It’s Not about Achieving Normal Cholesterol Levels, It’s about Achieving the Right Kind of Cholesterol

You may have heard this cholesterol statistic by now, but it’s worth repeating: at least half, if not more, of people who have heart attacks have normal cholesterol levels. Results from a large study out of UCLA, published in 2009 in the American Heart Journal, confirmed this, finding that half of the patients with a history of heart disease had LDL cholesterol levels lower than 100 mg/dL.

The UCLA study’s authors admitted that current cholesterol guidelines “are thus not effectively identifying the majority of individuals who will develop fatal and non-fatal cardiovascular events.” Its principal investigator, Dr. Gregg Fonorow, suggested that the current guidelines for LDL may not be low enough to cut heart attack risk. 

But wait. Is this really the way to cut heart attack risk, by continuing to recommend lower and lower LDL cholesterol level cutoffs, leading to more and more people on higher and higher doses of statins? While this may be the answer for those with previous heart attacks, an extensive number of research studies now suggest that for the majority of us, the focus needs to come off normal cholesterol levels. Instead, the top cardiovascular researchers say we need to pay more attention to whether or not we have the right kind of cholesterol.

Cholesterol types – the good, the bad….. and the really ugly

By now, many understand that not all cholesterol is the same. There is the “good” HDL (High Density Lipoprotein) cholesterol and the “bad” LDL (Low Density Lipoprotein) cholesterol. However, there is much more to the cholesterol story. The gist: different types of HDL and LDL exist and some are much more dangerous than others.

Since cholesterol is a fat, it does not dissolve in water. To circulate in the blood, which is mostly water, cholesterol must be wrapped in a protein shell to form a lipoprotein. The protein shell is like a container that carries the cholesterol throughout the body.  The lipoprotein is the combination of the cholesterol (lipid) and the protein shell. These lipoprotein particles contain about 50 percent cholesterol.  It is the lipoprotein particles, not necessarily the cholesterol within them, that are responsible for key steps in plaque production and the resulting development of cardiovascular disease.

Lipoprotein particle number more important than normal cholesterol level

The LDL particles are particularly worrisome. The higher the number of LDL particles, the more likely they are to break through the wall of the arteries and form plaque that causes atherosclerosis. Cardiovascular risk increases with a higher LDL particle count. With a higher LDL particle count the probability of particle penetration of the arterial wall rises, regardless of the total amount of cholesterol contained in each particle.

It is very possible for you to have normal cholesterol levels but a much higher than expected lipoprotein particle number, and hence a much greater actual risk. In fact, this condition, which is sometimes called “cholesterol-depleted LDL,” is thought to occur in more than 30 percent of the population. It is especially common if your triglycerides are high or HDL is low. In the population with a cholesterol-depleted LDL, there can be up to a 40 percent chance your risk won’t be identified correctly using standard cholesterol tests.

LDL particle size and density most important for determining risk

What’s more, LDL and HDL particles are not present in the circulation as single, well-defined structures; rather they are present as a continuum of size and density. Some particles appear large, while others are small and dense. The most dangerous are the small, dense LDL particles. They are better able to slip through the cells that line the walls of arteries, easily penetrating your arteries. Large, fluffy cholesterol particles are practically harmless–even if your total cholesterol is high. Because they are big and buoyant they easily bounce off the arteries, causing no harm.

The presence of small, dense LDL quadruples the risk of heart disease compared with the same total LDL concentration present in a large, buoyant form. Studies show that people whose LDL cholesterol is predominantly small and dense have a threefold greater risk of coronary heart disease. Other studies suggest that determining the number of small, dense particles in the blood predicts the risk of heart disease more accurately than simply measuring total LDL cholesterol.

Unfortunately, measurement of normal cholesterol levels on the standard cholesterol test does not reflect the actual particle numbers or tell you about the size and density of the particles. To better determine your cardiovascular risk, you need a more sophisticated test to find out your actual lipoprotein particle number and assess the size and density of your particles. The good news is that these types of tests are becoming more and more available and popular.

There are several types of these more sophisticated, advanced cholesterol tests, including the VAP (Vertical Auto Profile), the LPP (Lipoprotein Particle Profile), and the NMR Liporofile. Others are also available. These labs can be ordered by your doctor and some are covered by insurance. They are also available directly to anyone via a number of online “direct access laboratory testing” sites such as DirectLabs and Life Extension.

Steps to achieving the right kind of cholesterol

The factors these advanced tests measure are very important for going beyond normal cholesterol levels in order to fully differentiate the risk of your cholesterol and track your treatment. The first step is getting the test and determining your baseline. Then, if needed, you can take the necessary steps to transform your cholesterol from being small dense and dangerous to light and fluffy and innocuous. For almost everyone, this can be achieved through specific targeted nutrient therapy (Vitamin B3 or others) and through other natural healing protocols. For the specific details you will need to learn  how to use natural medicine to achieve the right kind of cholesterol, visit our  Heart Health resources.


[1] Brunzell JD, Davidson M, Furberg, CD, et al. LipoProtein Management in Patients with Cardiometabolic Risk. J. Am Coll. Cardiol. 2008;51;1512-24.

[2] Capuzzi D, Carey C, Lincoff A, Morgan J. High-density Lipoprotein Subfractions and Risk of Coronary Artery Disease. Current Atherosclerosis Reports. 2004;6:359-365

[3] Champeau R. Most heart attack patients’ cholesterol levels did not indicate cardiac risk. UCLA Newsroom. Jan 11, 2009.

[4] Crowell WC, Otvos JD, Keyes MJ, et. al. LDL particle number and risk of future cardiovascular disease in the Framingham Offspring Study – Implications for LDL management. J.Clin Lipidology, 2007;1(6):583-592.

[5] Fortmann S, Gardner C, Krauss R. Association of small low-density lipoprotein particles with the incidence of coronary artery disease in men and women. JAMA. 1996; 276(11); pages 875-881

[6] Otvos JD, Mora S., Shalaurova I, et al. Clinical Implications of Discordance Between LDL Cholesterol and LDL Particle Number. J.Clin Lipidology, 2011;5(2):105-113.

[7] Otvos J. Why Cholesterol Measurements May be Misleading about Lipoprotein Levels and Cardiovascular Disease Risk – Clinical Implications of Lipoprotein Quantification Using NMR Spectroscopy. J Lab Med. 2002;26(11/12):544-550

[8] Packard CJ. Small dense low-density lipoprotein and its role as an independent predictor of cardiovascular disease. Curr Opin Lipidol. 2006;17(4):412-7

[9] Sachdeva A, Cannon CP, Deedwania PC, Labresh KA, Smith SC Jr, Dai D, Hernandez A, Fonarow GC. Lipid levels in patients hospitalized with coronary artery disease: an analysis of 136,905 hospitalizations in Get With The Guidelines. Am Heart J. 2009 Jan;157(1):111-117.e2.

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