VAP Dietary Advice

      31 Comments on VAP Dietary Advice

A friend of mine recently had a VAP test done, and a reader happened to pick up a brochure on the VAP test around the same time.  Both sent me scans of one page that explains what a VAP test measures, and a separate Diagnosis/Lifestyle Therapy page offering advice on how to improve less-than-stellar lab scores.  (If you don’t already know, a VAP test is much more detailed than a standard lipid panel, measuring specific particle counts and sizes.)

Below, I’ve matched up some of the explanations with the advice.

VLDL Cholesterol
VLDL is the main carrier for triglycerides and, if elevated, can be an independent risk factor for heart disease.
Diagnosis: Elevated triglycerides and VLDL
Lifestyle Therapy: Low carbohydrate diet, exercise.

IDL Cholesterol
IDL cholesterol is a strongly inherited independent risk factor for heart disease and is elevated in patients with a family history of diabetes.
Diagnosis: Elevated IDL
Lifestyle Therapy: Low carbohydrate diet, exercise.

LDL Cholesterol Pattern
LDL exists in a range of sizes from small, dense “Pattern B” to large, buoyant “Pattern A.”  The smaller LDL cholesterol sizes are associated with an increased risk for heart disease.  Small, dense LDL is prevalent in patients with insulin resistance or diabetes.
Diagnosis: Small, dense LDL Pattern B
Lifestyle Therapy: Low carbohydrate diet, exercise.

Metabolic Syndrome
Metabolic Syndrome is characterized by the combination of several metabolic risk factors, including elevated triglycerides, low HDL, and small, dense “Pattern B” LDL that increase the overall risk for heart disease.
Diagnosis: Metabolic Syndrome
Lifestyle Therapy: Low carbohydrate diet, increased good fats in diet, exercise.

The “heart attack” cholesterol, Lp(a) is a strongly inherited risk factor for heart disease.  This does not respond to traditional LPL-lowering drugs.
Diagnosis: Elevated Lp(a)
Lifestyle Therapy: No direct effect.  Control other coronary risk factors.

So here’s the picture so far:  We have all these bad subfractions of cholesterol that may cause heart disease.  The advice for reducing them includes a low-carb diet.  Lp(a), the “heart attack” cholesterol, doesn’t respond to diet or LDL-lowering drugs, so the advice is to focus on lowering the other bad subfractions – again, with a low-carb diet.  We also want more good fats in the diet to raise HDL.

Now look at this explanation and advice:

Real LDL Cholesterol
The real LDL Cholesterol that circulates in your body.  Total LDL = Lp(a) + IDL + Real LDL.
Diagnosis: Elevated Real LDL
Lifestyle Therapy: Low fat diet, exercise.

So there you have it.  You can reduce the most damaging LDL subfractions with a low-carb diet (except for Lp(a), which doesn’t respond to diet), you can raise your HDL by eating more fat, but to reduce your total LDL and thus save yourself from a heart attack, you need a low-fat diet.

Right.  And here’s my advice for getting clean:  To clean your arms and legs, use soap and water.  To clean your chest and back, use soap and water.  To clean your face, use soap and water. But to clean your entire body, use dirt.

Head.  Bang.  On.  Desk.


31 thoughts on “VAP Dietary Advice

  1. Judy Baker

    Great post, Tom. Who published the pages about the VAP test? I’d like to show this to my husband and to my doctor.

    Both brochures have an Atherotech banner on them. Interestingly, one specifies a low-carb diet, while the other merely advises limiting refined carbohydrates.

  2. Susan

    I think I am going to skip the VAP and just stick with LCHF. The suggestions and recommendation change so often that I cannot keep up. It might be dangerous, but I am going to go with how much better my body feels, and it feels better eating LCHF. If I kick over, well, I kick over. My doc said I would kick over any time now by eating a LC diet, and that was almost four years ago. 🙂

    Give it another 50 years, and you may prove him right.

  3. Rakesh Patel MD

    The current VAP piece we have in our office actually states “limit refined carbs” under all the above headings. Obviously we translate that to apply to most carbs.

    We tell patients to ignore the low fat part on the LDL, since it is such a poor marker of real risk. But it does make the point of disconnect in dietary advice among physicians and dieticians.

    Also, you mention lp(a) does not respond to diet, this little gem from 1997 may suggest that (you got it) saturated fat may lower lp(a):

    Interesting study.

  4. Lori

    I’d say it was probably a typo or copyediting error, but most doctors don’t see anything wrong with the idea that humans are composed of parts that have nothing to do with each other.

  5. Bill Lee

    The heart health dietary advice equivalent to 1+1+1=37. As a wise man once said, “something here just doesn’t add up.”

    That wise man (Tom Monahan) is a pretty good musician too.

  6. Sol y Sombra

    Maybe they just forgot to change it at the end 🙂 After all, it’s a great progress that they recommend a low-carb diet throughout the brochure. I think there’s hope for change.

  7. desmond

    Consistency is not really a human trait. On the bright side, after viewing “Big Fat Fiasco” over Thanksgiving with my mother, I think I successfully convinced her to avoid statins, watch her carbs, and throw away the corn oil. I even sent her home with a jar of coconut oil and a couple pounds of fresh lard. If only we could convince my father to stop eating cookies and drinking soft drinks every day…

    That’s a fine early Christmas present you gave your mother.

  8. Liz

    People don’t realize that they have to trust themselves when making decisions. From the time we’re born we’re told what to do, especially in our school systems. I personally think it encourages adults to become dependent on others for their own decision-making.

    I’m glad I realized the low-fat diet full of carbs wasn’t working for me. Had I listened to “conventional wisdom,” I’d still be wondering what was “wrong with me,” you know?

    I’m pleased that my daughters (no doubt after frequently hearing their father bang his head on his desk) bring home health handouts from school and say, “Look, Dad. This is just all wrong.” The sooner they realize not everything they read is true, the better.

  9. Stacie

    I was going to comment that saturated fat reduces Lp(a), but Dr. Patel has already done that. This just reinforces in my mind that (for me) all versions of the Lipid Hypothesis are nonsense. Even people who do not believe it, still believe that the problem is the size of your LDL particles. Of course, now we have Dr. Dayspring and Dr. Attia saying that it is not the size, but the number of LDL particles. For me, BIG “Head bang on desk.” I think we need to leave cholesterol alone, move on, and look at all the other things that cause CVD(stress, microbial infections, vitamin K2, magnesium, vitamin D3, etc. deficiencies, and so on.) With all the versions of the hypothesis, there are so-called “paradoxes” and contradictions. It is time to abandon it, move it to the ash heap.


  10. Elena

    I saw your movie last summer and started right away the LCHF diet. It is hard in the beginning, and I ease myself into with, every day giving up on more carb. I am diabetic and my doctor is main stream, no fat or low fat and lots of healthy carbs. Today I just got my first blood tests since I started and I could not keep it for myself. I have A1C now at 6.1% down from 8.4% last time. So thank you very much.

    So in conclusion, I wash every day with water and soap and I tell my doctor that I use dirt. My A1C likes the soap though.

    It’s a shame when we have to lie to our doctors, but that’s where we’re at.

  11. Joy

    I just sent this to my husband. He has high cholesterol & triglycerides. The guidelines his doctor gave him are frustrating – to lower one thing, he’s not to eat carbs; to lower the other, he’s not to eat meats/fats. It seems like the only thing he can eat is lettuce 😉 *sigh*

    Perhaps he needs to become a breatharian.

  12. Kathy

    Tom – If you aren’t comfortable approving this comment, I get it. I don’t work for Direct Labs or anything like that, and they do provide a worthwhile service. Feel free to edit as you see fit if you approve.

    Many insurance plans won’t pay for more extensive tests of this kind. For anyone interested in your numbers, the VAP & NMR are available at a reasonable cost from Direct Labs ( You pay online and get the receipt, which you present to the local lab for the blood draw. I did it and my doctor found it interesting enough to ask for a copy to add to my file. He may be conventional, mainstream medicine, but he is fair and never gives me a hard time about my lifestyle.

    I’m happy to pass along the information.

  13. r2d2

    I have a question about being on the paleo/primal/whatever while only occasionally eating cakes/pizzas/etc.

    So, let’s say I eat lots of eggs and meats all the time as a part of my main diet.

    But then I go out with friends, and eat some cakes and later pizzas. Maybe once a month or so.

    Isn’t this dangerous? My simple logic goes like this: The cakes and pizzas will raise my blood sugar, inflaming my blood vessels, and then all the cholestrol/fat/etc. that I got into my blood from eating eggs/meats/etc. will get stuck in the inflammation, causing atherosclerosis.

    In other words: Is occasional junk food eating more dangerous for paleo people than others? What do you think?

    I think our bodies can handle the occasional indulgence. It’s frequent and on-going indulgences that overwhelm our ability to heal.

    That assumes, however that you’re not 1) dealing with a lot of existing metabolic damage, and 2) not prone to go on a binge after giving in “just this once.”

  14. Jesrad

    I’m a bit confused about the “pattern A” and “pattern B” LDL… Which one really is a problem and a true risk-factor for cardiovascular disease ? What I got from various websites points to either being a “worse” culprit than the other…

    The confusion is understandable. We have a particle called Lp(a) that’s considered bad, a pattern called “A” that’s good, and a pattern called “B” that’s bad. It’s easy to mix up those A’s and B’s.

  15. Brian

    That reminds me, are you going to repost your statin Christmas poem this year Tom?

    I forgot about that one. Sure, I’ll post it.

  16. Philip

    Current research shows that lipoprotein particles, not cholesterol levels, are most closely associated with artery health as accepted in a consensus statement by Cardiology and ADA (J Am Coll Cardiol. 2008;51(15):1512-1524). And, a scientific statement in 2011 by the Am Heart Assoc pointed out that particle counts, using ApoB measurements, to be more highly correlated with CVD (circulation 2011). In addition, the later article stated that the “lowest risk of incident and recurrent CVD in association with the lowest fasting triglyceride levels”. But, few medical providers or cardiologist are familiar with these facts. Ask you doc for an ApoB or use the TG/HDL ratio to see your real CVD risk.
    Of course what lowers TG and particle number? Low carb

    Unfortunately, you’re correct: many doctors haven’t kept up with the research. I had a doctor recommend I go on a low-fat diet because my total cholesterol was “elevated” at 203. My triglycerides were 70 and HDL was 64. It was right there in front on the lab results. He should have been congratulating me.

  17. Caitlin

    The research in Philip’s comment above scares me. I’ve been low carbing for a few years. Both I and my boyfriend decided to get an NMR test. His small particle count was very low (GOOD) but mine was sky-high, very high. But at the same time particle size came back “Pattern A”. HDL, Trigs, etc. the usual LC pattern. I don’t know what to think, but I’ve kept up the lifestyle.

    If by small particles they mean Lp(a), that’s largely genetic. According to Dr. “Wheat Belly” Davis, people with that gene especially need to avoid sugar, wheat, etc. He uses Niacin to bring down Lp(a).

  18. Pierce

    re: TriHealth-

    How is a private corporation doing what it pleases within the law (and I am not agreeing with that action) either “fascism” or contrary to libertarian thought?

    It isn’t. It’s merely astoundingly stupid.

  19. A Country Farmer

    Philip’s comment (and Tom’s response) were interesting. I found the two studies Philip mentioned [1,2], but I didn’t see any talk about Triglyceride/HDL ratio.

    I’m on a hunter-gatherer diet and recently got some numbers: Triglyceride=62, HDL=57 and non-HDL=329, which worried the doctor (although [1] doesn’t emphasize that diet elevates non-HDL, whereas [2] clearly shows that Triglycerides are impacted by diet). I think my next step is to get the apoB and LDL particle measurement through nuclear magnetic resonance.


    The NMR would be a good idea. In the meantime, here’s a study on TG/HGL ratio:


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