What tests are MORE important than cholesterol?

In the conventional practice of early heart disease prevention, cholesterol testing takes center stage. Rarely does it go any further, aside from questions about family history and obvious sources of modifiable risk such as smoking and sedentary lifestyle.

So standard practice is to usually look at your LDL cholesterol, the value that is calculated, not measured, then--almost without fail--prescribe a statin drug. While there are indeed useful values in the standard cholesterol panel--HDL cholesterol and triglycerides--they are typically ignored or prompt no specific action.

But a genuine effort at heart disease prevention should go farther than an assessment of calculated LDL cholesterol, as there are many ways that humans develop coronary atherosclerosis. Among the tests to consider in order to craft a truly effect heart disease prevention program are:

--Lipoprotein testing--Rather than using the amount of cholesterol in the various fractions of blood as a crude surrogate for lipoproteins in the bloodstream, why not measure lipoproteins themselves? These techniques have been around for over 20 years, but are simply not part of standard practice.

Lipoprotein testing especially allows you to understand what proportion of LDL particles are the truly unhealthy small LDL particles (that are oxidation- and glycation-prone). It also identifies whether or not you have lipoprotein(a), the heritable factor that confers superior survival capacity in a wild environment ("The Perfect Carnivore"), but makes the holder of this genetic pattern the least tolerant to the modern diet dominated by grains and sugars, devoid of fat and organ meats.

--25-hydroxy vitamin D--The data documenting the health power of vitamin D restoration continue to grow, with benefits on blood sugar and insulin, blood pressure, bone density, protection from winter "blues" (seasonal affective disorder), decrease in falls and fractures, decrease in cancer, decrease in cardiovascular events. I aim to keep 25-hydroxy vitamin D at a level of 60 to 70 ng/ml. This generally requires 4000-8000 units per day in gelcap form, at least for the first 3 or so years, after which there is a decrease in need. Daily supplementation is better than weekly, monthly, or other less-frequent regimens. The D3 (cholecalciferol) form is superior to the non-human D2 (ergocalciferol) form.

--Hemoglobin A1c (HbA1c)--HbA1c represents glycated hemoglobin, i.e., hemoglobin molecules within red blood cells that are irreversibly modified by glucose, or blood sugar. It therefore provides an index of endogenous glycation of all proteins of the body: proteins in the lenses of the eyes that lead to cataracts; proteins in the cartilage of the knees and hips that lead to brittle cartilage and arthritis; proteins in kidney tissue leading to kidney dysfunction.

HbA1c provides an incredibly clear snapshot of health: It reflects the amount of glycation you have been exposed to over the past 90 or so days. We therefore aim for an ideal level: 5.0% or less, the amount of "ambient" glycation that occurs just with living life. We reject the notion that a HbA1c level of 6.0% is acceptable just because you don't "need" diabetes medication, the thinking that drives conventional medical practice.

--RBC Omega-3 Index--The average American consumes very little omega-3 fatty acids, EPA and DHA, such that a typical omega-3 RBC Index, i.e., the proportion of fatty acids in the red blood cell occupied by omega-3 fatty acids, is around 2-3%, a level associated with increased potential for sudden cardiac death (death!). Levels of 6% or greater are associated with reduced potential for sudden cardiac death; 10% or greater are associated with reduced other cardiovascular events.

Evidence therefore suggests that an RBC Omega-3 Index of 10% or greater is desirable, a level generally achieved by obtaining 3000-3600 mg EPA + DHA per day (more or less, depending on the form consumed, an issue for future discussion).

--Thyroid testing (TSH, free T3, free T4)--Even subtle degrees of thyroid dysfunction can double, triple, even quadruple cardiovascular risk. TSH values, for instance, within the previously presumed "normal" range, pose increased risk for cardiovascular death; a TSH level of 4.0 mIU, for instance, is associated with more than double the relative risk of a level of 1.0.

Sad fact: the endocrinology community, not keeping abreast of the concerning issues coming from the toxicological community regarding perchlorates, polyfluorooctanoic acid and other fluorinated hydrocarbons, polybrominated diphenyl ethers (PDBEs), and other thyroid-toxic compounds, tend to ignore these issues, while the public is increasingly exposed to the increased cardiovascular risk of even modest degrees of thyroid dysfunction. Don't commit the same crime of ignorance: Thyroid dysfunction in this age of endocrine disruption can be crucial to cardiovascular and overall health.

All in all, there are a number of common blood tests that are relevant--no, crucial--for achieving heart health. Last on the list: standard cholesterol testing.

Comments (8) -

  • stuart

    5/13/2013 12:56:55 AM |

    Great summary Dr. Davis.  You're the best!

  • Sol y Sombra

    5/13/2013 11:07:44 AM |

    Thank you for the useful information you provide, Dr. Davis. But I have a question: Does it really take 3-4 years to replenish vitamin D stores in the body?

  • Amy Crain

    5/15/2013 2:26:51 AM |

    Dr. Davis..
    My husband decided to give going gluten free a try after I read your book, and shared many things with him.  He has a number of issues.  HBP and taking meds.  Asthma, knee injuries with multiple surgeries over the years, and based on his lipid panel numbers, his dr. like you said, wanted to put him on a chol. reducer.  He went gf for a month, this past month, and just this week had his blood work done.  His LDL # went up from 146 to 164, and his HDL went from 45 to 47.   His Trig at least, dropped from 190 to 122,  So he now has in hand a scrip for atorvastatin (sp.?)..  Even though my husband would be considered a slender 48 year old, he has lost 6 pounds during this month of being wheat free.  I personally began a trek of losing weight a year ago by cutting wheat and sugar, and lost over 30 pounds, going from a size 12 to a 2.  I never had any blood work done, since I didn't have any health issues.  I was really hoping for better results for my husbands numbers so that we could provide a valid testimony to those unbelievers within our family.  I don't have your book memorized, but I've scanned through the blog posts and comments and found bits and pieces about numbers and how some people experience an increase like my husband Bill did.  Could you give me a bullet point laymen's version of the reason for the increase, if it's a concern, and if not, should he get the prescription filled like the dr. ordered so that he can then do the 3 month follow up to see if the med. worked for lowering the #'s?
    OR should I just go back and do some more reading like of the above post and reread the book?

  • Lowering cholesterol diet

    5/17/2013 3:10:25 PM |

    Hey there,

    thanks for the article. I would also like to know does Vitamin C plays any role in lowering cholesterol? I am thinking about writing a blog post about it so thank you in advance dr. Davis.

  • Geoffrey Levens, L.Ac.

    5/17/2013 8:23:48 PM |

    List makes great sense to me but one question arises: In light of recent research showing increased risks outside range of 20–36 ng/ml, do you anticipate any change in your recommendations as to Vitamin D blood level?
    J Clin Endocrinol Metab. Published online March 26, 2013. Abstract

    Thank you.

  • [...] between triglycerides and HDL, those improve with LCHF diet. You can start reading more here;  What tests are MORE important than cholesterol? | Track Your Plaque Blog  Lipid researcher, 98, reports on the causes of heart disease | News Bureau | University of [...]

  • Stephen in Jacksonville

    6/14/2013 9:20:30 PM |

    Tests are important, and I think that there are more people today who are interested in keeping track of their cholesterol levels. This is why I think we live in such a special time. We have access to more information than ever before, and now people can learn about high cholesterol risks without having to go to the doctor. In fact, I have found a number of sites that allow people to track their cholesterol levels online. Obviously, there are some people who may go overboard with access to this information, but I do think that there are plenty of benefits to be had.

Low expectations

Low expectations

The Framingham Risk Calculator is a standard method used by many physicians to predict risk for heart attack or death from heart disease over a 10-year period. Low-risk is defined as <10% risk of heart attack or cardiac death over 10 years; high-risk is defined as 20% or more over 10 years; intermediate-risk is in between.

Let's put it to the test:

Amy is a 53-year old businesswoman. She is 5 ft 4 inches, weighs 150 lbs. Her father had a heart attack in his early 50s followed by the usual list of hospital procedures including bypass surgery at age 60.

What is Amy's risk for heart attack or death from heart disease over the next 10 years? If we enter her data into the Framingham risk calculator, the following result is returned:

Information about your risk score:
Age: 53
Gender: female
Total Cholesterol: 198 mg/dL
HDL Cholesterol: 74 mg/dL
Smoker: No
Systolic Blood Pressure: 120 mm/Hg
On medication for HBP: No
Risk Score: 1% Means 1 of 100 people with this level of risk will have a heart attack in the next 10 years.

So, according to the Framingham calculation, Amy has <1% risk for heart attack or death from heart disease over the next 10 years. Most primary care physicians would, at most, prescribe a statin drug and talk about a reduction in saturated fat.

Thankfully, Amy didn't fall for that bit of conventional mis-information. She instead got a CT heart scan, principally because of her father's history. Her score: 117. At age 53, this put her into 90th percentile, in the worst 10% of scores for women in her age group (50-55). By heart scan criteria, her risk for heart attack is probably more like 4-5% per year, or approximately 40-50% over the next 10 years.

Let's do just a bit more math. If Amy hadn't known about her heart scan score and no preventive action was taken, the expected progression of her heart scan scores would likely be:

Start: 117
Year 1: 152
Year 2: 198
Year 3: 257
Year 4: 335
Year 5: 436
Year 6: 567
Year 7: 737
Year 8: 958
Year 9: 1245
Year 10: 1618

In fact, given Amy's starting heart scan score of 117, it is highly unlikely that she survives the next 10 years without heart attack or a fatal heart event. Yet the Framingham risk calculator puts Amy's risk at less than 1%. Could anything be more wrong?

The folly of the Framingham calculator was highlighted by a recent publication from the large Multi-Ethnic Study of Atherosclerosis (MESA), in which 3600 women (45-84 years), all of whom fell into the "low-risk" category by the Framingham calculator--just like Amy--were tracked over approximately 3 3/4 years. This study generated several observations:

1) 30% of the "low-risk" women had positive heart scan scores.
2) 5% of the "low-risk" women had scores of 300 or greater (very significant for a woman). 8.6% of these women experienced a cardiovascular event like heart attack or death over the period. Women with a heart scan score of 300 or greater had a 22-fold greater event risk compared to women with zero heart scan scores.
3) Women with heart scan scores of 1 to 299 had a cardiovascular event risk of approximately 5-fold greater risk over the period.

Across the U.S., 90% of women younger than 70 years old fall into the Framingham "low-risk" category. Yet this fiction is accepted as the prevailing standard, along with LDL and total cholesterol, for determination of risk in women and men.

In my view, using the Framingham risk calculator is a misguided, misleading path, one that will mis-classify a substantial number of women who could otherwise be spared from heart attack and catastrophe.

By the way, Amy is also the Track Your Plaque program record holder (by percentage drop), with a 63% drop in heart scan score over a 15 month period.

Comments (6) -

  • lungdoc

    12/14/2007 4:21:00 AM |

    I just recently signed up to TYP. My CT score today was 794!
    I am 50 year old diabetic. My LDLs had been <70 and HDLs>50 for years. Recently found vit D was only 25 and now 66 after supplementation. HGB AIC had been 6-7 for years. I have now started concentrating on bringing it down. My most recent HS CRP was 1.3. My small ldl-p was 542 and homocysteine is 15.4
    What's my next step?

  • Dr. Davis

    12/14/2007 12:22:00 PM |

    The next step is to enter your data into the Track Your Plaque program generator to generate basic comments.

    Also, I invite you to participate in the Track Your Plaque Forum for more detailed conversations.

    I assume fish oil is part of your program, an absolute requirement along with with your vitamin D.

    You may benefit spefically from efforts to reduce small LDL.

  • Anonymous

    12/14/2007 5:29:00 PM |

    And perhaps we should do a bit more math in order to prevent terrorizing the readership (something most would not even think about because they're too frightened by the hype). If you do the simple math, you will see that only 15 women out of 3600 had a cardiac event over 3+ years of follow up. That means 4 out of 1000 low Framingham Risk women will have an event. That sounds like a pretty low risk to me.

    3600 total low risk

    5% with calcium score of 300 or more=180 women

    8.6% of the 180 women had an event in 3.75 yrs.=15 women in almost 4 years

    15 women out of the entire 3600 low Framingham risk group=0.004 or 4 per 1000 women in 4 years or 1/1000 per year.

    So with low Framingham risk, the calcium  score increases your relative risk but the ABSOLUTE risk remains very low.

  • Dr. Davis

    12/15/2007 12:11:00 AM |

    Yes, you are right: the absolute risk was low in the four year period of observation.

    Actually, there were 18 coronary events (defined as "CHD" in the study) and 24 events if strokes were included ("CVD" events).

  • MAC

    12/15/2007 3:51:00 PM |

    Dr. Davis,
        Do you Have any opinion regarding myeloperoxidase (MPO)?


    "One fascinating aspect of this study is that this marker of inflammation precedes by nearly a decade the development of clinical coronary disease,"

  • Dr. Davis

    12/15/2007 5:05:00 PM |

    Hi, MAC--

    I think myeloperoxidase holds promise as a marker for risk. What we do about it remains an open question.

    We are planning a Track Your Plaque Special Report on unique markers of risk for 2008 that will include a discussion about myeloperoxidase.