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Q: High Total Cholesterol vs. low LDL/HDL Ratio??? ( Answered 5 out of 5 stars,   1 Comment )
Question  
Subject: High Total Cholesterol vs. low LDL/HDL Ratio???
Category: Health
Asked by: schmooz-ga
List Price: $15.00
Posted: 31 Jan 2003 10:50 PST
Expires: 02 Mar 2003 10:50 PST
Question ID: 155701
Which is the biggest indicator of problems or risk?
*   The Total Cholesterol number or,
*   The ratio of LDL/HDL

How is the Total Cholesterol number calculated?
  (No matter what numbers I add up on a lab report, I cannot duplicate
   the number)

What may be some valid reasons for why a Total Cholesterol Number (say
286 but an extremely low ratio for LDL to HDL, say 1.2, a ratio that places
a woman in the 1/2 average risk range) might cause an insurance
company to either rate up or deny coverage - based on the Total
number without regard to the low risk ratio?

It appears that the ratio of LDL to HDL is the more important number
but my questions to insurance companies and research on the Internet
has not led me to any sort of an answer.  Can you help?

Request for Question Clarification by kevinmd-ga on 31 Jan 2003 12:29 PST
Hello,
I can answer all your questions except why an insurance company might
rate up or deny coverage.  I can only hypothesize reasons, but cannot
give facts since I do not know the inner workings of insurance policy.

Would answers to your other questions be acceptable?

Thanks,
Kevin, M.D.

Clarification of Question by schmooz-ga on 31 Jan 2003 13:01 PST
Most certainly - with much appreciation.
Answer  
Subject: Re: High Total Cholesterol vs. low LDL/HDL Ratio???
Answered By: kevinmd-ga on 31 Jan 2003 13:17 PST
Rated:5 out of 5 stars
 
Hello,
Thanks for asking your question.

1) Which is the biggest indicator of problems or risk? 
*   The Total Cholesterol number or, 
*   The ratio of LDL/HDL 

Both are associated with cardiac risk.  However, the LDL/HDL ratio is
a bigger indicator.  The components of a measured total cholesterol
(LDL, HDL, triglycerides) includes HDL ("good" cholesterol) which
correlates inversely with cardiac risk.

From Best Practice of Medicine:
"Although useful in screening large populations for dyslipidemias,
serum cholesterol cannot be considered the sole measure of risk for
CHD attributable to serum lipids. This is based on our current
understanding of lipoprotein cholesterol subfractions and the
availability of standardized laboratory methods to measure them in
clinical practice. Serum total cholesterol tends to index
low-density-lipoprotein (LDL) cholesterol, which varies directly with
CHD risk (Figure 6) and is considered atherogenic.
High-density-lipoprotein (HDL) cholesterol varies inversely with CHD
incidence and is considered anti-atherogenic or protective."
http://merck.micromedex.com/bpm/bpm.asp?page=CPM02CA335žion=report&ss=2

Here is a definition of the LDL/HDL ratio:
"Another ratio is LDL/HDL. The LDL/HDL ratio is actually a more pure
ratio than total cholesterol/HDL. Because LDL is a measure of bad
cholesterol and HDL is a measure of good cholesterol, whereas the
total cholesterol is the sum of HDL, LDL, and the VLDL. Yes, adding up
the HDL, LDL and VLDL makes up the total cholesterol measurement."
http://my.cardiovalens.com/featured/featuredisplay.asp?featureid=155

The data from studies suggests that the LDL/HDL ratio is more
predictive of cardiac risk:
"Data from the Lipid Research Clinics and the Framingham Heart Study
suggest that the total cholesterol (or
LDL-cholesterol)-to-HDL-cholesterol ratio may have greater predictive
value for CHD than serum total or LDL-cholesterol . . . In contrast,
serum total or LDL-cholesterol did not add independent predictive
value to the ratio." (1)

2) How is the Total Cholesterol number calculated? 

This is derived from the Friedewald formula for LDL cholesterol:
LDL-cholesterol = Total cholesterol  -  (triglycerides/5) - 
HDL-cholesterol

Thus, doing some basic algebra:

Total cholesterol = LDL-cholesterol + HDL-cholesterol +
(triglycerides/5)

3) What may be some valid reasons for why a Total Cholesterol Number
(say
286 but an extremely low ratio for LDL to HDL, say 1.2, a ratio that
places
a woman in the 1/2 average risk range) might cause an insurance 
company to either rate up or deny coverage - based on the Total 
number without regard to the low risk ratio? 

I cannot say for sure since I don't work for any insurance companies,
but I can hypothesize it is because of the triglycerides.  What is not
accounted for in a LDL/HDL ratio is the triglycerides (i.e. fat
content in the blood).  Even though the ratio is low, the fact that
the total cholesterol is high suggests that the triglycerides are
high.  High triglycerides are a negative predictor of cardiac risk. 
From UptoDate:
"Hypertriglyceridemia is associated with an increased risk for
cardiovascular disease . . . In the Physician's Health Study, the risk
of myocardial infarction (MI) was highest among men with the highest
tertile for both triglyceride and the TC/HDL-C ratio." (2)

From Best Practice of Medicine:
"Data from several studies, including the Framingham Study, suggest
that serum triglycerides may be important predictors for CHD in men or
women, but not consistently in both sexes. Despite these observations,
the current consensus holds that elevated levels of serum
triglycerides represent a risk marker for obesity, glucose
intolerance, and low HDL levels, all of which confer risk for CHD and,
to the extent possible, deserve preventive attention."
http://merck.micromedex.com/bpm/bpm.asp?page=CPM02CA335žion=report&ss=2

Please use any answer clarification before rating this answer.  I will
be happy to explain or expand on any issue you may have. 
 
Thanks, 
Kevin, M.D. 
 
Internet search strategy: 
No internet search engine was used in this research.  All sources were
from objective physician-written and peer reviewed sources. 

Bibliography:
1) Kinosian, B, Glick, H, Garland, G. Cholesterol and coronary heart
disease: Predicting risks by levels and ratios. Ann Intern Med 1994;
121:641.
2) Stampfer, MJ, Krauss, RM, Ma, J, et al. A prospective study of
triglyceride level, low-density lipoprotein particle diameter, and
risk of myocardial infarction. JAMA 1996; 276:882.

Links:
Best Practice of Medicine - Cardiac Risk Factors
http://merck.micromedex.com/bpm/bpm.asp?page=CPM02CA335žion=report&ss=2

Cardiovalens.com - Cardiac Risk Factors
http://my.cardiovalens.com/featured/featuredisplay.asp?featureid=155

Request for Answer Clarification by schmooz-ga on 31 Jan 2003 14:01 PST
This is the Best $15 I ever spent and I shall say so in my rating.  If
in the scenero we were talking about, total cholesterol of 286,
HDL/LDL ratio of 1.2 - the triglycerides were 67, is 67 a high number
for triglycerides with a VLDL number of 13?
(LDL 152 - HDL 120) 
I am in no way asking for a medical opinion.  

If a woman can look back on many years of labs, consistent with these
ratios and total cholesterol numbers
*  can diet or exercise make changes that would improve the numbers
and her health risk?

Request for Answer Clarification by schmooz-ga on 31 Jan 2003 14:07 PST
By accident, I punched the button before I finished.

*  If a woman already eats carefully and exercises is there something
that      else thatcould or should be done?

*  Does you research even show that something should be attempted to
bring down the total cholesterol number when the LDL/HDL Ratio is low?

I would like to add $15 because I have just asked you to pursue
several other related questions.  I will try to figure out how to do
this.

Clarification of Answer by kevinmd-ga on 31 Jan 2003 14:48 PST
Hello,
Thank you for your kind words.

One uncommon scenario that I neglected to mention that could cause a
low LDL/HDL ratio and high total cholesterol is your case.  That would
be an HDL ("good cholesterol") so high that it causes the total
cholesterol to rise.  An HDL of 120 is extrodinarily high - one if the
highest I've seen.  If you look at the formula:

Total cholesterol = LDL-cholesterol + HDL-cholesterol +
(triglycerides/5)

Although it is more common that a rise in triglycerides would cause
the total cholesterol to rise, you can see how a high HDL cholesterol
would lead to a high total cholesterol.

A HDL of 60 is already considered high, above 40 mg/dL is normal.  The
cardiovascular risk drops approximately 10-20 percent every 5 mg/dL
the HDL is above 40.  Note that the HDL in your case is 120 - it is
literally off the scale.

1) "Is a triglyceride of 67 high?"

No.  Normal triglyceride level is less than 150.  

2)  "Can diet or exercise make changes that would improve the numbers
and her health risk?"

Yes.  Lifestyle modifications are effective in treating triglycerides
and LDL. From UptoDate:
"Hypertriglyceridemia is often induced or exacerbated by secondary,
potentially correctable disorders. Thus, nonpharmacologic
interventions such as weight loss in obese patients, aerobic exercise,
avoidance of concentrated sugars and medications that raise serum
triglyceride levels, and strict glycemic control in diabetics should
be the first-line of therapy.

All patients with high LDL cholesterol should undergo lifestyle
modifications (therapeutic lifestyle changes as stated in ATP III)
such as reductions in dietary total and saturated fat, weight loss in
overweight patients, aerobic exercise, and plant stanols/sterols." (1)

3) If a woman already eats carefully and exercises is there something
that else thatcould or should be done?

The next step would be medication.  You may want to refer to the
National Cholesterol Education Program Guidelines for more
information:
http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm

4) Does you research even show that something should be attempted to
bring down the total cholesterol number when the LDL/HDL Ratio is low?

In most cases, the reason the total cholesterol is high becasue of the
LDL ("bad" cholesterol) or triglycerides is high.  Treatment in those
cases would involve improved diet, increased exercise, and perhaps
medication.  In this case, the HDL ("good" cholesterol) is causing the
high total cholesterol.  When the HDL is this high, it is acceptable
to tolerate a high total cholesterol.

Looking at the profile you provided, the LDL is 152.  The target level
is dependent on risk factors (i.e. < 100 for diabetes and heart
disease, <130 for 1-2 risk factors, <160 for no risk factors). 
Lowering LDL via diet and exercise would lower total cholesterol.

5) I would like to add $15 because I have just asked you to pursue
several other related questions.  I will try to figure out how to do
this.

Thank you for your generosity - this can be accomplished via the "tip"
function when the answer is rated.  I would strongly discussing this
lipid profile with your physician if the insurance company is raising
your rates because of these results.

Thanks,
Kevin, M.D.

Bibliography:
1) Rosenson, R.  Treatment guidelines for hypercholesterolemia. 
UptoDate, 2002.
schmooz-ga rated this answer:5 out of 5 stars and gave an additional tip of: $15.00
The best $15 dollars I have ever spent for an answer well researched
and well answered.  In fact, it is the best ever for double the price.
. . which. . . I think I will!

Comments  
Subject: Re: High Total Cholesterol vs. low LDL/HDL Ratio???
From: kevinmd-ga on 31 Jan 2003 16:17 PST
 
Thank you for the tip and generous comments.

Kevin, M.D.

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