It’s not the LDL cholesterol, stupid!

2) Insurance companies vigorously discourage testing beyond conventional lipids.

The array of objections we get from insurance companies is mind-boggling. It would be funny if human life and finances weren't at stake. These "new" tests are "experimental," "unproven," not endorsed by standard guidelines, not approved by some internal committee, or simply "We don't know what this test is."

What are the tests that are superior to Dr. Friendewald's calculated LDL? There are several, listed here in order of best to worst:

1) LDL particle number-the value generated by NMR lipoprotein testing. This is the gold standard, most reliable test available, and the one I recommend. (Ask your doctor about "NMR lipoprotein testing.")

2) Apoprotein B-More widely available even from conventional laboratories. It's not as accurate as NMR LDL particle number, but a pretty good choice. Apo B is the principal protein in LDL and is a better reflector of risk.

3) "Direct" LDL-This is LDL that is actually measured. Unfortunately, it ignores the issues of LDL size and has some other pitfalls, but it's still better than calculated LDL

4) Non-HDL cholesterol-So-called because it incorporates all undesirable cholesterol-containing lipids except good HDL, thus "non-HDL." This is another calculation, though better than LDL (because it sums up the risk from other apoprotein B-containing lipoproteins). Non-HDL is calculated from Total cholesterol - HDL. It's therefore available from any standard lipid panel. It's little used in everyday practice, however, because most people and their physicians find it confusing.

Imagine your realtor tells you your house's estimated value is $200,000 and that's what you sell it for to an eager buyer. After closing, you find out your house was really worth $350,000. You'd be upset. But that's what you're getting with LDL cholesterol: a bum deal.

It's part of the reason people will say, "My doctor said my cholesterol was fine and that no cause for my heart disease can be found. He said it was genetic." In reality, they could have sky-high LDL cholesterol revealed by LDL particle number or apoprotein B. This enormous inaccuracy of calculated LDL cholesterol therefore diminishes its usefulness in analyzing data from studies, including studies like Enhance.

Calculated LDL cholesterol is a seriously flawed tool to diagnose your initial level of risk. Ask for better.