What Do You Think You Know About LDL Cholesterol? (Pt 2 of 2)

Part One

The purpose of part one was to demonstrate the meaninglessness of calculated LDL cholesterol in relation to the equation used to calculated it, and how triglycerides, while being a very important risk factor for heart disease in its own right, have been steadily increasing on average and potentially giving a false sense of security as increases in triglycerides cause a mathematical (not necessarily biochemical) lowering of calculated LDL serum cholesterol.

I promised that in this second and final part, I will demolish the notion that you have any real idea of what your actual LDL cholesterol is, based on standard bloodwork involving calculated values. And I shall deliver.

Let me frame what I'm going to say this way: there are millions of people with low calculated LDL (say, <50-60) who are at infinitely more risk for atherosclerosis, rupture, and fatal heart attack than are many people with calculated LDLs in the high 200s and higher. If you eat significant amounts of carbohydrate, especially as processed food, have low HDL (<60), high triglycerides (>200), then it's essential to know exactly what your LDL really is. The standard blood panel is essentially worthless for this.

But I'm here to help. But first, let me show you what I mean by turning to Dr. William Davis, the cardiologist who originated Track Your Plaque and who blogs at The Heart Scan Blog. Dr. Davis, who used to practice by performing various coronary procedures such as installing stents, now spends his time detecting, preventing, and reversing heart disease.

He has lots of stories to tell. Let's get started.

Don't believe your LDL cholesterol!
"Harry's case is typical. For years, his doctor told him his LDL cholesterol of 123 mg was okay. But a heart scan score of 490 (90th percentile at age 52) made him question just where his coronary plaque came from.

"Lipoprotein analysis told a very different story: His LDL particle number was 2400 nmol, meaning his true LDL was more like 240 mg, nearly double the value of LDL obtained through his doctor. Harry had other sources of risk, too, but the LDL particle number was a clear stand-out. […]

"…When LDL's are actually meaured, you find that LDL is rarely accurate. In fact, in our experience, inaccuracy of 30-50% is the rule, sometimes 100%. The one telltale hint that calculated LDL is wrong is when HDL is <50 mg — that's nearly everybody. "

How accurate is LDL cholesterol?
"If there's so much attention paid to LDL, how accurate is it? 100%? 90%? 80%?

"Well, it varies widely. Occasionally, it's truly accurate, but most of the time it's miserably inaccurate. Every single day, I see people with LDL cholesterols that underestimates true (measured) LDL by 40%, 50%, and even over 100%. In other words, LDL cholesterol might be 120 mg/dl by the conventional method, but the genuine measured value might be 160 mg/dl, or even 240 mg/dl. It can be that far off — and it's not rare.

"The converse can occasionally be true, though rarely in my experience: that conventional LDL overestimates true LDL. I saw someone in the office today like this, with a conventional LDL of 142 mg/dl but a true measured LDL of 115 mg/dl. I may see one or two more people like this the rest of this year."

When LDL is more than meets the eye
"I pointed out to Jerry that, given the low HDL and high triglycerides, his calculated LDL of 112 was likely inaccurate. In fact, if measured, LDL was probably more like 140-180 mg/dl. LDL particles were also virtually guaranteed to be small, since low HDL and small LDL usually go hand-in-hand (though small LDL can still occur with a good HDL).

"So Jerry's LDL is really much higher than it appears. To prove it, Jerry will require an additional test, preferably one in which LDL is measured, such as LDL particle number (NMR), apoprotein B, or "direct" LDL.

"It's really quite simple. Jerry likely has a high number of LDL particles that are too small. This pattern confers a three- to six-fold increased risk for heart disease."

The many faces of LDL
"Ginnie came in for an opinion about her heart scan score of 393. At age 57, this put her in the 99th percentile, a high score.

"LDL cholesterol: 96 mg/dl – This value puts Ginnie's LDL in the most favorable 25% in the country.

"LDL particle number: 2140 nmol/l – This value is in the worst 25% of the country and is the equivalent of an LDL cholesterol of 214 mg/dl (take off the zero).

"In addition, over 90% of Ginnie's LDL particles fell into the small class."

Making Dr. Friedewald an honest man
"Colleen started with the usual discrepancy between conventional calculated LDL cholesterol of 121 mg/dl and the far more accurate LDL particle number (NMR) of 1927 nmol/L. […]

"In other words, by this simple manipulation, Colleen's Friedewald calculated LDL is off by 58%. This is very common, a phenomenon I witness several times every day.

"By LDL particle size, 75% of all Colleen's LDL particle were abnormally small (small LDL particle number 1440 nmol/L). This is a moderately severe small LDL tendency."

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%."


Had enough? Now do you see what I mean? I'll finish by quoting the heroic Dr. Davis once more from the last of those series of links.

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.

So, what's your LDL? Unless you've actually had it measured, you do not know. Neither does your doctor. Are you on medications or dietary prescriptions as a result of the fiction that you believe is your LDL? And how about particle size? Large & fluffy are actually good, while small and dense are very bad. You might have a low LDL, but with a high percentage of small and dense particles, and you could be at 6 or 10 times the risk as someone with an LDL of 250, but 99% large & fluffy. Don't be fooled by your doctor, HMO, hospital, or the drug companies.

And guess what will reduce your small and dense LDL every time? You guessed it: get off the grains, (particularly wheat), sugar, processed foods, processed vegetable oils; and take omega 3s and vitamin d to get your levels above 60.

How do you find out what your LDL actually is? Dr Davis says, "Our preferred method is NMR (LipoScience) LDL particle number, probably the most accurate of all. Second best: apoprotein B, direct measured LDL, and non-HDL."

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  1. Jeff on January 30, 2009 at 03:47

    I stumbled across this from another blog "Zeroing in on Health".


    Were you aware of this VAP test? It claims…

    "The VAP Test is a better cholesterol test. Like routine tests, the VAP Test measures total cholesterol, HDL (“good” cholesterol), LDL (“bad” cholesterol), and triglycerides. But the VAP Test also measures cholesterol subclasses that play important roles in the development of heart disease."

    They also claim it is comparably priced to the nonsense standard test.

  2. Jeff on January 30, 2009 at 03:28

    Another great post. Thanks for the guidance about the tests. I am really looking forward to getting my cholesterol measured, not calculated.

  3. Rob on January 30, 2009 at 05:56


    The VAP test is far better than the standard lipid test, but the NMR test is probably a better test as indicated by Dr. Davis.
    In most states you can order either test yourself using a company like directlabs or labsafe.

  4. Jeff on January 30, 2009 at 06:05


    Thanks for the info.


  5. keith norris on January 31, 2009 at 08:27

    Another informative post, Richard. Thanks so much for sharing your knowledge of this subject.

  6. yvonne on June 12, 2009 at 05:54


    Love your site very informational. I have high cholesterol and work very hard at controlling it. I exercise and try to eat a good diet low in fats. Your information will help me even more. I try to learn as much as I can about cholesterol. Thanks and keep up the good work!!!!!!!!!!!!!

  7. Richard Nikoley on June 15, 2009 at 13:47

    You might check out some of the links here:

  8. J P Hession on November 9, 2009 at 07:35

    Greetings. I have moderatly high LDL and moderately low HDL and normal Trigs. I was reading in a supposedly reputable natural medicine book that VLDL (Very Low Density Lipoproteins) are, in their estimation, a more important number in terms of heart risk than LDL. VLDL isn’t typically measured by my doctor, so I asked for the special test. The VLDL levels actually came back good.

    So my question is this…. are VLDL particles the same thing as these smaller, denser (and more dangerous) particles that this article is talking about?

    • Richard Nikoley on November 9, 2009 at 10:03


      No, VLDL is a different kind of lipoprotein, just like LDL and HDL. To determine particle count and size, you’ll need an MNR Lipoprofile or VAP test, either of which you’ll probably have to pay out of pocket for.

      You can find out how to get these tests by Googling.

  9. Peter Doherty on February 23, 2010 at 07:26

    I’ve recently discovered the same resources you’ve cited, specifically the heart scan blog and William Davis. It sounds as though you’ve spent a lot of time researching this topic so I was wondering what insight you might have about carbs. I’ve been reading a seperate book by Janet Brill called ‘Cholesterol Down’ which takes into account many of the same factors that Dr. Davis mentions like transforming harmful LDL but through foods like oats, almonds, flax and fiber. She cites studies that show how the beta-glucan found in whole grains can transform the small dense LDL particles into the more desireable light fluffy particles and the role beta-glucan plays in this. Like I mentioned, I’m new to reading Dr. Davis’s posts…do you happen to have more resources regarding why carbs and sugar are harmful in raising blood cholesterol?

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