You have likely been told that ‘bad’ LDL cholesterol clogs your arteries. The ‘story’ goes something like this. LDL cholesterol circulates in your blood and can get ‘stuck’ in your heart arteries causing plaques. These can build up till they block the artery causing coronary artery disease including heart attacks. The higher the LDL, the more cholesterol gets stuck in your arteries causing blockages and heart attacks.
There is no doubt that LDL cholesterol plays a part in the development of heart disease. However, the process of causing plaques is complex. The first step to understanding the development of plaques is identify the real culprits.
Research has highlighted that not all LDL particles are created equal. In particular, the size and density of LDL particles—specifically, small dense LDL (sdLDL) versus large benign LDL (lbLDL) play distinct roles in cardiac risk. Understanding these differences is crucial for a more accurate assessment of cardiovascular risk and for tailoring prevention strategies.
Coronary calcium CT scan
I have high cholesterol. Because LDL is potentially a risk factor, what I need to know is whether I am forming plaques. About 5 years ago, I was aware of a heart scan that showings whether plaques are forming in my heart arteries. This widely available test is called a Coronary Calcium CT scan. These are not funded and cost about $500. Read more at: https://theheartgroup.co.nz/patient-info/diagnostic-tests/calcium-score-test/.
My Scan showed that despite an LDL of 4, my heart arteries are in very good condition with no evidence of plaques. My doctor had been suggesting statins to me for years because of my high cholesterol. Based on the scan, he said that given my age of 65 (at the time) he would not recommend statins because I was clearly not forming plaques.
Cholesterol particle size test.
You can also have these done in NZ. These are not funded and cost about $500. Read more at Read more at: https://theheartgroup.co.nz/patient-info/diagnostic-tests/calcium-score-test/.
Next week we look at actual solutions. Please contact me if you have questions or need advice.
Research on LDL particle size and risk of heart disease
Since 2010, several studies have advanced our understanding of the distinct roles that small dense LDL (sdLDL) and large benign LDL (lbLDL) particles play in cardiovascular disease. A 2012 meta-analysis published in the Journal of the American College of Cardiology confirmed that higher concentrations of sdLDL are independently associated with increased risk of coronary artery disease, even after controlling for total LDL levels. In 2015, a study in Atherosclerosis highlighted that individuals with a predominance of sdLDL exhibited greater arterial stiffness and subclinical atherosclerosis compared to those with mainly lbLDL, regardless of overall cholesterol levels.
Further research in 2017 (European Heart Journal) demonstrated that interventions such as weight loss, exercise, and dietary modification can shift LDL particle distribution from small dense to larger benign forms, thereby reducing cardiovascular risk. In 2020, a cross-sectional analysis in the journal Lipids in Health and Disease showed that patients with metabolic syndrome had significantly higher sdLDL concentrations, which correlated with markers of inflammation and endothelial dysfunction. Collectively, these studies underscore the importance of assessing LDL particle size—rather than relying solely on total LDL cholesterol—for a more nuanced evaluation of cardiac risk and for guiding targeted prevention strategies. An example of such research can be found at: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0241993
Important!
The standard Cholesterol blood tests in NZ tell you nothing about the balance of sdLDL and lbLDL. You can have high LDL but little dangerous sdLDL and therefore low heart disease risk. Likewise, you can have low LDL but have a high proportion of sdLDL and have a high risk of heart disease. Relying on current cholesterol tests to predict heart disease are like relying on the oil level in your car to determine the state of the engine.
Changing risk through diet
Diet plays a significant role in influencing the ratio of small dense LDL (sdLDL) to large benign LDL particles, thereby impacting cardiovascular risk. Dietary patterns high in simple carbohydrates and sugars are associated with an increase in sdLDL particles.
High intake of simple carbohydrates, such as white bread and sugary beverages, tends to promote insulin resistance and elevated triglycerides, both of which are linked to a higher proportion of sdLDL.
Several studies have shown that adopting a Mediterranean-style diet, which emphasizes vegetables, fruits, legumes, nuts, and healthy fats like olive oil, can reduce sdLDL levels and increase large LDL particles. Similarly, including fatty fish rich in omega-3 fatty acids, such as salmon and sardines, has been shown to favourably alter LDL particle size distribution. Weight loss and increased physical activity, also contributes to a reduction in sdLDL and an increase in large LDL particles.
Reducing saturated fat from animal sources and replacing it with unsaturated fats from plant sources—such as avocados, nuts, and seeds—may further decrease sdLDL concentrations.
Statins
My discipline of Nutritional Medicine focusses on how to correct health problems using diet and supplements. There is no doubt that statins reduce cholesterol, especially LDL cholesterol. They also appear to reduce the dangerous sdLDL we have been discussing. However, the mechanism of statins means they have a significant impact on core energy systems. They impact the function of every energy producing cell in our body.
We should do everything we can through food, lifestyle and supplements before we consider statin therapy. If I had high LDL, I would consider a Coronary Calcium CT scan.
Supplements to promote heart health
In most cases I base a supplement programme on Cell eXtra, Vitamin D3/K2, CoQ10-Omega3 and Premium Fish Oil. Magnesium and CoQ10 are recommend supplements especially for those on statins.