#1 What is cholesterol?

#2 What is the relationship between the cholesterol we eat and the cholesterol in our
body?
#3 Is cholesterol bad?
#4 How does cholesterol move around our body?
#5 How do we measure cholesterol?
#6 How does cholesterol actually cause problems?
#7 Does the size of an LDL particle matter?
In this post well continue to build out the story with the next concept:
#8 Why is it necessary to measure LDL-P, instead of just LDL-C?
1. Cholesterol is just another fancy organic molecule in our body but with an interesting
distinction: we eat it, we make it, we store it, and we excrete it all in different amounts.
2. The pool of cholesterol in our body is essential for life. No cholesterol = no life.
3. Cholesterol exists in 2 forms unesterified or free (UC) and esterified (CE) and the
form determines if we can absorb it or not, or store it or not (among other things).
4. Much of the cholesterol we eat is in the form of CE. It is not absorbed and is excreted by
our gut (i.e., leaves our body in stool). The reason this occurs is that CE not only has to
be de-esterified, but it competes for absorption with the vastly larger amounts of UC
supplied by the biliary route.
5. Re-absorption of the cholesterol we synthesize in our body (i.e., endogenous produced
cholesterol) is the dominant source of the cholesterol in our body. That is, most of the
cholesterol in our body was made by our body.
6. The process of regulating cholesterol is very complex and multifaceted with multiple
layers of control. Ive only touched on the absorption side, but the synthesis side is also
complex and highly regulated. You will discover that synthesis and absorption are very
interrelated.
7. Eating cholesterol has very little impact on the cholesterol levels in your body. This
is a fact, not my opinion. Anyone who tells you different is, at best, ignorant of this
topic. At worst, they are a deliberate charlatan. Years ago the Canadian Guidelines
removed the limitation of dietary cholesterol. The rest of the world, especially the United
States, needs to catch up. To see an important reference on this topic, please look here.
8. Cholesterol and triglycerides are not soluble in plasma (i.e., they cant dissolve in water)
and are therefore said to be hydrophobic.
9. To be carried anywhere in our body, say from your liver to your coronary artery, they
need to be carried by a special protein-wrapped transport vessel called a lipoprotein.

10. As these ships called lipoproteins leave the liver they undergo a process of maturation
where they shed much of their triglyceride cargo in the form of free fatty acid, and
doing so makes them smaller and richer in cholesterol.
11. Special proteins, apoproteins, play an important role in moving lipoproteins around the
body and facilitating their interactions with other cells. The most important of these are
the apoB class, residing on VLDL, IDL, and LDL particles, and the apoA-I class,
residing for the most part on the HDL particles.
12. Cholesterol transport in plasma occurs in both directions, from the liver and small
intestine towards the periphery and back to the liver and small intestine (the gut).
13. The major function of the apoB-containing particles is to traffic energy (triglycerides) to
muscles and phospholipids to all cells. Their cholesterol is trafficked back to the liver.
The apoA-I containing particles traffic cholesterol to steroidogenic tissues, adipocytes
(a storage organ for cholesterol ester) and ultimately back to the liver, gut, or
steroidogenic tissue.
14. All lipoproteins are part of the human lipid transportation system and work harmoniously
together to efficiently traffic lipids. As you are probably starting to appreciate, the
trafficking pattern is highly complex and the lipoproteins constantly exchange their core
and surface lipids.
15. The measurement of cholesterol has undergone a dramatic evolution over the past 70
years with technology at the heart of the advance.
16. Currently, most people in the United States (and the world for that matter) undergo a
standard lipid panel, which only directly measures TC, TG, and HDL-C. LDL-C is
measured or most often estimated.
17. More advanced cholesterol measuring tests do exist to directly measure LDL-C (though
none are standardized), along with the cholesterol content of other lipoproteins (e.g.,
VLDL, IDL) or lipoprotein subparticles.
18. The most frequently used and guideline-recommended test that can count the number of
LDL particles is either apolipoprotein B or LDL-P NMR, which is part of the NMR
LipoProfile. NMR can also measure the size of LDL and other lipoprotein particles,
which is valuable for predicting insulin resistance in drug nave patients, before changes
are noted in glucose or insulin levels.
19. The progression from a completely normal artery to a clogged or atherosclerotic one
follows a very clear path: an apoB containing particle gets past the endothelial layer into
the subendothelial space, the particle and its cholesterol content is retained, immune cells
arrive, an inflammatory response ensues fixing the apoB containing particles in place
AND making more space for more of them.
20. While inflammation plays a key role in this process, its the penetration of the
endothelium and retention within the endothelium that drive the process.
21. The most common apoB containing lipoprotein in this process is certainly the LDL
particle. However, Lp(a) and apoB containing lipoproteins play a role also, especially in
the insulin resistant person.
22. If you want to stop atherosclerosis, you must lower the LDL particle number.
23. At first glance it would seem that patients with smaller LDL particles are at greater risk
for atherosclerosis than patients with large LDL particles, all things equal.
24. A particle is a particle is a particle. If you dont know the number, you dont know the
risk.

25. To address this question, however, one must look at changes in cardiovascular events or
direct markers of atherosclerosis (e.g., IMT) while holding LDL-P constant and then
again holding LDL size constant. Only when you do this can you see that the
relationship between size and event vanishes. The only thing that matters is the number
of LDL particles large, small, or mixed.

Concept #8 Why is it necessary to measure LDL-P, instead of just LDL-C?

In the growing list of reasons why I used to refer to myself as chick-repellant in college, I have
a confession to make: I find the topic of statistical concordance and discordance to be so
exciting, I sometimes have a hard time containing myself. This may explain the paucity of
girlfriends in college. Let me use an example to illustrate the distinction between these
terms. Lets say you want to predict the change in home prices in the following year (I used to
model this for a living). There are at least a dozen parameters linked to this, including: GDP
growth, unemployment, interest rates (both short term and long term, though to different
degrees), housing inventory (i.e., how many houses are on the market), housing absorption (i.e.,
how quickly houses go from being on the market to being sold), major stock indices, and
consumer confidence. Historically, from the mid-1990s until about the fourth quarter of 2006,
this worked like clockwork. While each of these variables had differing strengths of predicting
changes in home prices, they all moved together. For example, when GDP growth was robust,
unemployment was low, interest rates were modest, housing inventories were about 60 to 90
days, etcetera. All of these variables pointed to a predictable change in home values.
Around Q42006 (i.e., last 3 months of 2006), one of these variables began to deviate from the
others. The details arent important, but the point is one variable began to suggest home prices
would fall while the others all pointed to a continued rise. Prior to Q42006 these parameters
were said to be concordant they all predicted the same thing either up or down. By 2007,
they became discordant one variable said the sky was falling while others said everything was
fine.
This was true on the micro level, too. [What I described above is called macro level.] As a
lender, it should be very important to know the risk of each and every loan you make (clearly
this was part of the root problem in the age of mass securitization). Will this person pay the loan
back or will they default?
Same game here, but now a new set of even greater variables. As a lender, if I want to know if
YOU will default, I will want to know a lot of things about you, such as your agency credit risk
scores, your bank account activity, payroll activity, how much youre borrowing relative to the
value of your house, where your house is located, and about 50 other things (literally).
Not surprisingly, the same thing that happened on the macro side happened on the micro side. It
became difficult to predict who would default and would not default because there were so many
variables to consider and lenders didnt know which ones were still predictive. The models that
predict default are very sensitive to the balance of these inputs. When all of the variables are

concordant, their accuracy is prophetic, as was the case from the mid-1990s until late
2006. When some variables become discordant with each other, especially variables that were
historically concordant with each other, really bad stuff happens, as became evident to me,
personally, one Thursday afternoon in November 2007. It became clear the sky was about to
fall. And, of course, it did.

What does real estate have to do with atherosclerosis?

Fortunately, predicting heart disease is a little easier than predicting changes in home prices. Its
not perfect, of course, but its pretty good. Why is it not perfect? For one thing, we cant do the
perfect experiment. The perfect experiment would look something like this:
Take 100,000 people and randomize them into four matched groups, A, B, C, and D. Wave a
magic wand (you can see why this experiment hasnt been and wont be done) and give the
folks in Group A an LDL particle concentration of, say, 700 nmol/L; those in Group B you give
1,200 nmol/L; those in Group C you give 1,600 nmol/L; and those in Group D get 2,000
nmol/L.
In our dream world, due to the randomization process, these four groups would be statistically
identical in every way except one they would, thanks to our magic wand, have a different
number of LDL particles. We would follow them without further intervention for 10 years and
then compare their rates of heart disease, stroke, and death.
There are some areas in medicine where we can do such experiments. But, we cant do this
experiment for this question. Even when we do the next best thing give people a drug that
lowers their LDL-P and measure the impact of this intervention there is always a chance
weve done something in addition to just lowering LDL-P. If youve been reading this series,
you no doubt know my thoughts on this: while other factors are likely to be involved the
pathogenesis of atherosclerosis (e.g., endothelial health, normal versus abnormal
inflammatory response) the primary driver of atherosclerosis is the number of apoB
trafficking lipoproteins in circulation, of which LDL particles are the vast majority.
The data below should further clarify this association.

What do concordant LDL-C and LDL-P values look like?

Among the two largest studies tracking the association between cholesterol and atherosclerotic
mortality are the Framingham study and the MESA trial (the two largest trials were AMORIS
and INTERHEART). The figure below, which Ive graciously borrowed from Jim Otvos, shows
the risk stratification of LDL-C (top) and LDL-P (bottom) from the Framingham study and
MESA trial, respectively. As you can see, conveniently, LDL-C values in mg/dL are about 10x
off from LDL-P values in nmol/L. In other words, in the Framingham population, the 20th

percentile value of LDL-C was 100 mg/dL, while the MESA trial found the 20th percentile of the
population to have an LDL-P concentration of 1,000 nmol/L. As you will see by the end of this
post, this rule of the thumb should never be used to infer LDL-P from LDL-C.

If this were always the case that is, if LDL-C and LDL-P were always concordant we could
conclude that LDL-C and LDL-P would be of equal value in predicting heart
disease. Obviously this is not the case, or I wouldnt be making such a fuss over the
distinction. But how bad is it?

What do discordant LDL-C and LDL-P values look like?

The figure below, from the Journal of Clinical Lipidology, shows the cumulative incidence of
cardiovascular events (e.g., myocardial infarction, death) over time in three sub-populations:
1. Those with concordant LDL-P and LDL-C (black line);
2. Those with discordant LDL-P and LDL-C (LDL-P>LDL-C, shown by the red line);
3. Those with discordant LDL-P and LDL-C (LDL-P<LDL-C, shown by the blue line).

This analysis was done using a Cox proportional hazard model and was adjusted for age, sex,
and race. The steeper the line the more people in that sub-population died or experienced
adverse cardiac events relative to other sub-populations. In other words, the folks in the red
group had the worst outcomes, followed by the folks in the black group, followed by the folks in
the blue group.

What can we infer from these data?

First, we confirm what I alluded to above. Namely, that a non-zero percent of the population do
not have LDL-C and LDL-P values that predict the same level of risk. However, and perhaps
more importantly, we get another look at an important theme of this series: LDL-P is driving
atherosclerotic risk, not LDL-C. If LDL-P and LDL-C were equally bad even when
discordant you would expect the blue line to be as steep as the red line (and both to be steeper
than the black line). But this is not the case.
Lets look at these data parsed out another way. Below we see the four possible subgroups, from
the top:
1. Not low LDL-P, low LDL-C (red line);

2. Not low LDL-P, not low LDL-C (yellow line);

3. Low LDL-P, low LDL-C (black line); and
4. Low LDL-P, not low LDL-C (blue line).
Note that low is defined below the 30th percentile and not low is defined as greater than 30th
percentile for each variable. This figure is even more revealing than the one above. Again, it
demonstrates the frequency of discordance (about 20% in this population with these cut-off
points), and it shows the importance of LDL-Ps predictive power, relative to that of LDL-C.
In fact, though not statistically significant, the highest risk group has high LDL-P and actually
has low LDL-C (Ill give you a hint of why, below) while the lowest risk group has low LDL-P
and not-low LDL-C. *This is not a typo.

The highest risk and lowest risk groups are those with discordant LDL-C and LDL-P. The high
risk group has high LDL-P and low LDL-C, while the lowest risk group has high LDL-C
with low LDL-P. Only a minority of physicians would know that there is a segment of the
population with elevated LDL-C who are at low risk! The same conclusion will be drawn from
the next study.
Lets look at an even longer-term follow up study, below. This study followed a Framingham
offspring cohort of about 2,500 patients over a median time period of almost 15 years in each of
the four possible groups (i.e., high-high, high-low, low-high, and low-low) and tracked eventfree survival. In this analysis the cut-off points for LDL-P and LDL-C were the median
population values of 1,414 nmol/L and131 mg/dL, respectively. So high implies above these

values; low implies below these values. Kaplan-Meier survival curves are displayed over a 16
year period the steeper the slope of the line the worse the outcome (survival).

The same patterns are observed:

1. LDL-P is the best predictor of adverse cardiac events.
2. LDL-C is only a good predictor of adverse cardiac events when it is concordant with
LDL-P; otherwise it is a poor predictor of risk.
Amazingly the persons with the worst survival had low (below median) LDL-C but high LDLP. The patients most likely to have high LDL-P with unremarkable or low LDL-C are those with
either small LDL particles, or TG-rich / cholesterol poor LDL particles, or both (e.g., insulin
resistant patients, metabolic syndrome patients, T2DM patients). This explains why small
LDL particles, while no more atherogenic on a per particle basis than large particles, are a
marker for something sinister.

Populations where LDL-P and LDL-C discordance are even more prevalent
As I described above, the discordance between LDL-P and LDL-C is exacerbated in patients
with metabolic syndrome. The figure below, MESA data, again borrowed from Jim Otvos,
presents this difference in an elegant way. The horizontal axes show LDL-P concentration in the
usual units, nmol/L.

Patients with LDL-C between 100 and 118 mg/dL (i.e., second quartile of risk: 25th to 50th
percentile) are shown without metabolic syndrome (top) and with metabolic syndrome
(bottom). In the patients without metabolic syndrome, LDL-C under-predicts cardiac risk 22%
of the time, consistent with the population data I have shown you earlier. However, when you
look at the patients with metabolic syndrome, you can see that 63% of the time their risk of
cardiac disease is under-predicted. Again, not a typo.
There are so many subsets and cut-off points that I could devote ten more posts to showing you
every one of these analyses. Let me finish this point with the most recent, hot-off-the-press
(actually, still in press in the American Journal of Cardiology, though you can get a preprint
here) analysis of which Tom Dayspring is one of the authors.

These data were collected from nearly 2,000 patients with diabetes who presented with perfect
standard cholesterol numbers: LDL-C < 70 mg/dL; HDL-C > 40 mg/dL; TG <150
mg/dL. However, only in 22% of cases were their LDL-P concordant with LDL-C. That is, in
only 22% of cases did these patients have an LDL-P level below 700 nmol/L.
Remember, LDL-C < 70 mg/dL is considered VERY low risk the 5th percentile. Yet, by LDLP, the real marker of risk, 35% of these patients had more than 1,000 nmol/L and 7% were high

risk. When you do this analysis with the same group of patients stratified by less stringent LDLC criteria (e.g., <100 mg/dL) the number of patients in the high risk group is even higher.
The real world tragedy: 90-95% of physicians, including cardiologists, would bet their own
lives that persons with an LDL-C < 70 mg/dL have no atherosclerotic risk.
Tim Russert, shortly before his death, had his LDL-C level checked. It was less than 70
mg/dL. Sadly, his doctors didnt realize they should also have been checking his LDL-P or
apoB. The figure below, which is from one of Tom Daysprings presentations, shows data from
this study of nearly 137,000 patients hospitalized for coronary artery disease between 2000 and
2006. As you can see, LDL-C fails to even reasonably predict cardiovascular disease in a
patient population sick enough to show up in the hospital with chest pain or outright myocardial
infarction.

Why are LDL-C and LDL-P so often discordant?

Think back to what you learned in a previous post in this series. LDL particles traffic not only
cholesterol ester but also triglycerides. Each and every LDL particle has a variable number of
cholesterol molecules which, because of constant particle remodeling, is constantly changing. In
other words, of the several quadrillion LDL particles floating in your plasma, no two are carrying
the exact same number of cholesterol molecules. It takes many more cholesterol-depleted LDL
particles than cholesterol-rich LDL particles to traffic a given cholesterol mass (i.e., number of
cholesterol molecules) per volume of plasma (i.e., per dL). Core cholesterol mass is related to
both LDL particle size (the volume of a sphere is a third power of the radius it can take 4070% more small particles than large LDL particles to traffic a given cholesterol mass) and the
number of TG molecules per LDL particle.

TG molecules are larger than cholesterol ester molecules, so as the number of TG molecules per
particle increases, the number of cholesterol molecules will be less in a very non-linear
manner. Regardless of size it takes many more TG-rich LDL particles (which are necessarily
cholesterol-depleted) to traffic a given cholesterol mass than TG-poor LDL particles. The
persons with the highest LDL particles typically (though not always) have small LDL particles
that are TG-rich. These are incredibly cholesterol-depleted LDL particles.

Summary
Take a look at this figure below from the 2011 Otvos et al. paper I referenced above. Its a
scatterplot of each data point (i.e., patient) in the study. The solid red line shows perfect
concordance between LDL-P and LDL-C. The dashed red lines show a +/- 12% margin on each
side. Look at how many dots (remember: each dot represents a person) lie OUTSIDE of the
dashed red lines. Now look again.

When people argue with me about why its unnecessary to check LDL-P or apoB because its
much easier and cheaper to check LDL-C, I like to remind them of what Clint Eastwood would
probably say in such a situation: Youve got to ask yourself one question: Do I feel lucky?
Well, do ya, punk?