David is 52. He jogs nearly every second day, he tries to avoid sweets, is not overweight, and he doesn’t smoke. His GP orders a cholesterol panel as part of his annual check-up, and the results come back looking quite reassuring: total cholesterol of 5.2 mmol/L, LDL of 3.1 mmol/L and a HDL of 1.1 mmol/L, and triglycerides of 1.8 mmol/L. His fasting glucose on the day of the test was just within range at 5.3 mmo/L. His GP tells him his numbers are within range for his age.
David isn’t so convinced he’s off the hook. His father had a fatal heart attack in his early 60s, so he really wanted to dig deeper given that heart disease was in his family. He visits Melbourne Functional Medicine for a deeper look, this time to ask for an advanced cholesterol panel. Once his results are back, the story of his cholesterol-related biomarkers tells something quite different. Let’s take a look at what a standard cholesterol panel tells us and then move to compare that to what David learned in his advanced panel.
The standard panel: a good starting point but not the full picture
The standard cholesterol panel measures a handful of core lipid biomarkers. All important, but not a comprehensive view. Let’s explore what each marker means.
Cholesterol total
Cholesterol is a type of lipid, but it doesn’t get stored as body fat or used for energy the way triglycerides do, its job is more structural such as building cell membranes, making hormones, vitamin D, and forming bile acids. This marker shows your overall cholesterol level, combining LDL, HDL, and other lipid fractions. “Normal” total cholesterol can hide an unfavourable balance between the different particle types. But it is still a good, quick starting point.
Triglycerides
Another type of lipid/fat carried in your blood, largely reflecting recent diet, alcohol intake, and how well your body processes sugar. Elevated triglycerides are linked to insulin resistance and increased cardiovascular risk, especially when HDL is also low.
HDL (high-density lipoprotein)
A lipoprotein is a cholesterol transporter. Cholesterol cannot just travel as it is, it needs to be inside something. So think of lipoproteins as being like buses, with the passengers being cholesterol molecules. HDL is often called “good” cholesterol because it transports cholesterol out of your tissues and back to the liver. Higher HDL is generally protective, though very high levels don’t always confer extra benefit.
Non-HDL Cholesterol
Total cholesterol minus HDL. This captures all the potentially artery-clogging particles in one number (LDL and other cholesterol-containing particles), and is considered a better predictor of cardiovascular risk than LDL alone.
LDL (low-density lipoprotein)
Again, LDL is a cholesterol transporter. The LDL “bus” is often called “bad” cholesterol because it transports cholesterol from the liver into the bloodstream for use in various cellular processes. It can deposit into artery walls and contribute to plaque formation. LDL is the primary target of most cardiovascular risk assessments and treatment decisions.
Glucose (Fasting)
One reading of your blood sugar levels at fasting (before breakfast). Chronically elevated glucose damages blood vessels and increases glycation over time. Is closely tied to cardiovascular risk, independent of cholesterol.
By these measures, David’s results looked to be within conventional range points. Let’s take a closer look at what his advanced lipid panel came up with.
The advanced panel: what David’s silent drivers of cardiometabolic disease risk were saying
An advanced panel goes further than how much cholesterol someone has, and looks at what type it is, how it’s behaving, and what else might be driving cardiometabolic risk.
David’s ApoB came back elevated, despite his LDL cholesterol sitting within a normal range. We also picked up opportunities to improve insulin levels and homocysteine levels.
Apolipoprotein B / ApoB
Every high-risk lipoprotein transporter (LDL, VLDL, Lp(a)) carries one ApoB molecule, so this measures the total number of potentially harmful particles in your blood. Many researchers consider it a more accurate risk marker than LDL alone.
His panel also flagged some more issues to look at:
Elevated fasting insulin
In the body, there is a relationship between glucose and insulin. Whilst it is common to get fasting glucose tested, this can fluctuate day to day and can stay within range for years before showing signs of metabolic dysfunction. Fasting insulin, on the other hand, can provide insights into the sensitivity of the cells to insulin and therefore uptake of glucose. As cells become more insulin resistant, it takes more insulin to maintain normal glucose, and this process continues until eventually we start to see blood glucose also rise. And, despite having a normal BMI (body mass index) for his age and fasting glucose within range, David’s insulin came in at 9.4 U/L, much higher than optimal. Elevated fasting insulin, if caught early, can usually be reverted back to a normal range with lifestyle interventions.
David’s homocysteine was also higher than we would have liked to see. Homocysteine is an amino acid by-product of methylation that, at elevated levels, increases the risk of blood vessel damage and subsequent inflammation, which increases the risk of clot formation that can lead to strokes and heart attacks, independent of cholesterol levels. Elevated homocysteine can usually be brought back into range with methylation co-factors and addressing specific vitamin deficiencies. It can also be worth considering testing if there are methylation genetics at play impacting the number.
And, whilst David’s triglycerides were within range on his standard panel, his functional medicine practitioner pointed out that ideally, the ratio of triglycerides to HDL should be 1:2 and his was closer to 1:1. Some lifestyle adjustments were in order to support him back towards optimal ranges to get his biomarkers trending in a direction towards better heart health.
How functional medicine treatment informed new lifestyle actions for David
Between diet adjustments, lifestyle changes, addressing nutritional deficiencies and glucose control strategies, a personalised plan was prepared for David. We also included some further testing to scratch his itch of wanting to know more about what was ‘happening under the hood’. David’s next steps before the next appointment with his functional medicine practitioner were:
myDNA testing: David was keen to know more about how his body was methylating and how much was likely impacted by genetics.
2 weeks with a Continuous Glucose Monitor (CGM): We wanted to get a real handle on David’s blood glucose response to food, stress, exercise, and sleep. He wore a CGM for two weeks to help us personalise his dietary adjustments.
Nutrient testing: We sent David off with test kits for further testing into exactly which methylation co-factors and nutrients could have been deficient and driving up the high homocysteine and put his mind at ease that once we identified these, it should be a relatively easy intervention to bring his levels back into the optimal range.
Exercise changes: David had focused mostly on cardio for the last few years as it helped him “blow off steam” after intense days in the office. He needed to build up a bit more muscle to help manage blood glucose, slightly lower triglycerides and steady that elevated insulin. He started by swapping one running session a week with a weights session in the middle of the day at the gym downstairs from his office.
Cardiometabolic food guide: whilst David was generally eating well, he needed a bit more plant variety, some more foods with Omega-3, and a boost in fibre. We supplied him with our cardiometabolic food guide to review where he could shift on some of his food choices.
Learning new stress management tools: whilst running was his go-to for a stressful day or week, David never really thought about stress management as a health pillar. His practitioner recommended he spend some time learning other tools that he can use during days when he can feel his blood pressure and adrenaline pumping. He learned that he can control his physiology and response to stressors, and that could have a really positive impact on his heart health.
David also engaged the support of a health coach to help him navigate the habit tweaks needed in his day-to-day life to support an adjusted exercise regime, managing his CGM learnings (less potato and rice!) and moving onto the cardiometabolic food plan – for both him and his wife. Oh, and also learning those new stress management tools for a more balanced nervous system.
Enabling a more intentional health approach
Over 4 months of sticking to the recommendations and building on habit changes as more health data came in, we saw David improve his ApoB, homocysteine and fasting insulin levels back to a range we would consider closer to optimal. He also reported that although he felt pretty good when he started, he now realised he doesn’t have energy dips in the afternoon anymore, a persistent dry skin patch he had is now gone and he gets better recovery scores on his Whoop. Overall, the experience has made him feel much more in control of his health destiny.
