A Tale of Two LDL's

Kurt, a 50-year old businessman with a heart scan score of 323, had a :

--Conventional (calculated) LDL of 128 mg/dl
--Real measured LDL 241 mg/dl.


Laurie, a 53-year old woman who underwent a coronary bypass operation last year (before I met her), had a:

--Conventional LDL of 142 mg/dl
--Real measured LDL was 85 mg/dl.


(By "real, measured" LDL, I'm referring to LDL particle number in units of nmol/L obtained through NMR lipoprotein testing and dividing by 10, or just dropping the last digit to convert the value to mg/dl. This technique was arrived at by comparing the population distributions of these two parameters, LDL particle number and calculated LDL. This is the gold standard in my view. Similar numbers can be obtained by measuring apoprotein B, direct LDL, or calculated non-HDL, with diminishing reliability from first to last.)

In other words, Kurt's conventional LDL underestimated real LDL by 88%. Laurie's conventional LDL overestimated real LDL by 40%.

Interestingly, Laurie's doctor had insisted she take Lipitor for a high LDL cholesterol. Her real LDL was, in fact, low to begin with and benefits of a statin drug would be little to none. (Remember, in our Track Your Plaque approach, multiple other treatments are included, such as omega-3 fatty acids from fish oil, vitamin D normalization, and wheat elimination, strategies that yield benefits that others expect to obtain with statins.) Laurie's real cause of her heart disease proved to have nothing to do with LDL cholesterol, but involved lipoprotein(a) and thyroid issues.

Kurt proved to have a severe preponderance of small LDL particles--the worst kind of LDL, while Laurie had none--a benign pattern.

Then how can anyone make sense of the conventional, calculated LDL cholesterol that is generally (95% of the time) provided? If accuracy can stretch to plus or minus 80% . . . you can't. Conventional LDL is a miserably inaccurate number. The problem is that obtaining a superior number requires a step or two more testing and insight, something most busy primary care doc's simply don't have in the midst of a day filled with arthritis, bronchitis, diarrhea, belly aches, and seborrhea.

Yet conventional--I call it "fictitious"--LDL serves as the basis for this $27 billion (annual revenues) industry selling statin drugs.

This is meant to be neither an argument in favor of nor against statin drugs. However, it is plain as day that any study designed to reduce LDL cholesterol will be hopelessly clouded by calculated LDL imprecision. A calculated LDL of, say, 143 mg/dl might really be 187 mg/dl, or it might be 74 mg/dl--you can't tell by looking just at LDL. Yet billions of dollars of research and billions of dollars of healthcare costs are based on the treatment of this number.

This reminds me of the mark-to-market accounting magic that helped topple Wall Street.

I don't think that the statin world is poised for such a huge downfall. But I do see this as a source of enormous dilution of the effects of statin drugs. People who barely stand to benefit get the drugs, while others who might truly benefit are treated inadequately. It provides fuel to the growing idea that reducing LDL cholesterol fails to truly provide benefit.

I am no lover of statin drugs nor drugs in general. But I am a fan of knowing the truth. Despite my bashing of the drug industry (and make no mistake: the drug industry is a cutthroat, profit-seeking, do-anything-to-increase-sales industry), I do believe that there is a role for statin drugs (though far smaller than $27 billion per year). But the usual method of selecting people for treatment is pure fiction. The ATP-III cholesterol treatment guidelines? An anemic attempt to apply structure to meaningless values.

You and I do not need to subscribe to this sort of non-quantitative nonsense.

Comments (10) -

  • renegadediabetic

    1/15/2009 3:22:00 PM |

    It's just part of big pharma's racket.  The public has been propgandized to fear cholesterol, statin prescriptions are based on an antiquated calculation, and the people who set cholesterol targets have financial ties to the drug companies.  This has created a big cash cow for big pharma.

    The only people to benefit from statins are middle aged men who have had a heart attack and even then, the benefit is small.  If statins were restricted to those who would truely benefit, it would mean a lot less $$$$ for big pharma.

  • Alan S David

    1/15/2009 3:31:00 PM |

    Today's news said millions more Americans over 60 could benefit from statins to combat the c-reative protein problem. How many more so called great things will statins do for us? Is this another terrific marketing ploy?

  • Zbig

    1/15/2009 8:52:00 PM |

    Dear Doc,
    all this NMR is black magic to me so far, besides I will wait for some advanced lipid measurements until I am at least 40.
    But I suspect that the LDL size can be guesstimated from e.g. triglicerides / HDL ratio - could you please supplement your post with the figures for both persons. I suspect there will be a difference there. TIA

  • Steve L.

    1/16/2009 3:36:00 AM |

    And if a million or so "Lauries" are given Lipitor for their 85 mg/dl  real LDL, I don't expect their all-cause mortality will IMPROVE .

  • Richard Nikoley

    1/17/2009 5:43:00 AM |

    Doc:

    My speculation is that this is merely an effect of the huge to-market costs pharmaceutical companies must endure, owing to FDA regulations.

    If people didn't have false-security -- as you have shown -- of FDA hurdles and implicit [expensively purchased] assurances, they might just take a bit more proactive, intelligent and informed approach to their own health, and maybe drug companies might go back to serving an informed consumer who no longer simply bows to an authority (the FDA) because they have the power to be who they are.

  • jean

    1/17/2009 5:57:00 AM |

    My neighbor is being lipitor by his internist because both his parents have alzheimers. At least that is what my neighbor told me.  I told him I'd never heard of that and he said he'd trust the doctor to know.

  • Robin

    11/2/2012 4:58:02 AM |

    Statins don't lessen the risk of heart disease by lowering cholesterol. They work by lowering inflammation which is not what  they were designed to do and was not expected. Happens a lot - drugs being created for one thing and being found to work for something else so are then subscribed for other conditions.

    Statins are powerful and dangerous drugs that block the production of cholesterol. Our bodies NEED cholesterol. By blocking its production, it also blocks Co Q10 and dolichols, and more. Side effects range from minor muscle pains to the complete destruction of muscles, kidney failure then death. Also transient global amnesia (TGA) which doesn't show up immediately and is dismissed when it does. They cause depression and violent behaviour. That's why people on statins have a higher morbidity from all other causes and not heart attacks.

    As renegadediabetic  above says, they show slight benefit for middle-aged men who have already had a heart attack. Oh yeah, tell us again why we need them?

  • Robin

    11/2/2012 5:00:24 AM |

    "morbidity"? Um, mortality.

  • Robin

    11/2/2012 5:01:59 AM |

    Darn. Message went to wrong place. Mortality is what I meant.

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Test your own thyroid

Test your own thyroid

134 people responded to the latest Heart Scan Blog poll:


When I ask my doctor to test my thyroid, he/she:

Accommodates me without question 45 (33%)

Questions why, but orders the tests 49 (36%)

Refuses because you seem "healthy" 20 (14%)

Refuses without explanation 4 (2%)

Ridicules your request 16 (11%)



That's better than I anticipated: 69% of physicians complied with this small request. After all, you're not asking for major surgery. You're just asking for a very basic test, as basic as a blood count or electrolytes. 36% of respondents said that their doctor asked why, but still complied; this is simply practicing good medicine--If there is a problem, your doctor would like to know about it.

However, the remainder--31%--were refused in one way or another. Incredibly, 11% were ridiculed.

Although this was not asked in the poll, I believe that it is a safe assumption that you asked with good reason: you're abnormally fatigued, you have been gaining weight for no apparent reason or can't lose weight despite substantial effort, or you feel cold at inappropriate times.

Let's say you're tired. Ever since last summer, you've suffered a gradual decline in energy.

So you ask your doctor to assess your thyroid. He refuses. "You're just fine! There's nothing wrong with you."

You disagree. In fact, you are quite convinced that there is something physically wrong. What do you do?

You could:

--Drink more coffee
--Exercise more in the hopes that it will snap you out of your lethargy
--Sleep more
--Take stimulants of various sorts

Or, you could get your thyroid assessed and settle the issue. But how can you get this done when your doctor won't accommodate you, even though you have perfectly fine health insurance and are simply interested in feeling better and preserving your health?

You could test your thyroid yourself. This is why we're making self-testing kits available. Test kits are available here.

This is yet another facet of the powerful revolution that is emerging: Self-directed health.

Comments (15) -

  • Tom

    9/7/2009 2:47:55 PM |

    In addition to home kits we might create drop in health shops where healthy people are given a quick set of automated tests/scans and the results made available to them online.

  • Lincolnb

    9/7/2009 3:26:27 PM |

    This is a great tool as many of my clients mention their thyroids and wonder if there was a way to monitor it.  When will this be available in the UK?

  • Anna

    9/7/2009 4:11:56 PM |

    I'm not sure getting tested is as big of an issue as getting a proper diagnosis and treatment.  I know lots of women who have their their thyroids tested (at least minimally with a TSH) but the results are not properly interpreted or treated.   Usually they end up with anti-depressant meds or are told to eat less and exercise more (or both).

    My thyroid was tested for about ten years (mostly with just the TSH and total T4, not the full complement of thyroid tests) for more than ten years because of two infertility investigations and later, symptoms of fatigue, etc.  I didn't ask for these tests; they were routine as part of a panel or the doctor specified them.  

    My HMO network doctors failed to see that my TSH was slowly slowly rising in that decade because they only looked at the recent result and not the trend (and there was a faster rate of increase after 7-8 years of testing).  They also missed that my results  were always in the "upper end" of the reference range (in late 2002 at least two national medical boards said the upper range was suspicious of development of mild hypothyroidism and the range should be adjusted downward).  Last year when I brought these AACE and NACL recommendations to the attention of the local HMO network lab supervisor, he was unaware of of the new range recommendations and promised to look into it.  I was pleased to note the ref range was somewhat adjusted down a few months later.

    So for me, the lab tests were less an issue; I had numerous TSH and total T4 tests while my symptoms progressively increased, but with little good.  

    The biggest difficulty was getting a correct diagnosis and the proper treatment, instead of attempts to suppress symptoms with other meds (I felt in my gut this was the wrong approach and I mostly resisted it).  

    The best treatment I've tried to date has been desiccated thyroid hormone (I'm now taking 1 grain of Nature-throid daily); to get to this it took a full three years with a continual search to find a local doctor who would use and correctly interpret the right lab tests *and* take into account my symptoms.   I hear similar stories from other hypothyroid people.

  • Dr. William Davis

    9/7/2009 8:43:28 PM |

    Yes, absolutely correct, Anna. Getting tested is just the first step.

    Once tested, understanding what they mean is the next step. But at least you know where you start. It's certainly better than not having any data at all.

    Next hurdle: Getting treatment when you need it. A topic for future discussion!

    Lincolb--It is available in the U.K. by ordering.

  • Daddy

    9/7/2009 10:02:24 PM |

    I guess that's how CA and NY can justify putting restrictions on their sale.  Sheesh!  Reminds me of when CA was on the brink of criminalizing home-schooling.

  • Hot Cover Girls Central

    9/8/2009 1:28:17 AM |

    That's great! I will recommend that to my sister and friend who were always complaining that they might have thyroid problem.
    See yah!

    Cathy Young
    http://fashionhotcelebs.blogspot.com/

  • pooklaroux

    9/8/2009 3:18:20 PM |

    I have also been able to get my doctors to do TSH tests, but since my labs ate at the upper end of normal, they also pooh pooh my suggestion  that treating the thyroid might positively impact other issues they care about, like my cholesterol levels and my asthma.  But they would rather give me statins (which I refuse to take) and advair (which I take only because I have to be able to function.)  I think they have it in my notes that I am hypochondriac and uncompliant. So much for being proactive for my own health care! Now they think I am a nutcase!

  • Laura in Arizona

    9/8/2009 3:38:35 PM |

    I agree with Anna. My doc has routinely tested TSH for years. This past check up I told her I wanted more info on the thryoid because of my lack of energy and other symptoms. She ordered T3 and T4 along with TSH but nothing else. My TSH came in at 4.5 on a scale going to 4.5 which is a full point jump since my last test. My T3 is almost abnormal on the low end. However since they are within the lab's normal range, she says I am fine. I am making an appointment with doc #2 in my search for someone that knows what they are doing. I sure hope it does not take the 3 years to find him/her it took Anna!

  • Anna

    9/8/2009 4:06:54 PM |

    Laura,

    I'd also like to add that much of that 3 years looking for better care was also spent educating myself (I must have read every book available on hypothyroidism to get a sense of all the perspectives), so developed a sense of when to seek out another doctor's care and when to settle for "good enough for now".  

    For me, the hardest part was early on -  summoning the inner strength to get over my reluctance to find new care and thyroid hormone options.  I was acutely aware that my tactic might be viewed as "doctor-shopping" or hypochondria.   Each step wasn't always very far forward, but it was still progress in some way and far more therapeutic than stagnating (it didn't always feel like progress at the time, though).

    Good luck in your quest for better care and more thorough assessment of your thyroid function.  Be sure to get tested for anti-thyroid antibodies.

  • Anonymous

    9/8/2009 4:39:45 PM |

    Regular Doctors are always a crap shoot. If you don't mind switching Doctors, it is better to seek out a Doctor that you know will probably be receptive to alternative therapies right from the get go. Life Extension has a list of "Innovative Doctors" here:

    http://www.lef.org/Health-Wellness/InnovativeDoctors/

    Another good source for Doctors that would probably be receptive to taking a patients thyroid concerns more seriously can be found at the A4M site:

    http://www.worldhealth.net/pages/directory

    Likewise, if lipid disorders are your concern, you can find a Lipidologist at the following site:

    http://www.learnyourlipids.com/resources.php

    Hope this helps.

    John M.

  • kris

    9/8/2009 8:13:44 PM |

    here is the site to find thyroid hormones friendly doctors.
    http://www.armourthyroid.com/con_phLocator.aspx

    Dr Davis, I don't think that you are on there? LOL

  • Dennis Mangan

    9/9/2009 4:10:23 PM |

    Another option when faced with uncooperative doctors: order thyroid from an overseas pharmacy.

  • Anonymous

    9/19/2009 5:22:14 PM |

    You forgot the option of saying you look Healthy so the test is unnecessary and Ridiculing you -- but finally ordering the tests, because you wouldn't leave the room till he patronizingly agreed (hey, whatever works)... and it turns out I have multi-nodule goiter!!

  • Anonymous

    1/2/2010 10:25:33 PM |

    Your blog keeps getting better and better! Your older articles are not as good as newer ones you have a lot more creativity and originality now keep it up!

  • buy jeans

    11/3/2010 2:31:15 PM |

    Although this was not asked in the poll, I believe that it is a safe assumption that you asked with good reason: you're abnormally fatigued, you have been gaining weight for no apparent reason or can't lose weight despite substantial effort, or you feel cold at inappropriate times.

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