Types of Cholesterol | Dr. Sinatra's HeartMD Institute

By Stephen T. Sinatra, M.D., F.A.C.C., F.A.C.N., C.N.S., C.B.T.

There are all sorts of pages on the Web right now that still reflect outdated, overly simplified information about cholesterol, and your doctor may also be telling you the same things.

Here are the basics of cholesterol that you really need to know…

Why is Cholesterol Bad?

Trick question, folks – it isn’t. Yes, you heard me, most types of cholesterol aren’t bad for you. Once upon a time, like most doctors, I believed that high cholesterol was a major heart disease risk factor. Today, decades of research and clinical experience have shown me otherwise. I’ve got a much better understanding of how cholesterol relates to heart health and heart disease, and have since dismissed the vilification of cholesterol as “The Great Cholesterol Myth.”

Still seen by many as the perpetrator of heart disease – the #1 killer of both men and women in America today – cholesterol has a pretty horrible reputation. Truth is, cholesterol is vital for health: your body can’t function without sufficient amounts of it. It is a building block of cellular structures, especially cellular membranes, and your body uses it to synthesize steroid hormones as well as to fight infections. Almost every cell of your body produces cholesterol, with the cells in your liver and brain making a great portion of it. Your brain, in fact, needs 25 percent of the cholesterol your body makes to keep your nervous system operating properly. It’s no coincidence that statin users have reported amnesia and other brain dysfunction, as very low cholesterol levels are linked to poor cognitive performance.

Inflammation – The Real Risk Factor Emerges

Keeping cholesterol levels down is not the key to heart disease prevention: keeping inflammation at bay is. A healing mechanism, inflammation is actually a natural and necessary response that the body initiates after injury. The inflammatory process begins in response to common assaults like free radical stress, environmental toxins, food allergies, sugar, and other catalysts. The greater the assault of inflammatory stimuli, the more inflammation generated in the body. When inflammation becomes a silent, chronic condition, the pendulum moves from healing to destruction.

4 major causes of inflammation
The real (my “dirty dozen”) risk factors for heart disease (You can also download Must-Have Cardiovascular Tests for Men and Women from this page.)

Find more general information about inflammation and disease on this page.

LDL: Good or Bad?

As mentioned above, cholesterol – even LDL cholesterol – helps your body function properly. It only becomes dangerous when oxidized. Oxidation, or free radical stress, is one of the prime initiators of inflammation. Oxidized LDL can stick to the lining of arteries and damage them, contributing to a state of chronic inflammation.

Which Cholesterol Is Good?

You’ve heard the mantra, time and time again about the “two” different types of cholesterol: “LDL is bad and HDL cholesterol is good.” Fact is, the notions of “good” (HDL) and “bad” (LDL) cholesterol are completely outdated and oversimplified concepts. The basic old-school idea is as follows: LDL cholesterol is “bad” because, as a carrier to cells, it is responsible for causing cholesterol to build up in and clog arteries, and HDL cholesterol is “good” because it carries excess cholesterol back to the liver. Hence, the primary old-school prevention tactic is to lower cholesterol through lifestyle modification (e.g. avoidance of saturated fats in the diet – another outdated concept) and use of statin drugs.

New school thinking recognizes that it’s not just about types of cholesterol. We now know that there are many different “subtypes” of both HDL and LDL based on particle size, and they do very different things. Small particles of LDL (subtype B) are much more dangerous than LDL particles that are large and fluffy (subtype A). Why? Smaller, denser particles are more prone to oxidative damage and more likely to get lodged into arterial walls, which makes them much more likely to create a situation of arterial inflammation than larger particles, especially Lp(a) lipid particles. Even HDL isn’t “all good”. People with chronic diseases like diabetes and rheumatoid arthritis can have dysfunctional HDL, which is very different from the HDL in healthy individuals. Breaking cholesterol down into its particle size is the best way to determine the risk it poses to the individual.

The Real Numbers You Need to Know

Knowing your LDL and HDL count is marginally useful in determining whether you’re at risk for a cardiovascular event. You and your doctor are really in the dark unless you know how much of your LDL is of subtype A and/or B. People with more B-type particles (the smaller, denser, more harmful kind) are said to have a pattern-B distribution, while those with more A-type (larger, fluffier, more benign) particles are said to have a pattern-A distribution.

A total cholesterol number doesn’t mean much unless it is greater than 320, at which point a person may have an increased risk of thrombotic stroke (but also may be more protected against risk of a more serious hemorrhagic stroke). If your total cholesterol is this high, you can bring it down by losing weight, eating more fiber and making other positive lifestyle modifications (see Alternative Sinatra Solutions below). If your combined HDL and LDL numbers are below 320, ask your doctor to order you a VAP test and figure out “what kind” of particles you have.

Additionally, keep in mind that a calculation of your HDL to triglyceride ratio is a far better indicator of risk. Back in 1997, a Harvard study showed that, compared to people with the lowest triglyceride/HDL ratios, those with the highest had sixteen times the risk of developing heart disease! To get your triglyceride to HDL ratio, simply divide your triglyceride number by your total HDL number. For example:

If your triglycerides are 150 and your HDL is 50, your ratio is 3
If your triglycerides are 100 and your HDL is 50, your ratio is 2

If your ratio is 2, you’re probably just fine, no matter what your cholesterol numbers are. A ratio of 5 is problematic.

Read Let’s Clear Up the Cholesterol Confusion Once and For All or my book, The Great Cholesterol Myth for more detailed information about the various cholesterol subtypes and how they influence a person’s risk of heart disease.

The Best Cholesterol Tests and Where to Get Them

As I mentioned earlier, the best way to learn if your cholesterol is actually potentially harmful is to go beyond simple HDL and LDL numbers and discover what subtypes of each you have as well as analyze the particles comprising them. Ask your doctor to order you a Vertical Auto Profile (VAP) test or a Lipoprotein Particle Profile (LPP) test.

SpectraCell Laboratories in Houston, Texas offers the LPP test (http://www.spectracell.com/clinicians/products/lpp/) and Atherotech Diagnostics Lab provides the VAP test (www.thevaptest.com). When ordered by a physician, both tests are covered by Medicare and most insurance plans. To get an LPP test, your doctor needs to contact SpectraCell by calling 800-227-5227 or 800-227-5227 and request the collection kit. Your blood can be drawn at your doctor’s office or at an approved lab, and then SpectraCell will analyze the results and send them directly to your physician.

While both offer valuable information, I believe the LPP is slightly more advantageous, as it allows for more precise measurements and can measure remnant lipoprotein (RLP), a dangerous type of cholesterol that can enter the endothelial lining of your arteries and cause inflammation in the absence of oxidation.

Don’t be surprised if you ask your doctor about either of these tests and s/he doesn’t know what you’re talking about. A few years back, when I taught a continuing education course on anti-aging cardiology to 150 conventional doctors and cardiologists, most of them didn’t know that these new lipid tests existed.

Should You Take a Statin Drug?

Statin drugs, which serve to lower cholesterol levels in the body, have unfortunately become a holy grail of preventative cardiovascular care. According to a 2013 CDC report:

“In 2007–2010, cardiovascular agents (used to treat high blood pressure, heart disease, or kidney disease) and cholesterol-lowering (antihyperlipidemic) drugs were two of the most commonly used classes of prescription drugs among adults aged 18–64 and 65 and over.”

While statins are effective cholesterol-lowering and anti-inflammatory agents, they are also known to cause numerous negative side effects ranging from muscle pain and weakness, extreme fatigue, headache, nausea and related abdominal issues, to upper respiratory infections, sleep problems, memory and cognitive problems, and even sexual dysfunction. Besides lowering cholesterol so much that the body lacks what it needs to function well, statins also deplete the body of the important antioxidant and vitamin-like substance, coenzyme Q10, which is needed for energy production within every cell in the body, especially in heart cells. Lack of CoQ10 can result in severe heart and immune system dysfunction.

I do not recommend using statins for primary prevention, which should be based on a healthy lifestyle. Prescribing a statin to just anyone with high cholesterol is not a sound medical practice, in my opinion; the risks associated with statin use simply outweigh the benefits for the majority of people.

For whom do I believe the benefits of statins outweigh the risks? High-risk patients with documented heart disease:

Because of their anti-inflammatory and blood thinning effects, statins are very helpful for middle-aged men who have already had a heart attack and are at high risk of another (e.g. have lots of small-particle subtype-B LDL). I don’t usually recommend statins for men over the age of 75 unless they have chest discomfort or shortness of breath (there are too many downsides).
Women with arterial disease and a cholesterol profile showing high levels of small-particle LDL (B subtype) and other inflammatory markers can also benefit from the anti-inflammatory and blood-thinning properties of statins.

If your cholesterol numbers are high and your doctor tells you to take a statin, I would ask him or her to follow up with a VAP or LPP test to clarify which of the particular subtypes you have and in what amounts. If your results show you have fractions that indeed place you at risk of heart disease, then a statin may be in order as a treatment which complements healthy lifestyle modifications.

Alternative Sinatra Solutions to Support Healthy Cholesterol Levels

If you have very high cholesterol or want to prevent it, be sure to:

Stick to a healthier, anti-inflammatory diet, full of fresh fruits and vegetables, which give you nutrients and fiber, as well as healthy fats and lean proteins (see My PAMM Diet). You can learn all about healthy eating by reading Healthy Diet articles and watching my Healthy Cooking video series.
Lose any excess weight. Here are 11 Healthy Weight Loss Tips.
Engage in regular, moderate exercise, preferably something you enjoy that you are likely to do just about every day (walk, dance, bike, etc.).
Effectively manage the emotional stress in your life through various stress-relief techniques. Grounding, which helps balance autonomic nervous system activity, is another great way of de-stressing.
Supplement with targeted antioxidants, herbs, and nutraceuticals to help neutralize toxins and other destructive substances which force the body to produce more cholesterol in order to heal and repair.

When it comes to a complicated, systemic problem like heart disease, repeat after me – “an ounce of prevention is a worth a pound of cure.” Don’t wait until you have a cardiac event, super-high cholesterol readings, or become overweight and diabetic. Get started with a heart healthy, anti-inflammatory lifestyle today, and prevent silent inflammation from ruining your health and well being.