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Important Blood Tests to Get in Addition to LDL-C

Heart Health Cholesterol Genetics

If you’re like most people, you go to the doctor once or twice a year to get blood drawn. A few weeks later, you get a call to go over “the numbers.”

If your HbA1c, triglycerides and cholesterol numbers are in a healthy range, you rest easy.

If they’re bad, you explore your options, which often include some form of prescription medication. Once the results are in, and the plan has been set, most of us get back to our everyday lives and forget about the medical stuff until the next checkup. We don’t think to ask for additional lab tests, we assume we have all the data we need.

But do we?

What if I told you that most people receive only very basic blood tests that don’t give the full picture of their risk for a cardiovascular event in the near and short term?

Let’s walk through some important tests that most of us never receive.

Lp(a) – genetic bad cholesterol

Most Americans don’t get tested for Lp(a), which is a genetic marker associated with a modest, but consistent, increase in risk of developing heart disease, especially when levels exceed 50 mg/dl. 1

Celebrity trainer Bob Harper, of Biggest Loser fame, had high levels of Lp(a) when he suffered a heart attack a few years ago. Harper didn’t know he was at increased risk for heart disease until he had a heart attack. None of the doctors he had been seeing tested for Lp(a). Lp(a) “hides out” in the LDL-C number unless it is independently tested for. 2

Bob Harper’ story offers a cautionary tale, but our standard blood tests haven’t caught up. Basic lipid panels don’t just miss Lp(a), they also fail to include markers like APOB, which as we will learn in a moment, is the single most important metric anyone interested in heart health can measure. 3

Instead, we get LDL-C, total cholesterol, Triglycerides, and HDL, which are all important, but don’t always give us an accurate assessment of where things stand with our heart health.

Triglycerides and the Black community

The failure of appropriate lab testing especially applies to the Black community. One of the important heart health ratios the medical community uses to measure insulin resistance and heart health is the triglyceride to HDL ratio. Here’s the problem: African Americans, even when they are suffering from insulin resistance, often don’t have elevated triglycerides (TG). Instead of focusing on TG, physicians treating Black families need to have fasting insulin and glucose panels run.

What has developed is a system where there are two classes of testing. Those that have the best doctors get their blood sent to labs like Boston Heart Diagnostics which use the latest technology to offer patients the full spectrum of biomarkers relevant to their health. The second group, like Bob Harper before his heart attack, remains in the dark.

What is the solution?

The best one is to find a doctor who uses Boston Heart, True Health Diagnostics, or another lab that offers a full breakdown of not only lipids, but other important markers like hsCRP and homocysteine.

If you don’t have access to one of these labs it is possible to use combinations of basic tests to roughly estimate your LDL-P number, but as we will see in a minute, it’s far from an exact science.

But before I get to that, first a rundown of why the famous LDL-C “bad cholesterol” isn’t an accurate stand alone indicator of risk for a heart attack.

Why testing LDL-C alone isn’t enough

LDL-C is known as the “bad cholesterol,” but it’s not really cholesterol at all. Instead, LDL-C represents the amount of cholesterol within low density lipoproteins, which are the “taxis” that move cholesterol, and other fats, around the body. 4 LDL are thought to be bad because they can carry their cholesterol passengers into the wall of an artery and leave them there, which over time causes heart disease as these plaques accumulate and the immune system attacks the tissue to remove them. 5 So, it’s the role of LDL in transporting cholesterol, not the cholesterol itself, that causes danger.

But here’s the thing: cholesterol isn’t the only passenger carried by LDL taxis.

LDL also carry triglycerides, a type of fat the body uses for energy. And this is why measuring LDL-C isn’t enough: focusing only on the cholesterol cargo doesn’t tell us the total number of taxis on the road.

Only testing for ApoB, which measures the total number of LDL carrying both triglycerides and cholesterol, can do that. The problem is very few people know their LDL-P numbers. As we learned from the tragic death of the former host of Meet the Press, Tim Russert, LDL can do damage with triglycerides just as it can with cholesterol. Before his heart attack at age 58, Russert had low levels of LDL-C (less than 70 mg/dl), but high levels of triglycerides. The NY Times article detailing his battle with heart disease wonders out loud whether LDL-P / APOB would have been a better marker to gauge his risk of a heart attack than LDL-C.

What is APOB?

APOB, which stands for apolipoprotein B, is the protein that makes up each LDL particle. There is one APOB protein for every LDL particle which means you can gauge APOB from the LDL-P number and visa versa. LDL-P is of utmost importance because it represents the total number of chances that fat could be deposited into your arteries.

Lipid expert Peter Attia breaks it down this way:

If you want to stop atherosclerosis, you must lower the LDL particle number. Period

The tragedy of Tim Russert teaches us that high LDL-C is only a risk factor for heart disease when it matches with the LDL-P number.

As a practical matter, if you have low LDL-C and high LDL-P, it means that the LDL particles in your blood are rich in triglycerides, which is most often seen in people with very high blood sugar, sometimes called “insulin resistant.” This means your blood sugar numbers could clue you in on the state of your LDL-P in the absence of more advanced testing.

My experience measuring LDL-C vs. LDL-P

In my case, I have consistently good HbA1C, fasting glucose and insulin numbers almost irrespective of what I eat, but my lipids and levels of plant sterols can go slightly out of range. As I have written about previously, I have elevated Lp(a) which to date has ranged from about 33mg/dl to 49 mg/dl.

I am not insulin resistant (see table below) but I have seen higher triglycerides when I eat like crap.

My LDL-C will usually live in the 90 – 110 mg/dl range, but I sometimes do see discordance between the my particle count and my LDL-C.

In the Gene Food scoring matrix, I am a California Coastal diet type, a genotype our algorithm estimates could trend towards triglyceride rich particle, and I do see that when I go our of balance and eat foods I shouldn’t.

My Result
Unit of Measurement
Insulin Resistance Score (SJC)
< 33
> 66
Insulin, Intact, LC/MS/MS (5)(SJC)
≤ 16
> 16
C-peptide, LC/MS/MS (6) (SJC)
≤ 2.16
> 2.16

The confusing part about tracking lipids is, if you look at the table below for November, 2018, I have also seen the opposite situation where my LDL-C spiked to 119 mg/dl, but my APOB was in the green at 79 mg/dl (I believe this was due to taking a blood draw after a 36 hour fast). This small experiment demonstrates the importance of measuring LDL-P.

John's Lp(a) progress

Total cholesterol
August 2016
February 2017
November 2017
September 2018
November 2018
April 2019
72 nmol/L
June 2019
80 nmol/L
March 2020
113 nmol/L

While the LDL-C test is designed to get an idea of LDL-P, the two don’t always match.

If a doctor had just looked at my LDL-C number without referencing my APOB of 79 mg/dl, she might have suggested a statin. The APOB result actually makes the LDL-C number look far less dangerous, even benign depending on who you ask. In fact, in the world of discordant LDL-P and LDL-C results, the lowest risk group is those who have elevated LDL-C and low LDL-P. (R) By contrast, the highest risk group is the Tim Russert group where LDL-C is low, but LDL-P is high.

For more on the possible variations between LDL-P and LDL-C, I recommend this excellent blog by Peter Attia. It’s a deeper dive into the topics I am touching on here.

Key takeaways

LDL-C is an independent risk factor for heart disease, but it’s not the whole story. Lp(a), a genetically determined type of LDL particle, hides in the LDL-C number unless it’s independently tested for.

Further, the total number of LDL, called the LDL particle, is a bigger predictor of heart disease than is LDL-C standing alone.

John O'Connor

John O'Connor is the founder of Gene Food, a nutrigenomic startup helping people all over the world personalize nutrition. John is the host of the Gene Food Podcast and a health coach trained at Duke's Integrative Medicine Program. Read his full bio here.

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  1. Sarah Cummings says:

    Wow! Thanks for sharing this info! Of course, everyone should know the true condition of their heart. Great post! 🙂

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