The Benefit of non-HDL: Putting a Low HDL in Perspective.

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The Benefit of non-HDL: Putting a Low HDL in Perspective.

Postby JeffN » Sun Oct 29, 2017 11:22 am

Recently, several articles have come out confirming the benefit of looking at what is called non-HDL cholesterol as being the better marker then LDL. It is a simple number that is easy to calculate and doesn't need advanced lipid testing.

When I joined Pritikin in 1998, they started moving to using non-HDL as a marker. Over the years, the evidence has continued to grow. Here are some of their articles on it

What is non-HDL cholesterol?
Find Out Why Knowing Your non-Hdl Cholesterol May Be Even More Important Than Knowing Your Ldl (Bad) Cholesterol.
https://www.pritikin.com/your-health/he ... erolq.html

Non-HDL Cholesterol Goal | What’s Optimal?
For Years Most Scientists Agreed That Lowering LDL (Known As The “Bad” Cholesterol) Was The Most Important Goal For Reducing Heart Attack Risk. But there is now growing consensus that a better predictor of cardiovascular disease risk is non-HDL cholesterol. What is non-HDL cholesterol? What is an optimal non-HDL cholesterol goal? Find out in this article.
https://www.pritikin.com/good-non-hdl-cholesterol-goal

If you have ever had a private consult with me involving your lipid numbers, you know I would recommend looking at non-HDL and not just LDL.

In 2011, I had the following discussion on a list with some of the WFPB doctors on how and why non-HDL cholesterol could be a better choice then LDL or just LDL as you will see..

"An article in this week's New England Journal of Medicine (NEJM) is shedding some light on why the HDL cholesterol number may not always be as predictive as many clinicians have thought of. For more than 35 years, much emphasis has been placed by cardiologists and lipid specialists on the importance of high HDL numbers as a vaso- and cardio-protective substance.

In contrast, in our program we have emphasized the importance of LDL Cholesterol as the atherogenic particle that drives atherosclerosis and with that Coronary Heart Disease, especially when these numbers are above 90 mg. We have pointed to international clinical data that shows that some populations with HDL numbers of 20 to 25 are totally free of heart disease, which according to the HDL believers should have placed them at a high coronary risk, since the HDL numbers often used as being considered cardio-protective should be over 40 mg for men and over 50 mg for women. We have pointed out that the body does not need high protective HDL numbers if the dangerous LDL numbers are low (less than 90 mg%). This week's article in the NEJM goes one step further, in that it may not be the number in HDL that is influencing coronary risk but what its functional capacity is. Please take a look at a summary article by a science reporter at http://consumer.healthday.com/Article.asp?AID=648737

And for some of you: please stop worrying when the HDL numbers as a result of a healthier diet go down. Please note: when that happens as it usually does, you will also notice that the LDL numbers have dropped even further (percentage wise).

Lesson: When you don't have a lot of dangerous LDL hanging around, you don't need a lot of HDL to haul it off. And besides, the new wrinkle is: with a healthier diet, the HDL may become much more effective in its functional capacities."


None of this should be new to any of you. Low HDL in the presence of very low Total Cholesterol and LDL as a result of a healthy lifestyle and diet, is usually not an issue. And high HDL, in and of itself, may not be protective.

However, here was my response to the above, putting non-HDL into perspective...

One of the ways I have found to minimize the (misguided) focus on HDL that others have is to use. non-HDL cholesterol, which is actually a well established and known risk factor.

Here is an excerpt from an actual patient from this week...

+++++++++++++++++++++++++++++++++
Labs from 3/1/10

3/1/10

Total - 205
LDL - 126
HDL - 36
VLDL - 43
Trig - 214

Than labs from 10/29/10

Total - 99
LDL - 57
HDL - 25
VLDL - 17
Trig - 86

The patient was so concerned because his HDL dropped from 36, which was low, to 25, which was now alarming to them. And, of course, in spite of all the other highly significant drops in TC, LDL, VLDL, TG, his doctor was very concerned.

Here was my response to the patient...

Non-HDL cholesterol is based on the premise that if HDL is "good", and all else is "bad," not only your LDL cholesterol but also your levels of VLDL, IDL, and chylomicroms, then lets measure the total "bad". The standard recommendations are to keep non-HDL cholesterol to below 140, with 120 being better and 100 being optimal. All we have to do is subtract HDL from the Total cholesterol and we get total non-HDL cholesterol.

When we figure out his non-HDL cholesterol.

Before
205-36 = 169 which is high risk

After
99-25 = 74 which is no risk and optimal.

+++++++++++++++++++++++++++++++++++++++

As we can see in the above example, even with a lower HDL, the non-HDL puts it in better perspective.

I included 2 articles on non-HDL cholesterol for you too

Thanks
Jeff


These are the 2 articles I included.... (a pubmed search will review several overs)

NON-HDL CHOLESTEROL: MEASUREMENT, INTERPRETATION, AND SIGNIFICANCE*
Adv Stud Med. 2007;7(1):8-11)
Vol. 7, No. 1 February 2007

http://jhasim.com/files/articlefiles/pdf/8-11.pdf

ABSTRACT
The reduction of cardiovascular risk by low- ering low-density lipoprotein cholesterol (LDL-C) levels is well documented, and LDL-C remains the main target of lipid-lowering therapy. However, not all patients with coronary heart disease have elevated LDL-C levels. There is growing recogni- tion that non–high-density lipoprotein cholesterol (HDL-C) also strongly relates to cardiovascular risk. Non–HDL-C can be calculated by subtract- ing HDL-C from total cholesterol, and encom- passes all cholesterol present in potentially atherogenic lipoprotein particles (very low den- sity-lipoproteins, remnants, intermediate-density lipoproteins, LDL, and lipoprotein[a]). Non–HDL- C may be a particularly important measure in certain populations, such as patients with dia- betes, in whom dyslipidemia is characterized by low HDL-C levels and elevated triglycerides. Non–HDL-C has been shown to correlate with coronary artery disease severity and progression as well as predict cardiovascular morbidity and mortality.


Clinical Relevance of Non-HDL Cholesterol in Patients With Diabetes
Anne L. Peters, MD
Clinical Diabetes 2008 Jan; 26(1): 3-7. https://doi.org/10.2337/diaclin.26.1.3

Abstract

IN BRIEF

Patients with type 2 diabetes have high rates of cardiovascular disease (CVD), much of which may be preventable with appropriate treatment of lipid abnormalities. Diabetic dyslipidemia most commonly manifests as elevated triglycerides and low levels of HDL cholesterol, with a predominance of small, dense LDL particles amid relatively normal LDL cholesterol levels. In diabetic patients, non-HDL cholesterol may be a stronger predictor of CVD than LDL cholesterol or triglycerides because it correlates highly with atherogenic lipoproteins. Target goals for LDL and non-HDL cholesterol in patients with diabetes are < 100 and < 130 mg/dl, respectively. Failure to consider the importance of non-HDL cholesterol in type 2 diabetes may result in undertreatment of patients with diabetes.


Recently, there were two more articles on the topic that I think really confirm the value of non-HDL in a standard lipid profile....

The first, on non-HDL and its value over LDL

Why Do Doctors Still Rely on LDL Instead of non-HDL Cholesterol?
October 15, 2017
Larry Husten
http://www.cardiobrief.org/2017/10/15/w ... olesterol/

"–There’s broad agreement that non-HDL is a better measure than LDL.

For decades lipid experts have been saying that non-HDL is preferable to LDL cholesterol in the assessment of cardiovascular risk.

The subject is not controversial. Although they may disagree about its precise significance, every expert I contacted agreed that non-HDL is superior to LDL. Further, there is no downside to non-HDL, since obtaining a non-HDL level requires no additional cost or testing."



And the second on why non-HDL may be better then even the new LDL calculation.

CardioBrief: New And Improved LDL Numbers
Lab companies start reporting more accurate LDL cholesterol measurements
by Larry Husten, CardioBrief
October 27, 2017
https://www.medpagetoday.com/Cardiology ... rief/68836

The improved LDL number produces a risk estimate that is more concordant with non-HDL cholesterol, which many lipid experts say is the preferred number to use in risk calculations. .


I don't see this as breaking news, or saying that anything needs to change about the dietary guidelines and principles recommended.

What it does do for those following this way of life, is put the basic lipid profile into better perspective, especially in regard to the value of HDL, especially in regard to a low HDL,

In Health
Jeff
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Re: The Benefit of non-HDL: Putting a Low HDL in Perspective

Postby JeffN » Thu Oct 24, 2019 1:40 pm

Besides non-HDL, why Apo-B may be a better market then LDL


To help save the heart, is it time to retire cholesterol tests?
Mitch Leslie
Science 08 Dec 2017:
Vol. 358, Issue 6368, pp. 1237-1238
DOI: 10.1126/science.358.6368.1237
http://science.sciencemag.org/content/358/6368/1237

Summary
Doctors typically gauge our risk of developing heart disease from our levels of low-density lipoprotein (LDL) cholesterol or non–high density lipoprotein cholesterol. But some researchers argue that the blood protein apolipoprotein B (apoB) is a more accurate indicator because it captures the number of cholesterol-carrying particles that cause atherosclerosis. ApoB backers point to recent analyses that found high apoB levels better predicted patients' likelihood of suffering a heart attack or stroke and a genetic study that showed that reducing apoB had a bigger effect on cardiovascular risk than did reducing LDL cholesterol. However, many researchers remain convinced that switching to measuring apoB would not provide enough benefit to outweigh the disruption to clinical procedures that would result.


What is ApoB?

If You Want To Protect Yourself From Heart Attacks And Other Cardiovascular Woes, It’s A Good Idea To Learn About Apo B.
https://www.pritikin.com/what-is-apob

A growing body of research is finding that apoB may be a better predictor of heart disease risk than long-standing federal guidelines for “good” HDL and “bad” LDL cholesterol. What is apoB? (Its official name is apolipoprotein B.


Another one (a review) on why Apo B may be a better then LDL

Apolipoprotein B Particles and Cardiovascular Disease: A Narrative Review. JAMA Cardiol. Published online October 23, 2019. doi:10.1001/jamacardio.2019.3780

https://jamanetwork.com/journals/jamaca ... le/2753612

Abstract

Importance The conventional model of atherosclerosis presumes that the mass of cholesterol within very low-density lipoprotein particles, low-density lipoprotein particles, chylomicron, and lipoprotein (a) particles in plasma is the principal determinant of the mass of cholesterol that will be deposited within the arterial wall and will drive atherogenesis. However, each of these particles contains one molecule of apolipoprotein B (apoB) and there is now substantial evidence that apoB more accurately measures the atherogenic risk owing to the apoB lipoproteins than does low-density lipoprotein cholesterol or non–high-density lipoprotein cholesterol.

Observations Cholesterol can only enter the arterial wall within apoB particles. However, the mass of cholesterol per apoB particle is variable. Therefore, the mass of cholesterol that will be deposited within the arterial wall is determined by the number of apoB particles that are trapped within the arterial wall. The number of apoB particles that enter the arterial wall is determined primarily by the number of apoB particles within the arterial lumen. However, once within the arterial wall, smaller cholesterol-depleted apoB particles have a greater tendency to be trapped than larger cholesterol-enriched apoB particles because they bind more avidly to the glycosaminoglycans within the subintimal space of the arterial wall. Thus, a cholesterol-enriched particle would deposit more cholesterol than a cholesterol-depleted apoB particle whereas more, smaller apoB particles that enter the arterial wall will be trapped than larger apoB particles. The net result is, with the exceptions of the abnormal chylomicron remnants in type III hyperlipoproteinemia and lipoprotein (a), all apoB particles are equally atherogenic.

Conclusions and Relevance Apolipoprotein B unifies, amplifies, and simplifies the information from the conventional lipid markers as to the atherogenic risk attributable to the apoB lipoproteins.

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Re: The Benefit of non-HDL: Putting a Low HDL in Perspective

Postby JeffN » Thu Apr 22, 2021 10:43 am

When we adopt the McDougall program, some of us may see our HDL drop. This may concern us as we have long been told that HDL is the “good cholesterol” and having a high HDL is healthy and is even protective if you also have a High Total Cholesterol and/or LDL.

It turns out after decades of trying to prove the above and/or efforts to use drugs, supplements, foods, alcohol, exercise etc to raise HDL, these efforts have failed to prove any conclusive benefit from a high HDL or from increasing HDL. What it has done, unfortunately, is give some people who have a high cholesterol and/or LDL along with a high HDL a false sense of security.

As this thread points out, the most important number is your LDL (and even more so, your Apo-B). Here is one on the concerns of a high HDL



High-density lipoprotein cholesterol and risk of cardiovascular disease
Vol. 19, N° 3 - 04 Nov 2020
https://www.escardio.org/Journals/E-Jou ... ar-disease

Unlike low-density lipoprotein (LDL) cholesterol, the causality of high-density lipoprotein (HDL) in the development of atherosclerotic cardiovascular disease remains controversial. Prior observational studies have suggested a graded, inverse relationship between HDL cholesterol and both cardiovascular disease and total mortality, so that higher HDL is better. However, recent large-scale cohort studies and Mendelian randomisation trials have failed to confirm that higher HDL levels are associated with improved outcomes. Indeed, there are some reports of increased cardiovascular events and even increased mortality associated with very high levels of HDL. In addition, pharmaceutical intervention studies aimed at increasing HDL levels did not result in amelioration of cardiovascular outcomes.

There is a discrepancy between recent data and the currently accepted knowledge regarding the role of higher HDL cholesterol values on cardiovascular outcomes. However, the positive, neutral or negative influence of very high HDL has not yet been fully elucidated and remains a matter of debate. Until this topic has been clarified, we should keep in mind that HDL cholesterol may not be as protective as we believe. The current risk estimation tools may underestimate the cardiovascular risk of individuals with very high HDL values which may potentially lead to underuse of cardioprotective medicines such as statins.

“There is a discrepancy between recent data and the currently accepted knowledge regarding the role of higher HDL cholesterol values on cardiovascular outcomes. However, the positive, neutral or negative influence of very high HDL has not yet been fully elucidated and remains a matter of debate. Until this topic has been clarified, we should keep in mind that HDL cholesterol may not be as protective as we believe. The current risk estimation tools may underestimate the cardiovascular risk of individuals with very high HDL values which may potentially lead to underuse of cardioprotective medicines such as statins.”

(Or more importantly, lifestyle interventions)
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Re: The Benefit of non-HDL: Putting a Low HDL in Perspective

Postby JeffN » Sat Nov 13, 2021 1:23 pm

JAMACardiology | Original Investigation

Association of Apolipoprotein B–Containing Lipoproteins and Risk of Myocardial Infarction in Individuals With and Without Atherosclerosis Distinguishing Between Particle Concentration, Type, and Content

https://jamanetwork.com/journals/cardio ... .61026.pdf

Key Points
- Question Are common measures of cholesterol concentration, triglyceride concentration, or their ratio associated with cardiovascular risk beyond the number of apolipoprotein B (apoB)–containing lipoproteins?

- Findings In this cohort analysis, apoB was the only lipid parameter significantly associated with risk of myocardial infarction after adjustment. No association was found between the ratio of lipoprotein types and myocardial infarction, indicating that, for a given number of apoB-containing lipoproteins, one type may not be associated with increased risk.

- Meaning Risk of myocardial infarction may best be captured by the number of apoB-containing lipoproteins, independent from lipid content (cholesterol or triglyceride) or type of lipoprotein (low-density lipoprotein or triglyceride-rich


Commentary’
Apolipoprotein B vs Low-Density Lipoprotein Cholesterol
and Non–High-Density Lipoprotein Cholesterol as the Primary
Measure of Apolipoprotein B Lipoprotein-Related Risk
The Debate Is Over
https://jamanetwork.com/journals/cardio ... .71158.pdf

It is now more than 40 years since the first articles demon- strating the potential clinical utility of apoB were published.1,2 LDL-C does predict the atherogenic risk of lipoproteins be- cause it is highly correlated with the number of apoB particles. Trapping of apoB particles is the fundamental cause of ath- erosclerosis and the number of apoB particles in plasma is the most important driver of this trapping within the arterial wall.6 ApoB can be measured directly and accurately, and better pre- dicts risk than LDL-C or non-HDL-C. Accordingly, apoB should be the primary measure of the atherogenic risk of the apoB li- poproteins and the primary measure of the adequacy of therapy to lower the apoB lipoproteins. Using apoB is not the last step to improve clinical care, but it is an important next step. Given the totality of the evidence, to further delay introducing apoB into routine clinical care would break faith with our commit- ment to practice evidence-based medicine.”
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Re: The Benefit of non-HDL: Putting a Low HDL in Perspective

Postby JeffN » Thu Jun 30, 2022 6:11 am

The AHA just updated the Metrics for Life's Simple 7 changing it to Life's Essential 8. They added Sleep (7-9 hours) and expanded nicotine to include vaping & E-Cigs, Blood Glucose to include A1c and Cholesterol to include non fasting non-HDL.

Blood lipids (updated): The metric for blood lipids (cholesterol and triglycerides) is updated to use non-HDL cholesterol as the preferred number to monitor, rather than total cholesterol. HDL is the “good” cholesterol. Other forms of cholesterol, when high, are linked to CVD risk. This shift is made because non-HDL cholesterol can be measured without fasting beforehand (thereby increasing its availability at any time of day and implementation at more appointments) and reliably calculated among all people.

https://newsroom.heart.org/news/america ... -checklist

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Re: The Benefit of non-HDL: Putting a Low HDL in Perspective

Postby JeffN » Mon Jan 08, 2024 7:47 am

“In a population of initially-healthy older adults aged ≥75 years, high HDL-C levels were associated with increased risk of all-cause dementia.”


Association of plasma high-density lipoprotein cholesterol level with risk of incident dementia: a cohort study of healthy older adults
November 29, 2023
DOI:https://doi.org/10.1016/j.lanwpc.2023.100963

Full Text
https://www.thelancet.com/journals/lanw ... 66-6065(23)00281-X/fulltext


Research in context

Evidence before this study

While several longitudinal studies have shown an association between high high-density lipoprotein cholesterol (HDL-C) and adverse health outcomes, the evidence regarding dementia remains uncertain. A search of MEDLINE and Embase, on May 21, 2023, identified English language studies that examined elevated high-density lipoprotein cholesterol and dementia risk. Search terms, included “elevated high-density lipoprotein cholesterol”, “high high-density lipoprotein cholesterol”, “high HDL”, “elevated HDL”, “dementia”, “Alzheimer's”, “vascular” “cognitive decline”. Only one study of cohorts from Denmark was identified which suggested that high HDL-C is associated with dementia in people aged 47–68 years. Since, early onset dementia may have different pathophysiology than late onset dementia it is important to extend these results in well-characterised prospective studies of older people who are cognitively intact at the study onset.
Added value of this study

This is the most comprehensive study to report high HDL-C and the risk of dementia in older people. Data from the Aspirin in Reducing Events in the Elderly (ASPREE) trial, with participants free from evident cardiovascular disease, physical disability, or a chronic illness expected to limit survival to less than five years and cognitively intact, was analysed. Findings showed that high HDL-C was associated with dementia risk and the risk increased with age.
Implications of all the available evidence

High HDL-C is associated with an increased risk of all-cause dementia in both middle-aged and older individuals. The association appears strongest in those 75 years and above
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