Cholesterol - a Primer
I've been working on this for a while, and I think it's finally ready to post here. A lot of people post to LCF's forums freaking out about their cholesterol tests after going low-carb - their numbers are higher, their doctor wants them on statins, etc. and so forth. I've done quite a bit of research on the great cholesterol con, and I know how to interpret the results. But I think this is a tool that everyone should have, so without further ado, here's an article for you about cholesterol, what it does, and what those numbers mean.
DEFINITIONS OF TERMS
Total cholesterol: This is the total of all three kinds of cholesterol: HDL + LDL + Triglycerides. Each of them has a different function inside the body.
The recommended level of total cholesterol: <200
Cholesterol: A waxy substance that is actually an alcohol (hence the -ol suffix). It's carried by lipoproteins (fats and proteins) through the water-based environment of the bloodstream (remember that water and oil don't mix). It's necessary to sustain cell wall integrity and to repair damaged cell walls within (among other places) the arterial system of the body. Many things can damage the cell walls in the arteries and veins, including (but not limited to) stress, high blood sugar, high insulin levels, and lack of physical activity. When damage happens to these cell walls, the body has to do something about it. Normally, it will repair them with saturated fat and protein, which is what cell walls are made of, but if we're not eating those things, the body can't produce them out of thin air, so it sends cholesterol in as a stopgap measure. Your body uses cholesterol to make a "patch" over cell walls that need to be repaired, but if we don't give it the proper amount of raw materials (saturated fat and protein) to repair them with, the patch will stay there, and like any old bandage, eventually start to peel off. In the absence of the proper raw materials, the body slaps another layer of cholesterol over them to make sure that the patch doesn't break. This is where cholesterol buildup, or plaque, in the arteries comes from. The longer the body has to go without the right raw materials, the worse the problem gets, and these plaques can eventually break off, just like a scab on the outside of your body does, and block up the arteries, causing a heart attack or a stroke. The technical term used for "increases risk of heart disease" is "atherosclerotic," which, translated out of its non-English roots, means "athero" (artery) "sclerotic" (hardening).
One of the problems with the way that current medical science treats cholesterol is that it doesn't recognize the function of cholesterol. It just sees higher cholesterol readings and naively assumes that since high cholesterol and heart disease "seem" to go together, that cholesterol must be the cause of heart disease. The real cause of heart disease is what causes both the damage to the cell walls and the (ideally) temporary patches of cholesterol: not enough of the right raw materials being given to the body, and too much of the stuff that damages the cell walls being given to the body - to wit, too many carbs and not enough saturated fat or protein. It's like blaming firemen for a fire, or blaming a bandage for the wound, and saying "if we take away some firemen, the fire will die out," or "if we take the bandage off the wound, the wound will heal without help" (even though it's usually a wound that needs stitches in order to close up and heal). It's overly simplistic, it's a junior-high-school-level mistake, and it makes no sense.
LDL (Low-Density Lipoprotein): This has been blamed as the "bad" cholesterol because its job is to go around inside your body, bringing cholesterol from the liver to spots that need repair, and placing cholesterol "patches" on them. There are two types: Pattern A and Pattern B. Sometimes you'll have a mixed bag: Pattern A/B, some of each. When you have a VAP test, this is part of what gets reported. Pattern A is "large and fluffy" and non-atherosclerotic, like a cotton ball. Pattern B is "small and dense" and atherosclerotic, like a BB pellet. You want to have Pattern A. Pattern B is sometimes called "oxidized" cholesterol, and because it's so small and dense, it can penetrate the endothelium (the thin layer of cells that line the inside of the blood vessels), just like a BB pellet penetrates skin. So Pattern B LDL is worrisome, because it can also cause damage to the cell walls inside the arteries. LDL becomes Pattern B due to a number of reasons, but one of the main ones is insulin resistance. If you lower your insulin resistance (which low-carbers almost always manage to do), then your LDL Pattern B goes down, which is good.
Recommended level: <100.
HDL (High-Density Lipoprotein): This is considered the "good" cholesterol because its job is to go around inside your body and clean up used cholesterol. HDL goes around after the patched area has been repaired, and cleans up the old cholesterol patches, taking them back to the liver for processing and breakdown. You can see why HDL is high-density: it carries old cholesterols with it to the liver, so it's got lots of tightly-packed stuff on it, hence high-density. Low-density LDL is just the opposite - it's dropping cholesterol here and there, so it's no longer as dense.
Recommended level: >40 (women) and >50 (men). Some say >60 for both.
Triglycerides: The "cholesterols" made in the liver from the carbs you eat. They are technically not cholesterol at all, but fat. They're used by cells for energy. A third kind of cholesterol called VLDL (very low-density lipoprotein) carries triglycerides around in the body, delivering them to cells for energy. When VLDLs lose most of their triglycerides, they become smaller and denser, and now they're LDLs instead of VLDLs. Triglycerides can shoot the level of VLDL way, way up - the more triglycerides you have, the more VLDL is needed to move it around the body. So if you're eating lots of carbs, your triglycerides are going to be higher, and since VLDL becomes LDL when it deposits its triglycerides into the cells, your LDL will also be higher.
Recommended level: <150.
EQUATIONS USED FOR CHOLESTEROL MEASUREMENT
There are two equations used today for cholesterol measurement. The first one, and the one most commonly used, is called the Friedewald equation. It works fine as long as your triglycerides are at least 100 and below 400, but outside of that range things get wonky. And the main problem is, when your triglycerides are below 100, it overestimates LDL levels. Here it is:
LDL + HDL + [Trigs/5] = total
But because LDL are so small in comparison to the other particles, what they usually do is calculate your LDL. They measure your HDL, your Trigs and your Total - so the equation becomes:
Total - (HDL + [Trigs/5]) = LDL
(I don't know why the triglycerides are divided by 5. I haven't yet found that out.)
Because this equation miscalculates LDL if you drop below 100 trigs, I'd recommend that you always demand a VAP test, which is direct measurement of the LDL. People who restrict carbs usually have very low triglycerides, which means that we're going to have problems if the lab uses this equation to calculate our LDL levels. According to Dr. Mary Vernon, "These labs in which the LDL is calculated are not accurate if your triglycerides are below 100... The equation used to calculate these numbers makes assumptions which are not accurate when triglycerides are low." (from http://www.livinlavidalowcarb.blogsp...t-results.html).
To give an example of how it doesn't calculate LDL correctly, let's look at a hypothetical cholesterol result. Let's say that Joe the Low-Carber goes in for a lipid profile after six months on a low-carb diet. Here's his results (before they do the LDL calculation):
Total: 250 (ideal <200)
HDL: 70 (ideal >60)
LDL: ? (must be calculated) (ideal <100)
Trig: 40 (ideal <150)
This is a common profile for someone who's been low-carbing for a while. Now, when we put that into the Friedewald equation, here's what we get:
250 - (70 + (40/5)) = LDL
250 - (70 + 8) = LDL
250 - 78 = LDL
250 - 78 = 172
This may give Joe's doctor a heart attack if he doesn't know what he's looking at, as many doctors don't. To him, Joe's LDL and total cholesterol levels are way above the "ideal" numbers, and that must mean that Joe is headed for a heart attack or a stroke if he doesn't take a statin drug immediately and get those numbers down.
For many doctors, this level of analysis is as far as they go. The nuanced information about the two types of LDL is something they either don't have or aren't aware of. And recognizing that if Joe's HDL were lower, his total cholesterol would be lower too - they don't often see that, either.
However, there is a newer equation, called the Iranian Equation, that does a better job of calculating LDL when trigs are below 100. That equation is:
(Total/1.19) + (Trig/1.9) - (HDL/1.1) -38 = LDL
Let's plug Joe's numbers into this equation and see what we get.
(250/1.19) + (40/1.9) - (70/1.1) - 38 = LDL
210 + 21 - 64 - 38 = LDL
231 - 102 = 129
Look at that. It's a difference of almost 50 points in Joe's favor.
Part of the reason the Friedewald equation doesn't work so well is that Trig/5 issue. The Friedewald equation assumes that anything that isn't HDL or triglycerides is LDL. LDL is the "leftover" number. Well, when your trigs are 200/5, the number it will subtract from the overall total is 40, but when your trigs are 40/5, the number it will subtract from the overall total is 8. That's a big difference, because the smaller your trigs are, the more of the "leftover" number in the equation gets attributed to LDL, and that's really misleading.
CHOLESTEROL RATIOS, AND WHY THEY'RE MORE IMPORTANT THAN TOTAL CHOLESTEROL
There are three ratios that scientists have found which measure the impact of cholesterol in the body. These are the ratios between the total amount of cholesterol measured and the HDL (Total/HDL), between triglycerides and HDL (Trig/HDL), and between LDL and HDL (LDL/HDL). Each one is an indicator of something different. Many doctors don't pay attention to these ratios, and that's a shame, because they're a far better indicator of cardiovascular health than the total cholesterol number. You'll see why in a minute.
The ideal ratio of Total/HDL is 4.4 for women and 5 for men. Also, according to http://wwww.yourmedicaldetective.com/public/532.cfm and several other sites, the ratio of your trigs to your HDL will indicate whether your LDL is small and dense (bad - Pattern B) or large and fluffy (neutral - Pattern A). A larger number indicates smaller LDL particles and a smaller number indicates larger LDL particles. It's an inverse relationship.
The ideal ratio of Trig/HDL is 2 or below. 4 is high. 6 is "danger!!" This ratio indicates the level of risk for heart disease. Additionally, a low ratio of Trig/HDL is great because it's a semi-reliable indicator of lower free insulin levels. Lower free insulin is good. (However, this doesn't appear to work for those of African descent, so take that with a grain of salt.)
The ideal ratio of LDL to HDL is 4.3 or lower. 4.4 to 7.1 is average. 7.1 to 11 is moderate. 11 or more means you're at high risk for developing heart disease. The ratio of LDL to HDL is considered to be a marker of carotid plaque, or how much plaque you have built up in your arteries.
THE BOTTOM LINE
So if we look at Joe's results (using the Iranian equation), his ratios are:
Total/HDL: 250/70 or 3.57 (ideal = 5 or below)
Trig/HDL: 40/70 or 0.57 (ideal = 2 or below)
LDL/HDL: 129/70 or 1.84 (ideal = 4.3 or below)
Even if we use the Friedewald equation (with its misleading, overestimated LDL), Joe still does pretty well:
Total/HDL: 250/70 or 3.57 (ideal = 5 or below)
Trig/HDL: 40/70 or 0.57 (ideal = 2 or below)
LDL/HDL: 172/70 or 2.45 (ideal = 4.3 or below)
In all cases, Joe's ratios are well below the "ideal" - and being below the ideal is awesome. And look at that ratio of trigs to HDL! It's a great indicator of lower free insulin levels for Joe, and the ratio of Total/HDL also says that his LDL is probably (mostly) Pattern A.
Let's compare that to Pat, who's been on a low-fat, high-carb diet and overexercising, and whose doctor thinks he's doing really well because his cholesterol tests came back with these numbers:
LDL (calculated with the basic Friedewald equation): 131, or (calculated with the Iranian equation): 153
Pat's ratios are:
Total/HDL: 180/25 or 7.2 (ideal = 5 or below)
Trig/HDL: 120/25 or 4.8 (ideal = 2 or below)
LDL/HDL: 131/25 or 5.24 (Friedewald LDL); 153/25 or 6.12 (Iranian LDL) (ideal = 4.3 or below)
Compared to Joe, Pat's got one foot in a heart disease grave! His Total/HDL is way above the ideal, his trig/HDL is in the "nearly danger" zone, and his LDL/HDL says "Look, you're at average risk for heart disease and heading higher." But if the doctor only focuses on total cholesterol, Joe's the one who'll be put on a statin, while Pat might be advised to find ways to bring up that HDL number a little bit, if his doctor does anything other than congratulate him on his "good" cholesterol numbers. And way too many doctors focus only on total cholesterol.
Cholesterol levels: What numbers should you aim for? - MayoClinic.com for information on recommended cholesterol levels
Low-carbohydrate diets increase LDL: debunking the myth | The Blog of Michael R. Eades, M.D. for more information about cholesterol generally
http://www.atherotech.com/images/vap...sterolTest.pdf for more information about the specific results of a VAP test
High Ratio of Triglycerides to HDL-Cholesterol Predicts Extensive Coronary Disease for information about the ratio of triglycerides to HDL
Lipids Online: Educational Resources in Atherosclerosis has an article about the LDL/HDL ratio
What Does LDL And HDL Ratio Mean? has the numbers I cited for LDL/HDL ratio level meanings
http://www.atherotech.com/images/vap...VAPResults.pdf has information about insulin resistance raising Pattern B cholesterol.
Other information about cholesterol was found in Anthony Colpo's book "The Great Cholesterol Con" (which is entirely based on peer-reviewed research), the Protein Power books by Drs. Michael and Mary Dan Eades, Gary Taubes' "Good Calories, Bad Calories" (again, with a ton of peer-reviewed research), and Mark Sisson's "Primal Blueprint."
OMG. You rock so much. :notwrthy: Thank you!!
This should be a sticky!!! :notwrthy:
This is great info. Would you consider adding that there are health risks from too low a Total Cholesterol number too? I had understood that under 130 is unhealthy, since cholesterol is also used in brain functioning, but when I mentioned that someone posted a link where a fellow was saying that there are several problems with it being too low, starting at 180! I'm sure the reality has more to do with the various components as you have broken out, since lumping it all together is pretty unsophisticated. But at least a mention that there is a downside to the downside would probably be good too.
This is an excellent piece of work and a keeper (meaning, a hard copy). One thing I think is interesting is that in a study to determine exactly what a cholesterol blockage is comprised of, researchers found that there is a higher concentration of polyunsaturated fats and the sat fat concentration is actually very low. That is the main reason I have pretty much eliminated vegetable fat from my diet and increased sat fat.
I did some looking to see if I could find why only 20% of trigs are used in the calculations and all I could find after about 1/2 hour is that that is the amount of the concentration of VLDL in triglycerides and that is the number they are after. So, 20% of triglycerides = VLDL concentration.
I had to get some cardiology tests for clearance to have a total hip replacement last year. This was due to white coat syndrome at the doctor's office where I always had an elevated bp. My bp is never high at home -- rather, it's on the low side -- and I have compared my monitor to the doctor's and it's exactly the same reading, so I know my readings at home are accurate. But, I still had to go through the tests, which were fine.
The thing I'm leading to is that this cardiologist looked at my last cholesterol test and zoomed in on the LDL, which was 130 (Friedewald method, of course). I was ready for him, though. My HDL was 82, which he totally ignored until I pointed it out. I also whipped out a separate VAP breakdown I had had done in anticipation of his wanting to put me on statins and showed him my LDL was Pattern A, meaning that in the presence of low trigs (58, in my case), the LDL is always comprised mainly of large fluffy particles, which are protective to they heart. He was a bit taken aback that I was that knowledgeable of how the cholesterol numbers are arrived at and shut up about my LDL number after that. I got my clearance to have my hip replaced, and no hassle about my cholesterol test. (Eades did an article on his blog showing the studies that indicated that in the presence of low trigs, LDL particle size is always mostly the large, fluffy size.)
The main thing that is important about your excellent explanation is that it helps people become more in control of how their doctors will treat them. Doctors who only look at the LDL and then write a prescription for statins do so because of malpractice suit fears and also might be answerable to the practice's "standard of practice" directives. However, the patient does not have to comply with everything their doctors may think they should be doing in regards to their cholesterol numbers. It takes a very brave doctor these days to go against the current practice.
Thanks you for taking the time to write this up. Kudos.
Griffen, thank you for your post. It represents a huge amount of time and effort researching what's available. The examples utilized show clearly how many get started on statins today with little consideration for ratios and how HDL and higher Type A patterned LDL affects results considerably outside the realm of "quickie" medicine.
I do have one question though? I've thought regarding LDL/HDL ratios, the ideal is 3.O or lower vs. what you've mentioned at 4.3 or lower? A bit stricter in the end, or am I being picky?
Thanks for the consideration?
Very Clever Post thanks Griffen . It take note the ration it is very helpful and can be additional knowledge because got so curios with it ..
Excellent primer! I copied it into my personal LC/Paleo "handbook" so I have it for quick reference. I thought I noticed a discrepancy in you calculation for the Iranian Equation, and I was hoping you could confirm my math. You have listed HDL/1.1, but your example calculations bear out HDL/1.9 (the same denominator used for TC and Trigs). Please advise when you get a moment. I was going to reference your link to someone, and wanted to make sure it was accurate before doing so. Thank you for your time and attention.
Excellent reading!! I had been worried about my numbers from last year - actually had gotten with the low carb program again and then had to have my blood results done within a month of starting back. Not a good time but I had no choice. My total chol was 330 (had gone up), but my HDL was 111 and my LDL was 207 - trig were 61. My doctor (a new one) was dying to put me on a statin drug immediately - and was super concerned about the overall number as well as the LDL number. If I use the ratios provided I am well below in every category - 2.97 (5 or below), .55 (2 or below) and 1.86 (4.3 or below). Makes me feel better just to do these calculations!
There is a time limit to edit your post. Only an hour or so I've observed.
great info here! thanks for this.
WOW - lots of info here, thanks for sharing
I have been LC for 18 months. Reached my goal weight about 8 months ago.
My total cholesterol is 305, triglycerides 70, HDL 109 and LDL 189. The doctor retested my LDL and did a direct measurement and it came back at 195. She has been very supportive of my LC lifestyle but now we are both concerned about this LDL of 195. I am trying to get self-insured as well and have been denied because of these numbers. I am VERY depressed after all I read regarding bloodpanel numbers from everyone else I thought that these would be much lower. Any input.
Did you have a VAP test done? If your particles are large and fluffy then there isn't an issue.
Nice job. I appreciate the hours you put into this.
Griffen, would it be alright if I used your primer in a blog I'm putting together? I would of course 'credit' you. I don't know your full name though. Tried to see where I could message you on here but couldn't find it. Is there a way I could contact you? This was an excellent article!
This is an awesome post and incredibly helpful!! Thank you! :up:
X marks the spot! Thanks for sharing.
I know this is an old thread, but I just stumbled upon it, looking for cholesterol info.
Hit the jackpot, I did! :clap:
Thanks so much!
Just got cholesterol numbers today and based on the Iranian calculations, my cholesterol looks like this:
Total/HDL: 207/64 or 3.23 (ideal = 5 or below)
Trig/HDL: 74/64 or 1.16 (ideal = 2 or below)
LDL/HDL: 128/64 or 2.0 (ideal = 4.3 or below)
I've been a lazy low carber lately, but I'm gonna buckle down and try to get that Trig/HDL ratio lower.
Just wondering if the *ideals* are the same for men and women?
I noticed both examples in the OP were men (Joe and Pat).
My new cholesterol results--
Back in June here are my ratios:
total/hdl=4.33 (ideal= 5 or below)
Trig/hdl=3.69 (ideal = 2 or below)
ldl/hdl l=3.15 (ideal= 4.3 or below)
Here are my ratios after 6 months low carb::jumpjoy:
My doc still wants me to use Statins--any thoughts??
(I am also a Type 2 Diabetic and the June numbers were my baselines at diagnosis. My prior fasting glucose was 166 and now is 97 !)
Having blood work done today as part of my physical. Thanks for the refresher and will discuss with my Doctor during the interview.
Nice going! Show your doc the ratios. With those numbers, any thoughts? You bet - Just Say No.
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