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The Cholesterol Conundrum -“Know Your Metrics”
www.thefatemperor.com
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2013 Ivor Cummins BE(Chem) MIEI
1. Cholesterol Units 1012. Standard Lipid Test
• Total Cholesterol Concentration• LDL / HDL Cholesterol Concentration• Serum Triglyceride
3. The All-Important Ratios• Total Cholesterol / HDL• Triglyceride / HDL
4. Introduction to some other Critical Metrics• Fasting Insulin, Blood Glucose/HbA1c, 25 Hydroxy Vitamin D
5. Conclusion
Metrics Content:
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2013 Ivor Cummins BE(Chem) MIEI
1. Cholesterol Units 101
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2013 Ivor Cummins BE(Chem) MIEI
1. Cholesterol Units 101 Cholesterol and Triglyceride can be measured in mg/dL (e.g. USA) or
mmol/L (e.g. Europe)
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2013 Ivor Cummins BE(Chem) MIEI
1. Cholesterol Units 101 Cholesterol and Triglyceride can be measured in mg/dL (e.g. USA) or
mmol/L (e.g. Europe)
Be careful converting – Cholesterol and Triglyceride both have DIFFERENT conversion factors as you switch from one unit to another
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2013 Ivor Cummins BE(Chem) MIEI
1. Cholesterol Units 101 Cholesterol and Triglyceride can be measured in mg/dL (e.g. USA) or
mmol/L (e.g. Europe)
Be careful converting – Cholesterol and Triglyceride both have DIFFERENT conversion factors as you switch from one unit to another
To convert CHOLESTEROL from mmol/L to mg/dL, multiply by 38.7
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2013 Ivor Cummins BE(Chem) MIEI
1. Cholesterol Units 101 Cholesterol and Triglyceride can be measured in mg/dL (e.g. USA) or
mmol/L (e.g. Europe)
Be careful converting – Cholesterol and Triglyceride both have DIFFERENT conversion factors as you switch from one unit to another
To convert CHOLESTEROL from mmol/L to mg/dL, multiply by 38.7
To convert CHOLESTEROL from mg/dL to mmol/L, divide by 38.7
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2013 Ivor Cummins BE(Chem) MIEI
1. Cholesterol Units 101 Cholesterol and Triglyceride can be measured in mg/dL (e.g. USA) or
mmol/L (e.g. Europe)
Be careful converting – Cholesterol and Triglyceride both have DIFFERENT conversion factors as you switch from one unit to another
To convert CHOLESTEROL from mmol/L to mg/dL, multiply by 38.7
To convert CHOLESTEROL from mg/dL to mmol/L, divide by 38.7
To convert TRIGLYCERIDE from mmol/L to mg/dL, multiply by 88.6
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2013 Ivor Cummins BE(Chem) MIEI
1. Cholesterol Units 101 Cholesterol and Triglyceride can be measured in mg/dL (e.g. USA) or
mmol/L (e.g. Europe)
Be careful converting – Cholesterol and Triglyceride both have DIFFERENT conversion factors as you switch from one unit to another
To convert CHOLESTEROL from mmol/L to mg/dL, multiply by 38.7
To convert CHOLESTEROL from mg/dL to mmol/L, divide by 38.7
To convert TRIGLYCERIDE from mmol/L to mg/dL, multiply by 88.6
To convert TRIGLYCERIDE from mg/dL to mmol/L, divide by 88.6
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2013 Ivor Cummins BE(Chem) MIEI
1. Cholesterol Units 101 Metric Current Desired Action Result
Tot Chol 200 mg/dL mmol/L Divide by 38.7 5.16 mmol/L
LDL 100 mg/dL mmol/L Divide by 38.7 2.58 mmol/L
Tot Chol 6.8 mmol/L mg/dL Multiply by 38.7 263 mg/dL
HDL 1.7 mmol/L mg/dL Multiply by 38.7 66 mg/dL
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2013 Ivor Cummins BE(Chem) MIEI
1. Cholesterol Units 101 Metric Current Desired Action Result
Tot Chol 200 mg/dL mmol/L Divide by 38.7 5.16 mmol/L
LDL 100 mg/dL mmol/L Divide by 38.7 2.58 mmol/L
Tot Chol 6.8 mmol/L mg/dL Multiply by 38.7 263 mg/dL
HDL 1.7 mmol/L mg/dL Multiply by 38.7 66 mg/dL
Triglyceride 150 mg/dL mmol/L Divide by 88.6 1.69 mmol/L
Triglyceride 0.78 mmol/L Multiply by 88.6 69 mg/dL
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2013 Ivor Cummins BE(Chem) MIEI
1. Cholesterol Units 101 Metric Current Desired Action Result
Tot Chol 200 mg/dL mmol/L Divide by 38.7 5.16 mmol/L
LDL 100 mg/dL mmol/L Divide by 38.7 2.58 mmol/L
Tot Chol 6.8 mmol/L mg/dL Multiply by 38.7 263 mg/dL
HDL 1.7 mmol/L mg/dL Multiply by 38.7 66 mg/dL
Triglyceride 150 mg/dL mmol/L Divide by 88.6 1.69 mmol/L
Triglyceride 0.78 mmol/L Multiply by 88.6 69 mg/dL
RatioUse mg/dL(!)
Ivor Guide My Target Result
Tot Chol/HDL 263 / 66 <4.5 <4.0 ~3.5
Trig/HDL 69 / 66 <2.0 <1.0 ~1.0
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2 Standard Lipid Test
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2.1 Total Cholesterol
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<200 200-240 240-280 >280
2.1 Total Cholesterol Is the use of cholesterol in mortality risk algorithms in clinical guidelines valid? Ten years prospective data from the Norwegian HUNT 2 study (>58,000 Participants)Halfdan Petursson MD,1 Johann A. Sigurdsson MD Dr med,2 Calle Bengtsson MD Dr med,3
Tom I. L. Nilsen Dr Philos4 and Linn Getz MD PhD5
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<200 200-240 240-280 >280
2.1 Total Cholesterol Is the use of cholesterol in mortality risk algorithms in clinical guidelines valid? Ten years prospective data from the Norwegian HUNT 2 study (>58,000 Participants)Halfdan Petursson MD,1 Johann A. Sigurdsson MD Dr med,2 Calle Bengtsson MD Dr med,3
Tom I. L. Nilsen Dr Philos4 and Linn Getz MD PhD5
Total Cholesterol:•Hopelessly confounded•Only useful for research•But interesting interaction with w6/w3 ratio…
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2.2 LDL & HDL Cholesterol
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2.2 LDL & HDL Cholesterol
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2.2 LDL & HDL Cholesterol
LDL•Confounded
HDL•Guide >40mg/dL•Generally true…
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2.3 Serum Triglyceride
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2.3 Serum Triglyceride (< 2.25 mmol/L)(> 2.25 mmol/L)
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2.3 Serum Triglyceride (< 2.25 mmol/L)(> 2.25 mmol/L)
Triglyceride:•Guide <150mg/dL•Ideally <100mg/dL
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3 All-Important Ratios
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3.1 – The Total Chol / HDL Ratio
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3.1 – The Total Chol / HDL Ratio
Ratio <5, LDL being low or High is irrelevant
Ratio >5, LDL being low or High is irrelevant
Am J Cardiol. 2001 Oct 1;88(7):737-43.Efficacy of cholesterol levels and ratios in predicting future coronary…..
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3.1 – The Total Chol / HDL Ratio
Tot Chol / HDL Ratio:•Guide <4.5 or 5•Ideally <4.0
Ratio <5, LDL being low or High is irrelevant
Ratio >5, LDL being low or High is irrelevant
Am J Cardiol. 2001 Oct 1;88(7):737-43.Efficacy of cholesterol levels and ratios in predicting future coronary…..
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3.2 The Trig / HDL Ratio
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3.2 The Trig / HDL Ratio Study: “High Ratio of Triglycerides to HDL-Cholesterol Predicts Extensive Coronary Disease”
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3.2 The Trig / HDL Ratio
Triglyceride / HDL Ratio:•Guide <2.0•Ideally <1.0
Study: “High Ratio of Triglycerides to HDL-Cholesterol Predicts Extensive Coronary Disease”
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4 Other Key Metrics
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4.1 Fasting Insulin
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4.1 Fasting Insulin
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4.1 Fasting Insulin
Fasting Insulin:•Guide: Unclear•Ideally <10uU/mL•Again, watch the units!
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4.2 Fasting Glucose
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4.2 Fasting Glucose
“The apoB/apoA-I ratio: a strong, new risk factor for cardiovascular disease and a target for lipid-lowering therapy – a review of the evidence”. WALLDIUS1,2 & I . JUNGNER3 , 4 From the 1King Gustaf V Research Institute, Karolinska Institute, Stockholm; 2AstraZeneca, So¨derta¨lje; 3Department of Medicine, Karolinska Institute, Epidemiological Unit, Stockholm; and 4CALAB Research, Stockholm; Sweden
Journal of Internal Medicine 2006; 259: 493–519
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4.2 Fasting Glucose
Blood Glucose:•Guide <6 mmol/L•Ideally <5 mmol/L
Note 1: watch the units(!) – mmol/L used above, but multiply by 18 to get mg/dL
Note 2: HbA1c is a more stable indication of long-term blood glucose levels
“The apoB/apoA-I ratio: a strong, new risk factor for cardiovascular disease and a target for lipid-lowering therapy – a review of the evidence”. WALLDIUS1,2 & I . JUNGNER3 , 4 From the 1King Gustaf V Research Institute, Karolinska Institute, Stockholm; 2AstraZeneca, So¨derta¨lje; 3Department of Medicine, Karolinska Institute, Epidemiological Unit, Stockholm; and 4CALAB Research, Stockholm; Sweden
Journal of Internal Medicine 2006; 259: 493–519
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4.3 25 Hydroxy Vitamin D
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4.3 25 Hydroxy Vitamin D Study: “Association of vitamin D deficiency and coronary artery disease with cardiovascular risk factors”
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4.3 25 Hydroxy Vitamin D
25 Hydroxy Vit D:•Should be >=75 nmol/LNote: watch the units again(!) – 75nmol/L used above equates to 30ng/ml: so, divide by 2.5 to get from nmol/L to ng/ml, and vice versa)
Study: “Association of vitamin D deficiency and coronary artery disease with cardiovascular risk factors”
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5 – Conclusion
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5 – Conclusion •Need to understand lipid unit conversion to avoid confusion•Traditional Tot Chol and LDL are outdated predictors•Tot Chol / HDL and Trig / HDL are powerful predictors•Fasting Insulin, HbA1c and other metrics are underused•25 Hydroxy Vitamin D level is critical and underemphasised
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5 – Conclusion
Watch “The Cholesterol Conundrum – Root Cause and Solution” for engineering-level explanation of this arena.
•Need to understand lipid unit conversion to avoid confusion•Traditional Tot Chol and LDL are outdated predictors•Tot Chol / HDL and Trig / HDL are powerful predictors•Fasting Insulin, HbA1c and other metrics are underused•25 Hydroxy Vitamin D level is critical and underemphasised