LDL Cholesterol Nonsense

Cholesterolcon-1 Well, I was all prepped for a link and quick hits roundup, but first up was a bit about LDL cholesterol, as in the calculated one...as in the one most of you get when you have your blood work done. After a bt of poking around, the link roundup can wait.

But back up a bit, all the way to here, where I posted my first lipid panel about a year ago. At a calculated LDL of 104, I got a warning of "elevated" from the doc. Then, as some of you may recall from last February, those lipid numbers caused one naturopath to email me with some concerns. The solution? Well, in a nutshel, the solution would be to dramatically increase my triglycerides (fat in your blood) from a low of 47 to somewhere perhaps in the 150ish range, thus letting the Friedewald equation do its thing. How's that, you ask? Well, I laid it all out in this post: What Do You Think You Know About LDL Cholesterol? This post has been picked up in links a couple of times in the last few days. The first was by Tom Naughton, maker of Fat Head, a film I highly recommend as a way to introduce people to the fraud of conventional "wisdom" in nutrition.

In brief, the Friedewald equation for calculating LDL (direct measurement is expensive) is that you take total cholesterol, subtract HDL, and then subtract further your triglycerides divided by 5:

LDL (calculated) = Total Cholesterol - HDL - Triglycerides/5

A cursory glance at that equation should help explain what I meant above, where I wrote that the way to have low(er) LDL would be to dramatically increase my triglycerides. How does one do that? It's quite simple: eat lots of hearthealthywholegrains. You can even get the job done quicker by tossing in sugar, sodas, and any manner of processed food in abundance. I think the average Trig level in America is in the area of 200 and increasing. All else remaining equal, had my Trigs been 200 instead of 47, then I would have been able to subtract 40 (200/5) instead of 9.4 (47/5). Thus: 219 - 106 - 40 = 73. That would earn me a hand shake from my physician, all for replacing a good deal of the meat, eggs, veggies, and fruit I eat with bread, pasta, sweets and other crap. (Of course, if I were to do that, all things would not remain equal, because my HDL would also take a huge nosedive.)

Next, Sephan at Whole Health Source picked up that link and also came up with something of help for those of you out there who may not want to go to the expense of paying for your own NMR Lipoprofile or a Vertical Auto Profile (VAP). What has been known for a long time is the Friedewald becomes very unreliable at Trig levels over 400. It has also been suspected that it's equally unreliable for Trig levels below 100, a level of triglycerides achieved by almost al low-carb / paleo practitioners. Dr. Eades explains it in this post.

So, what Stephan came up with is an equation that purportedly does a better job at calculating your LDL when your Trigs are below 100.

LDL (calculated) = Total Cholesterol/1.19 + Triglycerides/1.9 - HDL/1.1 - 38

Now, if I run my same 219 total, 47 Trig, 106 HDL through this new equation, I get a calculated LDL of 75 and not the 104 that motivated my doctor to caution me (and to probably make a note that I'll soon be a candidate for a statin prescription).

Well, guess what else? Turns out I had another lipid panel done a while back and I convinced them to do a direct measure of LDL: 66. That's not too far off the 75 rendered by the equation above, and so, while an NMR, VAP, or direct measure is the best way to go, you can at least perhaps get some immediate peace of mind by doing your own calculation per the above formula.

Would be very interested to see your comments comparing your latest numbers, Friedewald verses the new equation, particularly if you have Trigs significantly below 100.

Finally, my friend Jimmy Moore recently interviewed Dr. Malcolm Kendrick, author of The Great Cholesterol Con. I recommend both.

Free The Animal is supported by readers like yourself shopping Amazon and CLICKING HERE to do so. Costs you nothing but sure helps out around here quite a lot. Always appreciated.

Comments

  1. Thanks for tying this all together, Richard. My LDL improves from 318 calculated to 253 with the new equation. I am still going to actually test my LDL next winter.

  2. jon winchester says:

    Richard – how much of your energy intake is from fat (vs carb)? have you run across any ideas on what's "optimal" from the perspective of high-intensity exercise? what about for a job that involves miles of medium-intensity work?

    I used to have trouble getting above 50-60% fat, but adding liberal coconut milk to my coffee has got me up to about a 75/15/15 ratio, and I'm curious about how to get higher while still enjoying a bit of variety, and whether it's worthwhile. I still have a feeling that going below 15% carb might leave me "running out of gas" with exercise, but I'm open to ideas.

  3. Richard,
    The formula isn't Stephen's. It came from a paper cited in Dr. Easdes' blog from the Archives of Iranian Medicine, May, 2008: The Impact of Low Serum Triglyceride on LDL-Cholesterol Estimation.

  4. A little different for me. My blood panel from the doctor was CHOL=160, HDL=44, LDL=99, TRIG=87, GLU=80

    This formula gives me 102 LDL if I did it correctly, almost the same as the 99 they calculated. I think my TRIGs were a little higher than yours, that may have been what threw it off.

    I'm sure I'm not eating enough good fat. Thanks.

  5. Hey. Just stopping by from BlogExplosion to say hi. Love your blog. I'll be bookmarking it for daily visits :)

  6. Ray,
    This formula may or may not be appplicable to you, even though your trigs are <100 mg/dL. The formula was developed from a study in which all the patients (230) had total cholesterol > 250 mg/dL.

  7. Eileen says:

    Here's mine from December (insurance screening):
    TC 214 TRI 89 HDL 40 LDL 156

    and last week:
    TC 239 TRI 66 HDL 41 LDL 185

    If I use Stephan's formula that leaves me with LDL 160, which is still in the "high" category. Of course my doctor was "very concerned" about the LDL rise and wants to retest in 2 months. No, he won't do the NMR – just the same old standard test.

    It's becoming increasingly clear that the same old standard test just doesn't cut it for large segments of the population.

  8. I got the LDL warning from my doctor, too (in 2006 my LDL was calc at 165, with the new formula I calc it at 150).

    TC 246, TG, 77, HDL 66, LDL-calc 156, TC/HDL ratio 3.7

    My 2007 results (from a health food store setup)
    TC 230, LDL-calc 146 (121 with the recalculation), HDL 72, TG 59, TC/HDL ratio 3.19.

    Paula's point about this new formula being more applicable to those with higher TC is a good one. Either way, the only thing that concerns me about cholesterol (assuming my TG stay low and my HDL doesn't drop) is not having enough cholesterol; because low is associated with other serious health conditions I'd rather not have, esp in women and the elderly.

    I calmly told my endo I've investigated my cholesterol numbers and that my LDL pattern was most likely the non-atherogenic large fluffy pattern due to my low carb paleo-ish diet. Furthermore, my HDL always hovers around 70 at least, and my TG have dropped from nearly 200 on my old high carb WOE to always under 80, creating a great ratio. If he was worried, I was happy to take a direct LDL measurement or a VAP/NMR to satisfy him. He dropped the subject.

    In the past few years I've learned to be a bit more assertive when it comes to doctors. Often they will run the detailed tests you want (VAP, NMR, 25 (OH)D D) for example, if you simply ask. So ask. If they won't, ask why. If it's a cost difference, offer to pay the difference. Sometimes that's enough to get them to write up the order and you don't have to pay anything. In other words, be a slightly squeaky wheel and get some grease. But don't be annoying. Even if you do have to pay something, it could be worth it to have the more detailed information (information that could get the doc off your back about a statin Rx). Often, doctors will order tests if for no other reason than to "humor" the patient. My sister's and her kids' doctors did this with the Vit D test (I suspect my endo does this, too) and were shocked when they turned out to be seriously Vit D deficient. I'll say it again – the squeaky wheel gets the grease. But make it a small squeak; the loudly squeaky wheel sometimes gets replaced, too. ;-)

    If any doctor wants to prescribe an Rx for statins or other serious meds for lipids, I would definitely insist first on the full lipoprotein testing with Lp(a) and Apo B (some blood lipid abnormalities won't respond to statins anyway so a statin wouldn't make a difference). The test isn't that expensive that it should make a difference to an insurance company that would pay out for an expensive lifelong statin Rx. Statins aren't candy; hold out for the detailed test before agreeing to even consider an Rx.

    And finally, another strategy to get the info you want if your doctor won't humor you or cooperate, is to go around your doctor and either go to another doctor who will order the tests you want or just get the test done yourself (of course, you may not be reimbursed for it if it's out of network, so it pays to shop around). In a few states patient self-testing is made extra difficult (NYS is one that comes to mind that thinks patients are dolts – NYS law requires a Dr order, and CA has some regulatory hoops to jump through, too, but in CA the hurdles are a bit easier). I've gone outside my HMO network to see other doctors several times and then I take the the lab slips to my HMO lab (my insurance covered them), but the results go into my HMO records, too, in addition to being faxed to my non-HMO doctor.

    Also, there are numerous labs that will work with patients to directly test at competitive rates – http://www.mymedlab.com is one (no affiliation, but some friends have used the lab with satisfaction). Dr. Davis's Heart Scan Blog offers some self-ordered tests at competitive rates through ZRT labs. And it's private, so you don't even have to share the info with your insurance company or doctor.

  9. Jon:

    I have no idea what my macro ratios are. I don't count anything, just eat real food and try to have days where I eat little to no carb. Of course, there's the fasting as well.

    Not sure what optimal would be. I like to do my workouts hungry, and in fact, the few times I've eaten within a few hours of exercise, I always feel lousy.

    I've heard about the coconut oil/milk in coffee. Got to give it a try.

  10. jon winchester says:

    interesting. since living alone for the summer I have been stricter about paleo w/IF, and started tracking on fitday. this is a self-experiment to see what happens to HDL and triglycerides. first thing I noticed was total calorie intake below 2500, which I attribute to insulin being under control so I'm just not hungry. (but after a fast I can easily hit 4000.)

    I do wonder what "optimal" means for blood lipids in relation to disease risk, and whether it's the same as optimal for athletic performance. I know that somebody with 100 triglycerides is healthier than 200, but is 20 better than 40? since almost everybody is far out of the healthy range, there is a gaping lack of research on this.

    I do a crossfit-type workout once in awhile, and those are ok while fasting. I also do fieldwork that involves carrying a moderate load for 10-15 miles. I have found that while fasting, my endurance is fine at a slow pace, but it's tough to go fast for hours while hungry. my theory is that once glycogen is depleted, fueling muscles from stored fat is slower than from snacking on carbs.

  11. There's a wealth of information here. I'm going to look further into that reference to mymedlab. I'm tired of arguing with doctors.

  12. what is normal range of LDL and HDL concentrations in rats?

  13. Calculating Cholesterol says:

    I have looked at many sites on this subject and not come

    across a site such as yours which tells everyone everything that they need to know. I have

    bookmarked your site. Can anyone else suggest any other related topics that I can look for

    to find out further information?

  14. This article and comments are great. ……I am a novice on this subject, but I have 2 doctors who are trying to force me onto Statins and I am not happy. My nutritionist claims that my Cholesterol is great, and these doctors simply do not understand. However, I am concerned that the TC has risen from 200 Sep 09 to 219 in Mar 10 and again to 230 in Aug 10. Would appreciate any credible advice I can get. I am 5’10” 200lbs, used to be very active athletically, worked out most of my life, but not much in the last year couple of years. My numbers are as follows: TC 230, LDL 154, HDL 68, TG 41, Glucose 90. I do take supplements to keep my blood clean. Thanks, Bill