Don't be a dipstick

If I want to know how much oil is in my car's engine, I check the dipstick.

The dipstick provides a gauge of the amount of oil in my engine. If the dipstick registers "full" because there an oil mark at one inch, I understand that there's more than one inch of oil in my engine. The dipstick provides an indirect gauge of the amount of oil in my engine.

That's what cholesterol was meant to provide: A gauge, a "dipstick," for the kind of lipoproteins (lipid-carrying proteins) in the bloodstream.

Lipoproteins are a collection of particles that are larger than a single cholesterol molecule but much smaller than a red blood cell. Lipoproteins consist of many components: various proteins, phospholipids, lots of triglycerides, as well as cholesterol. In the 1960s, methods to characterize lipoproteins were not widely available, so the cholesterol in lipoproteins were used as a "dipstick" to assess low-density lipoproteins ("LDL cholesterol") and high-density lipoproteins ("HDL cholesterol"). (Actually, even "LDL cholesterol" was not measured, but was derived from "total cholesterol," the quantity of cholesterol in all lipoprotein fractions.)

Some other component of lipoproteins could have been measured instead of cholesterol, such as apoprotein B, apoprotein C, or others, all meant to act as the "dipstick" for various lipoproteins.

Relying on cholesterol to characterize lipoproteins provides a misleading picture. Imagine watching cars go by at high speed while standing on the side of the highway. You want to count how many people--not cars, but people--go by in a given amount of time. Because you cannot make out the detail of each and every car whizzing by, you count the number of cars and assume that each car carries two people. Whether it's rush hour, Sunday morning, late evening, rainy, sunny, or snowing, you make the same assumption: two people per car.

That's what cholesterol does: It is assuming that each and every lipoprotein particle (car) carries the same amount of cholesterol (people).

But that may, obviously, not be true. A bus goes by carrying 25 people. Plenty of cars may carry just the driver. People carpooling may be in cars carrying 3 or 4 people. Assuming just 2 people per car can send your estimates way off course.

That is precisely what happens when your doctor tries to use conventional cholesterol values (total cholesterol, LDL cholesterol) to gauge the lipoproteins in your bloodstream. Measuring cholesterol can also provide the false impression that cholesterol is the cause of heart disease, even though it was originally meant to simply serve as a "dipstick."

What we need to do is to characterize lipoproteins themselves. We can distinguish them by size, number, density, charge, and the type and form of proteins contained within. It provides greater insight into the composition of lipoproteins in the blood. It provides greater insight into the causes underlying coronary atherosclerotic plaque. It can also tell us what dietary changes trigger different particle patterns and how to correct them.

Until you have a full lipoprotein analysis, you can never know for certain 1) if you will have heart disease in your future, or 2) how your heart disease was caused.

Unfortunately, the vast majority of doctors are perfectly content to just count cars going by and assume two people per car, i.e., confine assessment of your heart disease risk using cholesterol . . . just as drug industry marketing has instructed them.

It's not your job to educate your doctor. If he or she refuses to provide access to lipoprotein testing to better determine your heart disease risk, then consider going out on your own. Many of our Track Your Plaque program followers have obtained lipoprotein testing on their own through Direct Labs.

Comments (32) -

  • Anonymous

    10/3/2010 3:58:23 PM |

    Nice analogy.

    Any idea where we can go for equivalent tests in the UK?

    Nina

  • Kurt

    10/3/2010 6:02:39 PM |

    Thanks for the 10% off at Swanson's (your ad)!

    I took the VAP test and my results were excellent. It was very reassuring.

  • Jonathan

    10/3/2010 10:55:51 PM |

    That dipstick showing a lot or a little oil also doesn't tell you about the sand that chewed up your cylinders.

  • Kathryn

    10/4/2010 1:09:03 AM |

    I've used Direct Labs & others to order my own tests directly.  It works very well.

    Currently i'm working with a doc who seems willing to work with me.  However the cholesterol panel he ordered recently did not include the part that actually measures LDL (as opposed to "calculate" it).  He is not opposed to running that test, but tells me he doesn't know if Medicare (my insurance) will cover it.

    What is the name of the test i would need to run that actually measures LDL?

  • skepticaldoc

    10/4/2010 1:29:11 AM |

    Great analogy!!!

  • Anonymous

    10/4/2010 3:33:01 PM |

    Very nice post, but interesting irony.  The doctor implies it is drug companies responsible for the lack of useful testing, and then someone from the UK wants to know where he/she can go for equivalent tests.  Surely not to your primary care physician!  Many Canadians will also want to know because govts are much tighter than insurance companies, since the latter must compete for business.  Lesson: govt health care monopolies spend less because they do less (e.g., testing) and do it slower.

  • Anonymous

    10/4/2010 4:15:09 PM |

    Long time reader, just wanted to post some info that comes within the industry:
    "The nmr is not an accurate test. I cannot tell you how many physicians have lost confidence in the results due to the high variance in particle number. One physician ordered 2 nmrs on the same patient by accident and the difference in LDL-p was over 800. Pathetic. Stick to apoB." Sorry that this complicates things.

  • CarbSane

    10/4/2010 9:21:17 PM |

    Unfortunately, some states (I think at this point only NY & Cali) do not allow patient initiated tests outside the "system".  

    With Obamacare, I fear more states will follow this, as gawd forbid anyone tries to get a handle on their own health markers, at their own expense and/or try to do anything (like changes in diet) to improve them.

  • Anonymous

    10/5/2010 3:14:15 AM |

    "With Obamacare, I fear more states will follow this, as gawd forbid anyone tries to get a handle on their own health markers, at their own expense and/or try to do anything (like changes in diet) to improve them."

    Please tell me what, specifically, in "Obamacare" would prohibit the sort of tests you're interested in?  I'm pretty sure you can't provide an answer.  Your claim (and fears) is not grounded in fact, but rests on the ideologically motivated obfuscations of others who have a vested interest in resisting meaningful healthcare reform.  I'm sure we all had it much better the day before "Obamacare" went into effect.

  • Anonymous

    10/5/2010 6:06:32 AM |

    Please post the components of the complete lipoprotein panel that you suggest.  Thank you

  • CarbSane

    10/5/2010 12:54:06 PM |

    Obamacare is all about government controlling the type of medical care we receive.  It is dictating the type of insurance we are required to carry, and it is all about getting our information into the "system".  

    If I'm willing to pay for any diagnostic test, why can't I do this without a note from my doctor?  You can't in NY and California.  I see this spreading to other states rather than being repealed.  Too much freedom.

  • Anonymous

    10/6/2010 9:34:11 PM |

    I too would like to avail of an NMR cholesterol test in Europe, so would appreciate any information on where it is available.

    I also read a review recently (but can't find it now) of the NMR and VAP tests, dated 2009. The author concluded that there was little consistency between them and suggested that perhaps the technologies were not yet mature. Any thoughts on that?

  • Anonymous

    10/7/2010 4:53:04 AM |

    I think this kind of test is only available in USA

  • Prostatic Adenocarcinoma

    10/7/2010 12:37:34 PM |

    I am quite interesting in this topic hope you will elaborate more on it in future posts.

  • Anonymous

    10/8/2010 5:10:07 AM |

    Hi Dr. Davis,

    Would be useful to get your thoughts if there is any truth to the claims that NMR and VAP are too imprecise to be reliable...

    Thanks,
    David

  • health

    10/8/2010 10:23:38 AM |

    If you're looking to buy best protein powder (or related protein products) but not sure what to look for, this free expert-nutrition tutorial can help.

  • grandpa

    10/8/2010 11:57:08 AM |

    I went to direct labs but not sure which ones are the ones to order. Any suggestions? Thanks in advance.

  • Anonymous

    10/11/2010 6:23:39 PM |

    Which test do we order at Direct Labs?

    THANKS

  • TedHutchinson

    10/11/2010 7:11:02 PM |

    Sorry I forgot to mention Direct labs also do the VAP Cholesterol Test

  • Anonymous

    10/12/2010 3:55:25 PM |

    @ Ted,

    Is it possible to have a blood sample drawn in the UK and sent to these labs for analysis?

    Keep up the good work on your own blog!

  • TedHutchinson

    10/12/2010 5:34:16 PM |

    Is it possible to have a blood sample drawn in the UK and sent to these labs for analysis?
    Sorry the answer's NO.
    Pity as I'd really like a VAP test done.

    But while I was talking to them I asked if there was any time limit on this months Vitamin D special offer $39 testing.
    They said tests ordered this month at $39 would be valid for 6 months.
    So US readers could buy/use one now 2nd week in October, buy a second next week for use in 3 months time (January) and a third before the end of October for use before the end of April before six months is up.
    That way they would have a pretty good idea of just how much D3/DAILY their individual body requires to stay above 60ng/ml through the winter.
    Altered post to make avoid potential misunderstanding

  • Anonymous

    10/12/2010 8:22:21 PM |

    @ Ted,

    Thanks for that.

    Do you know of any advanced lipoprotein available in Europe? Any advance on the standard TC/TG/HDL/LDL would be great.

    Seems a bit mad to have to go to the US to get a good cholesterol test!

  • Anonymous

    10/12/2010 8:24:07 PM |

    That should read 'any advanced lipoprotein testing...'

  • Dr. William Davis

    10/12/2010 11:00:02 PM |

    Gentlemen--

    Sorry, but I know of no way in the U.K. to obtain lipoprotein testing.

    Should you discover some means please come back and let us know.

    You might consider contacting one of the lipoprotein testing companies, such as Liposcience, Atherotech, or Berkeley HeartLab. (All have websites with contact info.)

  • Dr. William Davis

    10/14/2010 2:25:13 PM |

    In response to the several questions re: what lipoproteins to obtain.

    We start with a lipoprotein analysis (LDL, HDL, and VLDL quantification and particle size). Some forms of lipoprotein testing require that you specify lipoprotein (a), if you are interested in obtaining that measure.

    There are measures, of course, outside of lipoproteins that are also important, e.g., thyroid measures, 25-hydroxy vitamin D, blood glucose/HbA1c, etc., all relevant to heart disease prevention.

  • Anonymous

    10/15/2010 10:08:32 PM |

    I too, like Ted, would like to have an advanced lipoprotien test,as I think my LDL may be a shade high for comfort. My numbers are:

    TC:  6.7 or 259
    TG:  1.05 or 41
    HDL: 1.23 or 48
    LDL: 4.99 or 193
    TSH: 3.77
    Glucose: 5.2


    The only dietary changes I have made in the last year were to take 4 Minami MorEPA softgels most mornings and markedly reduce but not eliminate carbs from my diet.

    Dr Davis, I have contacted Liposcience and NMR. Liposcience have no facility to test outside of the USA. NMR have not replied. I will retry NMR and also contact the other company you mentioned.

    I will post any information I receive, here.

  • Anonymous

    10/15/2010 10:14:44 PM |

    Correction:
    Atherotech responded, no reply from Liposcience.

  • Anonymous

    10/15/2010 11:56:08 PM |

    Correction No 2:

    TG:  1.05 or 93

  • Anonymous

    10/16/2010 12:19:36 AM |

    http://circ.ahajournals.org/cgi/content/full/119/17/2396

  • Anonymous

    10/19/2010 10:26:57 PM |

    Reply from Liposcience:

    Thank you for your inquiry and interest in the NMR LipoProfile test.  currently, the NMR LipoProfile test is only available in the US and performed in our laboratory in Raleigh, NC. Early next year, a laboratory platform will be launched to allow for expanded offering of the test outside the US.

    Thank you,

    LipoScience, Inc.

    PS  The link I posted in the last entry from AHA Journals, is the paper I found on the inaccuracies of advanced lipoprotein testing. That said, I'd still do the NMR test, if I could.

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Small LDL: Simple vs. complex carbohydrates

Small LDL: Simple vs. complex carbohydrates

Joseph is a whip-smart corporate attorney, but one who accepts advice at his own pace. He likes to explore and consider each step of the advice I give him.

Starting (NMR) lipoprotein panel on no treatment or diet change:

LDL particle number 2620 nmol/L (which I would equate to 262 mg/dl LDL cholesterol)
Small LDL 2331 nmol/L--representing 89% of LDL particle number, a severe dominance of small LDL

I advised him to eliminate wheat, cornstarch, and sugars, while limiting other carbohydrate sources, as well. Joseph didn't like this idea very much, concerned that it would be impractical, given his busy schedule. He also did a lot of reading of the sort that suggested that replacing white flour with whole grains provided health advantages. So that's what he did: Replaced all sugar and refined flour products with whole grains, but did not restrict his intake of grains.

Next lipoprotein panel with whole grains replacing white refined flour:

LDL particle number 2451 nmol/L
Small LDL 1998 nmol/L--representing 81.5% of LDL particle number.

In other words, replacing white flour products with whole grain products reduced small LDL by 14%--a modest improvement, but hardly great.

I explained to Joseph that any grain, complex, refined, or simple--will, just like other sugars and carbohydrates, still provoke small LDL. Given the severity of his patterns, I suggested trying again, this time with full elimination of grains.

Next lipoprotein panel with elimination of whole grains:

LDL particle number 1320 nmol/L
Small LDL 646 nmol/L
--48.9% of total LDL particle number, but a much lower absolute number, a reduction of 67.6%.

This is typical of the LDL responses I see with elimination of wheat products on the background of an overall carbohydrate restriction: Big drops in precisely measured LDL as LDL particle number (i.e., an actual count of LDL particles, not LDL cholesterol) and big drops in the number of small LDL particles.

You might say that wheat elimination and limitation of carbohydrate intake can yield statin-like values . . . without the statin.

Comments (17) -

  • medeldist

    5/4/2010 8:26:52 AM |

    Interesting. I'm looking through my screening results (I'm in Europe) and there is no mention of LDL, but I have two other values, P-Apo A1 (1.77 g/L) and P-Apo B (1.09 g/L). Is there a relation between these and LDL/HDL?

  • tom

    5/4/2010 1:02:12 PM |

    It is good to have positive feedback via blood testing to show changes one is making to their body. I wonder what is a good interval between tests to show cholesterol changes?

    On a similar note, I have been eating low carb for 4 months using my blood meter to reduce both blood sugars and insulin resistance for pre-diabetes. I am still thinking about your slo-niacin suggestions and how the bad increase in blood sugar and insulin resistance vs the good cholesterol effects would affect me. I am waiting to get results from my first NMR lipoprofile to make a decision.

  • Ned Kock

    5/4/2010 3:49:58 PM |

    Indeed, restricting carbohydrates is more similar to taking statins than many people think. With the advantage that it does not have the side effects of statins, and is not costly at all.

    Many people do not know that carbohydrates stimulate the production of VLDL, suppressing the production of free fatty acids and ketones. Our liver then pumps out small VLDL particles at a high rate, and these end up as small-dense LDL particles. The potentially atherogenic type, in the presence of other factors (e.g., chronic inflammation).

    Low carbohydrate dieting stimulates the production and release of free fatty acids and ketones, suppressing the production of VLDL. Our liver then pumps fewer VLDL particles into the bloodstream (since FFAs and ketones are already doing a good job at feeding muscle and brain tissue), and when it does it lets out big VLDL particles, which end up as large-fluffy LDL particles prior to re-absorption by the liver.

    If anyone wants to see what these particles look like, the figure in the post below may be useful:

    http://healthcorrelator.blogspot.com/2010/02/large-ldl-and-small-hdl-particles-best.html

    Ketones are not shown because they are water soluble:

    http://healthcorrelator.blogspot.com/2010/04/ketones-and-ketosis-physiological-and.html

  • Anonymous

    5/4/2010 4:01:31 PM |

    Do you have any comments on oatmeal? I've noticed that for me personally, it doesn't significantly spike my blood sugar, and I've heard a lot about how oatmeal can improve cholesterol -- but of course this is often just focused on total cholesterol or general LDL amount.

  • Anonymous

    5/4/2010 5:05:47 PM |

    Hi Dr. Davis
    I'm really hoping to hear your opinion on this study:
    http://www.pnas.org/content/early/2009/08/21/0907995106.abstract?sid=

  • Dr. William Davis

    5/5/2010 1:38:40 AM |

    Hear, hear, Ned!

    I agree: Carbohydrate restriction is the unsung hero of VLDL and LDL reduction, though actual measurements are required to appreciate this effect.

  • Dr. William Davis

    5/5/2010 1:40:35 AM |

    Oatmeal anonymous--

    It's all about individualizing your food choices.

    Checking postprandial blood sugars is an excellent way to know if these issues apply to you or not, or to what degree.

  • Jeff

    5/5/2010 11:56:35 AM |

    What are your thoughts on Amlamax for the reduction of LDL?

  • Lucy

    5/5/2010 3:41:11 PM |

    OK, so here's my question... I am young (late twenties), thin (BMI: <20.2), and active (run, bike).  However, I still have almost all small, dense LDL.   I'm an ApoE 3/4, which I understand means I need to limit the amount of fat in my diet.  However, if grains also contribute to small LDL, what am I supposed to eat?   I don't eat much wheat as it is (my husband is celiac), but I do enjoy oats, rice, and the occassional piece of bread when we eat out, etc.  Would cutting all grains from my diet and living on only vegetables, some fruits, and lean meats be acceptable? Sounds like a boring and sad diet...

  • pjnoir

    5/5/2010 9:58:04 PM |

    Oatmeal reducing Cholestral is a joke. If I eat Oatmeal for breakfast( even a 1/2 cup) my BG numbers stay HIGH all day. Oatmeal is not a food I have on my breakfast table ever.

  • Anonymous

    5/9/2010 3:08:36 PM |

    Over what time period were these
    panels taken or in other words, how many weeks or months in-between test?
    Love the blog!
    CB

  • Conrad

    5/11/2010 2:28:43 PM |

    Who knows where to get an (NMR) lipoprotein panel in Toronto/Mississauga?

  • holym

    5/12/2010 6:36:06 PM |

    You say, "LDL particle number 2620 nmol/L (which I would equate to 262 mg/dl LDL cholesterol)"

    Why would you equate 2620 nmol/L to 262 mg/dl? The conversion factor given at http://jama.ama-assn.org/content/vol295/issue1/images/data/103/DC6/JAMA_auinst_si.dtl is roughly 1mmol/l = 39mg/dl.

  • Dr. William Davis

    5/12/2010 10:21:43 PM |

    Holym--

    I believe you are confusing Friedewald calculated LDL in nmol/L and LDL particle number--two entirely different things.

    My simple conversion is meant to yield a "Friedewald-like" LDL cholesterol from LDL particle number.

  • Dolly.G

    5/14/2010 3:34:18 AM |

    I do agree!!

  • Anonymous

    5/22/2010 11:06:37 PM |

    Where can I find the peer reviewed research upon which you base your advice? Thanks

  • David M Gordon

    6/15/2010 1:18:55 AM |

    My lab results are in, and they are,  on balance, not much improved. I think.

    The changes I effected since my prior panel panel 3 months ago:
    1) Lost 20 lbs
    2) Ingest 6,000mg of fish oil for a total of 1200mg (total) of DHA and EPA/day
    3) Ingest 500mg of Slo-Niacin/day (with 125oz of water/day)
    4) Ingest 6,000mg of Vitamin D/day (Changed to the proper Vitamin D soy capsule from the powdered tablet)
    5) Eat a large handful of almonds/day
    6) Exercise hard (weight training and cardio intervals for a minimum of 90 minutes/day).

    The (worsened) numbers:
    1) Total Cholesterol: 269 (from 267)
    2) LDL Cholesterol: 186 (from 175)

    The (improved) numbers:
    3) Triglycerides: 201 (from 280)
    4) HDL Cholesterol: 43 (from 36)

    Unfair to ask you, I know, but I am frustrated. What do I do wrong? What can I do more? I am VERY reluctant to take a statin, as I have tried many, all with terrible side-effects. And, fwiw, I started today on my wheat-free diet.

    Thank you for your guidance,
    David

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