2

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Weird lipid panel (NMR), advice?

Answered on August 19, 2014
Created March 08, 2013 at 5:05 AM

Recently I had a bunch of blood tests done including an NMR lipid panel. Everything is great except for one number. The problem is that some people say that's the only number that matters.

The number is LDL-P, the number of LDL particles, which is 1905. That's officially considered to be "a lot" and puts me somewhere above the 95% percentile. I am aware that there are other people (like Jimmy Moore of the Livin' La Vida Low Carb fame) in the same situation with even worse numbers.

Other things are good: TG 51, HDL-C 80, LDL pattern A, small LDL-P is only 149, HDL-P is 37.1.

LDL-C is 160 which actually seems lowish for the particle number of 1900. My ApoB is 120 which also seems lowish for that LDL-P since each LDL particle has exactly one ApoB molecule. TC is 250.

I am eating nonspecific paleo-style, low-carb (but not VLC, I'm not usually in ketosis). My thyroid panel is normal, TSH is 1.2, free T3 is 3.3. My inflammation markers are low, CRP is 0.47. I don't have glucose problems, HbA1C is 4.9% and the NMR panel gave me the insulin resistance score of 6. I'm not actively losing weight. I doubt I'm copper-deficient as my Ceruloplasmin is 18 which is well within normal range.

So all in all I'm not terribly worried, but I still don't like that LDL particle number. Recent studies like MESA point to the LDL-P being a better predictor of CVD to the extent that once you account for it, other common predictors (like LDL cholesterol, LDL-C, or particle size) become insignificant.

So what's the paleohack wisdom on the subject?

800e726cb5dff569fd8edf604c3e2793

(1655)

on July 22, 2013
at 05:11 PM

I had FT3 measured both times. Don't have the numbers at hand here, but they were average (around 3.0, I think, smack in the middle of the lab's reference range) and if anything it went a bit down between January and June...

D33a8d5f095a8532ddf7a0d6c27bfe63

(578)

on July 20, 2013
at 01:25 AM

Next time you measure your LDL or LDL-P, get FT3 measured and see if it's correlated.

D33a8d5f095a8532ddf7a0d6c27bfe63

(578)

on July 20, 2013
at 01:25 AM

Actually, now that I've looked at your labs more thoroughly, there is another strong possibility. It's your low FT3. You say it's normal but it could be low normal in response to a VLC or a low carb diet for which you may not be suited. Typically happens on a ketogenic or sub 100g carb diet. Easy way to check is look at your prior labs and compare FT3. If it was higher before, it's very likely due to carb/caloric restriction. That's why upping the carbs will kill 2 birds with one stone: i.e., if you're ApoE4 and/or if you're sensitive to LCing.

800e726cb5dff569fd8edf604c3e2793

(1655)

on July 19, 2013
at 04:51 PM

Well, I now have a bit of evidence that saturated fat in my diet will affect my LDL -- see below. No, haven't checked my ApoE yet. Yes, I know that high LDL-P does not equal severe atherosclerosis. But it's a definite risk factor.

D33a8d5f095a8532ddf7a0d6c27bfe63

(578)

on July 11, 2013
at 03:42 AM

CVD is multifactorial. High LDL-P does not always equal severe atherosclerosis. There're intermediate steps involved, the most important of which is the role played by HDL-P. Plus, even if you have moderate atherosclerosis, your Trigs/HDL ratio protects you by keeping inflammation low.

D33a8d5f095a8532ddf7a0d6c27bfe63

(578)

on July 11, 2013
at 03:33 AM

Same comment as above: limit SaFA, see if LDL-C goes down. If so, your TC will go down and your TC/HDL will be at an ideal ratio (sub 3.5x). Right now it's 4.4x, high enough to be concerned when LDL-P is high. But again, ApoB is low vis-a-vis LDL-P. Rather than taking Niacin, the better solution is to increase your TC/HDL by (1) lowering your LDL and by extension TC and (2) exercising. I'd pay $99 and get genes tested to confirm that you're ApoE4. No need to, however, if your LDL and TC were much lower prior to your VLC diet (judging by how low your trigs are).

D33a8d5f095a8532ddf7a0d6c27bfe63

(578)

on July 11, 2013
at 03:27 AM

If you're that serious about CVD risk, I'd get a coronary calcium test for about $99. I'm willing to bet your score is close to zero, just like Jimmy Moore (i.e., no atherosclerosis). Second, get your ApoE genotype and if you happen to be ApoE4 homo or heterozygous, then incorproate safe starches to your diet. Lower your SaFA portion a bit (but not avoid it entirely). That should lower your LDL-C AND your LDL-P. But then the validity of LDL-P isn't as strong as people think; LDL-P is almost always trumped by TC/HDL and Trigs/HDL.

D33a8d5f095a8532ddf7a0d6c27bfe63

(578)

on July 11, 2013
at 03:24 AM

I don't know what makes you think omitting SaFA will increase your trigs and lower HDL. SaFA may be a problem if you're ApoE4 and it could increase your LDL mainly but it could increase your HDL somewhat. But the HDL increase is marginal. Instead of repeating your NMR, why don't you get your genotype. Yes, ApoB and LDL-P could be contradictory but I tend to put more stock on TC/HDL (3.1x)and Trigs/HDL (0.6x). Based on that, your HDL does enough to keep atherosclerosis at bay, despite the large number of LDL-P going into your artery walls. Here's the solution:

800e726cb5dff569fd8edf604c3e2793

(1655)

on March 14, 2013
at 03:05 PM

@John The poster (not sure there's more than that) is here -- http://content.onlinejacc.org/article.aspx?articleid=1665624 but there's little useful information in it. To put it up as a question, hmm, I'll think about it...

Ea1bb0c24b59345463ef96880b6b27fc

(300)

on March 14, 2013
at 10:23 AM

The actual study is only reported on here: http://www.businesswire.com/news/home/20130311006185/en/Data-Links-Lipoprotein-Particles-Cardiovascular-Disease-Risk in the form of a press release. As for your comments on "not eating SFA's" your conclusion about HDL/Trig's (not to mention your actual health) does not follow. It is possible to change your diet so as to likely bring down way out of range LDL without the changes you claim but we would need an actual question to discuss this.

800e726cb5dff569fd8edf604c3e2793

(1655)

on March 12, 2013
at 03:11 PM

@John Could you give me a link to that discordance research? I've seen a few papers on discordance between LDL-P and LDL-C, but not ApoB. I'll probably repeat the NMR in a month or two and see what's happening with my lipids. I know how to reduce my LDL -- don't eat SFAs -- but that will also reduce my HDL and spike my trigs so I'm not sure there'll be much advantage to that. I think I'll also try to persuade my doc to run tests for FH and ApoE alleles...

Ea1bb0c24b59345463ef96880b6b27fc

(300)

on March 12, 2013
at 10:15 AM

I just came across brand new research indicating that "discordance" between LDL-P and ApoB is a known phenomenon. Given that, I would repeat the NMR to be sure and then begin using it as the measure to follow. Yes, the pattern is not rare but that doesn't mean it should be ignored and it can get much, much worse. You have the choice of retesting/waiting or trying to address it now. Let us know what you want to do.

Ea1bb0c24b59345463ef96880b6b27fc

(300)

on March 09, 2013
at 05:43 AM

Variability determined under research conditions is not the same as variability arising from standard labs. You can ignore the LDL-C but your particle tests are somewhat contradictory. Hence the need for one indicator measured at different times to get another picture. Your original questions identified "weird" results, so the obvious answer is to redo them.

800e726cb5dff569fd8edf604c3e2793

(1655)

on March 09, 2013
at 12:43 AM

It was a quite comprehensive bloodwork set, I guess my doctor just gave up and said "everything" :-) I do like tests which measure the same thing as I prefer multiple data points to a single one. Theoretically (there was a paper), the LDL-P number has the intraassay coefficient of variability of 4-4.5% so e.g. if the number comes out as 1900, the 95% probability interval is more or less 1800-2000. But yes, the ApoB and the LDL-P values do not exactly match. On the other hand, the pattern of low trigs, high HDL and high LDL is not exactly rare in the LC world.

Ea1bb0c24b59345463ef96880b6b27fc

(300)

on March 08, 2013
at 11:18 PM

It makes no sense to me that both and NMR and an ApoB/A test were ordered since both are measuring the same thing. In addition, the result is contradictory since the LDL-P is high while the ApoB is not as high. Since you may be running into lab variability issues, I would suggest picking one test and repeating it a couple more times over a period of months to get a better picture. As it stands, its hard to day anything definitive.

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5 Answers

1
800e726cb5dff569fd8edf604c3e2793

on July 19, 2013
at 04:46 PM

OK, I did a re-test recently. It's interesting partially because I had lipid panels done at two different places from the same blood sample (well, different vials but drawn at the same time). This way we have three different sets of numbers. The numbers tagged NMR-Jan are from the first test discussed in the OP. The numbers tagged NMR-Jun are from a recent re-test, same lab (Liposcience). And the numbers tagged BHL-Jun are from the same re-test, but coming from the Berkeley Heart Lab.

Tot-C: 250 (NMR-Jan), 205 (NMR-Jun), 227 (BHL-Jun).
LDL-C: 160 (NMR-Jan), 124 (NMR-Jun), 144 (BHL-Jun).
HDL-C:  80 (NMR-Jan),  69 (NMR-Jun),  68 (BHL-Jun).
Trigs:  51 (NMR-Jan),  60 (NMR-Jun),  73 (BHL-Jun).

LDL-P: 1905 (NMR-Jan), 1611 (NMR-Jun).
HDL-P: 37.1 (NMR-Jan), 31.7 (NMR-Jun).
Small LDL-P: 149 (NMR-Jan), 608 (NMR-Jun).

ApoB: 120 (Jan),  107 (Jun), 94 (BHL-Jun).

In both cases pronounced LDL pattern A (large & fluffy).

What changed besides time? My diet changed a bit (not hugely), in the direction of less saturated fat and more MUFA and more carbs. A fair chunk of that additional carbs was fruits, so fructose.

The direction of lipid changes is a bit of a trade-off. Certainly LDL went down a noticeable amount. But HDL went down as well and trigs went up. Not up into worrisome territory, but still up.

The spike in small LDL-P is puzzling. It may be an error as the LDL size profile from Berkeley Heart Labs says that only 11% of my LDL particles are small and dense. Yes, I know that the definitions of what's "small" do not match -- I'll look into it further.

Still haven't done ApoE testing, but at the moment it does seem that my LDL is sensitive to the amount of saturated fat in my diet. N=1, of course.

D33a8d5f095a8532ddf7a0d6c27bfe63

(578)

on July 20, 2013
at 01:25 AM

Next time you measure your LDL or LDL-P, get FT3 measured and see if it's correlated.

D33a8d5f095a8532ddf7a0d6c27bfe63

(578)

on July 20, 2013
at 01:25 AM

Actually, now that I've looked at your labs more thoroughly, there is another strong possibility. It's your low FT3. You say it's normal but it could be low normal in response to a VLC or a low carb diet for which you may not be suited. Typically happens on a ketogenic or sub 100g carb diet. Easy way to check is look at your prior labs and compare FT3. If it was higher before, it's very likely due to carb/caloric restriction. That's why upping the carbs will kill 2 birds with one stone: i.e., if you're ApoE4 and/or if you're sensitive to LCing.

800e726cb5dff569fd8edf604c3e2793

(1655)

on July 22, 2013
at 05:11 PM

I had FT3 measured both times. Don't have the numbers at hand here, but they were average (around 3.0, I think, smack in the middle of the lab's reference range) and if anything it went a bit down between January and June...

1
3491e51730101b18724dc57c86601173

(8395)

on March 08, 2013
at 05:43 PM

I had a high-ish LDL-P (1567) too, but my other numbers looked great. I'm going to repeat the test in 6 months to see which way it's trending. For all I know it may be on its way down, as it was my first NMR.

There's no data on whether higher LDL-P might be a natural healthy response to lower carb diets, or how it correlates to risk in people following a low carb diet. I'm not necessarily taking comfort in that fact because we just don't know. But I'm not ready to panic yet, either. If I'm trending downward at 6 months that's good, but if its going up I'll have a lot to consider.

1
800e726cb5dff569fd8edf604c3e2793

on March 08, 2013
at 03:36 PM

(sorry, too new here to be allowed comments :-/)

I haven't had any bloodwork done for years and years and this is my first lipid panel ever. All tests were done from blood samples taken at the same time.

The non-NMR part of bloodwork didn't mention any cholesterol numbers, but measured ApoA (205, out of the reference range, consistent with my high HDL), ApoB, and Lp(a) which was 4.

800e726cb5dff569fd8edf604c3e2793

(1655)

on March 09, 2013
at 12:43 AM

It was a quite comprehensive bloodwork set, I guess my doctor just gave up and said "everything" :-) I do like tests which measure the same thing as I prefer multiple data points to a single one. Theoretically (there was a paper), the LDL-P number has the intraassay coefficient of variability of 4-4.5% so e.g. if the number comes out as 1900, the 95% probability interval is more or less 1800-2000. But yes, the ApoB and the LDL-P values do not exactly match. On the other hand, the pattern of low trigs, high HDL and high LDL is not exactly rare in the LC world.

Ea1bb0c24b59345463ef96880b6b27fc

(300)

on March 09, 2013
at 05:43 AM

Variability determined under research conditions is not the same as variability arising from standard labs. You can ignore the LDL-C but your particle tests are somewhat contradictory. Hence the need for one indicator measured at different times to get another picture. Your original questions identified "weird" results, so the obvious answer is to redo them.

Ea1bb0c24b59345463ef96880b6b27fc

(300)

on March 08, 2013
at 11:18 PM

It makes no sense to me that both and NMR and an ApoB/A test were ordered since both are measuring the same thing. In addition, the result is contradictory since the LDL-P is high while the ApoB is not as high. Since you may be running into lab variability issues, I would suggest picking one test and repeating it a couple more times over a period of months to get a better picture. As it stands, its hard to day anything definitive.

Ea1bb0c24b59345463ef96880b6b27fc

(300)

on March 12, 2013
at 10:15 AM

I just came across brand new research indicating that "discordance" between LDL-P and ApoB is a known phenomenon. Given that, I would repeat the NMR to be sure and then begin using it as the measure to follow. Yes, the pattern is not rare but that doesn't mean it should be ignored and it can get much, much worse. You have the choice of retesting/waiting or trying to address it now. Let us know what you want to do.

800e726cb5dff569fd8edf604c3e2793

(1655)

on March 12, 2013
at 03:11 PM

@John Could you give me a link to that discordance research? I've seen a few papers on discordance between LDL-P and LDL-C, but not ApoB. I'll probably repeat the NMR in a month or two and see what's happening with my lipids. I know how to reduce my LDL -- don't eat SFAs -- but that will also reduce my HDL and spike my trigs so I'm not sure there'll be much advantage to that. I think I'll also try to persuade my doc to run tests for FH and ApoE alleles...

800e726cb5dff569fd8edf604c3e2793

(1655)

on March 14, 2013
at 03:05 PM

@John The poster (not sure there's more than that) is here -- http://content.onlinejacc.org/article.aspx?articleid=1665624 but there's little useful information in it. To put it up as a question, hmm, I'll think about it...

Ea1bb0c24b59345463ef96880b6b27fc

(300)

on March 14, 2013
at 10:23 AM

The actual study is only reported on here: http://www.businesswire.com/news/home/20130311006185/en/Data-Links-Lipoprotein-Particles-Cardiovascular-Disease-Risk in the form of a press release. As for your comments on "not eating SFA's" your conclusion about HDL/Trig's (not to mention your actual health) does not follow. It is possible to change your diet so as to likely bring down way out of range LDL without the changes you claim but we would need an actual question to discuss this.

D33a8d5f095a8532ddf7a0d6c27bfe63

(578)

on July 11, 2013
at 03:27 AM

If you're that serious about CVD risk, I'd get a coronary calcium test for about $99. I'm willing to bet your score is close to zero, just like Jimmy Moore (i.e., no atherosclerosis). Second, get your ApoE genotype and if you happen to be ApoE4 homo or heterozygous, then incorproate safe starches to your diet. Lower your SaFA portion a bit (but not avoid it entirely). That should lower your LDL-C AND your LDL-P. But then the validity of LDL-P isn't as strong as people think; LDL-P is almost always trumped by TC/HDL and Trigs/HDL.

D33a8d5f095a8532ddf7a0d6c27bfe63

(578)

on July 11, 2013
at 03:42 AM

CVD is multifactorial. High LDL-P does not always equal severe atherosclerosis. There're intermediate steps involved, the most important of which is the role played by HDL-P. Plus, even if you have moderate atherosclerosis, your Trigs/HDL ratio protects you by keeping inflammation low.

D33a8d5f095a8532ddf7a0d6c27bfe63

(578)

on July 11, 2013
at 03:24 AM

I don't know what makes you think omitting SaFA will increase your trigs and lower HDL. SaFA may be a problem if you're ApoE4 and it could increase your LDL mainly but it could increase your HDL somewhat. But the HDL increase is marginal. Instead of repeating your NMR, why don't you get your genotype. Yes, ApoB and LDL-P could be contradictory but I tend to put more stock on TC/HDL (3.1x)and Trigs/HDL (0.6x). Based on that, your HDL does enough to keep atherosclerosis at bay, despite the large number of LDL-P going into your artery walls. Here's the solution:

800e726cb5dff569fd8edf604c3e2793

(1655)

on July 19, 2013
at 04:51 PM

Well, I now have a bit of evidence that saturated fat in my diet will affect my LDL -- see below. No, haven't checked my ApoE yet. Yes, I know that high LDL-P does not equal severe atherosclerosis. But it's a definite risk factor.

0
E1c6e8005795364ef33867073e5d4ec1

(109)

on March 08, 2013
at 03:50 PM

I just had an MNR panel as well with some similar numbers to you, with my LDL-P at 2251. My TG 31, HDL 55, LDL pattern A, small LDL-P 445 and HDL-P 31.2. LDL-C 179 and ApoB 127. C-reactive protein 1.5 mg/L. I've been Paleo about 2 years.

My doctor who I got off the Paleo physicians network suggested I take Niacin to address some of the cholesterol issues.

D33a8d5f095a8532ddf7a0d6c27bfe63

(578)

on July 11, 2013
at 03:33 AM

Same comment as above: limit SaFA, see if LDL-C goes down. If so, your TC will go down and your TC/HDL will be at an ideal ratio (sub 3.5x). Right now it's 4.4x, high enough to be concerned when LDL-P is high. But again, ApoB is low vis-a-vis LDL-P. Rather than taking Niacin, the better solution is to increase your TC/HDL by (1) lowering your LDL and by extension TC and (2) exercising. I'd pay $99 and get genes tested to confirm that you're ApoE4. No need to, however, if your LDL and TC were much lower prior to your VLC diet (judging by how low your trigs are).

0
Ea1bb0c24b59345463ef96880b6b27fc

(300)

on March 08, 2013
at 10:53 AM

An NMR does not report ApoB...when did you have this test and was it at the same or a different time from the NMR? Also, any other lipid paels yo have had would be useful before trying to address this one.

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