Re: Question for Quentin (cholesterol ratios)

On Tue, 21 Mar 2006 08:36:50 +1200, Quentin Grady
<quentin@xxxxxxxxxxxxxxx> wrote:

This post not CC'd by email
On Mon, 20 Mar 2006 10:37:55 -0500, bittersweet
<bittersweet@xxxxxxxxxxxxxxxx> wrote:

Hello--

A brief history/intro:
Type II for 5 years
Age: mid 40's
Rx: 500 mg Metformin twice a day; 40 mg Lipitor
Weight at dx: > 220 lb
Weight for last 2 years: 110-115 lb (height 5'2")
A1c at dx: 7.4
Last 3 A1c readings (covering 2 years): 5.1 each time
FBG at dx: 146 mg/dL
FBG for last 2 years: usually ~75
2-hour PP BG: usually 85-90
annual liver/kidney/eye tests: all normal
D&E: low carb and lots of walking

(I lurked here briefly for a while several years ago, and found lots
of useful information -- thank you, everyone -- but eventually I
stopped reading.)

I have a question for Quentin. I remember reading a long time in a
post of his about what some good target values were for ratios of the
various forms of cholesterol.

With help of Lipitor and lifestyle changes, my cholesterol has
improved, as shown below.

Then:
Total: 205 mg/dL
HDL: 40
LDL: 136
trig: 150
total/HDL: 5.125
LDL/HDL: 3.4
trig/HDL: 3.625

Now:
Total: 175 (target: <200)
HDL: 58 (target: > 50)
LDL: 102 (target: < 100)
trig: 75 (target: < 150)
total/HDL: 3.02 (target: < 4)
LDL/HDL: 1.76 (target: < 3)
trig/HDL: 1.29 (target: < 2)

My question is about the target ratios -- are those correct, and where
do they come from? I just wrote them down in a spreadsheet a long
time ago and have been using them ever since for tracking, but I don't
really remember the source. The reason I'm wondering is that my
doctor is concerned about my LDL being over the target of 100, but to
me it seemed okay because the ratios looked good. But I didn't have
anything official to show her to back it up.

thanks.

--bittersweet


G'day G'day Bittersweet,

Thank goodness I had a good nights sleep before waking to a challenge
like this. I'm not a doctor. I don't have your full medical history
and family history etc that your doctor has. All I can offer is to
look at it for whatever educational value there might be in it for us
all.

Thank you very much for your detailed reply, Quentin -- I hope you
were able to cut & paste a lot of this. I certainly didn't mean to
make you type this much!


Firstly let me compliment you on your achievements which are
considerable. You have RAISED your HDL from 40 to 58. That is a 45%
rise. Raising HDL is difficult. For me it has been next to
impossible. My GP says that is genetic. I once walked up Dobell hill
for most days of a month in order to push up HDL by the standard
techniques of exercise and more exercise. I got fitter but the HDL
did not budge. Since I didn't smoke, I couldn't give up smoking.
Initial weightloss had helped by a few percent. What I'm trying to
say here and perhaps not to elegantly is that you have made a
considerable improvement to you expected future health and it shows
even when we look at one single aspect of your blood test.

Thanks -- I'm not sure whether it's changes in diet or exercise or the
Lipitor that pushed the HDL up -- or possibly a combination of all
three (although it doesn't sound like the Lipitor would have made much
of a contribution). That, plus the genetics, as you mention. It has
been a long slow climb for the HDL, with it creeping up a bit every
year.


If we look at TG:HDL we see you have gotten a ratio of 1.3 That is
phenomenal. Statins often help with the LDL and even HDL but often
don't do jack for the triglycerides. Most people are happy if with
American units they get below 3. Can you see me smiling wryly as I
notice that you have set the IDEAL goal of under 2 as YOUR goal.
Doctors don't often use TG:HDL as a predictive ratio.
IMHO they should.

I don't know where I got the target of "2" from -- it could be that I
meant to type "3" in the spreadsheet and it was a simple typo! Well,
better to err in that direction, I guess -- I'll leave it at 2 :-)


Please excuse the lengthy explanation.

Risk of coronary heart disease is somewhat loosely correlated with
cholesterol levels. Even LDL levels have only a relatively loose
correlation. The hidden reason is that some LDL is more dangerous
than some other LDL. The body recognises danger. It responds to
danger. When LDL is oxidised the body produces antibodies to this
oxidised LDL. This is the LDL the body knows to get rid of to ensure
survival. How the antibodies recognise the oxidised LDL I don't know.
How we can recognise oxidised LDL is somewhat simpler. The oxidised
LDL is smaller and denser. It is known in the literature as sd-LDL.
It is well established that sd-LDL has TWICE the risk factor of LDL.

I hadn't heard of sd-LDL -- is it the same thing as VLDL?


How can one know whether one's LDL is predominantly sd-LDL?

The question isn't academic in your case.

Statins tend to reduce the levels of the big fluffy relatively
harmless LDL first. The sd-LDL is the nasty stuff that statins don't
get so well unless one ups the dose of statin or uses a superstatin.
In your case there are grounds for confidence in your having gotten to
the sd-LDL It is that fabulously low TG:HDL ratio.
Run it past your thinking again and again.

Your TG:HDL ratio is fabulous, better than what is regarded as ideal.
It is a powerful indicator that your LDL is not sd-LDL.

Ah, this is good to know. Thank you.


These days I don't much like discussing cholesterol. The reason is
that by itself it correlates relatively poorly with CHD. When
cholesterol lowering drugs were introduced they reduced cholesterol
but didn't reduce CHD deaths. That was until statins entered the
scene. Statins worked to reduce cholesterol. Statins worked to reduce
CHD mortality BETTER than could be accounted for by the cholesterol
hypothesis. It was obvious to all in sundry who bothered to look at
the situation that it was doing something else, something MORE
IMPORTANT than lowering cholesterol which lowered morbidity. When the
pharmaceutical companies became aware that statins weren't initially
getting the sd-LDL their response was to advocate lower levels of
acceptable LDL. It's not a bad strategy though it is reminiscent of
the management motto, "When the screw won't turn, buy a bigger
hammer."

Research on statins has preceded in many directions eg reduction of
deaths from flu. Statins appear to work in the field of inflammation.
The latest recommendations for diabetics appear to be to recommend
statins when either LDL is higher than 70 or C-reactive protein is
above 2 ppm (Two parts per million) CRP is a marker for silent
inflammatory disease. We didn't hear anything much of the C-reactive
protein, CRP until the statin manufacturers found they were the
pharmaceutical answer to them. Strange that.

The nutritional answer has been around for yonks. Eat greens cooked
with olive oil and/or use high grade canola or mustard seed oil that
hasn't been partially hydrogenated for cooking. Oh, and there are the
other anti-inflammatory strategies to be found in nutrition. Lowering
blood glucose is an important part of that. It is hardly surprising
that A1c has been found by some researchers to be a better predictor
of arterial health than cholesterol.

Again, thank you very much for that very detailed reply. I will be
re-reading it several times.

--bittersweet



.

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