LDL Cholesterol, Particle Number and Particle Size Made Easy

Measurements of lipids levels in blood are frequently used to assess the risk of future heart disease. The most commonly used measurements are total cholesterol, triglycerides and high density lipoprotein cholesterol (HDL-C). These numbers are then used to calculate low density lipoprotein cholesterol (LDL-C), which has been found to be strongly correlated with the risk of heart disease.

Recently measurements of atherogenic lipoprotein particles, such as LDL-P (LDL particle number), apolipoprotein B (apoB) and lipoprotein(a) have been found to be very useful to assess risk.

19040750_mLDL-P measures the actual number of LDL particles (particle concentration). 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 heart disease, particularly if your LDL-P is elevated. Discordance is considered present if LDL-C differs from LDL-P.

LDL-C is a measure of the cholesterol mass within LDL-particles. LDL-C only indirectly reflects the atherogenic potential of LDL particles. ApoB and LDL-P on the other hand reflect the number of atherogenic particles, with no mention of cholesterol mass. ApoB and LDL-P are believed to be better risk predictors than LDL-C.

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.

Sometimes it is difficult to understand the difference between LDL-C and LDL-P and how particle size comes into the picture. It is quite likely that LDL particle number and size will be used more often in the future to assess risk. Therefore I decided to share with you four slides I often use to simplify these issues. In the slides LDL lipoprotein is presented as trucks carrying sand (cholesterol).

Hope you enjoy the slides although you may find my chemistry to be on preschool level.




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83 thoughts on “LDL Cholesterol, Particle Number and Particle Size Made Easy”

  1. Hi, Dr. Sigurdsson. You’ve got a very nice blog going here, mainly because of its two primary features: there is your medical expertise which oversees it all, plus the fact that it is not all about one-sided advocacy (especially with the diversity of commenters). That said, I don’t think that you would deny that you have an obvious leaning toward low carb – though I’m not quite sure if you favor that approach for everybody or instead mainly for the insulin resistant.

    My aim is to try and discover what is best to do, so I have zero interest in being part of any ‘movement’ or engaging in the diet wars. (I have an Fx of CVD, but not much personal risk, AFAIK.) I’m not exactly a beginner, but I’m going farther now with trying to get a good overview of all the major studies on CVD prevention, as well as getting some practical insights from a practicing clinician. This looks like the best place to do that. So keep up the good work 🙂

    • Thanks KV. Appreciate your interest in my blog. Hope you continue visiting and feel free to share your thoughts 🙂

  2. Hi, Jerry. Logically, the opposite would be true. As the result of advanced lipid testing, some people would get reclassified to a higher risk category. If those people cannot or will not lower their LDL-P through lifestyle changes, they might very well be put on statins and/or other meds.

    Statins do lower LDL-P – just generally not as much as they lower LDL-C. Apparently, niacin might also lower LDL-P (because it lowers triglycerides); but as far as I know the OTC fast-acting niacin is safer on the liver than the prescription slow-acting Niaspan.

    A standard lipid panel here costs around US$30, while the NMR test for LDL-P has been dropping and is around $75 now.

  3. I’m a 54 year old male, 6’1″ and 225lbs. A recent physical revealed results that had my doctor prescribe statins. I have read very detrimental information and have resisted. Apart from the cholesterol numbers, I’m a picture of God health and eat a LCHF diet.

    Here are my numbers age results from a website that does a basic calculation:

    Your Total Cholesterol of 244 is HIGH RISK
    Your LDL of 162 is HIGH RISK
    Your HDL of 65 is OPTIMAL
    Your Triglyceride level of 85 is NORMAL

    RATIOS:

    Your Total Cholesterol/HDL ratio is: 3.75 – (preferably under 5.0, ideally under 3.5) GOOD
    Your HDL/LDL ratio is: 0.401 – (preferably over 0.3, ideally over 0.4) IDEAL
    Your triglycerides/HDL ratio is: 1.308 – (preferably under 4, ideally under 2) IDEAL

    LDL-P: 2048
    HDL-P: 43.9
    Small LDL-P: 856
    LDL Size: 21.0

    I’ve decided to once again put off the statins as a physical 2 years ago produced similar results and I’ve stayed statin-free.

    Any thoughts on this?

  4. If anyone can help out, would be greatly appreciated… since I been on a Ketogenic Diet.. my Apolipoprotein B went up to 230, and my lipoprotein (a) is at 99, what am I doing wrong, am I consuming too much Saturated Fats.. is it the grass fed butter, or the Caprilic Acid C8 from Brain Octane…

    • speaking from personal experience — my spouse can eat like you and his cholesterol and BP remain optimal. If I even look at a hamburger, mine goes up, it has never been optimal. It’s your genetics.
      I eliminated all cheese from my diet and began taking Cholest-off (an OTC plant stanol), and now consume under 10 grams of saturated fat a day. Use Fitday.Com (it’s free) and you’ll see it. I got my numbers down and put off statins for another year. PS your ideal # goes down as you age. I’m 66.

      • After major research, and read over 20 + books… I think I finally found an answer. that I am looking to get done this weekend… I think when the liver makes bile, the bile should be stored in the gallbladder (1L a day). but if your gallbladder has gallstones(cholesterol Stones) it prevents it from working properly and or holding enough bile to be used when you consume food, and specially fat.. I think thats why my cholesterol levels keep increasing dramatically every time I consume fat… and its taking a very long time to lower it… I will do a liver and gallbladder flush and see what happens.. keep you updated… As the Ultra sound scan does not show any stones in the liver nor the gallbladder…

      • Hi Maurice…any updates on this? Did the liver and gallbladder flush help with the cholesterol levels?

        Thanks!

      • After the flush. Cholesterol LDL was a bit high but had gone down 20 points. So I increased my magnesium and vitamin c and only ate one protein meal a day with the secondary meal being 3 plates of cooked organic zucchini and 3 weeks and increased probiotics with every meal my cholesterol dropped from being as high as 10.3 down to 4.2 the doctor was shocked . So now for the past 4 weeks I increased the fats again to see if it was the fats or my gallbladder is clean and blood is stable.

  5. Dr. Sigurdsson, just came upon this site. It’s fascinating, thank you. I’m a 66 year old male who, until recently, thought he was pretty healthy. I always knew my total Cholesterol number was elevated-It’s currently 260. My doctors had always said though that the hdl/ldl ration was good and not to worry. So I didn’t worry. A recent series of tests including a CAT scan indicated that I have some moderate blockage in and a cardiologist wants to put me on statins.
    The calcium test has these numbers: Left main=34,
    Left Anterior Decending=61
    Left Circumference=75

    At this point i’m reluctant to begin taking a drug that has as many negative affects as positive in my opinion. I just learned about the small vs large ldl particles but this was not part of the latest blood test. the numbers I have are:
    Triglicerides-94
    LDL-151
    HDL-90
    Cholesterol/HDL Ratio-2.9
    TSH Ultrasensitive- 1.530
    Free T-4 – 6.2
    T-3 Uptake _ 35.6
    T-3 Total -0.82.
    Trigliceride/ HDL Ratio is-1.04.

    With these numbers I dont know what my next step should really be. I did start a Vegan diet eliminating all meat,fish, dairy, and oils. It’s killing me. Could there be another option other than a lifetime of statin drugs and do you think this type of diet could reduce the blockage?

    • Hi Jerry

      The TG/HDL-C ratio is relatively benign suggesting that it’s unlikely that you have insulin resistance or a small LDL-pattern.
      https://www.docsopinion.com/2014/07/17/triglyceride-hdl-ratio/

      Looking only at your lipid numbers I would probably not suggest statin treatment. However, your coronary calcium score is just above median for your age suggesting that you may be at slightly increased risk. Some doctors will recommend statins in this situation.

      But, although statins may reduce risk to a slight extent, healthy lifestyle is the most important thing in my opinion. Furthermore, some people experience side effects from statins. But, it’s a choice you have and should discuss with your doctor.

      https://www.docsopinion.com/2014/08/19/coronary-calcium-score/

      I would suggest a real food diet with lots of vegetables, fresh meat and fish. I recommend avoiding sugars and refined carbs, and refined foods in general. I’m not afraid of healthy natural fats, cheese, avocado, eggs, olives and olive oil, nuts etc.

      • Dr., thank you for your speedy reply. As I seem to have, according to your own posting, moderate coronary artery disease:

        (“Coronary Calcium Score Interpretation

        Based on a number of studies, the following definitions are used to
        relate the coronary artery calcium score to the extent of
        atherosclerotic coronary artery disease:

        Coronary calcium score 0: No identifiable plaque. Risk of coronary artery disease very low (<5%)

        Coronary calcium score 1-10: Mild identifiable plaque. Risk of coronary artery disease low ( 400: Extensive atherosclerotic plaque. High likelihood of at least one significant coronary narrowing.”)

        A cardiologist said that I have coronary disease with the calcium score of 170. I shared the information and concerns about a life taking statins with my family doctor and he suggested I look in to the research of the Drs Esselstyn and Ornish. The diet I began a month ago, was developed by Dr. Caldwell Esselstyn and also, with some modification, by Dr. Dean Ornish. I have always had what I thought was a good diet- In fact, your dietary suggestions to me is almost exactly the way I’ve been eating most of my life. I’m 66 and have always weighed around 150 pounds. These doctors frown on ANY oil at all and in fact, their mantra is eat nothing with a mother or a face- including eggs. Doesn’t leave much. IN fact, I have already lost about 5 pounds and don’t feel that I have the energy or that I am getting the protein I need in my diet even with the beans and legumes.So, once again, with the numbers I quoted above, is there another test that would offer a more detailed analysis of my specific plaque issue or a known way to reduce the plaque itself without the use of statins. I could not get a consultation appointment before mid August with a cardiologist so I appreciate your input and your time. Your site is fascinating. Thank you again. Jerry Knaster

      • Jerry, Alex is not going to have your heart attack for you. You are. The cardiologist that told you about going on a Whole Food Plant Based lifestyle change (as low in all fats as possible- more a little later) is telling you the truth. In that way there is the possibility of decreasing the size of the atherosclerotic plaques already built up in you coronary arteries that are, quite literally, going to kill you if you don’t begin to take action soon. You don’t really have to worry about not getting enough protein as your body is very efficient with recycling the amino acids the your body needs to stay healthy. The nuts/legumes/nuts that will become part of your lifestyle will provide you with the essential amino acids that you may fall short of. Realistically proteins need not be more than 5% of your caloric intake. Go to the “Forks over Knives” website for inspiration and recipes to make eating interesting. [No I have no affiliation.] I’m talking about a lifestyle change here Jerry because the scientific evidence is staring you in the face. You have been mistaken believing that you have been eating a healthy diet; if you stick with it it will be your death-style, like so so many people. You will need to take in a very small amount of fats in order to absorb Vitamins A, D, E, and K. At 66 you want to make sure that Omega 3’s make up some of that fat. If you don’t want to lose weight increase the number of calories of either by eating more resistant starch, or fruits and vegetables with fiber added to help with satiation. This will help with the feeling of not enough energy.

        Alex’s stroking your ego by telling you that your coronary calcium score is just above the median is a moot point because the calcium found in the atheroma is not what will kill you. If your current cholesterol is 260, what has it been for the last 45 years? That is why you are in the situation you find yourself in now. It is cholesterol that makes of the majority of the structure of the atheroma and once it become supersaturated it will crystallize and those crystals will pierce the epithelium of the artery; this will set of the wound healing mechanisms of the body in motion within the artery causing a thrombosis to form, cutting off the blood to all down stream myocardial tissue. And damage done will depend on where specifically this happens along that artery; and remember your percentages of blockage here Jerry; this is not an if situation here it’s a when in your case. Make the change. I won’t quote the research papers because I’m not going to get into a my scientific studies are better than your scientific studies argument with Alex.

      • Jerry,
        Alex is not going to have your heart attack for you. You are. The
        doctor that told you about going on a Whole Food Plant Based lifestyle
        change (as low in all fats as possible- more a little later) is telling
        you the truth. In that way there is the possibility of decreasing the
        size of the atherosclerotic plaques already built up in you coronary
        arteries that are, quite literally, going to kill you if you don’t take
        action. You don’t really have to worry about not getting enough protein
        as your body is very efficient with recycling the amino acids the your
        body needs to stay healthy. The nuts/legumes/beans that will become part
        of your lifestyle will provide you with the essential amino acids that
        you may fall short of. Realistically proteins need not be more than 5%
        of your caloric intake. Go to the “Forks over Knives” website for
        inspiration and recipes to make eating interesting. [No I have no
        affiliation.] I’m talking about a lifestyle change here Jerry because
        the scientific evidence is staring you in the face. You have been
        mistaken believing that you have been eating a healthy diet; if you
        stick with it it will be your death-style, like so so many people. You
        will need to take in a very small amount of fats in order to absorb
        Vitamins A, D, E, and K. At 66 you want to make sure that Omega 3’s make
        up some of that fat. If you don’t want to lose weight increase the
        number of calories either by eating more resistant starch, or fruits and
        vegetables with fiber to help with satiation. This will help with the
        feeling of not enough energy.

        Alex’s stroking your ego by telling
        you that your coronary calcium score is just above the median is a moot
        point because the calcium found in the atheroma is not what will kill
        you. If your current cholesterol is 260, what has it been for the last
        45 years? That is why you are in the situation you find yourself in now.
        It is cholesterol that makes up the majority of the structure of the
        atheroma and once it become supersaturated it will crystallize; those
        crystals will pierce the epithelium of the artery; this will set of the
        wound healing mechanisms of the body in motion within the artery causing
        a thrombosis to form, cutting off the blood to all down stream
        myocardial tissue. The damage done will depend on where specifically
        this happens along that artery; and remember your percentages of
        blockage here Jerry; this is not an if situation here it’s a when in
        your case. Make the change. I won’t quote the research papers because
        I’m not going to get into a my scientific studies are better than your
        scientific studies argument with Alex.

      • Hi Jerry, what side statin side effects are you worried about? I was a bit on the fence myself for years, however no diet helped lower cholesterol (in my case, it is genetic). I’ve been now taking for 7 or so years without any noticeable side effect.

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