You have heard of “good” cholesterol (HDL) and no doubt heard of “bad” cholesterol. But have you heard of the “ugly” cholesterol (small dense LDL)? Small dense LDL are one particular dangerous type of LDL. Unfortunately their measurement is not captured in the regular cholesterol profile, or in the regular LDL measurement. So you can have a PERFECTLY NORMAL, or even LOW LDL number, but have a high proportion of small dense LDL, and be at greatly increased risk for heart attack and stroke. In fact, 50% of women who have heart attacks and strokes have normal, or even “great” cholesterol profiles.
Small dense LDL particles (I call it “ugly” cholesterol) enter the artery wall (the “intima media”) and release inflammatory signals. Regular LDL doesn’t do this, at least not nearly to the same extent. Your immune system moves in to try to clean them up the low density LDL. The immune cells “eat” (the official word is “phagocytose”) your small dense LDL particles. This forms plaques in the arteries that can break off and travel upstream to cause heart disease and stroke.
For more information, have a look at this video for some new insights into the kind of cholesterol you need to be concerned about.
Thinking of your cholesterol number is like thinking of the cumulative score of a baseball game. Say 32. But you won? It is much more important to know the score of each team.
The same applies to cholesterol. The kinds of cholesterol that contain a protein called apo-lipoprotein A1 are good. (Super! A1!). That’s because they circulate throughout the body picking up excess cholesterol, including the kind accidentally deposited in the blood vessel wall by small dense LDL, and take it back to the liver. All types of cholesterol that contain a protein called apo-lipoprotein B-100 are bad, and are associated heart disease risk, but some much much more so than others. This “bad” group includes VLDL (very low density lipoprotein), LDL (low density lipoprotein) and intermediate density lipoprotein (IDL). Small dense LDL is the worst. Downright ugly. It is the most inflammatory, and plaque forming lipoprotein.
If your overall cholesterol “score” is 194, it would be considered “normal”. However, if a high portion of that “score” is bad cholesterol (as measured by apo-lipoprotein B-100), and within that a high proportion is small density LDL, you are still at high risk for heart disease.
Insulin resistance conditions, including polycystic ovarian syndrome, which we see so much of in our clinic, prediabetes and diabetes, all increase the proportion of these small dense LDL particles. Small dense LDL is more likely with obesity, with metabolic syndrome and in patients with renal dysfunction. Trans-fat increases the levels of small dense LDL (ugly cholesterol).
Although regular LDL (bad) cholesterol is not increased with diabetes, small dense LDL (ugly) cholesterol is.
Small dense LDL is highest before breakfast, and lowest after eating. (Another important reason not to skip breakfast).
Small dense LDL is specifically reduced with certain structured lifestyle changes, and with smoking cessation, as well as treating insulin resistance. Statins decrease overall cholesterol levels but do NOT alter the proportion of cholesterol that is “bad” and “ugly”. In fact, statins actually INCREASE the proportion of small dense LDL particles (ugly) relative to the other types of particles (good and bad), in some situations, such as when triglycerides (blood fats) are low. Niacin and fenofibrates can change the proportions.
The structured lifestyle changes we are talking about are pretty specific. Modified mediterranean diet, with a low glycemic index, to minimize insulin resistance, exercise, particularly the kind that builds lean body mass, stress reduction and smoking cessation are all helpful. Metformin can be helpful as well.
Small density LDL needs a special test to measure it, called a “particle test”. Common types include NMR, VAP, Berkeley labs, and a few others. We use a lab which will bill your insurance, but will not ever bill you directly, even if your insurance doesn’t cover it, or cover all of it.
Find out more by setting up an appointment with one of our providers at Women’s Health Connection. Call (509) 465-8885, or visit our website at www.whconnection.com.