Extracts - ATLCX (Episode 29): Dr. Thomas Dayspring | Cholesterol Testing: What Matters Most?

Extracts - ATLCX (Episode 29): Dr. Thomas Dayspring | Cholesterol Testing: What Matters Most?

"LDL particle concentrations is the type of testing we all need to have done"
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Particle count - big picture

• HDL-cholesterol has as its surface apoprotein, apolipoprotein A-1
• ApoA-I measurement serves as an HDL particle count
• You can have a lot of HDL particles, but low HDL-cholesterol
• Thus although apoA-I and HDL-C usually correlate, in some folks they do not (discordance)
• People with low HDL-C but normal apoA-I tend not to get heart disease
• people with high HDL-cholesterol could have low Apo A-1 (low HDL particle count)

Evidence supporting LDL-P approach?

• His 2012 study of diabetics looking at LDL particles (American Journal of Cardiology Sept 2012)
• Check out information on why LDL particle tests good

Official standards?

• There are 5 US specialty Society guidelines do advise apoB or LDL-P testing
• These specialty societies are ADA, ACC, AACC, ACE, NLA
• Apo B is in the European guidelines, but not LDL-P (LDL-P by NMR is not available in Europe)
• Guidelines are never meant to be cutting edge
• The majority of doctors don’t know understand or know of Apo B and LDL-P
•  Apo B is a worldwide standard for lipid/lipoprotein health
• You can get Apo B test run in any lab in America
•   The VAP test offers a calculated Apo B–BOGUS!
• Calculated LDL-cholesterol is an imprecise equation
• If your trigs are under 100, divide by 5 for VLDL-cholesterol determination
• Once you have VLDL-C, you can calculate LDL-C using the equation: - LDL-C = TC minus HDL-C – VLDL-C

Particle count - what it should be

• LDL cholesterol levels under 100 mg/dL has long been the standard
• LDL-P of 1600 nmol/L is in the 80th percentile
• A desirable LDL-P of 1000 is the 20th percentile population cut point
• ie. 80% of the populations has a higher level
• LDL-P under 700 is in the 5th percentile population cut point
• ie. 5% of folks are less and 95% are higher

Particle count too high, causation and cure

• Insulin resistance is at the heart of high LDL-P\
• cutting carbs will reduce it
• a low-fat diet (without carb restriction)
• its the “worst thing you can do” in a person with IR and high LDL-P
• Drugs are almost always necessary unless you start eating low-carb ASAP

BACKGROUND


Particle count - physiology basics

• There is one apoB molecule per VLDL, IDL and LDL particle: 
apoB is not on HDL particles
Apo B testing measures how many VLDL, IDL and LDL exists per deciliter of plasma
Apo A-1 particle do not deposit cholesterol in the artery: they may in fact remove it.
• Apo B particles after entering the artery sticks
• White blood cells (macrophages) ingest apoB particle carrying cholesterol and initiate inflammation
• VLDL takes lipids (mostly TG, but also cholesterol) out of the liver;
• VLDL traffic TG to muscle and fat cells and as TG exit the VLDL shrinks, creating IDLs
• Most IDLs are cleared at the liver but some IDL shrink and become LDLs
• Liver isn’t as efficient at clearing LDL particles compared to IDL
• thus extending LDL plasma residence time
• A normally composed LDL half-life is 2-3 days; compared to VLDL 2-6 hours or IDL 1-2 hours
• Thus Apo-B test actually measures LDL-P in the blood (vast majority of apoB particles are LDLs)
• Can’t change LDL-P by eating carbs day before test (LDL half life is typically 3 days)
• Takes trigs a few days to alter lipoprotein metabolism and jack up your LDL-P
• Total cholesterol minus HDL is called non-HDL cholesterol
• it reveals how much cholesterol is in the apoB particles
• and thus serves as a better measure of atherogenic apoB particles than does LDL-C
• However, even Non-HDL cholesterol misses 30% of persons with high apoB (LDL-P) at-risk cases

Triglycerides

• Triglycerides is a key marker that few health care professionals truly, understand
• Trigs over 70 in an IR adult, LDL-P needs checking
• LDL is supposed to carry primarily cholesterol with only small amount of TG (4:1 ratio)
• Increased LDL/triglyceride level occurs when LDLs are trafficking more TG than normal –
• in such cases they are therefore carrying less cholesterol than they should
• These are therefore cholesterol-depleted LDLs.
• It takes 40-70% more cholesterol-depleted particles to traffic a given amount of cholesterol
• In such cases we need a therapy to remove triglycerides from LDL
• High triglycerides/low HDL-cholesterol ratio (> 3.0) is very indicative “insulin resistance”


ApoE genotype

• What Apo E genotype issues you should be aware of
• Apo E4 is a marker of elevated risk of heart disease
• ApoE2 is usually desirable
• but Apo E2 with high triglycerides is a high risk lipoprotein abnormality
• ie - with normal LDL-P: but they have too many VLDLs and IDLKs, but not LDLs.
• Apo E4 is also associated with Alzheimer’s disease
• A ketogenic diet might ward off Alzheimer’s longer
• Drown yourself in omega-3 fatty acids” if Apo E4
• Whether an Apo E4 needs to lower their fat intake is truly not known at present
• Are they REALLY over-absorbing fat–maybe, maybe not
• If your lifestyle controls Apo B, no need to worry
• What one test gives most info on heart disease risk: ApoB and LDL-P
• No matter what Apo B is, other tests such as inflammatory markers can also tell about CV risk
• The totality of tests help doctors treat you better
• Triglycerides and Apo B/LDL-P gets most info needed to start

Discordant test results

• LDL cholesterol might be low, but LDL-P could be high:
• How you can have low LDL-cholesterol and yet high LDL-P numbers (discordance)
• normally the two tests should correlate very well
• when they do they are concordant and when they do not they are discordant
• If Apo B and LDL-P come back one high, one normal – discordance is present
• It happens in 10-12% of people; repeat test again
• If LDL-P is high and Apo B is normal, there is no consensus on what to do
• LDL-P tends to “outperform” Apo B as a key marker

LDL particle size

• Particle size has no bearing on whether LDL enters the artery wall or not
• Insulin resistant Diabetics typically have the small LDL regardless of LDL-C

Not keen on heart scan testing

•  What he thinks about having a heart scan conducted
•  His concern over having a CT scan of your chest: too much radiation