The mere word cholesterol gives many goose bumps. We have been indoctrinated since the well-known Framingham Studies that the higher the blood cholesterol level, the higher the risk of heart disease 1-3. However, much has been discovered in medical research since then. Today there is compelling evidence showing that strict reliance on the traditional cholesterol test that is routinely run in the clinic can falsely tell you and your doctor that you’re fine, even if you aren’t. Here you will find out what to look for…
The traditional cholesterol test
Unless you have a good doctor who keep tabs on medical research, when you do your blood work (which I hope you do regularly as a preventive measure), the traditional cholesterol test that’s part of a regular health check will only give you information on the following measurements:
– Total cholesterol level
– LDL (low-density lipoprotein, the “bad” cholesterol)
– HDL (high-density lipoprotein, the “good” cholesterol)
– Triglycerides (aka blood fats)
This traditional cholesterol test is also called the standard lipid panel. Lipid is a catch-all term for fats and cholesterol, which are characterized by their water insolubility. Hence the need for lipoproteins, which are molecules that transport cholesterol and fats in the blood. Blood cholesterol gets its name based on what particle that carries it in the blood stream. Even though you often hear discussions about bad and good cholesterol, the cholesterol in LDL and HDL is the same; the difference lies in their respective transport molecule (ie, the lipoproteins).
Doctors have historically blindly relied on this standard lipid panel (traditional cholesterol test) to assess their patients’ risk of cardiovascular disease and prescribe cholesterol lowering drugs. However, there are serious limitations in relying solely on the standard cholesterol panel. Most importantly, it can identify only about 40% of people at risk for coronary heart disease 4, and the extent of cardiovascular disease varies greatly among individuals with similar “standard” cholesterol levels 5,6. Over the past decade, an immense amount of scientific research has shown that within each cholesterol class (LDL, HDL etc) distinct subclasses exist, that confer different degrees of cardiovascular disease risk 7. For example, it is the small LDL particles that are dangerous, and not so much the larger LDL particles 8-10. This discovery has given rise to the “pattern A” and “pattern B” notations (see below) and explains why a simple total LDL level test doesn’t tell you the full story and can be misleading.
VAP – the next generation of cholesterol testing
The VAP (Vertical Auto Profile) test provides this valuable information on cholesterol/lipoprotein subclasses. The expanded information from the VAP test includes:
– More accurate, direct measurement of LDL:
The standard lipid panel only indirectly gets your LDL level by a calculation, which is fraught with questionable assumptions 11-13.
– Measurement of LDL particle number and density:
This is important because small, dense and numerous LDL particles (“Pattern B”, see below) cause a 3-fold increase in risk of a heart attack independent of the total LDL level 9,14.
– Measurement of lipoprotein subclasses and related molecules.
This includes, LDL1, LDL2 and LDL3, HDL2 and HDL3, intermediate-density lipoprotein (IDL), very-low-density lipoproteins (VLDL1, VLDL2, VLDL3), and lipoprotein(a) [ Lp(a) ], a particularly dangerous lipoprotein that can lead to heart attacks and strokes. The VAP test will also give your apo-B level; apo-B is a molecule that is attached to each LDL particle, and gives another dimension of your LDL particle number.
People who test “normal” in a standard cholesterol test often are found to be at risk for heart disease after taking the VAP test. This is because individuals with the same LDL level may have high or low numbers of LDL particles. Because LDL particle number is an independent and more sensitive indicator of risk than LDL (or non-HDL), these individuals will differ in terms of heart disease and cardiovascular risk, despite having same LDL level 8,15. This is clearly of utmost importance, for both prevention and treatment.
Nail down you LDL pattern – are you an A or B?
When you get your VAP results, all the numbers can make you dizzy. No worry, the main thing to find out is your LDL pattern. The LDL patterns A and B refer to the size of LDL cholesterol particles in the blood.
Persons with LDL pattern A have large, buoyant LDL particles. Individuals with pattern A are more likely to have normal blood levels of HD
L and triglycerides. Pattern A is usually not associated with cardiovascular risk.
Persons with LDL pattern B have predominantly small and dense LDL particles. Pattern B is frequently associated with low HDL levels, elevated triglyceride levels, and high blood sugar levels and risk for type II diabetes. Individuals with pattern B are also more likely to develop high blood triglyceride levels after a fat-rich meal (a medical condition called postprandial hyperlipidemia).
Why is this important?
Smaller LDL particles are more dangerous than the larger ones because they can more easily squeeze through the endothelium (a single cell layer that lines blood vessels) and clog up the artery walls. Smaller LDL particles also are more easily oxidized, and oxidized LDL is a significant contributor to the formation of plaques in the arteries.
More and more scientific medical research is showing that the total LDL level is not the best indicator of heart disease risk that has been attributed to LDL. The reason for this is that the risk correlates more strongly with the number of circulating atherogenic LDL particles (as can be found out in a VAP test) rather than the quantity of cholesterol carried by those particles (as shown in a standard lipid panel test) 16. If this is over your head, don’t fret; just make sure you’re a pattern A. And that’s easy because the VAP results page tell you right upfront what pattern you are, so yo u don’t have to do any calculations.
As you can see in the graphic nearby, the LDL fraction is further split into four parts; small LDL particles, large LDL particle, Lp(a) and IDL. Other than telling you whether you are an A or B (ie, whether you have a predominance of dangerous small or less dangerous large LDL particles), the VAP test report also informs you on your standing with these other variables.
Where can I get the VAP test?
If you don’t have health insurance, or if your insurance doesn’t cover it, you can easily order a VAP test for $90 from Life Extension
Here’s an explanation of all the variables you find on the VAP test
Here you can check out a sample VAP report
Other similar advance blood lipid tests
In this article I’ve covered the VAP test from Atherotec, www.thevaptest.com, which is based on the ultracentrifugation technique.
There are also other, similar advanced lipid test available. The most notable is the one based on the nuclear magnetic resonance (NMR) technique from LipoScience, www.lipoprofile.com.
Then we have a gradient gel electrophoresis based test, from Berkeley HeartLab, www.bhlinc.com, and another one based on the ion mobility technique. Since this is an intense research area, we can expect to hear about new advanced lipid test in the near future.
The point I want to make is that, unless your doctor order a specific advanced lipid test for you (buy him/her flowers if that’s the case!), pick one and stick to it. The reason being that the different tests can give you different readings. Thus, you cannot directly compare your VAP reading with an NMR reading if you do both.
You should to do your advanced lipid testing not just once, but regularly to monitor your health status, and effectiveness of your diet and exercise program etc. As of this writing, the VAP test is cheapest.
Who should you care about getting the advanced VAP cholesterol test?
Everybody! Prevention is key for healthy longevity. The “good” thing with cardiovascular disease risk factors is that if you detect them at an early stage, you can easily fix them with diet and exercise, and thereby avoid becoming a victim for heart disease, which is still the number one killer.
If your standard lipid panel shows that you have a high triglyceride level, and/or a low HDL level, you definitely should get the VAP test, since a high ratio of triglyceride/HDL is often accompanied by small LDL particle sizes 17,18. Another simple way to tell is you could be at risk is if you have a belly fat. Having a belly is not just an esthetic issue, it is also a great health risk that should be taken very seriously.
Another important indication that you should have a VAP test, is if are on statins. I am not going to get into the evils of statins here. For the purpose of this article, I just want to inform you that they are the most lucrative drug ever developed by the pharma industry, and unfortunately the first-line drug prescribed by cardiologist to treat high LDL levels. The reason you have to do a VAP test if you are on statins is that statis lower your overall LDL level more than they lower your LDL particle number 19. Thus, statins can lower your LDL level to the normal range, but still leave you with lots of deleterious LDL particles, and thereby falsely give an indication of a successful treatment. Therefore, if your doctor is only monitoring your overall LDL level while prescribing you statins, get another doctor.
Also, if you are eating loads of carbs, you definitely should have a VAP done, because it is well-documented that a high-carb diet has detrimental effects on cardiovascular risk factors. Among other things, eating lots of carbs increases both your blood fats (triglycerides) and your number of small deleterious LDL particles 20-24.
In addition, certain health promoting supplements can actually elevate your total and LDL cholesterol levels, while beneficially affect your LDL particle distribution. Notable examples are fish oil and algae oil supplements 25,26. By getting your VAP test you have your back covered if you start taking fish oil and your doctor starts pulling his hair because your LDL level has increased.
While financial investments can be risky, investing in your own health is totally risk free. And on top of that it gives you an invaluable return; health, happiness and longevity!
About the Author:
Monica Mollica has a Bachelor’s and Master’s degree in Nutrition from the University of Stockholm, Sweden, and is an ISSA Certified Personal Trainer. She works a dietary consultant, health journalist and writer for www.BrinkZone.com, and is also a web designer and videographer.
Monica has admired and been fascinated by muscular and sculptured strong athletic bodies since childhood, and discovered bodybuilding as an young teenager. Realizing the importance of nutrition for maximal results in the gym, she went for a BSc and MSc with a major in Nutrition at the University.
During her years at the University she was a regular contributor to the Swedish bodybuilding magazine BODY, and she has published the book (in Swedish) “Functional Foods for Health and Energy Balance”, and authored several book chapters in Swedish publications.
It was her insatiable thirst for knowledge and scientific research in the area of bodybuilding and health that brought her to the US. She has completed one semester at the PhD-program “Exercise, Nutrition and Preventive Health” at Baylor University Texas, at the department of Health Human Performance and Recreation, and worked as an ISSA certified personal trainer. Today, Monica is sharing her solid experience by doing dietary consultations and writing about topics related to health, fitness, bodybuilding, anti-aging and longevity.
1. Castelli WP, Anderson K, Wilson PW, Levy D. Lipids and risk of coronary heart disease. The Framingham Study. Annals of epidemiology. Jan-Mar 1992;2(1-2):23-28.
2. Brown MS, Goldstein JL. A receptor-mediated pathway for cholesterol homeostasis. Science. Apr 4 1986;232(4746):34-47.
3. Castelli WP, Anderson K. A population at risk. Prevalence of high cholesterol levels in hypertensive patients in the Framingham Study. The American journal of medicine. Feb 14 1986;80(2A):23-32.
4. Superko HR. Did grandma give you heart disease? The new battle against coronary artery disease. The American journal of cardiology. Nov 5 1998;82(9A):34Q-46Q.
5. Freedman DS, Croft JB, Anderson AJ, et al. The relation of documented coronary artery disease to levels of total cholesterol and high-density lipoprotein cholesterol. Epidemiology. Jan 1994;5(1):80-87.
6. Grover SA, Coupal L, Hu XP. Identifying adults at increased risk of coronary disease. How well do the current cholesterol guidelines work? JAMA : the journal of the American Medical Association. Sep 13 1995;274(10):801-806.
7. Packard CJ, Shepherd J. Lipoprotein heterogeneity and apolipoprotein B metabolism. Arteriosclerosis, thrombosis, and vascular biology. Dec 1997;17(12):3542-3556.
8. Cromwell 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. Journal of clinical lipidology. Dec 2007;1(6):583-592.
9. Austin MA, Breslow JL, Hennekens CH, Buring JE, Willett WC, Krauss RM. Low-density lipoprotein subclass patterns and risk of myocardial infarction. JAMA : the journal of the American Medical Association. Oct 7 1988;260(13):1917-1921.
10. Lamarche B, Lemieux I, Despres JP. The small, dense LDL phenotype and the risk of coronary heart disease: epidemiology, patho-physiology and therapeutic aspects. Diabetes & metabolism. Sep 1999;25(3):199-211.
11. Sniderman AD, Blank D, Zakarian R, Bergeron J, Frohlich J. Triglycerides and small dense LDL: the twin Achilles heels of the Friedewald formula. Clinical biochemistry. Oct 2003;36(7):499-504.
12. Wang TY, Haddad M, Wang TS. Low triglyceride levels affect calculation of low-density lipoprotein cholesterol values. Archives of pathology & laboratory medicine. Mar 2001;125(3):404-405.
13. Ahmadi SA, Boroumand MA, Gohari-Moghaddam K, Tajik P, Dibaj SM. The impact of low serum triglyceride on LDL-cholesterol estimation. Archives of Iranian medicine. May 2008;11(3):318-321.
14. Lamarche B, Tchernof A, Moorjani S, et al. Small, dense low-density lipoprotein particles as a predictor of the risk of ischemic heart disease in men. Prospective results from the Quebec Cardiovascular Study. Circulation. Jan 7 1997;95(1):69-75.
15. Superko HR, Gadesam RR. Is it LDL particle size or number that correlates with risk for cardiovascular disease? Current atherosclerosis reports. Oct 2008;10(5):377-385.
16. Davidson MH, Ballantyne CM, Jacobson TA, et al. Clinical utility of inflammatory markers and advanced lipoprotein testing: advice from an expert panel of lipid specialists. Journal of clinical lipidology. Sep-Oct 2011;5(5):338-367.
17. Grundy SM, Vega GL, Tomassini JE, Tershakovec AM. Comparisons of apolipoprotein B levels estimated by immunoassay, nuclear magnetic resonance, vertical auto profile, and non-high-density lipoprotein cholesterol in subjects with hypertriglyceridemia (SAFARI Trial). The American journal of cardiology. Jul 1 2011;108(1):40-46.
18. McLaughlin T, Reaven G, Abbasi F, et al. Is there a simple way to identify insulin-resistant individuals at increased risk of cardiovascular disease? The American journal of cardiology. Aug 1 2005;96(3):399-404.
19. Sniderman AD. Differential response of cholesterol and particle measures of atherogenic lipoproteins to LDL-lowering therapy: implications for clinical practice. Journal of clinical lipidology. Feb 2008;2(1):36-42.
20. Faghihnia N, Tsimikas S, Miller ER, Witztum JL, Krauss RM. Changes in lipoprotein(a), oxidized phospholipids, and LDL subclasses with a low-fat high-carbohydrate diet. Journal of lipid research. Nov 2010;51(11):3324-3330.
21. Krauss RM. Dietary and genetic probes of atherogenic dyslipidemia. Arteriosclerosis, thrombosis, and vascular biology. Nov 2005;25(11):2265-2272.
22. Dreon DM, Fernstrom HA, Miller B, Krauss RM. Low-density lipoprotein subclass patterns and lipoprotein response to a reduced-fat diet in men. The FASEB journal : official publication of the Federation of American Societies for Experimental Biology. Jan 1994;8(1):121-126.
23. Parks EJ, Hellerstein MK. Carbohydrate-induced hypertriacylglycerolemia: historical perspective and review of biological mechanisms. The American journal of clinical nutrition. Feb 2000;71(2):412-433.
24. Kasim-Karakas SE, Lane E, Almario R, Mueller W, Walzem R. Effects of dietary fat restriction on particle size of plasma lipoproteins in postmenopausal women. Metabolism: clinical and experimental. Apr 1997;46(4):431-436.
25. Maki KC, Van Elswyk ME, McCarthy D, et al. Lipid responses to a dietary docosahexaenoic acid supplement in men and women with below average levels of high density lipoprotein cholesterol. Journal of the American College of Nutrition. Jun 2005;24(3):189-199.
26. Neff LM, Culiner J, Cunningham-Rundles S, et al. Algal docosahexaenoic acid affects plasma lipoprotein particle size distribution in overweight and obese adults. The Journal of nutrition. Feb 2011;141(2):207-213.