Alternative to NMR Scan? ApoB

I am blatantly recopying this without permission because this information was burried in the comments thread to this post on cholesterol by Perer Attia. The info is very useful to everyone living outside of the US interested in getting a measurement of their LDL-P.


The NMR scans you are so keen on do not seem to be available in the UK (so I suspect also not in many other places outside the USA): this being the case can you give advice as to how we can make the best use we can of the standard lipid panel, e.g. say a bit more about the usefulness of ratios like that of triglycerides to HDL (giving – with all necessary caveats – broad information about good, bad and middling ratios). – Roger Butler, May 17, 2012


You’re right. Outside of the US the best thing to is have apoB directly measured, as it’s done by a number of labs. This is the best proxy for LDL-P and is more available. – Peter Attia

Note that you will see the test referred to as both “Apo B” and “ApoB” in different places.

So what is ApoB?

From John Hopkins Health Alerts:

The problem with using LDL cholesterol levels to determine heart attack risk is that the test measures only the amount of cholesterol in the LDL cholesterol particles, not the number or size of these particles. Apo B measurements, on the other hand, provide information on the number of LDL cholesterol particles.

Apo B is a protein found on the surface of LDL cholesterol particles. Because each LDL particle contains only one molecule of apo B, the total amount of apo B in the blood is equivalent to the number of LDL cholesterol particles. The size of these particles can sometimes be inferred from the total amount of apo B and the LDL cholesterol level.

For example, people with a higher apo B value than LDL cholesterol value tend to have smaller, denser LDL cholesterol particles. Studies have shown that small, dense LDL cholesterol particles are more strongly associated with heart attack risk than large, “fluffy” LDL cholesterol particles.

Research published in The Lancet reviewed five studies of LDL cholesterol and apo B in nearly 200,000 people. The researchers concluded that high levels of apo B were more strongly linked with future heart attack risk than LDL cholesterol levels.

Apo B is measured with a simple blood test. Proponents of apo B argue that the test is accurate, inexpensive, and does not require fasting, as LDL cholesterol testing usually does. However, the American Heart Association has determined that the evidence to date is not strong enough to recommend that apo B testing become standard procedure.

Even apo B researchers recognize that LDL cholesterol is an important predictor of heart attack risk and suggest that apo B is most helpful for predicting risk in people with normal or low LDL levels but high triglyceride levels. Overall, if one’s LDL cholesterol value is high, an apo B measurement is not necessary.


How Gluten Free impaired my cholesterol numbers…

I recently did a lipid test and in one year, my ratio of Triglycerides/HDL has increased from 0.8 to 1.2.

The absolute number is not bad but the trend is poor.

I know this is directly a result of having more carbs in my diet. I went gluten free and in the process added more carbs than before. The carbs are in the form of rice, potatoes and gluten-free wheat subsitutes.

I was working a theory that possibly my body can tolerate carbs and it only has a problem with tolerating wheat.


Eliminating wheat has certainly improved many digestive problems I experienced. I now have less cramping (IBS) and reflux.

But my weight has crept up and my triglycerides jumped. This is quite upsetting. I am going to stay off wheat but, for me, it is back to a stricter low-carb regime.

26 May’11 24 May’12
HDL 68 67
LDL 156 147
Triglycerides 54 82
Total 234 230
Total Chol / HDL 3.44 3.43
Triglycerides / HDL 0.79 1.22
Age 46 47

High HDL, Low Triglycerides & Particle Count

The most popular post on this (largely dormant) blog is High Cholesterol – Low Triglycerides. A lot of people are trying to make sense out of their lipid scores and are looking for help.

The new gospel is that the most important thing to understand is what your cholesterol particle count is. If you know that, the rest of your lipid profile is almost irrelevant. Problem is, finding that out your particle count requires expensive NMR testing.

It is possible, however, to use the Triglyceride/HDL ratio as a rough estimate of particle count. If the ratio is >3 you are at high risk for lipid problems and should go for more testing. If the ratio is low, you can probably breath a sigh of relief (always with the caveat: there are some exceptions).

In this video, the clinician touches on this topic using a case study:

Yes, that is Gary Taubes sitting on the right.

Another great video on the subject can be found here: “Advanced Lipid Testing” Comes Alive . Registration is free.

The latter video does explain that, in rare cases, the high HDL, low triglyceride profile does not mean you are out of the woods. So the “poor man’s estimate” of risk is not foolproof. The only real way to know your risk is to find out your cholesterol particle count through an NMR profile.

Want to find out more? If you are prepared to do the heavy lifting on understanding cholesterol, then check out The Straight dope on cholesterol which is a 7 part expose on the facts and myths surrounding this highly misunderstood substance.

Drug companies working on ways to raise cholesterol

I have been awakened from my slumber by an article which has completely floored me.

On discovering, shock horror, that high HDL levels in men confer longevity, the drug companies saw a marketing opportunity (my highlights):

“It’s difficult to change HDL levels,” Barzilai said. Exercise might raise it a few points, but it isn’t a very efficient way to improve, he said. “We need to get a drug eventually.”

Merck and Roche are both working on an HDL raising drug, he told Reuters Health. Pfizer stopped its research into another such drug, torcetrapib, in 2006 because people taking it along with Lipitor in a study had a higher rate of death. – Reuters

Wow. Just wow.

It should also be noted that Total Cholesterol = Triglycerides + LDL + HDL so if HDL goes up, so will the total. And then they will be in a tizzy because the total is too high.

They didn’t bother to mention what the total cholesterol numbers were for these long lived men but I willing to bet they were at levels which would have Merck and Roche screaming for force feeding of statins.

PS: you don’t need drugs to boost your HDL.

NEW YORK (Reuters Health) – Men who reach their 85th birthdays tended to have high levels of good cholesterol while in their 60s, a new study says.

Researchers found that men with the highest good (HDL) cholesterol were 28 percent less likely to die before they reached 85, compared to men in the lowest HDL group.

This paper, published in the American Journal of Cardiology, adds to the evidence that HDL is important for a long life, said Dr. Nir Barzilai, who heads the Institute for Aging Research at Albert Einstein College of Medicine in New York and was not part of the study.

However, “we always have to remember that it’s an association,” and it does not mean that having high HDL increases life span, he told Reuters Health.
About 12 million men suffered from heart disease and stroke in 2006, but high levels of HDL cholesterol may reduce the risks, according to the American Heart Association.

Low levels of HDL, less than 40 milligrams per deciliter (mg/dL) of blood for men, are known to increase the risk of heart disease, according to the heart association.

The researchers, from the Massachusetts Veterans Epidemiology and Research Information Center in Boston, looked at the medical records of about 650 veterans when they were around 65 years old, then grouped them based on HDL levels.

Starting with low levels of 40 mg/dL, they found that for each ten mg/dL increase of HDL, the men were 14 percent less likely to have died by 85. Overall, 375 survived to that age.

Also, fewer of the men with higher HDL were overweight, and they tended not to have more than 2 drinks a day. And fewer of them had heart disease or smoked, compared to the lowest HDL group.

These other factors might have had an effect on survival, Barzilai said. However, the researchers did account for this, and still showed a link between reaching 85 and high HDL levels, he told Reuters Health.
“It’s difficult to change HDL levels,” Barzilai said. Exercise might raise it a few points, but it isn’t a very efficient way to improve, he said. “We need to get a drug eventually.”

Merck and Roche are both working on an HDL raising drug, he told Reuters Health. Pfizer stopped its research into another such drug, torcetrapib, in 2006 because people taking it along with Lipitor in a study had a higher rate of death.

The B-vitamin niacin may raise HDL levels 15 to 35 percent. However, side effects can include liver damage and increased blood sugar, according to the Mayo Clinic.

A three-month supply costs about nine dollars. Niacin is also found in dairy products, lean meats, nuts, eggs and fish.

However, it’s unclear how much raising HDL will prevent heart disease, Barzilai said, so whether drugs might improve people’s health remains to be seen.

The study authors could not be reached by deadline.

SOURCE: The American Journal of Cardiology, online February 4, 2011.

Dr. Davis Primer

Whenever I implicate carbs instead of fat as a major risk factor for obesity and heart disease, I am met with rolling eyes and eventually that look that says “you’re insane.”

In an ongoing effort to convince my audience that I am NOT nuts, I encourage them to read the advice of someone with better qualifications on the subject: a cardiologist.

Not just any cardiologist mind you, but a rare breed actually concerned with prevention:
Dr. William Davis

Dr. Davis’ Heart Scan Blog is full of great info but there is a LOT to wade through.

To make your first encounter with Dr. D easier, let me start you off with a few recommendations:

1. Know your risk factors for heart disease

2. Understanding cholesterol Values
The LDL/HDL/Total cholesterol numbers are NOT a good indication of your risk of heart disease. These number can mislead by underestimating or overestimating risk. Learn what Lipoprotein analysis (NMR) is and understand what small LDL particles are.

3. Reducing your risks and reversing heart disease
There is no one post that pulls this all together* but his advice is consistent:

  • Eliminate sugars, wheat and cornstarch
    Eliminate–not reduce, but eliminate wheat products from your diet, whether or not the fancy label on the package says it’s healthy, high in fiber, a "healthy low-fat snack", etc. This means no bread, pasta, crackers, cookies, breads, chips, pancakes, waffles, breading on chicken, rolls, bagels, cakes, breakfast cereal. This includes
  • Eliminate junk foods
    such as candies, cookies, pretzels, rice cakes, potato chips, etc.
  • Take Omega 3
    It must be from fish oil There is no need for expensive brands like Lovaza (aka Omacor). Dosing frequently (eg 2-3 times per day) seems to enhance the effect. Take a minimum EPA + DHA of 1200 mg per day (ie 4000mg standard fish oil) or more.
  • Take Vitamin D3
    This should be oil based (ie gel not tablet). Dr. D has on occasion recommended Carlson’s and Vitamin Shoppe brands.
    "Though needs vary widely, the majority of men require 6000 units per day, women 5000 units per day. Only then do most men and women achieve what I’d define as desirable: 60-70 ng/ml 25-hydroxy vitamin D blood level." ref
  • Dr. D has also mentioned that exercise may enhance the benefits of these changes but he does not discuss exercise much.

    Likewise he has stated that one should not allow saturated fats to dominate but again his blog does spend a lot of time on this recommendation. In this respect he is more conservative than much of the low-carb community particularly given that he remains anti-egg yolk: "One yolk per day is clearly too much."

    More info:

* Note that this list is my own compilation from various posts and may not accurately reflect Dr. Davis’ protocol due to errors of omission or emphasis.

Ideology trumps evidence

Fantastic opinion piece in the NYT:
Believing in Treatments That Don’t Work

Treatment based on ideology is alluring. Surgeries to repair the knee should work. A syrup to reduce cough should help. Calming the straining heart should save lives. But the uncomfortable truth is that many expensive, invasive interventions are of little or no benefit and cause potentially uncomfortable, costly, and dangerous side effects and complications.

The critical question that looms for health care reform is whether patients, doctors and experts are prepared to set aside ideology in the face of data. Can we abide by the evidence when it tells us that antibiotics don’t clear ear infections or help strep throats? Can we stop asking for, and writing, these prescriptions? Can we stop performing, and asking for, knee and back surgeries? Can we handle what the evidence reveals? Are we ready for the truth?

And when we insist on evidenced based healthcare, will our doctors accept it?

High Cholesterol – Low Triglycerides

I recently got my lipids tested. Unfortunately I do not have access to detailed subfraction tests so I was only able to get the high level numbers.

I’ve been low-carbing for quite a while now. I’ve generally had good cholesterol figures so this would be telling for the increased consumption of fat in my diet.

The results, however, were a bit confusing:

Total cholesterol
  229 – high
54 – low


My total cholesterol number has climbed significantly over the past 2 years (it was ~170 before) which is a concern. However the low triglycerides with the high cholesterol figure gives contradictory risk indications for heart disease.

Now I’m aware that not all LDL are created equal but I wanted some definitive advice on this point (it wasn’t coming from my doctor who didn’t even remark on the triglyceride number).

In my searching, I found this interesting and succinct comment on the subject here which I am reprinting as it addresses my question directly:

LDL cholesterol can be broken down into two kinds, pattern A and pattern B. LDL pattern A is large fluffy particles that are less dense than pattern B and not easily oxidized. LDL pattern A is essentially benign with respect to heart disease. LDL pattern B on the other hand is small dense particles that are easily oxidized and more closely associated with heart disease. It has been theorized that the harm to the arteries is associated with oxidized cholesterol. Ok, enough about that. To summarize, LDL pattern B (think small dense BBs) is bad, LDL pattern A (light and fluffy) is not a problem.

Now you would think that the lab actually measured your LDL, but they likely didn’t. Most labs just calculate LDL from the following equation:

LDL = Total Cholesterol – HDL – triglycerides/5

So from this, you don’t know if you are predominately LDL pattern A (no big deal) or predominately LDL pattern B (much more risk). Some labs do have the capability to measure the LDL gradient and can determine your predominate LDL pattern type. However, there is another way. Studies have shown that there is a strong correlation between a low triglyceride/high HDL level and LDL pattern A (the non risky kind), and conversely, a high triglyceride/low HDL level is strongly associated with LDL pattern B (the harmful kind). This is one reason that high triglycerides alone are an independent risk factor for heart diease.

Ok, where am I going with this with respect to your situation. Other studies have shown that a high triglyceride/HDL ratio is the best indicator for heart disease risk (approximately 8x better at predicting heart disease risk than high total cholesterol alone). A triglyeride/HDL ratio of 5.0 is moderate risk and the higher the number, the higher the risk, while a ratio of <2.0 is very low risk.

From what I have just described, you can see that with your very low triglyceride level (<100) and moderately high HDL level (>50) you are at very low risk of heart disease. Also, your very low triglyceride level indicates that your LDL is predominately pattern A, the harmless kind. If you are still concerned, you can have your LDL gradient measured to determine your LDL pattern type.

I wouldn’t even remotely consider cholesterol lowering medications without knowing your LDL pattern type to see if there is any risk associated with your lipid levels because there are potential significant side effects (muscle damage, neurological damage, liver damage, even death – i.e. the Baycol recall) associated with many cholesterol lowering medications (statins in particular).

Oh, and I think that your low sugar, lower carbohydrate diet is the way to go to lower your risk of heart disease because of the positive effects it has on triglycerides and HDL.


Unfortunately the mystery man Alan does not provide any references however this is broadly in line with what I have read elsewhere. My triglyerides/HDL = 1.18 which suggests, according to Alan, that I am very low risk for heart disease.

I will, however, get my LDL gradient tested at the first opportunity.



Follow Up Here: How Gluten Free Impaired my Cholesterol Numbers


Vitamin D Home Test

As a follower of  Dr. William Davis’ Heart Scan blog, I am a convert to the Vitamin D message.

For eight months now I’ve been supplementing with  6000-8000 IU of D3 on a daily basis. In the absence of any initial test of blood levels, my self-prescription was a complete shot in the dark based loosely on posts I’d read on his and others’ blogs.

A Trip to the GP

Finally, a few weeks back, I decided it was time to find out how the supplementation was going. So I asked my GP if he could do the Vitamin D (25-OH) blood test. His immediate response was, “Why do you need that? Just go outside in the sun.” I explained that, being over 40, I was concerned my ability to make my own Vit D was impaired hence the supplements and follow up test. This irritated him even more at which point I was told he was “too busy to discuss this now” and “go talk to the receptionist.”

To make a long story short, the lab they work with does not do this test. I suppose this story is irrelevant other than to warn you that your “weird” views on Vitamin D may be met with derision.


Saved again by the internets!

Fortunately, I had already learned that I could order a home test over the net. They even do the tests internationally! The cost for those outside the US is US$90 including shipping.

So I placed the order and it arrived promptly by courier a few days later.

Basically you need to prick your finger and put a few drops of blood on a paper tablet then return it through the post to the lab.

It’s almost a no-brainer however I would definitely recommend that before you prick your finger, you should swing your arm around a few times to ensure that you get enough flow to fill the card. Swinging your arm after you prick your finger results in a scene out of CSI.

I suppose the swinging bit may not be necessary in all cases but my initial pricking effort produced only one drop of blood. But I digress…

With the test complete including only minor spillage on the test card (excluding aforementioned spatter on walls, ceiling and floor), I sent it back through the regular post… And about two weeks later my results arrived by mail.



Verdict? My 25-OH score was 73 ng/ml – pretty good. This is very close to optimum (the ranges doctors work to vary but for the proponents of Vitamin D it’s typically in the 50-70ng/ml range).

However, my results came with this warning:

Your blood vitamin D level is with the reference range (32-100ng/ml), but slightly above the range most experts consider as optimal for health (50-70 ng/ml). Excessive levels of Vitamin D over a prolonged period of time can be unhealthy.

I suppose they have to say that to cover themselves but frankly I was hoping they were going to tell me what a star I am.

It’s also worth noting that the quote, repeated verbatim, shows some wavering over whether or not to capitalize “Vitamin D.” As I was looking for guidance on that point I’m still lost.


The Test Kit Contents


My Bloody Results


PS: I’m going to drop my daily dose of D3 to 2000IU.

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Ethical Quandary – Industry Money in Med Schools

Give your doctor a break, he doesn’t know he has been brainwashed:

In a first-year pharmacology class at Harvard Medical School, Matt Zerden grew wary as the professor promoted the benefits of cholesterol drugs and seemed to belittle a student who asked about side effects.

Mr. Zerden later discovered something by searching online that he began sharing with his classmates. The professor was not only a full-time member of the Harvard Medical faculty, but a paid consultant to 10 drug companies, including five makers of cholesterol treatments.

“I felt really violated,” Mr. Zerden, now a fourth-year student, recently recalled. “Here we have 160 open minds trying to learn the basics in a protected space, and the information he was giving wasn’t as pure as I think it should be.”

More – New York Times

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