What Is the Best Indicator Of Heart Disease Risk?

When was the last time your Dr. measured your LDL Particle Number (LDL-P)?

If you’re like me, you probably never had it tested. Your Doc probably only measures your Total Cholesterol, HDL and LDL.

But we should all know our LDL-P because it’s the #1 marker of heart disease risk according to Dr. Peter Attia, a brilliant Medical Doctor from Stanford who’s clinical obsession (his words) is lipidology.

In this article I’m going to “hopefully” extract the golden nuggets from this article titled “When Does Heart Disease Begin” that Peter published on his site June 27, 2016.

Here are my top take-aways from this article:

  • LDL-P is the most important marker (indicator) of heart disease
  • There are 4 reasons LDL-P is elevated. Diet impacts 1.5 of them (Peter’s comment)
  • The NMR test is the only test Peter uses to test lipoproteins including Lp(a)-P (vs. mass or cholesterol)
  • What is a normal level of LDL-P. Peter’s response: “50th percentile is about 1,200 nmol/L so probably around there”
  • Sugar probably contributes to heart disease by not only increasing LDL-P, but also amplifying the particle response (retention, oxidation, etc.)
  • It makes sense to see a lipidologist now if there is any family history of heart disease. (I know this is the 6th bullet point but it was too important to leave it out)

How Do We Check Our LDL-P

As I mentioned in one of the bullet points above, the “NMR” test is the only test Dr. Attia uses to test lipoproteins. So that’s the test I will be specifically asking for from my primary care Doc to test my LDL-P. If you don’t want to go through your primary care doc for this test, you can order it online as well for about $100 from places like Life Extension.

In case you’re wondering what a “lipoprotein” is you can find an explanation here but in short, it is a compound that contains both “lipid” and “protein” which is important because lipids (for purposes of this article we’re talking about the lipid cholesterol) are not water soluble. So in order for lipids to move through the blood stream to get where they are going, they need something to carry them – a protein. Hence lipoprotein – a protein carrying around a fatty molecule (cholesterol) through the blood stream so it can get to where it needs to go.

Why Is Total Cholesterol Used To Asess Heart Disease Risk

Like many things, it takes a long time for certain patterns to change and it has definitely taken a LONG time for most primary care physicians and the general public to realize that the standard “Total Cholesterol” blood test is NOT the most accurate predictor of heart disease risk.

The LDL-P test is a MUCH better predictor of heart disease risk and apparently this was discovered back in 1967.

Check out the below statement I pulled from LabCorp’s NMR Lipoprofile Test technical review document.

Since the National Heart Institute’s publication, “Fat Transport in Lipoproteins––An Integrated Approach to Mechanisms and Disorders” in the New England Journal of Medicine in 1967, it has been understood that atherosclerosis is caused by high concentrations of lipoprotein particles. The ability to quantify the number of particles had not been discovered, so cholesterol was adopted as a surrogate to estimate a patient’s lipid-related CHD risk; however, due to the variable size and cholesterol content of LDL particles, LDL-C alone may not be a reliable predictor of LDL-P and the risk for CHD.

So LDL-P was show tobea better predictor of heart disease back in 1967, however, they didn’t have the ability to test for the quantity of particles so the best measure to use at that time was total cholesterol until the mid to late 1990’s when the technology to check LDL-P was widely available.

So why are most primary care Docs still using “total cholesterol” to assess heart disease risk?

The answer to this question could be an entire article but I think it comes down to Docs just not being aware of the latest scientific research and “maybe” a little too much influence from the pharmaceutical industry which derives a significant portion of revenues from statin drugs to the tune of about $30 Billion per year.

So what can we do to lower our LDL-P?

As always, our health is impacted by diet, exercise, sleep and our mental/emotional state. So let’s keep a list of things we can do in each category to reduce our LDL-P.

What dietary changes can reduce LDL-P?

Reduce Blood Sugar

Peter mentioned that “diet” impacts 1.5 of the reasons why LDL-P would be elevated and he mentions in the above mentioned post that “sugar” increases LDL-P so lowering blood sugar would be 1 good way to lower LDL-P and therefore reduce risk of Heart Disease.

So sugar actually increases LDL-P but not only does it increase LDL-P but sugar also contributes to Heart Disease by amplifying the particle response (retention, oxidation).

If you’re confused what that means, here’s Dr. Attia’s explanation:

When LDL particle concentration is elevated, the lipoprotein penetrates into the subendothelial space. Once in the intimal layer, they are securely attached to intimal proteoglycan molecules. The first step in atherogenesis is surface phospholipid (PL) exposure to reactive oxygen species and oxidation of the PL. LDL particles that are not oxidized are not atherogenic.  To be clear, it’s not the “getting in there” part that is the problem (HDL particles do this all the time and so do LDL particles, for that matter), it’s the “getting stuck and oxidized in there” part, formally known as retention and oxidation.

So my own laymen’s explanation for this process is this –

  • The more LDL particles you have, the higher the chance they will get stuck your arteries. We want to reduce that.
  • However, just getting stuck is not really the problem. It’s getting stuck and then oxidized that’s the problem.
  • Dr. Attia thinks that sugar not only helps to increase the number LDL particles but also helps them to oxidize.

How Can Exercise Increase or Decrease LDL-P?

How Can Our Mental/Emotional State Increase or Decrease LDL-P?

How Can Sleep Increase or Decrease LDL-P

What Causes Elevated LDL-P?

Another way to look at how we can lower LDL-P is to look at the things that increase LDL-P. Fortunately Chris Kresser wrote an article on this already.

The below points are from Chris Kresser’s article on The 5 Primary Causes of Eleveated LDL Particle Number :

  1. Insulin Resistance & Metabolic Syndrome
  2. Poor Thyroid Function
  3. Infections (ex: bacterial infections like Chlamydia pneumoniae and H. pylori, which is the bacterium causes duodenal ulcers, and viral infections like herpes and cytomegalovirus and elevated lipids)
  4. Leaky Gut
  5. Genetics (Familial hypercholesterolemia causes high LDL-P but this condition is very rare and only affects about 1 in a million people)
  6. Environmental Toxins (mentioned in this Chris Kresser podcast episode)

So what can be done to address the above items?

  1. How to reverse Insulin Resistance & Metabolic Syndrome
  2. How to improve Thyroid Function
  3. How to diagnose and treat bacterial and viral infections
  4. How to heal Leaky Gut
  5. What to do if you have FH?

Other Reliable Markers Of Heart Disease

Chris Kresser just mentioned in this recent podcast episode that he believes LDL-P is a very good marker for Heart Disease risk but there is an even better marker – lipoprotein(a) or Lp(a).

The below snippet is directly from Chris Kresser’s podcast titled “The Functional Medicine Approach To High Cholesterol.” 

With lipoprotein(a), we know this is a different type of lipoprotein. I’m not going to go into a lot of detail here because it’s, I guess, pretty geeky, but it’s known as one of the most atherogenic lipoproteins that have been identified and it’s the single most significant lipid risk marker for heart disease. Of all of the things we could measure in terms of lipid markers, lipoprotein(a), or Lp(a), is the most predictive for future risk of heart disease.

Other Heart Disease Markers 

In addition to checking LDL Particle Number (LDL-P), HDL Particle Number (HDL-P) and lipoprotein(a) (Lpa) Chris Kresser recommends checking these markers as well:

  • Inflammatory Markers
    • C-reactive protein
    • fibrinogen
    • Lp-PLA2
    • oxidized LDL
  • Metabolic Markers
    • fasting insulin
    • fasting glucose
    • fasting leptin
    • post-meal blood sugar
    • hemoglobin A1c

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