Why LDL is Not Enough: The Tests Your Doctor is Missing to Assess Your Risk of Heart Disease | Know Your Numbers

Heart disease is the world's leading cause of death. For years, the diet-heart hypothesis, which centers on high cholesterol as the primary culprit, has dominated the medical discourse. But now, we're beginning to appreciate the complexity and nuance of how the outer workings of our environment influence the inner workings of our physiology and risk for heart disease.

In today’s episode of a new series I’m calling Know Your Numbers, I deep dive into the Functional Medicine approach to assessing cardiovascular risk and why this is key to preventing and, in some cases, reversing cardiovascular disease. You can test your cardiovascular risk with Function Health, a company I co-founded. It has been a lifelong dream for me. Function is the first-ever membership that includes 100+ lab tests and personalized insights from globally renowned doctors based on your results. Join Function at FunctionHealth.com.

Recommended Diagnostics

Comprehensive lipid testing

  • Total cholesterol
  • Triglycerides
  • HDL
  • LDL
  • Apolipoprotein B (ApoB)
  • Lipoprotein fractionation (NMR)
  • Lipoprotein A
Metabolic labs
  • Insulin
  • Glucose
  • HbA1c
Additional labs
  • hs-CRP
  • Kidney
  • Liver
  • Hormones
  • Uric acid
  • oxLDL, f2 isoprostane
  • LpPLA2
  • MPO
AI-enhanced CT angiograms, imaging tests (preventative)
  • Carotid ultrasound
  • CT Coronary Angiogram
  • CT Coronary Artery Calcium Score
  • Cleerly Scan
Advanced tests
  • Lipid genetics: GB Insights
    • Familial Hypercholesterolemia
    • Lean Mass Hyperresponder / Hypercholesterolemia
  • Biomarkers of excess cholesterol production in the liver or absorption of cholesterol from the gut
Normal vs. Optimal Reference Ranges Total Cholesterol
  • “Normal”: < 200 mg/dL
  • Optimal: < 180 mg/dL
  • Conventional:
    • 0-149 mg/dL (“Normal”)
  • Functional Medicine :
    • <70 mg/dL (Optimal)
    • > 100 mg/dL (insulin resistance)
    • > 150 mg/dL (concerning)
    • > 300 mg/dL (severe, requires aggressive treatment with diet, lifestyle, and sometimes medication)
  • Conventional Medicine (“Normal”): ≧ 40 mg/dL (men); ≧ 50 mg/dL (women)
  • Functional Medicine (Optimal): > 60 mg/dL
  • Conventional Medicine (“Normal”): < 100 mg/dL
  • Functional Medicine (Optimal): < 70 mg/dL
    • Need to look at the number and size of LDL cholesterol particles (lipoprotein fractionation) to determine if cholesterol is atherogenic or benign
    • Conventional Medicine (“Normal”): 20 - 90 mg/dL; risk increases the most > 120 mg/dL
    • Functional Medicine (Optimal): 40 - 70 mg/dL
      • Those with pre-existing heart disease < 50 mg/dL
      • < 30 mg/dL indicator of other health issues (same as low cholesterol)
  • If your LDL is high and your ApoB is low, your risk of heart disease is low
  • If your LDL is normal or low and your ApoB is high, your risk of heart disease is high
  • Should be < 1,000
LDL Small
  • 0-100 nmol/L
LDL Medium
  • Optimal: < 215 nmol/L
  • Moderate: 215-301 nmol/L
  • High: > 301 nmol/L
HDL LARGE PARTICLES Optimal Reference Range
  • > 6729 nmol/L
  • Pattern A is optimal:
    • Pattern A is bigger, more buoyant, usually not associated with heart disease
  • Pattern B is a risk marker:
    • Pattern B is smaller and denser particles, which are atherosclerotic risk markers
  • Studies have shown varying risks for CAD and other CVDs at different Lp(a) cutoff points
  • Generally, the lower, the better (< 20)
    • Risk varies with age
    • Risk is higher in individuals with lower Lp(a) levels and smaller apo(a) isoforms
  • Conventional Medicine (“Normal”): <130 mg/dL
  • Functional Medicine (Optimal): 100 mg/dL or lower
  • Ideally, it should be 1:1
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