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NMR LipoProfile

A while back I blogged a two-parter on LDL Cholesterol (Part 1 / Part 2). Part 1 deals with how unreliable standard blood tests are for determining your real risk. In part 2, I highlighted real world examples from the offices of doctor William Davis.

And now, I'm going to show you a real world example from a reader and (obviously) fellow high-fat paleo eater. Click here to access Patrik's NMR LipoProfile (Nmrlipo PDF) He kindly gave permission to share it with you.

The fist thing to notice is that his LDL cholesterol – calculated, just like the one you get — is a whopping 204. Bet that'd make you worry, eh? However, his actual particle number for LDL is 1417, corresponding to a measured LDL of 141, a full 63 points lower. So the cholesterol tests like the ones you get — the ones on which basis doctor prescribes statins to millions — is a full 45% overstated in this case. However, it should be noted that if you eat a lot of carbohydrates, grains in particular, it's far more likely that your measured LDL is far higher than your calculated one. In essence: same problem, opposite error.

But here's the really big deal: he has ZERO small dense LDL particles, the only ones that matter. Had he taken conventional medical advice, he'd be on statins and probably other stuff, and yet he has absolutely no risk in terms of the huge association with small dense LDL and heart disease. Read more about this on the LioPanel website:

Why cholesterol may not be enough

Why your LDL particle number is important

How can I get the NMR LipoProfile test?

Understanding your test results

Meet Theresa : Age 57

Oh, and we ought to also mention that he's got a respectable HDL of 63, as well as killer Trigs at 40 (lower than mine, at 47). Good job, Patrik. Congratulations.

Richard Nikoley

I'm Richard Nikoley. Free The Animal began in 2003 and as of 2021, contains 5,000 posts. I blog what I wish...from health, diet, and food to travel and lifestyle; to politics, social antagonism, expat-living location and time independent—while you sleep—income. I celebrate the audacity and hubris to live by your own exclusive authority and take your own chances. Read More

21 Comments

  1. Patrik on March 12, 2009 at 21:56

    Thanks Richard. I am going to contact the lab about the zero small dense LDLs, just to double-check that it is not an error.

  2. Patrik on March 12, 2009 at 22:08

    @Richard (or anyone else)

    I eat Paleo, but do eat a fair amount of dairy such as cheese and full-fat cream (for coffee).

    Do you think cutting out dairy completely would improve my lipid profile?

  3. Joe Matasic on March 13, 2009 at 05:15

    I agree with Richard there. Great profile. I need to get this done sometime, even though my doctor has quit arguing with me.

    Eat the dairy. You need the cheese for the K2 anyways 🙂

    I just use heavy cream in my coffee and ice coffee on weekends. Sometimes in protein shakes for fat, because I haven't bought MCT oil yet. The only reason I worry about it is all the extra calories. Still trying to lose and am not convinced that extra calories don't slow that.

  4. Richard Nikoley on March 12, 2009 at 22:31

    Jesus Christ. 🙂

    Your lipids are ideal. Enjoy your life. You have earned it (as easy and enjoyable as the journey is).

    Richard Nikoley

  5. damaged justice on March 13, 2009 at 07:29

    My dad just got his heart test results back and apparently it's enough to convince him to partially emulate me and at least cut down on sugars and grains/carbs (especially wheat). I still wish he'd have the more extensive lipo analysis, but I'm glad for any positive change!

  6. Tobbe on March 13, 2009 at 15:12

    How much carbohydrates do you guys eat? Would there be an advantage eating carbohydrates on its own? I'm thinking the time insulin is elevated must be substantially shorter. I feel more clear-headed eating paleo-style, but sometimes I get too low blood sugar and also brain fog.

  7. Patrik on March 14, 2009 at 11:01

    Thanks again Richard. BTW I did double-check with the lab:

    Hi,

    I recently had a NMR LipoProfile test done. One of the results it returned was 0 (zero) for small LDL-P – is this an error? See lab results attached.

    Their response:

    We have had the medical director look at your results and he says that they are accurate, that you have a “large LDL-P pattern” which is better than a “small”. He would suggest repeating the test (after treatment with diet and exercise or with medication, per your primary care physician’s recommendations) and fasting 16-26 hours rather than just overnight to remove any question of accuracy.

    ——

    I guess, according to the Lab Corp people I need 'diet' and exercise, I guess Paleo and CrossFit doesn't cut it…. 🙂

    Is it just me or does anyone else think it ironic that we are using mainstream medicine's tools to subvert (for lack of a better word) mainstream medicine? 🙂

  8. Tobbe on March 14, 2009 at 14:44

    I made the masaman dish served with 1 cup boiled rice. In the following hours I felt kind of jittery. Normally I don't eat that much carbohydrates at once, but hey, that masaman was tasty! Fruit is eaten by it's own so I'll try eating less carbohydrates with the protein & fat.

  9. Patrik on March 14, 2009 at 15:37

    Probably not. 🙂

    —–

    Also I pinged Peter of Hyperlipid as well.

    He has kindly allowed me to share his thoughts publicly:

    "The lipid profile looks like it belongs to someone who eats a high saturated fat LC diet and, as such, should be at very low risk of cvd. So you have no small dense LDL and huge amounts of large fluffy LDL, a decent dose of HDL and minimal trigs.

    The lab, and almost any cardiologist (and I would extend this to Dr Davis), aim for an LDL as low as possible. This I would fundamentally disagree with. An LDL of 60mg/dl is a great marker for increased all cause mortality.

    There is a study (can't relocate it) claiming that LDL particle number, not size, is what matters, again I disagree. Mainstream cardiology has no experience of people eating real food on a high fat, LC basis. I wouldn't take a statin in your situation any more than I would myself, with a calculated LDL of nearly 300mg/dl.

    Your numbers look fine to me, but bare in mind that I view your lipids as a marker of what you are eating. What you eat matters, not the lipids. Your lipids say you are eating Food. That's good.

    All the best

    Peter"

  10. Marc on March 14, 2009 at 17:36

    Small LDL-P of "zero" is not common, but not rare either. I've seen it several times, including this past week.

    In reality, nobody literally has a Small LDL-P of zero, but when Small LDL-P is very, very low, then laboratory testing runs into a phenomenon termed "limits of detection." In other words, the laboratory test reliably states that there is very, very little (or zero) presence of the parameter being assayed, but it isn't really "zero." It's just really low, which is as good as zero. The test isn't giving you mis-information, it just ran into "limits of detection."

    Note: Total LDL-P (the most important parameter) does not fall prey to the limits of detection that subparticle analysis sometimes can, so Total LDL-P will still be reliable, and is actually MUCH more accurate and reproducible than cholesterol testing.

  11. Marc on March 14, 2009 at 17:52

    Peter stated that he disagrees with the notion that LDL particle number, not size, is what matters.

    Peter, I can refer you to NMR LipoProfile analyses of samples from VA-HIT, MESA, Framingham, and several other published studies indicating that LDL particle number is indeed more important than LDL particle size. I can also point you to expert opinions from a 30-person/10-country panel (2006 Journal of Internal Medicine), the American Diabetes Association & American College of Cardiology (2008) and the American Association for Clinical Chemistry (lab experts – in press now). ALL of these expert panels have extensively reviewed the current literature and concluded that the value of knowing LDL particle size is "unclear" when LDL particle number is known.

    Furthermore, I can point to two distinct populations of people:

    1. Populations with diabetes or metabolic syndrome have HIGH NUMBERS of SMALL LDL particles – and they have a lot of risk. Doctors see these folks all day long.

    2. Populations with Familial Hypercholesterolemia have HIGH NUMBERS of VERY LARGE LDL particles – and they have a lot of risk. Doctors don't see these folks too often (FH affects 1 out of 500 in the population), but these folks do have LARGE LDL particles – and a lot of risk.

    The common theme between these high risk populations is LDL particle number – not size.

    If you want specific citations, please email me at: marcwgarber@comcast.net

    I've got more data on particle number than you can imagine! And since this is a low carb forum, I should also mention that low carb diets DO generally lower LDL particle number MORE than LDL cholesterol. This is a very good thing, because LDL particle number (LDL-P) is much more predictive of risk than LDL cholesterol (LDL-C).

  12. Marc on March 14, 2009 at 18:38

    With regard to Patrick's NMR LipoProfile results (available via a link at the top of this post):

    Please be advised that although his LDL-P of 1417 does indeed indicate a far lower level of risk than his LDL-C of 204, 1417 is STILL not a great value. Briefly put, Patrick's LDL-C of 204 indicates that his concentration of Low Density Lipoproteins is beyond the 95th percentile of the population (very high risk), and Patrick's LDL-P of 1417 reveals that his ACTUAL concentration of Low Density Lipoproteins is lower (but not "low"). 1417 corresponds to the 60th percentile of the population – so 60% of people have FEWER LDL particles than Patrick, and he does indeed still have LDL-related risk!

    Is Patrick's risk significantly lower than his LDL-C indicates? YES! Is the risk conferred by an LDL-P of 1417 acceptable for him? The answer to that question depends on whether he is a low-risk patient, a moderately high-risk patient, a high-risk patient, or a very high-risk patient. Patrick should ask his doctor about this, and if his doctor says:

    Low Risk: LDL-P <1600 is "technically" ok, but still not good!

    Moderately High Risk: LDL-P <1300 is the goal.

    High Risk or Very High Risk: LDL-P <1000 is the goal.

    In summary, Patrick's LDL-C is overstating his LDL-related risk. This is not uncommon in people on low carb diets. However, even though Patrick's LDL-related risk is lower than his LDL-C indicates, an LDL-P of 1417 is STILL NOT GOOD. If Patrick has multiple risk factors (age, smoking, hypertension, low HDL-C, Family History of cardiovascular events, etc) then Patrick should probably add a statin on top of diet and exercise. The GOOD NEWS is that a relatively low dose, generic ($4 at some pharmacies) statin such as simvastatin 20mg or 40mg can very likely get Patrick's LDL-P below 1000. If not, try Vytorin 10/20 or Crestor 10 (whichever one is "Tier 2" on your insurance plan).

    In summary, low carb diets DO IMPROVE LIPOPROTEINS, and this is a good thing. However, many folks will still benefit from drugs. Diet may reduce the number of drugs needed, and reduce the doses that are needed, but please don't ignore drugs. Drugs (such as the "dreaded" statins) really do help.

    Diet and exercise are crucial. A Couch Potato can out-eat the benefit of any pill (or combination of pills), but a fitness-guru like Jim Fix can also drop dead of a massive heart attack while running. Drug-therapy is a very important adjunct to diet and exercise.

  13. Richard Nikoley on March 14, 2009 at 11:58

    I don't eat a lot. Very little fruit, nowadays. Occasionally, I'll have a little bit of potato. I don't actually count carb grams but I'm sure that on average it's probably less than 100 per day.

    I don't have issues with brain fog, but them I've been at this for quite a while.

  14. Richard Nikoley on March 14, 2009 at 14:10

    Unbelievable. I'll bet they almost NEVER see a zero.

  15. Richard Nikoley on March 15, 2009 at 11:12

    "Peter, I can refer you to NMR LipoProfile analyses of samples from VA-HIT, MESA, Framingham, and several other published studies indicating that LDL particle number is indeed more important than LDL particle size."

    More important to whom?

  16. Richard Nikoley on March 15, 2009 at 11:19

    "In summary, Patrick's LDL-C is overstating his LDL-related risk. This is not uncommon in people on low carb diets. However, even though Patrick's LDL-related risk is lower than his LDL-C indicates, an LDL-P of 1417 is STILL NOT GOOD."

    You can't possibly know that.

    And, also, as I understand it, Patrik is on a paleo-like diet, i.e, low carb is not the emphasis but real and natural foods to the exclusion of processed foods, vegetable oils (high pro-inflammatory n-6s) and such.

    Where is the discussion of inflammation? In everything I've been reading, cholesterol has little to nothing to do with anything. It's inflammation at the root, and if Patrik is eating a diet that does not promote inflammation, such as all those "wonderful, heart health grains" and processed derivative franken-crap, then it's likely that his arteries are nice and smooth.

    There is a world of difference between a low-carb focus and a paleolithic, real food focus.

  17. Marc on March 15, 2009 at 20:04

    Richard:

    LDL particle number is more important than LDL particle size to the people who participate in the aforementioned studies. The folks with lower LDL particle NUMBER have lower rates of cardiovascular events (regardless of LDL particle size). Events track with NUMBER.

    Best Regards,

    Marc

  18. Marc on March 15, 2009 at 20:29

    Richard quoted me as saying:

    "In summary, Patrick's LDL-C is overstating his LDL-related risk. This is not uncommon in people on low carb diets. However, even though Patrick's LDL-related risk is lower than his LDL-C indicates, an LDL-P of 1417 is STILL NOT GOOD."

    And then Richard stated:

    "You can't possibly know that."

    You're right. And you're wrong. Patrick is an individual. He (as an individual) may or may not die as the result of cardiovascular disease. But he DOES HAVE MORE LDL PARTICLES than 60% of the U.S. population, and having a high number of LDL particles does indicate high cardiovascular risk (at a population-level).

    Richard then asked:

    "Where is the discussion of inflammation?"

    Studies are continuing in this area. The data is not yet conclusive. At this point, inflammatory markers may be useful as a risk stratification tool, but not as a management goal of therapy (and there is a fundamental difference at stake here). Call Paul Ridker at Harvard – he's the guru on hs-CRP).

    Then Richard stated:

    "In everything I've been reading, cholesterol has little to nothing to do with anything."

    Well, yes, and no. I am talking about lipoprotein particles – not cholesterol.

    LDL = Low Density Lipoprotein (particles)

    LDL-C = the cholesterol within LDL particles

    LDL-P = the NUMBER of LDL particles

    Again, I have been talking about LDL-P, not LDL-C, and there is a fundamental difference.

    Richard then claimed:

    "It's inflammation at the root, and if Patrik is eating a diet that does not promote inflammation, such as all those "wonderful, heart health grains" and processed derivative franken-crap, then it's likely that his arteries are nice and smooth."

    Three different Expert Panels have recommended measuring and managing LDL particle number (or apoB) in the past 30 months (because the data is overwhelming). NO EXPERT PANELS have suggested managing markers of inflammation (because the data is, at this point, inconclusive).

    "There is a world of difference between a low-carb focus and a paleolithic, real food focus."

    Point taken, and thank you for the clarification.

    Similarly, there is a world of difference between LDL-cholesterol (LDL-C) and LDL particle number (LDL-P). I have not been talking about CHOLESTEROL (as you stated). I have been talking about LDL PARTICLE NUMBER. Big difference.

    Best Regards,

    Marc

  19. Richard Nikoley on March 16, 2009 at 07:37

    And how many of those people are on strict paleo-like diets. See, it's an apples & oranges thing. While I can buy the association, I do not think LDL is causal. I think it's inflammation and that LDL then becomes dangerous. There's too much out there about high-fat eating primitive populations without heart disease.

    I'm sure you know of the Masai, Inuit and others. Have you seen the info on the 50% energy from saturated fat Tokelauans?

    https://freetheanimal.com/root/2009/01/saturated-fat.html

    Here's one specific to cholesterol and cardiovascular health:

    http://wholehealthsource.blogspot.com/2009/01/tokelau-island-migrant-study.html

  20. Richard Nikoley on March 16, 2009 at 07:52

    Marc:

    For starters, here's something youy might find interesting (on the matter of inflammation, primarily). Fist, heart surgeon Dwight Lundell.

    https://freetheanimal.com/root/2009/02/dont-listen-to-me.html

    https://freetheanimal.com/root/2009/02/dont-listen-to-me-part-2.html

    And, Steven Gundry.

    https://freetheanimal.com/root/2009/02/enlightened-heart-surgeons-and-cardiologists.html

    Finally, there's cardiologist William Davis (Track Your Plaque) who deals with thousands of patients to detect and reverse heart disease. He think's Patrik's NMR is fine. I quote from an email, the first part of which if Dr. BG of Animal Pharm blog:

    ~~~

    My assessment precisely as well.

    I believe the absence of ALL small dense particles — both small dense HDL (bad) and small dense LDL (again, bad) shows that this gentleman Patrick has obtained an awesome lipoprotein profile — one that is entirely large fluffy bouyant anti-atherogenic. Dr. Davis does say that we do not know the longterm effects of large amounts of LARGE particles… but I would say it probably is not assoc with much clinical disease that I can find.

    Here are some of Dr Davis' points (I asked him b/c I'm not an expert yet on NMR):

    "As you pointed out, he has pure large LDL, which accounts for the huge discrepancy between Friedewald LDL of 204 mg/dl and a "real" LDL of 141 mg/dl (LDL particle number minus last digit). "

    "The NMR report seems abbreviated because page 2 is missing–yes, that notorious issue that everyone complains about. Page 2 contains the breakdown of HDL subclasses by nmol/L, IDL, and VLDL subclasses. In actuality, you can still extract good information without page 2.

    His large HDL is quite good–around 15 nmol/L or greater is very good. To convert to mg/dl, you need page 2 to calculate the proportion of large HDL in nmol/L over total HDL in nmol/L, then multiple that proportion times the total HDL in mg/dl. A direct conversion factor can be used, but is somewhat inaccurate due to variation in HDL size. Crudely, multiple HDL in nmol/L by about 1.8 to get mg/dl."

    ~~~

  21. MJ on July 28, 2009 at 09:59

    I too had a zero small LDL-P count! I have been on a modified Atkins lifestyle for years. But my total cholesterol was high.
    There are several good patient stories at

    (you just have to scroll down)
    MJ

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