Wednesday, August 31, 2011

The Nutrition Debate #25: Understanding Your Lipid Panel

As has been pointed out with each column, I am not a doctor or a health care professional, and I do not offer dietary or health-related advice. You must draw your own conclusions from my ramblings, and of course you do so at your own risk. Here comes the “however”: I can do simple math and read a lab report, especially one that gives an “IN range,” “OUT range,” and “Reference Range,” plus other guidance, for each test ordered.

At each office visit, my doctor always orders a complete blood count and a comprehensive metabolic panel, including a lipid panel and an Hb A1c, plus, from time to time, other specialty tests (Cardio High Sensitivity CRP, etc.). This column is going to be about understanding the lipid panel. That includes Total Cholesterol, HDL Cholesterol, LDL Cholesterol (calculated), Triglycerides, and the (total) Cholesterol/HDL Ratio. Some panels also include VLDL.

Most people know the drill: “high” total cholesterol is not a good thing, that there is “good” cholesterol (HDL) and “bad” cholesterol (LDL), and that we should try to get our circulating triglyceride levels down. If we aren’t successful at doing this through dietary restriction of saturated fat and cholesterol containing foods (per our doctor’s advice), he is going to prescribe a pharmacological solution to lower our LDL, and thereby our Total Cholesterol as well. We are going to be asked to support the $20 billion dollar annual statin market by taking Crestor, Lipitor, or Zocor (or Simvastatin, its generic equivalent). These are listed with the most recent and most effective first. But, is it that simple?

We shall ignore the efficacy of the dietary advice for purposes of this example, but I want it to be clear that I totally and completely disagree with that advice, based on all the science I am reading and on my own personal (n = 1) experience. Nevertheless, let us suppose that two people (or the same person, in two “snapshots” of lipid panels taken a few years apart) have identical Total Cholesterol, to wit: 200mg/dl (milligrams per deciliter). One has an HDL of 40mg/dl, an LDL of 130mg/dl (calculated), a Triglyceride count of 150mg/dl, and a Total Cholesterol/HDL ratio of 5.0. ALL FIVE OF THESE VALUES ARE BORDERLINE OUT OF RANGE. They would appear in bold in the “OUT range” column on your lab report. Your doctor would tell you, according to my understanding of the “Standards of Practice,” to cut down on all those saturated fat and dietary cholesterol containing foods, and probably to exercise more as well. BAD ADVICE, IMHO.

Now let’s look at another lipid panel: Total Cholesterol also 200mg/dl, HDL = 80mg/dl, LDL = 110mg/dl (calculated), Triglycerides = 50mg/dl, and a Total Cholesterol/HDL ratio of 2.5. The only value that is borderline high in this panel is Total Cholesterol at 200mg/dl. Everything else is textbook WUNDERBAR! It’s true, the LDL is above optimal (<100mg/dl), but remember LDL is a derived (calculated), not a measured value. The formula for LDL in the simple lipid panel is LDL = Total Cholesterol – HDL – Triglycerides/5. And, if your doctor was worried about your less than optimal LDL’s (because of existing heart disease, other cardiac risk factors such as hypertension, obesity, metabolic syndrome or higher than “normal” fasting plasma glucose or Hb A1c scores) he could order the VLDL test, or an even more sophisticated VAP test of LDL particle size (“A”= “large and buoyant” or “B” =“small and dense.”) Regardless, this lipid panel would NOT lead your doctor to prescribe statins or require dietary change. He would tell you to “continue with whatever you are doing.”

Bottom line: a Total Cholesterol test score of 200mg/dl on your lipid panel, with the first subset of values, can put you in the “dog house,” on dietary restrictions, and soon thereafter when dietary changes don’t work, on a diet of statins.

Or, you could have a lipid panel similar to the second example* and become your doctor’s poster boy, as I did after I’d been on a very low carb, high fat and moderate protein way of eating for a year or so. My doctor (a cardiologist) just tells me to keep on doing what I’m doing. Even though he started me on this program, he doesn’t want to know what I eat. For him, it’s no more lectures, just smiles, and when the test results come in, a congratulatory phone call.

For my doctor, my office visit is one of the “high points” of his day, he says. I can believe it. No stress (for him). No more arguments (from me). No latent suspicions or overt charges of “non-compliance” (cheating) with the dietary restrictions he imposed. And, above all, no hypocrisy for having to preach the baloney -- excuse me -- the bad medical advice that the public health, big pharma, media and the medical establishment continue to dish out to the lemmings who put their trust, and their lives, in the hands of “big brother,” the dietary Dictocrats, our nanny state. Sorry – I just had to vent, (and crow, of course)

* My most recent (8/15/11) lipid panel: TC = 209, HDL = 92, LDL (calc.) = 111, TC/HDL = 2.3, Triglycerides = 32

© Dan Brown 8/28/11

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