium Score Obtained (result: zero) Statins stopped due to side effects (libido, muscle soreness(mild), multiple colds and memory issues(per wife)).
05/2011 278/93/170/80
Anyway since stopping the statins I feel great. I have repeated my lipids multiple times and always about the same high LDL (130-190), high HDL (75-103) and low TG (50-70). When I learned about NMR Lipoprofile (LDL-P)I had one performed with results below
NMR lipoprofile results 12/3/2012
LDL-P: 1502 nmol/L
LDL-C: 192 mg/dl
HDL-C: 75 mg/dl
Triglyceride: 52 mg/dl
Total Cholesterol: 277 mg/dl
HDL-P: 36.4 micromol/L
Small LDL-P: 121 nmol/L
LDL Size: 21.6 nm
LP-IR Score: 3
I think I am doing most of the right things with watching my sleep and stress, exercising taking vitamin D and fish oil. I don’t smoke, my BP is 110′s/60′s and my body fat is less than 20%. My hs-CRP’s are consistently < 0.1. Since the LDL-P test, I am restructuring my diet to try to decrease the extra saturated fat. Because of my previous side effects I am a little leery about starting statins again without really thinking about it.
From my limited knowledge it is obvious that my particle number is too high but I can't find any data about patients with similar overall lipid profile. Niacin might be an option but it also has issues and is not often considered a first line agent. Any comments would be greatly appreciated.
Thank you for the post Joe. As carbohydrate restriction and Paleo is becoming so common these days, it is important to understand what happens to our blood lipids with these lifestyles. Although there are a number of short term studies looking at risk factors such as blood pressure, lipids and glucose metabolism, we still don´t know the long-term health effects. There seems to be a general pattern in the lipid response to low carb high fat (LCHF) diets, but there is a lot of individual variation.
Most often, like in your case, total cholesterol (TC) and LDL-C will go up on LCHF. However, this will probably depend on what types of fat are consumed. Saturated fats would be expected to elevate TC and LDL-C more than mono-or polyunsaturated fats. There is usually lowering of TG and elevation of HDL-C, thus the TG/HDL-C ratio improves. We still don´t really know what this means in terms of risk. Will the elevation of LDL-C increase the risk of cardiovascular disease (CVD)? Will the elevation of HDL-C and lowering of TG lead to less risk of CVD? What will the be the net result? Studies are definitively lacking when it comes to hard clinical endpoints.
Therefore the debate is ongoing. Many of the Paleo and carbohydrate restriction theoretics say that TC and LDL-C are not important. They highlight the positive effect on HDL-C and TG and they refer to studies showing that the number of small-LDL-P decreases which they consider important. However, the conventional cardiologist is still focusing on LDL-C and lately non-HDL cholesterol (TC minus HDL-C) and that is what clinical guidelines still recommend. The evidence supporting the role of LDL-C as a marker for risk is very strong and so is the evidence that lowering LDL-C will lower risk.
I agree with you that your situation is indeed very common. If we only look at your lipids we might say that it´s a pity that you can not stay on statin therapy. However, loooking at your total risk, I definitvely don´t think it´s obvious that you should be put on statin therapy. Furthermore, the side effects appear very clear in your case, indicating that the negative effects of statin drugs on your health will be much larger than the positive effects.
Again, looking at your lipid profile, here are a number of positive things. TG are low, HDL-C and HDL-P are relatively high. TG/HDL ratio es less than 1. Small LDL-P is low and LDL size is relatively high.
So the question remaining is how much you should worry about your TC, LDL-C and LDL-P. You probably would want to see all thes numbers a bit lower. Statin therapy would do it, but it´s out of the picture because it will make your general health worse. Looking at your general/total risk profile, the lipids seem to be your only risk factor, apart from the family history. Your healthy lifestyle, absence of hypertension, diabetes and smoking certainly make your total risk quite low indeed. Familial hypercholesterolemia (FH) appears unlikely in your case. The zero calcium score is certainly a positive thing.
Again, many of the LCHF and Paleo theoretics might tell you not to worry about TC and LDL-C, not least because the other lipid parameters look so good. However, looking at the available science on the importance of LDL-C, most cardiologists would probably recommend cutting down on saturated fats and cholesterol. You might try to select more mono and polyunsaturated fats instead. You can still stick with Paleo and carbohydrate restriction if you want to.
Just got some testing back, after a long period of weight loss and transition from strength athletics to endurance athletics, all the numbers were nicely in their reference range… except that LDL-P, which was obnoxiously high at ~2000. So we’re going back on the simvastatin; but in reading stuff on “metabolic syndrome” which the doc seemed concerned that I might be trying to develop, I see recommendations for a low carb approach. I figure while I’m still used to micromanaging my diet, if I could get a recommendation for ratios (carb/fat/protein) for a 3200kcal / day diet, it’d be easy enough to tweak, while also matching the carbs against times when there’s room for them in recovery of skeletal muscle glycogen. It’d be cool to drag that number back to something sane while not interfering with recovery rate.
I think I will miss the cookie dough though….
I just got my first LDL-P test = 1755. My triglycerides = 48 and my LDL-C = 114. This does not see match the pattern described in the article in that my triglycerides are low and LDL-C not too high. I take 20 mg simvastatin. Take about 3 grams of fish oil per day. BMI around 24. Don’t seem to be a metabolic syndrome candidate. My diet tends toward high carb and my execise level is on the low end.
Not sure of the best course of action in this situation. Maybe someone could comment on this general situation.
Total Cholesterol 365; LDL-C 214; Triglicerides 404; Apo B 189; LDL-P 3500 (yes 3500) What can I eat??? 5’6″, 130#, non smoker, female A little bit scared!
Nette. I don´t know about your age or your family history. Looking at your lipid numbers there is a possibility that you have what is called familial combined hyperlipidemia. My suggestion is that you seek a specialist, either a cardiologist or a lipidologist. Have you done that?
John Male Age 42
Family History – Father had first HA at 46 and is a Diabetic
Ht – 6’3
Wt – 230 lbs (lost 15 lbs in 2 months)
TC 202
LDL-C 106
LDL-P 1667
HDL 57
TRiG 218
Blood Glou 107
After two months of Meditarian diet and 6x a week exercise I dropped 300 from my LDL-P. My NP still wants me to start statin therapy which scares me. I want to keep trying to lose weight. I’m afraid statins will push into diabetes.
John. Your lipid profile is not that bad really and does by itself not support statin therapy, considering that we are talking primary prevention. I agree with you that you should continue trying to lose weight. I think a Mediterranean type diet including exercise is definitively a good option in your situation. This will hopefully help lowering your TG. Indeed, a low carb version of the Mediterranean diet might be something to look at as well.
I have a problematic set of results on my NMR. At least I cannot figure what they mean.
Story: obese most of my adult life; low carb 2.5 years; in first 18 months lost 25 pounds with work; discovered the T2D 1 year ago; added metformin and lost another 10 pounds; weight and BG stuck both still somewhat high; high FBG. In mild ketosis much of the time, with periodic breaks with added carbs.
What does it mean if both LDL-P and HDL-P are off the charts high, IF I am on a long term low carb regimen with high saturated fat with controlled Pre-T2D (a1c 5.8; can’t seem to get it lower), low insulin (6), and good IR numbers; taking 2000 mg metformin. Also LP(a) is very high (137).
Where do I look for what this means? Not theoretical, as my mother had strokes and early-onset Alzheimer’s in her mid-50s. Is the risk real? Can it be managed without drugs?
If you have any suggestions on what to read or where to research, I’d appreciate it. It almost feels as if this is two problems, not one. Or the risk factors have not been vetted against my scenario.
Thanks so much,
Mary
_______________________
The data:
* unexpected results
A1C 5.8
Insulin 6 uIU/ml
LP(a) 137*
B12 331
D 64
LDL-P 2341*
LDL-C 149
Small LDL-P 724
LDL size 21
HDL-P 49.2
HDL-C 88
IR Numbers:
Large VLDL-P < .7
Small LDL-P 724
Large HDL-P 11.4
VLDL Size – not enough to measure
LDL Size 21
HDL Size 9.4
LP-IR Score 15th percentile (good)
@ mpanttaja. As you probably know the high levels of HDL-C and HDL-P are good things in terms of risk. Considering your weight and diabetes I would suspect you fulfill criteria for the metabolic syndrome. So it is a bit surprising that your LP-IR score is this low. Actually, you can often get confused with all these numbers. Maybe you should look at your lifestyle in general and see what you can do to reduce your risk. The saturated fats will not help you lower LDL-C. I wonder whether switching to a more of a Mediterranean type diet, using more monounsaturated and omega 3 fats, might help you. It is a good diet for type-2 diabetes and for weight loss.
Total Cholesterol: 170
LDL-C: 109
LDL-P: 1686
HDL-C: 43
Triglycerides:125
hight 5’7″
wieght:187
I am worried due to my weight and LDL-P ratings. Should I be and what should I do. My overal Cholesterol has dropped from 238 when I was 28 to this number now that I am 48. I take Lipator 10mg.
Thanks
@ Harold. Considering that you are overweight, weight loss probably reduces your risk. Cutting down on sugar and refined carbohydrates often helps lowering LDL-P
Thank you for your thoughts. I believe the IR is under control because of 2.5 years of very serious low carb and a year of metformin. I control post prandial glucose rigorously by eating very few if any carbs. I don’t smoke, I exercise and lift weights, bike to work, ski. I will look into shifting some of the fats to olive oil and avocado and such (from dairy cream and butter), but I don’t think I can increase my carb load as described in that experiment (Mediterranean diet) without raising my a1c. I’m a bit stuck between a rock and a hard place. Obviously, there are some things we do not understand yet. Thanks again for considering.
Thank you for you very enlightening blog. A high LDL-P number often is cited by Drs. Dayspring and Attia as a deciding discordant/concordant indicator of CVD risk. For those in adhering to Low Carb/Paleo, many are confounded when LDL-C has gone up instead of staying low. And worst yet, a high LDL-P number seems to affirm the CVD risk, in concordance w/ the LDL-C level.
A physician who treats those w/ metabolic disorders encountered such a conundrum himself: http://azsunfm.blogspot.com/2012/09/font-definitions-font-face-font-family.html
In Dr. Patel’s premise, a high LDL-P number, in the absence of other risky indicators (TG/HDL ratio <2, fasting blood sugar, low CRP, obesity, hypertension) for metabolic syndromes, by itself, maybe of little value, since other indicators are in the safe zone. A body with low inflammation, there should be no arterial damage from glycation. Therefore, the LDL-P has no injury to deposit its load of cholesterol for repair, thus no plaque.
You take? Thanks.
Hi Peter. Sorry for my late response. I read Dr. Patels article. Very interesting. I think you are right. We often tend to treat laboratory values. We have to see the whole picture. If there are no other risk factors, healthy lifestyle etc, a laboratory value such as LDL-C or LDL-P may be of limited value. We know that inflammation plays a role in atherosclerosis, and we know that lipids do as well. Possibly, turning down inflammation may make high LDL-C or LDL-P harmless. We still don´t know. There are ongoing clinical trials on the effects of anti-inflammatory drugs in patients with heart disease. They might actually provide some answers to the role of inflammation in cardiovascular disease.
“Possibly, turning down inflammation may make high LDL-C or LDL-P harmless.”
Evidence of this?
There’s plenty of evidence of inflammation dying out when dyslipidemia gets treated. It is a pro-inflammatory state.
Lowering lipids is important and will affect risk. But it´s not a one way street. Affecting other risk factors is important as well, and will help reduce risk of heart disease. The importance of lipids as a risk factor becomes less if you can reduce the role of other risk factors.
Good morning Doc. I’m thrilled to have found your blog, after receiving my NMR and Lp PLA 2 labs. There are a lot of FLAGs on the results, so trying to decide if I should see a cardiologist or regular doctor. Your thoughts??
Heart disease runs in my family, with mother having a heart attack in her mid 60′s. She had a stent implanted and no other occurances. She’s now 90! I am also a carrier of the KIF6 Genotype 719 Trp/Arg heterozygous.
I ‘m now 60 and have a similar build to my mom, 5’6″ at 136 lbs. I’m currently not on any medication. I’ve been taking Bios Slim for 1.5 months and have reduced total cholesteral 41 points and have lost 12 lbs. I’ve also implemented better eating habits by eating healthier; steel cut oatmeal, fish, etc. and trying to eliminate all sugars. Also exercising at least 5 days a week for 30 min.
Besides getting my LDL down & HDL numbers up, I was wondering if there is a way to enlarge those LDL & HDL particles. Here are my numbers:
LDL Size 21.0
LDL-P 1712 (high)
Sm LDL-P 833 (high)
LDL-C 134 (high)
HDL-C 44
HDL-P TTL 28.8 (low)
Trigly 111
Chol TTL 200
HDL Size 8.8 (low)
Lg VLDL-P <0.7
Lg HDL-P 5.5
LP-IR Score 31
LP-PLA 196
@ Kathy. Thank you for your post and for sharing your numbers. I have very limited experience with the clinical utility of The KIF6 Genotyping Assay. However, I understand that some studies have shown that statins may be effective for prevention when the KIF6 polymorphism is present, while this was not confirmed by rosuvastatin in the JUPITER trial.
We still have a lot to learn on dietary interventions to lower LDL-P and increase LDL and HDL particle size. Carbohydrate restriction, Mediterranean diet and Omega -3 fatty acids may all be helpful. Avoiding sugars, eating healthy natural fats and exercising are probably helpful. I believe you are on the right track by eating healthier; steel cut oatmeal, fish, etc. and trying to eliminate all sugars as well as exercising. It´s probably more a question of staying focused and keep it going. Good luck.
Hi Dr Sigurdsson,
Would love you to get your thoughts on my numbers. I’m 37, no family history of heart disease, was a social smoker for about 15 years – smoking when I drank alcohol. I started going to a cardiologist about a year go as I was having some random chest pains, he attributed this to stress after a battery of tests – EKG, Stress test, Echo, Echo stress, CIMT but I did discover I had a leaky aortic heart value, mild to moderate leak. During my visits there I got my blood work done a few times and was shocked to learn my LDL-P was 2119! Since then, 8 months ago, I have dropped 20 lbs, starting running 4 times a week and removed all sugary drinks from my diet. I’m very conscious as to what I put into my body. During my last visit, my Dr mentioned going on a statin, would love to get your thoughts on this.
Below are my recent numbers:
Total Cholestrol 165
Triglycerides 81
HDL-C, Direct 52
HDL-C as % of Total 32
Cholestrol/ HDL-C Ratio 3.2
LDL/HDL-C ratio 1.9
Non-HDL Cholestrol 113
VDVL Cholestrol 16
LDL-C Direct 99
LDL – P 1461
Small LDL – P 733
LDL Particle Size 20.6
HDL – P 32
Large HDL – P 5
LP-a 13
hs-CRP 0.8
Lp-PLA2 157
Apo A1 150
Apo B 89
Apo B/A-1 Ratio 0.59
Hemogloblin AIC – 5.7
Glucose – 97
Blood pressure generally around 115/75
Best regards
Mike
Hi Mike.
You´ve certainly managed to improve your LDL-P by changing your lifestyle. Well done, congratulations. To me your numbers don´t look bad at all. Total cholesterol, triglycerides, HDL-C all quite acceptable. ApoB is fine and so is Lp (a). HsCRP is ok. No diabetes. Considering the absence of other risk factors such as family history, hypertension and smoking, the risk of cardiovascular disease in the near future should be quite low. It´s not for me to decide whether you should have statin treatment, but I would consider it very aggressive considering that your general risk is low and your lipids are not that bad really. I don´t think such as decision would be supported by any scientific trial.
My doc insists I am at high risk for a sudden cardiac death if I don’t go on statins right away. She is focused on the LDL-P number (1934) and says none of the other numbers matter. My gyno ran the basic cholesterol test in December, and all those numbers (total cholesterol, HDL, LDL, triglycerides) improved by the time the referred doc ran the Lipid Cascade test in Jan (doc didn’t see me until last week, but called a statin prescription to my pharmacy 6 wks ago. No one told me). Should I continue very low carbing? Should I take the statin? I’m 52 and post-menopause. My most recent A1C is 5.5; my bp typically remains below 120/80 unless I’m at a doc’s office, where it is usually 145/90. Thank you for any clarity you can provide.
Total cholesterol: 274
HDL: 87
LDL: 163
Triglycerides: 66
LDL-P: 1934
LDL particle size: 21.7
LP(a)C: 41.4
hs-CRP: 2.1
LP-PLA2: 253
Apolipoprotein A-1: 225
Apolipoprotein B: 145
@Sylvia
I would not consider you at high risk for sudden death if you don´t go on statins right away. However, I understand why your doctor worries about your lipid profile and assumes he/she may be able to lower your risk by prescribing statin therapy. Total cholesterol is a bit high, so is LDL-choleseterol. Both ApoB and LDL-P are to high. However, when considering risk and potential benefits of statin therapy you have to look at other risk factors as well, such as family history, smoking and blood pressure. You will also have to keep in mind potential side effects of such therapy.
Your hsCRP is just above 2, so according to the JUPITER trial, statins may lower your risk for future cardiovascular events.
Some specialists have claimed that the efficacy of statin therapy in primary prevention may be less in women than men. Dr.Barbara Roberts has written a wonderful book (The truth about statins) where she discusses the pros and cons of statin therapy and suggests that such treatment may be less influential in women than in men.
I agree with your doctor that there are studies indicating that statin therapy may lower your risk of hart attack and stroke. The important thing however, is that you understand the magnitude of benefit, in relation to the risk of side effects. That is something you should be able to discuss with your doctor.
I´m not sure that very low carbing is the best way to go for you. It might be, if you are overweight or have signs of the metabolic syndrome. If we look at cardiovascular risk in general, a Mediterranean type diet may be helpful.
There are exactly *zero* methodologically-sound, clinical trials showing that statins benefit women of any age for any cardiovascular-related diagnosis. Any physician pushing this class of drugs for women is ignoring the evidence, or lack thereof. Whatever problem you might have, statins won’t cure it. Even to say that no other markers matter, like your TG/HDL ratio (yours is outstanding), is not sound decision-making. At the least, you should ask for a coronary calcium test to get a picture of the degree of blockage (if any) in one of your major blood vessels.
Even with LDL-P being the newest darling marker for predicting heart attack, there’s still some question about what the appropriate optimum numeric range is for those on a ketogenic (i.e., less than 50g net carbs/day) diet. In a conversation with Dr. Tom Dayspring, a prominent U.S. cardiac health educator, Jimmy Moore discussed his sky-high LDL-P, and how it was discordant with other markers of cardiovascular health in his case. Dr. Dayspring admitted that there are no good studies of very-low-carbers, and that a different standard might be appropriate.
Hello Doc. Thank you for all this information and for helping all of us. I’m hoping you might help me navigate my husbands numbers… He is 42, about 5’9 and 160 lbs. His father had a major stroke at age 55 and now lives in an assisted care facility. This has obviously been a difficult thing for his family and so this whole cholesterol issue is quite emotional and scarey for my hiusband. We’ve been ‘paleo’ for about 1 1/2 years now. We started with low carb but have increased them in the last few months. It seems his LDL is increasing rapidlyof late. I’m still trying to get the previous lipid panel but this most recent is as follows:
(Values in mmol/L)
Total LDL 6.05 (my husband says that’s up from 4.8 ish last test which was just a standard lipid panel a couple of months ago and since it might be pertinent in considering familial I believe his LDL was within normal limits pre-paleo)
LDL-R 5.15
LP(a) 0.18
Total HDL 1.91
Total cholesterol 8.48
Trigs-VAP .96
non HDL chol 6.57
remnant lipoproteins 1.03
LDL pattern A (less risk)
ApoB100 1.53
ApoA1 1.92
AppB100/ApoA1ratio 0.8
My limited understanding is that apoB predicts particle # (do you know what this apoB number would translate to in LDL-P?) and that this 1.53 is high. However the ratio,which I’ve also read is similar in predictive value to particle number is in the acceptable range. I think his LP(a),trigs and HDL are all good. From what I remember of his previous bloodwork his bp is good, c-reactive p was good, vit D good, thyroid was fine (but I’ve read it can elude standard testing-should we pursue further?). He doesn’t have tendon (or other) xanthomas that I’m aware of. We eat mostly fruit, veg including starchy, well raised meat inc liver and some heart, eggs(mostly raw yolks in smoothie-about 2 yolks/day), lots of canned salmon, high fat raw dairy (cream in coffee, some sour cream..), fermented foods, some raw nuts (and i bake muffins w almond flour), coconut oil. We drink freshly pressed green juice most mornings (spinach, carrot parsley ginger apple lemon). We don’t eat vegetable oils (only olive), grains (except white rice), legumes and very very little sugar and maybe 2-3 glasses of wine/week) Is latent chronic infection a possibility? I wonder about fungal/parasitic and or gut issues (bad dandruff, aggressive belching-even upon waking in the morning on empty stomach), smelly sneezes at times, possibly a little ringworm occasionally and peeling feet very recently -assuming fungal). My oh my I haven’t painted the prettiest of pictures here so you might be surprised to hear that he’s very attractive actually
looks quite healthy and is in good physical shape-he’s a natural athlete-plus lots of walking, some yoga and I’m pushing him to add more high intensity exercise. Bahhhh! Sorry for the excessively long message. Just frustrated after putting so much care and effort into making good choices and getting results like this. Any feedback on which direction to turn would be helpful. I’m thinking turn more Mediterranean, fish, less chol/sat fat(?) double checking thyroid, and looking into infections… We don’t want to go the statin route if possible-are we putting my husband at risk not going straight to statins as the doctors are recommending?
Thank you so much for your time.
Hi Tami. Thanks for your post. Although Paleo and low carb diets have many health benefits they are certainly not the best diets to lower total cholesterol and LDL-cholesterol. In a normal weight person with LDL-levels this high, I would rather go for a Mediterranean type diet as you suggest, as it might lower cardiovascular risk. I don´t know whether your husband has any family history of premature coronary artery disease. If he had, you would certainly have to wonder whether he has familial hypercholesterolemia (FH). Maybe he should discuss with his doctor about genetic testing for FH. An Apo B of 1.53 g/L is certainly high as well. Under these circumstances, with the high ApoB and LDL-C, most cardiologists would recommend statin therapy. Lipid guidelines usually recommend statins if LDL-C is above 4.9 mmol/L 190 (mg/dL).
Thank you for your reply. I really appreciate your feedback. There is no family history of coronary artery disease, just the stroke as I mentioned above. We will still rule out FH. The interesting thing about this situation is that for the first year plus of paleo his cholesterol rose only modestly-this past reading increased from an LDL of 4.3 to 6.05. I appreciate that there’s a certain number after which statins are recommended, however this rapid surge begs the question why? Is it possible that there is an explanation or cause that should be at least looked for and addressed before artificially lowering the number? I’d love to understand the cause (could diet ALONE cause this dramatic sudden rise when we’ve been eating this way for almost 2 years? If so, then shouldn’t diet alone be able to lower it?).
I understand your concern Tami. You´re wondering why there has been such a change in a short time. Maybe he could try a Mediterranean type diet for a while, and try to avoid animal fats and dairy fats in particular, as well as refined sugars and processed meats, which I´m in fact almost sure he already does. Fish oils and omega-3 supplements may be helpful as well. Then he could have his lipid numbers reevaluated in six months. Sometimes hypothyroidism (low thyroid function) causes elevation of LDL-cholesterol, but I assume this has been ruled out already.
I am 43 with a LDL-p 2530 Total cholesterol was 209 LDL-c 128 HDL-c 52 Triglycerides 199 Non HDL-c 157..
HDL2 7 HDL-P 40.5 elevated hs=CRP 6.23 Fribrinogen 475
Anyway, wondering what diet I could do to lower LDL-p..? I have Hoshimotos, could that make my LDL-p so high.
I am a women 5 10″ 172lbs.
Thanks,
Lisa
@Lisa. You appear to have a typical discordance with an LDL-C that´s not to bad, but and LDL-P that´s quite high. Your triglycerides are high as well. However, to your benefit HDL-C is high as well. There is no particular diet that lowers LDL-P. A Mediterranean type diet may be helpful. Omega-3 may help as well. Reducing carbs may help. The Hashimotos might possibly explain the elevated hcCRP. Hypothyroidism may affect cholesterol levels, but I´m not aware of how, or if Hashimoto´s may affect LDL-P.
I am 60 years old. I consider myself to be in great shape. Most people think I am 50. I don’t smoke, I exercise a lot, I eat what I think is healthy. My numbers are:
Total cholesterol 218
LDL 155
HDL-C 68
Triglycerides 51
Apo B 110
LDL-P 1712
Apolipoprotein E 3/4
MTHFR677 T/T
Omega 3 Total 9.9%
T4 6.9
T3 uptake 37.2
Free Thyroxine Index 2.6
TSH 1.636
Liver and Kidney numbers are good
CRP was 9.8 – must have had infection took antibiotic and it is now 1.6
Lp-PLA 226
Lots of other numbers – not sure what you would want. My doctor wants me to take a baby aspirin. My last doctor said to quit the baby aspirin. That doctor did the Berkley test which showed LPA-AspirinChexk Ile/Ile – not sure if that is why he said stop. What do you think? What else can I do to avoid problems? Thank you so much. Just found this site and it is so informative.
@Judy. I hope you understand that it is very difficult and irresponsible of me give individual recommendations. Therefore I can only answer you in very general terms. If you don´t smoke, don´t have high blood pressure, diabetes, obesity or family history of premature coronary artery disease, your general risk is probably rather low despite the lipid numbers. Of course we would like to see lower numbers for LDL-C, LDL-P and ApoB. Your lifestyle appears to be healthy. Avoiding refined sugars and processed meat will probably help. A Mediterranean type diet may lower cardiovascular risk and may also lower your LDL-P. Lots of fish, vegetable, fruit, fiber and seeds is not a bad idea. Fish oil and/or omega-3 might be a good idea as well.
Thank you so much for responding. I appreciate your suggestions and will work on them. God bless.
Hi Doc! Thank you for this information. I have recently been put on statin and niacin therapy and would like to ask your opinion. I am a 34 yr old female, 5′ 6, 142 lbs. I am heterogenous for prothrombin mutation and MTHFR. I mention this because I recently had a stroke in the ear and suffered SSHL. Here are my numbers:
Total – 174. 3 months prior=174
LDL-C. 108. 97
HDL-C 63. 59
Triglycerides 90. 75
NonHDL-C 111. 115
ApoB 93. 96
LDL-P 1548. 1116
SdLDL-C31. 24
%sdLDL-C 29. 24
Apo A-1 133. 132
HDL2-C 15. 19
Apo B:apo A-1 ratio .70. .73
Lp-PLA2 234. 239
HsCRP 1.3. 20.4
After my test 3 months prior I was put on niacin and baby aspirin once per day. Now my doctor has added pravastatin. I eat an anti inflammatory diet, mostly gluten and dairy free. I’m not a beef eater and never have been. I have a glass of red wine every evening while cooking dinner. I do EVERYTHING right with eating exercising etc. what do you think about this?
Thank you! I never expected to have to deal with this stuff so young….
After reading my post I want to make sure it makes sense. The first numbers after the type of protein, etc are the most recent results taken in February. The second number is from the test taken in December 2012 after the stroke. I’m wondering why some of my numbers went up after being put on Niacin and baby aspirin??
@MomOfTwo. Sorry to hear about your stroke. I guess the main reason you are being treated with statins is the stroke, rather than the lipid numbers per se. In my practice we more or less give statins to all persons who suffer ischemic stroke. However, niacin is much less used in Europe than in the US. If your lifestyle is healthy as you suggest, including exercise and healthy food choices, I guess there is probably not much more you can do. According to the studies on the Mediterranean diet, a glass of red wine won´t hurt. I assume you are taking aspirin or some other blood thinner as well.
Over the past 2 years I suffered 2 PE’s that I think chronic lyme contributed to.
CHD runs in the family
Two weeks ago I ran these tests
Tot Chol 289
LDL 199
HDL65
Trig 143
ApoB 150
LDL-P2410
sdLDL-C 57
Apo A1 154
HDL-P 45
HDL2-C 14
CRP .4
Lipo (a) 31
5 weeks before total cholesterol was 251 and Lipo (a) was 8. the only difference was upping coconut oil and taking a B12/Folic/ B6 supplement.
I am on coumadin due to the PEs and am considering adding 500mg niacin and maybe 500mg Omega 3. I don’t eat junk but am not sure which way to go with my diet, if I should add the supplements (will they thin the blood too much while on coumadin) and how concerned I should be with these lab values? And is it common for Lipo (a) to go from 8 to 31 in 5 weeks? Thanks in advance
I am a 58 year old with a BMI of 29 and a family history of chd. I have cleaned up
my diet and take fish oil, aspirin, metoprolol and atorvastatin (40mg).
Can you give me any advice on reducing my risk?
My blood work recently showed me in the high risk category as shown below.
LDL-P 1213
LDL-C 64
HDL-C 49
TG 54
HDL-P 27.9
SMALL LDL-P 852
LDL SIZE 20.2
Thank you for any advice.