LDL- Bad or Good?

During cardiology training, we were taught LDL is the bad cholesterol and HDL is the good version. The endless waves of pharmaceutical salespeople affirmed this faulty categorization. Further reinforcement came from watching television and the constant barrage of drug ads to lower the bad LDL cholesterol.


But LDL, or low density lipoprotein, has a purpose. That is why we as humans manufacture it. That is why other animal species make it. The LDL particle is like a bus. Made in the liver, the LDL bus contains passengers such as cholesterol, Co Q 10, phospholipids, triglycerides, and fat soluble vitamins. The main function of LDL is as a transport vehicle to deliver triglycerides for storage or immediate utilization for energy.


So is high LDL a problem? This is where it gets a little tricky. Historically, LDL was measured by its total weight in a given volume. This value is somewhat correlated with heart disease risk. Yet, so many people with high LDL have no evidence of coronary artery disease, while those with low LDL levels may have significant blockages.

Over the years, researchers have learned that LDL particle numbers are what really count. The more particles, the higher the risk of coronary artery disease. Think of a bottle full of LDL. The bottle could be full of LDL particles the size of marbles or particles the size of BB’s. In reality, LDL occurs as a mixture of the large and small spheres.


The risk is much higher in the person with lots of LDL particles the size of BB’s. You could fill the bottle with thousands of BB’s versus hundreds of marbles. BB’s easily cross the lining of coronary arteries, and because there are more of them, are highly correlated with heart disease risk.

In a study from 2001, the investigators looked at heart attack risk based on particle size. What they found was those with the highest amount of LDL particles had 4x the risk of a heart attack versus those people with the least amount (1). Many subsequent trials have found the same results.

A 2007 trial determined that LDL particles were twice as predictive for cardiac events as LDL concentration, the old way of looking at things (2). This is the reason why advanced particle analysis is necessary. LDL concentration with values between 70 and 170 do not offer much in the way of help. Is an LDL of 120 bad or good? We need to know the particle number. This number can be anywhere from below 1000 to above 3500.

As a holistic cardiologist, I try to find my patient’s perfect “caveman” cholesterol. What is appropriate and normal for one person is different from another. Eat Paleo, avoid chemicals, and stay active. Your body will make what it needs if you give it the appropriate fuel.

What should you do if your LDL particle number is high?

Nutrition, nutrition, nutrition are the keys to healthy lipid numbers. If, despite your best efforts, LDL particle counts are still high, here are some supplement approaches to lower the number down without resorting to dangerous pharmaceuticals.

  • This molecule derived from plants has been studied by the Chinese for many years. Berberine is an excellent supplement to lower LDL particle numbers as it works to increase hepatic LDL receptors to clear LDL from the blood stream. Berberine also lowers blood sugar.
  • Plant sterols and fiber products. These agents act to inhibit re-absorption of cholesterol in the gut making less available for packaging inside LDL. If there is less cholesterol available, the liver can’t make as many LDL particles. My personal choice in this category is psyllium husk from Organic India. Stay away from pesticide psyllium products like Metamucil. Go organic!
  • Red yeast rice (RYR). I reserve RYR for my most stubborn cases of elevated LDL who also have a history of coronary artery disease (CAD). My cut off is an LDL particle number above 2000 WITH a history of CAD.
  • A recent meta-analysis of many trials concluded probiotics lower LDL. Particle size was not looked at and the mechanism of action is not clear.

In conclusion, demand your health care provider get out of the dark ages and check advanced lipid particle analysis. If they don’t, find a doctor who will.


  • Campos, H. 2001; 286(12):1468-1474.
  • Cromwell, W. J Clin Lipidol. 1:583-592.
  • Shimizu, M. PLoS One. 2015 Oct 16.

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