Do you have high LDL or high total cholesterol? If you read my previous article about cheese, you may recall that these LDL or total cholesterol numbers alone are not reliable predictors of mortality from heart disease.
An NBC News piece went further to cite American science writer Gary Taubes who reported that the LDL and total cholesterol numbers have been such poor predictors of disease risk that early screening tests should have likely just tested for HDL and triglycerides and nothing else.
A 1977 NIH study — an early set of papers from the now legendary Framingham Heart Study — confirmed that high HDL is associated with a reduced risk of heart disease. It also confirmed that LDL and “total cholesterol” tells us little about the risk of having a heart attack, language that heart-disease authorities would downplay years later. Given this finding, as Gary Taubes writes in “Good Calories, Bad Calories,” we would have been better off to start testing for HDL — or even triglycerides — and nothing else.
A more nuanced view associates the risk of atherosclerosis and heart disease with the type of LDL particles. There are two patterns (also referred to as “phenotypes”) of LDL particles.
- Pattern A: large, fluffy LDL particles which are largely benign
- Pattern B: small, dense LDL particles which are more likely to oxidize and lodge themselves to arterial walls
Studies have long shown the impact of LDL particle size on disease risk. A 1988 study in the Journal of the American Medical Association documented the association between Pattern B (small, dense) particles and disease risk:
The LDL subclass pattern characterized by a preponderance of small, dense LDL particles was significantly associated with a threefold increased risk of myocardial infarction, independent of age, sex, and relative weight.
So why not test for LDL particle size? The tests are more expensive!
However, there is an answer. While testing for LDL particle size is more expensive today than commonly used cholesterol tests, a triglyceride / HDL ratio of 3.8 or higher can predict pattern B with high confidence. A 1997 Harvard Medical School study also confirmed the efficacy of triglyceride / HDL ratio to predict the risk of myocardial infarction.
Given the age of these studies, the use of HDL and triglycerides has become accepted practice in some circles, as described by Everyday Health.
According to Scott W. Shurmur, MD, the medical director of the cardiovascular center at Texas Tech University Health Sciences Center in Lubbock, Texas, the particle test should be used for people who have other risk factors for heart disease or stroke, such as a family history of heart disease at early ages. “At the same time, standard cholesterol tests like HDL and triglycerides provide similar information (and are less expensive), particularly if non-HDL cholesterol is incorporated into the assessment,” says Dr. Shurmur.
Unfortunately, there are no widely adopted standards today for metrics of triglyceride / HDL ratios in common clinical practice. Some researchers have provided guidelines, including Zone Diet creator Dr. Barry Sears who wrote:
How can you tell which type of LDL you have? All you have to do is determine your ratio of triglycerides to HDL cholesterol, which would be found as part of the results of your last cholesterol screening. If you ratio is less than 2, you have predominantly large, fluffy LDL particles that are not going to do you much harm. If your ratio is greater than 4, you have a lot of small, dense LDL particles that can accelerate the development of atherosclerotic plaques – regardless of your total cholesterol levels.
Still, patients who view their standard lab test results will notice that standard lab results list other ratios including Total Cholesterol / HDL and LDL / HDL ratios, but they do not list Triglyceride / HDL ratios.
(TG/HDL = 138/83 = 1.7)
So why aren’t Triglyceride / HDL ratios more in use, or why aren’t LDL particle sizes discussed more often in the doctor’s office? After all, most of the research cited in this blog article is decades old!
Frequent readers of this blog know my skepticism around a lot of Western Medicine. Most continuing education for doctors is sponsored by pharmaceutical companies who have commercial interests in promoting use of lab numbers that their drugs can lower! According to an academic paper titled “Statins Do Not Decrease Small, Dense Low-Density Lipoprotein:”
Our study suggests that statin therapy—whether or not recipients have coronary artery disease—does not decrease the proportion of small, dense LDL among total LDL particles, but in fact increases it, while predictably reducing total LDL cholesterol, absolute amounts of small, dense LDL, and absolute amounts of large, buoyant LDL.
In other words, drug companies likely suppress the information about LDL particle sizes because their drugs preferentially target the benign “Pattern A” particles over the more harmful “Pattern B” particles!
My opinion: Before going on cholesterol lowering drugs, take a look at your triglyceride / HDL ratio. You may have “Pattern A” LDL particles and be at lower risk of heart disease than your LDL or total cholesterol numbers suggest.
Thanks, very interesting.
So, if my triglyceride level is 123 and my HDL is at 49 , the ratio is around 2.5— which is okay? Even though my LDL is at 192 ?
Your triglycerides are normal, and so are your HDLs. I think most doctors would recommend your taking a test for lipid subfractionalization by ion mobility. I did this in Germany, and my results showed “pattern A” with a high relative number of larger “fluffy” particles, and a small relative number of smaller “dense” LDL particles. The tests are offered in the US, too.
https://www.questdiagnostics.com/home/physicians/testing-services/condition/cardiovascular/cardio-iq-ion-mobility.html
The most recent Cleveland Heart Lab Cardio IQ test panel has my triglycerides at 103 and my HDL at 49, a ratio of about 2.1-1. Unfortunately it also shows I have far too many small lipid particles. Both LDL and HDL particles are too small according to the test results. I had 1909 LDL particles which is far too high according to their test. Small LDL, and medium LDL were both at 490, far above the maximums considered satisfactory. Large HDL came back with a number of 3881, which is far too low according to their test.
Lipoprotein(a) was a bright spot. I was only at 15 nmol/L according their test, much lower than the maximum of 75 considered optimal. What exactly should I make of these results?
You are a pattern B. For a complete picture I would suggest doing an inflammation panel by Cleveland heart labs. Also 9p21 and Apo B test.
It’s my understanding from research I’ve seen, that pattern B LDL has free cholesterol bound to the outside of its ‘shell’ but when that cholesterol becomes esterified, it gets drawn into the shell, swelling the pattern B LDL to become large fluffy pattern A.
IF this is so, the question in my mind is how to deliberately trigger that esterification?
I recently ran an expensive Cardio IQ test and discovered that I have a huge problem with small, dense LDL. The same test showed very low levels of Lipoprotein (a). The results of recent cardiac calcium scoring tests and Lp-PLA2 blood tests show I need to be very concerned because of increasing arterial inflammation and greatly increased calcium deposits. I am currently running HDL numbers in the low to mid forties and triglycerides in the 170-200 range with total LDL usually over 200.
I would suggest finding a provider that is associated with the BaleDoneen method. Look at their website. They have been treating this condition for the last 15 years with huge success. Their specialty.
Second that on the Baledoneen method. Their forte.
With an HDL of 97 and triglycerides of 50, I guess a forumula determined LDL of 161 should not be too worrisome?
I would be more concerned with the number and size of LDL particles. If you have large numbers of small LDL particles, that would be of concern. If they are mostly large particles, I wouldn’t be concerned at all. Cleveland Heart Lab’s lipoprotein fractionation tests or Labcorp’s NMR lipoprofile test panel would tell you about the number and size of LDL particles.
Cholesterol levels are the wrong thing to test for. You can be harmed by having too many LDL particles, too many small LDL particles in particular, or too many oxidized particles.
Thank you!
According to my recent lab results , Cardio IQ, I have LDL pattern B. LDL small and medium lipoprotein fractionation, ion mobility are both in the moderate risk category while HDL large is well within the high risk category. Can you direct me to any articles or information on what I can do to lower my risk?
Can a person have both pattern A and pattern B LDL’s?
I’m looking more deeply than just whether they classify me as pattern A or pattern B. They use somewhat arbitrary dividing lines for classification. I’m still overweight but less than I used to be. My apolipoprotein B levels are still too high. My Lp-PLA2 levels remain too high. Just getting labeled by Cleveland Heart Lab as pattern A isn’t good enough.