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This week's topic: LDL Cholesterol
Hyperlipidemia is still one of the primary factors that influences the #1 killer in America: heart disease.
Functional medicine recognizes the role of LDL in heart disease (and we will use statins if indicated!), but considers other factors when interpreting test results.
Overview of today's email:
- LDL cholesterol
- Other testing considerations
- Practical clinical tips
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1. LDL cholesterol
Cholesterol is necessary for many processes in the body, but when endothelial damage is present and cholesterol tries to repair this, cholesterol can become "bad".
Most commercial labs (and integrative cardiologists) note a high LDL-C is anything over 100 mg/dL.
But, depending on what research you are citing or what training organization you have been trained through, there are some that feel that it should only be lowered when over 180 mg/dL (if it's the only risk factor that is present)! I do not abide by this recommendation, though.
Some basic physiology:
- LDL half life is around 3-5 days (but when made in the brain, can have a half life up to 6 months)
- The brain makes 25% of the body's LDL (but it doesn't mix with systemic LDL)
- Main function of LDL is to bring cholesterol to the liver for processing (highly dependent on the number of receptors on hepatocytes)
- Cholesterol is "expensive" to make (takes a lot of ATP), so the body often reabsorbs and "recycles" it
A few important points:
- LDL is not "bad" cholesterol - it has many benefits when it isn't trying to repair our blood vessels (e.g. supports cell membrane fluidity, bile salts to help absorb fat-soluble vitamins, vitamin D synthesis)
- Contrary to what many functional medicine forums mention, LDL that resides in the brain is NOT affected by systemic LDL (BBB prevents this) (Article)
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2. Other testing considerations
When I work up a patient with high cholesterol, I educate patients as to why we check cholesterol, and I provide the analogy of a recipe (i.e. LDL is one out of dozens of ingredients that create plaque). Here's what I often tell patients:
High LDL cholesterol is concerning because of its potential to cause plaque build up. But it's not the only "ingredient" that makes plaque! Other "ingredients" to evaluate (most can be run via commercial labs):
- Glucose dynamics (fasting glucose, HgA1c, fasting insulin)
- Inflammation (hsCRP, ferritin, homocysteine, LFTs, omega index, vitamin D and A)
- Thyroid function (hypothyroidism can cause elevation of LDL)
- Reproductive hormones (especially estradiol and testosterone)
- Other cholesterol markers: Apolipoprotein B (ApoB), sdLDL, Lp(a), triglycerides, HDL
I also advise anyone with high risk factors to get screened for plaque buildup (since high cholesterol does not always cause plaque formation, but plaque is the reason we screen cholesterol). Here are some of my go-to recommendations:
- Gold standard CT Angiogram (e.g. Cleerly scan) (can find hard and soft plaque)
- Coronary Artery Calcium (CAC) score (only looks for calcified, stable plaque, though)
- And/or carotid ultrasound (bonus if you can get a CIMT measurement as well through a company like VasoLabs).
- Triple vessel screen (using ultrasound, looking for soft plaque) (not easy to find anymore, though)
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3. Practical Clinical Tips
If a patient mainly has isolated LDL or ApoB, all other testing is optimal, and ASCVD and/or Mayo Statin Decision Aid score is normal, I document appropriately (for legal reasons), recommend pharmaceuticals if LDL is persistently over 150 mg/dL, and prioritize lifestyle education and optimization.
Top 3 lifestyle recommendations I recommend:
- Stress management (stress can cause endothelial damage, which is the reason that plaque forms in the first place!)
- Dietary fiber, at least 25 grams daily from various sources
- Increase omega 3s (4-6oz 2-3x/week) via SMASH fish (Salmon, Mackerel, Anchovies, Sardines, Herring)
What I don't recommend?
Red yeast rice (RYR) products.
Why?
There's no guarantee on dosing of the active ingredient, and the FDA monitors them since lovastatin is a regulated drug that has the same chemical structure as the monacolin K (found in RYR). I also don't see a signification lowering of cholesterol with these when a patient chooses to try them on their own.
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ANNOUNCEMENT: The Functional Medicine Collective Mentorship is open! As a bonus for being a founding member, those that join before the end of June will get two 1:1 mentor calls with me to chat about anything or going over a case! Click the button below to learn more and apply!
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I hope this was clinically useful!
To nerd out more on this topic, look into presentations and podcasts with Dr. Thomas Dayspring and Dr. Peter Attia.
Next newsletter topic: HDL.
Meg
Additional resources that may be helpful
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