> Other than the expense of an office visit, why not go in?  It's another education opportunity, which you have already mentioned he is open to.
> 
> Your ratio is good.  Both the total and the calculated LDL are outside the reference range.  He might be concerned about either one.  On the other hand, he may be surprised that they aren't much higher, if he has the "conventional wisdom" opinion of a high fat diet.   Did *he* say he "flagged" you because of the total, or are you just assuming that?

I opted to answer him via snail mail.  I waive my HIPAA rights in posting this ;-)

Dr. XXXXXX,

Thank you for my recent physical.  From that examination it would appear my health looks good -- I am exercising at an optimum level and my blood pressure, pulse, and weight are certainly within acceptable limits.  And, boy, and I am ever proud to sport the “prostate of an 18 year old”!

The reason I write is your nurse called me in for a follow up visit with you to discuss my blood test results, presumably because of the three circled numbers (Total Cholesterol, LDL Cholesterol, and Vitamin D) on the copy I requested be mailed to me.   Putting aside the Vitamin D numbers, I’d like to talk about the cholesterol for a minute.

Clearly good are my HDL (113 vs. reference of >39), Triglycerides (46 vs. reference range of 0-149), and Serum Glucose (78 vs. reference range of 65-99).  But not so good, apparently, is my LDL (107 vs. reference range of 0-99).  

It seems to me this LDL number is not an outrageous number, but here is the vital question a standard lipid panel doesn’t answer:  How much of the number is comprised of Large Fluffy Particles(“Pattern A”), which are neutral if not beneficial, and how much is comprised of Small Dense Particles (“Pattern B”), the clearly bad subgroup of the whole LDL equation?  [Again, Pattern A, good, versus Pattern B, bad.]

There’s little use talking about LDL without this information.  While I realize that there exist costly tests such as gel electrophoresis, nuclear magnetic resonance, and ultracentrifugation,  I have come across in my reading a great rule of thumb to help estimate whether LDL is Pattern A  -- comprised mostly of good, harmless Large Fluffy particles -- or Pattern B -- comprised mostly of bad Small Dense particles. * 

Per McLaughlin, the formula Triglycerides over HDL is “an effective surrogate for LDL particle size.  Values of TG/HDL-C over 3.5 indicate [a probability of] Pattern B with a predominance of Small LDL particles [and also probably] insulin resistance.”

So taking my numbers, TG is 46 and HDL is 113.  46 over 113 is .41 -- which is well below McLaughlin’s ratio of 3.5.  Looks like I’m Pattern A and therefore the LDL numbers are good.

If you’d like to see me about the Vitamin D numbers, please let me know.  With the amount of wild fatty fish I eat and with summer coming on -- and therefore lots more sunlight in my future -- I am not concerned there either.  Can we maybe wait for a retest next physical?



*McLaughlin, T., “Is there a simple way to identify insulin-resistant individuals at increased risk of cardiovascular disease?” Am J Cardiol, 2005, 96(3): p. 399-404.