In my last post I shared the notes I took from my consultation with the lipidologist.  During that initial meeting she ordered all the labs we discussed and many that we didn’t.

After a week the results came back and we discussed them over the phone.  Unfortunately there was a lab screw up and a bunch of the insulin resistance labs she ordered weren’t processed.

I of course took diligent notes that I’ll share below.  As a warning, like the past couple of posts in this series, things do get a bit dense and technical, but I’d rather give you more information than less.  I included a too-long-didn’t-read summary at the end for those that want to skip ahead.

I know the text in my scanned reports can appear small so feel free to click on them for a larger version of the image.

The first thing the doctor said to me was, “Your labs don’t look pretty,” which is undoubtedly what I just wanted to hear (insert sarcastic tone).

So, without further ado… here goes:

Lipids and Inflammation

Lipids:

• The traditional panel is not very different from the ones I’ve had in the past, and the numbers are reflective of that.
• My high Total Cholesterol and high LDL-C are still here.
• Triglycerides and HDL are normal, which they’ve pretty much been in the past.
• Typically when we think about insulin resistance, people will make an assessment based on the triglycerides and HDL, but this is where things can fall short, because not everyone who has insulin resistance has triglyceride and HDL problems.
• She feels based on the rest of my information that there is a genetic thing going on.

Lipoprotein Particles and Apolipoproteins:

• Apo-B and LDL-P reflect the number of atherogenic lipoproteins.
• Apo-B is an immunologic assay and LDL-P is an NMR assay.
• My ‘numbers are very very elevated,’ especially for someone of my age with my level of fitness.
• Typical Apo-B numbers in guidelines should be between 60-90, and she is more aggressive in people with a prior heart attack, wanting to keep it under 60, but regardless, my numbers are off the charts.
• She would like to keep LDL-P under 1000.
• These numbers tell her that we need to be more aggressive in treating what’s going on, whether it’s diet, or supplements, or medication.
• Small LDL-P: Gives us a window into insulin resistance and often this will give us a window into insulin resistance years before we will ever see changes in fasting blood sugars and HbA1c.
• Since my small LDL-P numbers are so high, this tells her that at least one of the contributing factors is insulin resistance.
• This might be one of the first things we try to treat, if it’s the underlying insulin resistance that is driving the particles up.
• We don’t just want to start taking a medication to lower the cholesterol if there’s something there, like insulin resistance, that is driving the particles up.
• HDL-P: These are normal, and are a more accurate measure of HDL-C. This is simply a genetic marker. Simply knowing HDL status doesn’t really tell you whether or not you’re protected from heart disease, and in my case, I’m definitely not protected from heart disease even though my HDL numbers are normal because my other numbers are so bad.
• Lp(a)-P: My number was normal before on a test by a different type of technology.   This is a difficult marker to measure, this is why she likes to measure the Lp(a) particle via electrophoresis assay.
  • She isn’t overly concerned with my number which is on the low end of the ‘intermediate risk range.’ She typically sees people with the particle count in the 300s.
  • This is something we may want to check again, because there is a little bit of variability.
  • Niacin is something can actually lower it by up to 20%. Sometimes high dose fish oil or aspirin, but won’t really move it a whole lot.
  • Since I’m so close to normal, it’s not something we need to worry about a lot (whew, first bit of good news)
  • If we check it in the future though, would be better to check the Lp(a) Particle count.

Inflammation and Oxidation

• Fibrinogen and HS-CRP are both acute inflammatory markers, and lots of things can cause them to be elevated them.  Fortunately mine are both normal.
• Fibrinogen does have some association with blood clotting.
• Lp-PLA2: Suggests that there is inflammation in the blood vessel walls. However she’s seen avid exercisers that have elevations in Lp-PLA2 that don’t make clinical sense.
• In my case because of my other numbers (Apo B and LDL-P), it’s something that gives her pause for concern.
• She has less faith in this assay that she used to. She’s seen a lot of people that are athletic with elevations in this because exercise can increase it.
• She’s not sure if my exercise levels are throwing a monkey wrench in this or not, but it’s definitely something to pay attention to.
• Myeloperoxidase: Similar to Lp-PLA2 and also looks at vascular inflammation. Sometimes when people have dysfunctional HDL, this can give information on that. She’s more reassured that this is normal because she’d be extremely worried about my arteries if both Lp-PLA2 AND Myeloperoxidase were elevated.
• Oxidized LDL: New test, looks at how much of my LDL particles are oxidized. Since mine are normal, it’s reassuring, but we still can’t ignore my markedly elevated LDL-P.
• I ask, on the whole, if she were to say whether or not I’m inflamed and she said “that it doesn’t really look like there’s much inflammation going on.” (yay, more good news)
• She says I probably have a little bit of inflammation going on because of the Lp-PLA2 and the AspirinWorks study showing my platelets are a little sticky.
• But she wouldn’t say that inflammation is an issue of great concern for me because my diet is pretty anti-inflammatory and I exercise and am relatively fit.

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 Endothelial Function, Myocardial Stress, Platelets, and Genetic Testing

Endothelial Function:

• ADMA and SDMA are both markers of endothelial dysfunction. A healthy endothelium allows blood vessels to vasodilate and impacts how we make nitric oxide.
• ADMA and SDMA have been shown in trials to be associated with cardiovascular risk. This can be elevated many many years before the onset of a heart attack clueing you in that there is some sort of underyling endothelial dysfunction.
• ADMA: Mine is normal.
• SDMA: Slightly high but not super high.
• ADMA/Arginine Ratio: A little bit elevated.
  • We will probably want to check this again.
• Things we can do to address these include exercise (which I already do), weight loss (which she doesn’t think I need), sleep, reduced salt diet, stress management.
• Foods that are higher in arginine – chocolate, coconut, nuts, seeds, barley, brown rice.
• I want to have more arginine, so if I want to, I can increase intake of these.
• I can also supplement with L-Arginine and L-Citrulline. She doesn’t think my numbers are high enough to warrant it, but wanted to give me this information anyways.
• ACE inhibitors are also something that can effect these.

Myocardial Structure/Stress/Function

• NT-pro-BNP: Looks at whether heart muscle is having to work harder to meet the demands of the body. Things like hidden hypertension, sleep apnea, congestive heart failure can cause this to be elevated
• Mine was completely normal so it’s not something I need to worry about.

Platelets

• AspirinWorks: Helps detect platelet reactivity and how ‘sticky’ they are, because the more sticky they are the more likely they’ll clot.
• Taking Aspirin can produce benefits in reducing cardiovascular risk in older patients (55 years or greater), but in people in my age group, we don’t really know.
• If there is a significant abnormality on this test, she recommends a baby aspirin.
• In my case, my number is elevated, but it’s not significantly elevated. She see’s patients with numbers of 4000 and 8000. I’m just barely out of the normal range. She’s not even sure she wants to say this is abnormal.
• If I were to take aspirin as a preventive measure, especially given my other risk factors, I could start with 81 mg two to three times a week because Aspirin is actually quite long acting with a half life of 7 days. There are also risks involved with taking Aspirin like bleeding.
• Aspirin may even benefit my Endothelial function numbers as well.

Lipoprotein Genetics

• Apolipoprotein E 3 / 4 – This places me at higher cardiovascular risk. Sometimes these people don’t respond well to statins.  She never uses high dose statins on these patients.
• If I ever decided I wanted to take a statin, because of my genetics, I should probably never take a high dose.
• Some people with a 3/4 have a good response to lifestyle changes, but she thinks that I’ve already maximized everything I can do with that.
• Some of the earlier studies suggested that people with a 3/4 don’t do as well with a high fat diet, but she thinks those studies were pretty poor. That being said it’s probably not a good idea for me to be on a high saturated fat diet.
• It’s important for people that are APOE 3/4 to be on adequate amounts of Omega 3s to protect the brain and there are increased risks for Alzheimers in the future.

Coagulation Genetics

• MTHFR C677T and A1298C SNPS – I have a minor mutation of the C677T. She would be more worried if I was a ‘compound heterozygote’ meaning having one mutation in both SNPs, but in my case my mutation is probably not clinically significant.
• It still makes sense for me to take methylated forms of folate and B12.
• Nothing in my coagulation panel suggests that I have a higher risk of clotting.

Metabolic and Renal

Metabolic

• These can drive ApoB and LDL-P up.
• Despite a normal fasting glucose and insulin, my HbA1c is up.
• HbA1c of 5.9 – Technically classifies me as pre-diabetic. This can explain my high particle count
  • (This is also the worst it’s been.  I think this could be related to my recent increased intake of carbs or possibly just due to differences in lab technique… but in any case, this is something I’ll need to keep a close watch on).
  • Because I’m not eating any sort of high carb diet and am pretty fit, this tells her that there is clearly a genetic predisposition to insulin resistance.
  • I can try to address this via life style, or can consider taking it a step further by taking a medication.
  • She’s had experience using Metformin or Actos, to help address people with pre-diabetes and elevated particles and ApoB. In some cases the particles can drop significantly.
  • There are studies on Actos lowering LDL-Particles and less data on Metformin, but a lot more data on how it addresses pre-diabetes.
• Given my current data, she is confident that I have borderline insulin resistance.
• My insulin isn’t elevated, so this tells her that I don’t have severe insulin resistance.
• Vitamin D – She likes to keep it between 50-90. Because I’m not symptomatic supplementation isn’t required, but in her practice she likes it higher. Vitamin D can even help alleviate muscle aches in patients on Statins.
• TSH – She would check this annually, because thyroid problems can cause particles to go up. She likes it under 2.
• Homocysteine – Another marker of cardiovascular and clotting risk, and of B12 deficiency. Mine is normal.
• B12 – Mine is normal. Metformin can drop B12 levels, so it’s important to check this if I decide to use Metformin.

Renal

Everything is normal here.

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Sterol Absorption and Synthesis Markers

• She feels strongly that my LDL-P and Apo-B are not due to diet.
• I show increased cholesterol synthesis in my liver, and this is usually the result of something genetic or medication.
• I also show increased cholesterol absorption.
• Typically with hypersynthesizers the treatment would be Statins. But in hyperabsorbers, statins can actually make the problem worse!
• In my case because I have BOTH increased synthesis and increased absorption! (Lucky ME!)
• The question is, is the increase in my absorption a genetic problem? Or is it something related to some other aspect of gut health?
• She’s been trying to learn a lot more about gut health and the microbiome recently. Probiotics can play a role.
• Intestinal permeability can also play a role.
• Zetia can be used to treat cholesterol hyperabsorption, but she doesn’t want to jump immediately to that because she wants to see if there are issues with my gut that we can address first.
• We could consider doing a stool test to see if there’s anything going on there… or just jump straight to a probiotic.
• I ask her opinion on Benechol – she says that in her experience it takes 5-6 tabs per day to be effective and each tab is filled with high fructose corn syrup. It’s something like 5 gm of sugar per tab, which is her only hesitation.
• Benechol margarine has trans fats in it, which she never recommends.
• When she uses Zetia, she never uses high doses, she prefers ½ tabs so if a tab is 10 mg, she likes to give 5 mg.
• She might even use combinations of Zetia and Metformin, but unfortunately there aren’t any randomized clinical trials on this.
• She’s not saying that I need to be on meds yet, she’s just telling me the options.
• I ask if my absorption and synthesis markers tell her if one is contributing more than the other.
• She says sterol absorption abnormalities are very common. She sees less synthesis abnormalities unless there is a genetic issue.
• She’s more concerned about my synthesis abnormalities.
• Niacin – While this can help with lipoprotein particles it can worsen glucose and insulin resistance, so this probably isn’t something we should consider.

Chemistries and CBC

Not much to talk about here since everything was normal.

Omega 3 Index

 

• Mine is 6.7. Optimal is more than 8.0%. I can try to increase my intake of fish and fish oil.
• I ask how much is too much fish oil? She said that I don’t need to take massive amounts.

Too Long, Didn’t Read: Summary

My LDL-P is still off the charts and my HbA1C of 5.9 confirms to her that I’m insulin resistant, which likely plays a role in my LDL-P elevation.  The sterol markers show I have BOTH increased cholesterol synthesis AND increased cholesterol absorption.  She thinks the synthesis is at least partly related to underlying insulin resistance and suspects the increased absorption is related to an underlying issue with my gut health.

My LpPLA2 test is still high, but this is equivocal since it can be elevated in people who exericse a lot (I do BJJ ~ 6 hrs per week and weight lift 2 hrs per week), and none of my other inflammatory markers are elevated.

I’m also an Apo E 3/4 which means that I should cut back on saturated fat and that I should be sure to eat fish and supplement with fish oil for the neuroprotective effects since I can have an increased risk for Alzheimers in the future.

Next up… I discuss my gameplan and the therapeutic interventions I decide to pursue.

*Image found here