There’s enough misinformation about cholesterol to fill a book– which is exactly what cardiologist Steven Sinatra, MD and I did in our recent, updated and expanded edition of The Great Cholesterol Myth. One of the book’s most important take-home points — and there are many you should know about– is the difference between “cholesterol” and “lipoprotein”.
The distinction is absolutely critical to your understanding of why cholesterol tests as we know them are wildly out-of-date.
See, cholesterol– contrary to conventional opinion– can’t travel in the blood. Trying to transport cholesterol through the bloodstream without putting it in a container would be like trying to transport a picnic basket across a lake by throwing it in the water. It just doesn’t work. The picnic basket needs a rowboat to get it where it’s going—a carrier.
So does cholesterol.
Cholesterol is hydrophobic, which means it hates water – or any aqueous solution like blood. Cholesterol, like the picnic basket, has to be carried in a container.
And in your body, that container isn’t called a rowboat – even though it functions like one. It’s called a lipoprotein.
The lipoprotein is the boat. Cholesterol is the cargo.
“Lipoprotein” is what the “L” in both HDL (the so-called “good” cholesterol) and LDL (the so-called “bad” cholesterol) stand for. LDL is a “low density lipoprotein”, meaning if you put it in water it will float because it’s not very heavy. HDL is a “high density lipoprotein” meaning it is very heavy, molecularly speaking, and it’ll sink if you try to float it in the water. So let’s be clear—both HDL and LDL contain some cholesterol, but they an entirely different kind of molecule. Calling HDL and LDL “cholesterol” is like calling the rowboat a picnic basket.
Why is this incredibly important to you?
Well, if we’ve learned anything at all about cholesterol and heart disease in the decade since the first edition of Great Cholesterol Myth, it’s this: The action in heart disease prevention is with the lipoproteins.
It’s lipoproteins that initiate the formation of plaque. They break, they get damaged and inflamed, and they wind up stuck in places they don’t belong, such as behind the endothelial wall (the one-celled lining of your arteries). Once a damaged, inflamed, athrogenic particle like a rogue LDL gets stuck there, it begins to come apart, dumping its cargo (which is not just cholesterol, by the way). This starts a long chain of events (including the creation of plaque, the capping of that plaque by calcium, and the resultant narrowing and stiffening of arteries).
Cholesterol is just a relatively harmless passenger on the lipoprotein ship. It’s the actually the behavior of the lipoproteins we need to be paying attention to.
Think about it. The more rowboats in the water, the more likelihood someone gets hit with a row. The more people in a nightclub the more likely it is that someone will spill a drink, bump into someone else, and possibly start a fight. We need to start paying attention to cholesterol tests that measure the number of boats in the water.
Fortunately for us, those tests exist, and have been around over a decade. They’re called “particle tests”. Different labs (i.e. Quest, LabCorp) have different names for them, but all of them measure the number of actual lipoproteins in the bloodstream, which turns out to be a far better predictor of future cardiac events than “LDL cholesterol” ever was.
And it’s not just the number of lipoprotein boats—technically called particles — it’s their shape and size. We now know that the lipoproteins that carry cholesterol—along with triglycerides and protein—don’t just come in two ‘flavors’, simplistically and incorrectly characterized as “good” and “bad”. Modern lipidologists know that there are at least 13 identified types of lipoproteins: for example, HDL2a, HDL2b, LDLllla, oxLDL, etc. These lipoproteins come in different sizes, and fall into different patterns. Some are big and fluffy and not very harmful at all, while others are small, mean little athrogenic particles that are indeed a problem.
But none of this—none—can be seen on the old-fashioned “good” and “bad” cholesterol test. Using that test to diagnose and treat heart disease is like using a flip phone to text with when you have an iPhone 12 available.
It’s also wise to remember that there is no such thing as “good” cholesterol and “bad” cholesterol, a categorization that has long outlived its usefulness. Cholesterol is cholesterol, whether it travels in a LDL, a HDL, or even the lesser known VLDL’s (very low density lipoproteins) and IDLs (intermediate density lipoproteins). It’s all the same cholesterol—what’s different is the density (composition) of the lipoproteins.
So here’s the take-away when it comes to statin drugs, which are drugs given by your doctor to “lower your cholesterol”:
Never—never—accept a prescription for a statin drug based solely on the old, past-its-expiration-date measure of “HDL” and “LDL”. If your doctor says your LDL is too high so you need a statin, ask your doctor “what KIND of LDL are you talking about doc?” “How many lipoproteins (particles) do I have? And are they in pattern A or pattern B? Ask—no, demand—the more modern tests that look under the hood and tell you what’s really going on with your “cholesterol”.
And if your doctor says you don’t need a test like that because the old one is just fine, change doctors.
The old fashioned test is like basing a diagnosis on a one-paragraph astrology forecast in Cosmopolitan Magazine. It might be right—just like a crystal ball might be—but it’s certainly not based on the latest science.
Neither is the HDL-LDL test.
It’s way past time to retire it forever.
Article By Jonny Bowden, PhD, CNS. Author (with Steven Sinatra, MD) of The Great Cholesterol Myth: Revised and Expanded 2020.