Adirondack Sports November 2023

NOVEMBER 2023 17
NON-MEDICATED LIFE
Potential Benefits of
Advanced Cholesterol
Testing, PART ONE
By Paul E. Lemanski,
MD, MS, FACP
Medicines are a mainstay of
American life and the healthcare
system not only because they are
perceived to work by the individuals
taking them, but also because their
benefit may be shown by the objective
assessment of scientific study. Clinical
research trials have shown that some
of the medicines of Western science
may reduce the risk of Type 2 diabetes,
heart attacks, strokes, cardiovascular
death and even some cancers.
In the first 111 installments of the
Non-Medicated Life, a healthy diet and
lifestyle has been shown to accomplish
naturally for the majority of individuals
most of the benefits of medications in
the prevention of the chronic medical
conditions mentioned above. In
order to maximize the benefit of lifestyle
changes it is best to first establish
a baseline of laboratory tests of
so called “surrogate markers” of risk.
Markers such as fasting blood sugar,
Hgb a1c, total cholesterol, HDL (the
good cholesterol) and LDL (the bad
cholesterol) and Triglycerides (blood
fats) are routinely followed serially to
determining increasing or decreasing
risk. After a discussion with your primary
care physician or cardiologist
additional testing may be helpful.
“Advanced” cholesterol testing such
as High Sensitivity C-Reactive Protein
(HS-CRP), Apolipoprotein B (Apo B),
Trimethylamine-N Oxide (TMAO),
and Nuclear Magnetic Resonance
LipoProfile (NMR LipoProfile) may
offer additional identification of risk
and when measured serially may help
direct and refine lifestyle choices. In
this two-part article, Part One will
address the first two advanced tests,
Part Two the remaining advanced tests.
HS-CRP (cardiac CRP) is a mark-
Editor’s Note: This is the 112th in a
series on optimal diet and lifestyle
to help prevent and treat disease.
Any planned change in diet, exercise
or treatment should be discussed
with and approved by your personal
physician before implementation. The
help of a registered dietitian in the
implementation of dietary changes is
strongly recommended.
er of inflammation. Atherosclerosis (literally,
athero equals artery, sclerosis
equals stiffening), the hallmark of arterial
disease-and the cause of heart attacks
and strokes-occurs as a consequence of
inflammation. LDL (the bad) cholesterol
normally exists as spherical particles in
the blood and, generally, when the concentration
is low atherosclerosis risk is
low. However, when excess LDL cholesterol
is produced, it penetrates the arterial
wall, where it forms a structure called
a plaque. A decreased consumption of
the natural antioxidants in vegetables
and fruit results in the LDL in the plaque
becoming oxidized (Ox-LDL). Ox-LDL is
recognized by the immune system as nonself
and is attacked by specialized white
blood cells called macrophages. Literally,
it is the infiltration of macrophages into
the plaque that causes the plaque to
become inflamed setting up the conditions
for a heart attack or a stroke.
In most non-acutely ill individuals
HS-CRP measures the inflammation
caused by the process of atherosclerosis.
Unfortunately, if someone were to
be acutely ill with a cold or flu this could
cause the HS-CRP to be elevated as well.
It is, therefore, best to measure when you
are not acutely ill and if elevated it is best
to remeasure a second time, the lowest
value generally being the most accurate
measure of risk. Individuals with other
inflammatory conditions such as rheumatoid
arthritis and inflammatory bowel
disease may not use the test to indicate
cardiac risk. Physicians may use HS-CRP
to determine whether medication is
needed in individuals at an intermediate
level of cardiovascular risk as determined
by the American Heart Association and
American College of Cardiology risk calculator
(tools.acc.org/ldl/ascvd_risk_estimator).
Elevated HS-CRP values greater
than 3.0mg/dl generally indicate higher
risk, 1-3mg/dl moderate risk, and less
than 1.0mg/dl lower risk.
How does an individual lower HS-CRP
with lifestyle changes? Daily aerobic exercise,
increasing the consumption of vegetables
and fruit, and the consumption
of whole grains as with a Mediterranean
diet, increasing consumption of omega-3
and omega-9 oils (olive), and decreasing
consumption of omega-6 oils, avoiding an
excess of simple sugars, losing weight when
overweight, and stopping smoking, all will
help lower HS-CRP. The benefit of the test is
that it provides you a quantitative measure
of the benefit of such lifestyle changes.
Apo B is another advanced marker of
cardiovascular risk and in clinical trials
proves a better predictor of risk that the
more widely used LDL (bad) cholesterol.
In part, this is because while a major contributor
to risk for most individuals, LDL
is only one of several plaque forming particles
including more rare species called
intermediate density lipoprotein (IDL)
and chylomicron remnants (CR). In part,
it is because LDL particles come in different
sizes that carry different levels of risk.
LDL exists as particles of varied sizes,
some particles being smaller, some medium
sized, and some larger. The relative
number of particles of different sizes
approximate a bell curse in normal individuals,
with medium size particles at the
central portion of the bell curve predominating.
Individuals at higher risk have
proportionately more numerous smaller
particles and fewer medium size and large
particles- at the same total level of LDL.
Moreover, the smaller LDL particles are
more likely to form a plaque because they
more easily penetrate between the cells
that line the artery walls to get deeper layers
where plaque accumulates. Thus, an
LDL equal to 100 mg/dl may be achieved
by more numerous smaller particles or
fewer larger particles and routine testing
does not differentiate between the two.
Because a single apo B molecule is found
in each atherogenic particle regardless of
size, a measure of apo B gives an accurate
measure of all atherogenic particles,
including LDL as well as IDL and CR.
Unfortunately, apo B is a significantly
more expensive test than LDL, and may
not be covered by insurance. However,
a close approximation of apo B derived
risk may be gleaned from a normal,
inexpensive lipid profile by calculating
the non-HDL cholesterol. Indeed,
the National Cholesterol Education
Program (NCEP) guideline recommends
using the non-HDL cholesterol
as a secondary target of treatment after
LDL. In short, the non-HDL cholesterol
equals the total cholesterol – the
HDL (good) cholesterol. Thus, the
total minus the good yields what’s bad
and this would include all bad species
of particles including LDL, IDL and
CR. NCEP recommends a non-HDL
cholesterol 30mg/dl higher than LDL
target. Thus, for example, if you had a
heart attack, the LDL target would be
50-70mg/dl and the non-HDL target
would be 80-100mg/dl.
How do you lower apo B or the
non-HDL cholesterol using lifestyle?
The two most powerful ways would be
weight loss, if overweight, and daily
aerobic exercise. The benefit of this test
is that it provides you a quantitative
measure of the benefit of such lifestyle
changes.
In summary, in most individuals
the standard lipid profile provides
important information in calculating
an individual’s global cardiovascular
risk. More recently, “advanced” cholesterol
testing has become available
to further refine the calculation of risk.
HS-CRP and apo B are two markers of
cardiovascular risk that may help in
this regard. Beginning with a baseline,
serial measures may allow a quantitative
measure of the benefit of lifestyle
changes, and serve as both useful feedback
and an aid in
sustaining such
changes. Look to
Part Two (January
2024) for a discussion
of two additional
“advanced”
tests, TMAO and
NMR LipoProfile.
Paul E. Lemanski, MD, MS, FACP
(plemanski3@gmail.com) is a boardcertified
internist practicing internal
medicine and lifestyle medicine in
Albany. Paul has a master’s degree
in human nutrition, he’s an assistant
clinical professor of medicine at
Albany Medical College, and a fellow
of the American College of Physicians.