Small LDL: Simple vs. complex carbohydrates

4. May 2010 William Davis (17)
Joseph is a whip-smart corporate attorney, but one who accepts advice at his own pace. He likes to explore and consider each step of the advice I give him.

Starting (NMR) lipoprotein panel on no treatment or diet change:

LDL particle number 2620 nmol/L (which I would equate to 262 mg/dl LDL cholesterol)
Small LDL 2331 nmol/L--representing 89% of LDL particle number, a severe dominance of small LDL

I advised him to eliminate wheat, cornstarch, and sugars, while limiting other carbohydrate sources, as well. Joseph didn't like this idea very much, concerned that it would be impractical, given his busy schedule. He also did a lot of reading of the sort that suggested that replacing white flour with whole grains provided health advantages. So that's what he did: Replaced all sugar and refined flour products with whole grains, but did not restrict his intake of grains.

Next lipoprotein panel with whole grains replacing white refined flour:

LDL particle number 2451 nmol/L
Small LDL 1998 nmol/L--representing 81.5% of LDL particle number.

In other words, replacing white flour products with whole grain products reduced small LDL by 14%--a modest improvement, but hardly great.

I explained to Joseph that any grain, complex, refined, or simple--will, just like other sugars and carbohydrates, still provoke small LDL. Given the severity of his patterns, I suggested trying again, this time with full elimination of grains.

Next lipoprotein panel with elimination of whole grains:

LDL particle number 1320 nmol/L
Small LDL 646 nmol/L--48.9% of total LDL particle number, but a much lower absolute number, a reduction of 67.6%.

This is typical of the LDL responses I see with elimination of wheat products on the background of an overall carbohydrate restriction: Big drops in precisely measured LDL as LDL particle number (i.e., an actual count of LDL particles, not LDL cholesterol) and big drops in the number of small LDL particles.

You might say that wheat elimination and limitation of carbohydrate intake can yield statin-like values . . . without the statin.
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Comments (17) -

  • medeldist

    5/4/2010 8:26:52 AM |

    Interesting. I'm looking through my screening results (I'm in Europe) and there is no mention of LDL, but I have two other values, P-Apo A1 (1.77 g/L) and P-Apo B (1.09 g/L). Is there a relation between these and LDL/HDL?

  • tom

    5/4/2010 1:02:12 PM |

    It is good to have positive feedback via blood testing to show changes one is making to their body. I wonder what is a good interval between tests to show cholesterol changes?

    On a similar note, I have been eating low carb for 4 months using my blood meter to reduce both blood sugars and insulin resistance for pre-diabetes. I am still thinking about your slo-niacin suggestions and how the bad increase in blood sugar and insulin resistance vs the good cholesterol effects would affect me. I am waiting to get results from my first NMR lipoprofile to make a decision.

  • Ned Kock

    5/4/2010 3:49:58 PM |

    Indeed, restricting carbohydrates is more similar to taking statins than many people think. With the advantage that it does not have the side effects of statins, and is not costly at all.

    Many people do not know that carbohydrates stimulate the production of VLDL, suppressing the production of free fatty acids and ketones. Our liver then pumps out small VLDL particles at a high rate, and these end up as small-dense LDL particles. The potentially atherogenic type, in the presence of other factors (e.g., chronic inflammation).

    Low carbohydrate dieting stimulates the production and release of free fatty acids and ketones, suppressing the production of VLDL. Our liver then pumps fewer VLDL particles into the bloodstream (since FFAs and ketones are already doing a good job at feeding muscle and brain tissue), and when it does it lets out big VLDL particles, which end up as large-fluffy LDL particles prior to re-absorption by the liver.

    If anyone wants to see what these particles look like, the figure in the post below may be useful:

    http://healthcorrelator.blogspot.com/2010/02/large-ldl-and-small-hdl-particles-best.html

    Ketones are not shown because they are water soluble:

    http://healthcorrelator.blogspot.com/2010/04/ketones-and-ketosis-physiological-and.html

  • Anonymous

    5/4/2010 4:01:31 PM |

    Do you have any comments on oatmeal? I've noticed that for me personally, it doesn't significantly spike my blood sugar, and I've heard a lot about how oatmeal can improve cholesterol -- but of course this is often just focused on total cholesterol or general LDL amount.

  • Anonymous

    5/4/2010 5:05:47 PM |

    Hi Dr. Davis
    I'm really hoping to hear your opinion on this study:
    http://www.pnas.org/content/early/2009/08/21/0907995106.abstract?sid=

  • Dr. William Davis

    5/5/2010 1:38:40 AM |

    Hear, hear, Ned!

    I agree: Carbohydrate restriction is the unsung hero of VLDL and LDL reduction, though actual measurements are required to appreciate this effect.

  • Dr. William Davis

    5/5/2010 1:40:35 AM |

    Oatmeal anonymous--

    It's all about individualizing your food choices.

    Checking postprandial blood sugars is an excellent way to know if these issues apply to you or not, or to what degree.

  • Jeff

    5/5/2010 11:56:35 AM |

    What are your thoughts on Amlamax for the reduction of LDL?

  • Lucy

    5/5/2010 3:41:11 PM |

    OK, so here's my question... I am young (late twenties), thin (BMI: <20.2), and active (run, bike).  However, I still have almost all small, dense LDL.   I'm an ApoE 3/4, which I understand means I need to limit the amount of fat in my diet.  However, if grains also contribute to small LDL, what am I supposed to eat?   I don't eat much wheat as it is (my husband is celiac), but I do enjoy oats, rice, and the occassional piece of bread when we eat out, etc.  Would cutting all grains from my diet and living on only vegetables, some fruits, and lean meats be acceptable? Sounds like a boring and sad diet...

  • pjnoir

    5/5/2010 9:58:04 PM |

    Oatmeal reducing Cholestral is a joke. If I eat Oatmeal for breakfast( even a 1/2 cup) my BG numbers stay HIGH all day. Oatmeal is not a food I have on my breakfast table ever.

  • Anonymous

    5/9/2010 3:08:36 PM |

    Over what time period were these
    panels taken or in other words, how many weeks or months in-between test?
    Love the blog!
    CB

  • Conrad

    5/11/2010 2:28:43 PM |

    Who knows where to get an (NMR) lipoprotein panel in Toronto/Mississauga?

  • holym

    5/12/2010 6:36:06 PM |

    You say, "LDL particle number 2620 nmol/L (which I would equate to 262 mg/dl LDL cholesterol)"

    Why would you equate 2620 nmol/L to 262 mg/dl? The conversion factor given at http://jama.ama-assn.org/content/vol295/issue1/images/data/103/DC6/JAMA_auinst_si.dtl is roughly 1mmol/l = 39mg/dl.

  • Dr. William Davis

    5/12/2010 10:21:43 PM |

    Holym--

    I believe you are confusing Friedewald calculated LDL in nmol/L and LDL particle number--two entirely different things.

    My simple conversion is meant to yield a "Friedewald-like" LDL cholesterol from LDL particle number.

  • Dolly.G

    5/14/2010 3:34:18 AM |

    I do agree!!

  • Anonymous

    5/22/2010 11:06:37 PM |

    Where can I find the peer reviewed research upon which you base your advice? Thanks

  • David M Gordon

    6/15/2010 1:18:55 AM |

    My lab results are in, and they are,  on balance, not much improved. I think.

    The changes I effected since my prior panel panel 3 months ago:
    1) Lost 20 lbs
    2) Ingest 6,000mg of fish oil for a total of 1200mg (total) of DHA and EPA/day
    3) Ingest 500mg of Slo-Niacin/day (with 125oz of water/day)
    4) Ingest 6,000mg of Vitamin D/day (Changed to the proper Vitamin D soy capsule from the powdered tablet)
    5) Eat a large handful of almonds/day
    6) Exercise hard (weight training and cardio intervals for a minimum of 90 minutes/day).

    The (worsened) numbers:
    1) Total Cholesterol: 269 (from 267)
    2) LDL Cholesterol: 186 (from 175)

    The (improved) numbers:
    3) Triglycerides: 201 (from 280)
    4) HDL Cholesterol: 43 (from 36)

    Unfair to ask you, I know, but I am frustrated. What do I do wrong? What can I do more? I am VERY reluctant to take a statin, as I have tried many, all with terrible side-effects. And, fwiw, I started today on my wheat-free diet.

    Thank you for your guidance,
    David

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Coronary arteries aren't what they seem

Coronary arteries aren't what they seem

12. November 2007 William Davis (5)
Why do stress tests so often fail to detect coronary atherosclerotic plaque? Why do even heart catheterizations--the "gold standard"--fail to disclose the full extent of plaque within the walls of coronary arteries?

We owe much of the explanation of these phenomena to Dr. Seymour Glagov, retired professor of pathology at the University of Chicago.



When studying the coronary arteries of people who died, he observed that people commonly had plenty of atherosclerotic plaque lining the artery wall, yet it did not necessarily impinge on the artery "lumen," or the internal path for blood to flow.

The only time the lumen became obstructed by plaque was when either 1) plaque grew to overwhelming levels and was severe and extensive, or 2) when a plaque had "ruptured," meaning its thin covering had been penetrated and eroded by the underlying plaque tissue like a volcano emerging from the surface and erupting.

This groundbreaking observation, now dubbed "the Glagov phenomenon," explains why someone can have a normal stress test on Tuesday but erupt a plaque on Wednesday.

The Glagov phenomenon also explains why heart scans can detect plaque when both stress tests and heart catheterizations fail to do so. Many physicians will then interpret this to mean that the heart scan was wrong. With the Glagov phenomenon in mind, you can see that the heart scan is not wrong, it is simply detecting coronary atherosclerotic plaque at a stage that is not yet detectable by the other methods.

In the illustration, you can see that the lumen of the vessel is maintained--despite the artery on the left having minimal plaque, the artery on the right containing moderate plaque. If either artery were examined by a test that relies on blood flow--stress test or heart catheterization--both would appear normal. But a test that examines the artery wall, such as a heart scan, would readily detect the artery on the right and probably even the artery on the left.




I am very grateful to Dr. Glagov and his insight into this important process. Otherwise, we might still be floundering around trying to understand the apparent discrepances between these tests that simply provide different perspectives on the same problem.
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Comments (5) -

  • Anonymous

    11/13/2007 1:04:00 AM |

    I saw a new small 2 pound ultrasound machine for detecting plaque in neck arteries just hit the market place.  Article was at: http://www.newstarget.com/022212.html

    It sounds exciting that something like this would be easily accessible - as the author speculates.  Do you think this new small devise will be helpful - if one has plaque in neck arteries does that typically also mean plaque in the heart?

  • Dr. Davis

    11/13/2007 2:54:00 AM |

    Actually, I purchased one of these devices about 7 years ago. The data is reasonably well worked out: carotid ultrasound for a measure called intima-media thickness is a reasonable second choice to coronary plaque measurement. It can be useful to augment information from direct coronary scoring, or when heart scanning is impossible, e.g, some people after bypass surgery.

  • Anonymous

    11/13/2007 7:11:00 PM |

    You've been concentrating a lot on coronary arteries, and the effect of plaque build up. What about the valves of the heart? Can plaque build up on, or otherwise affect them?

  • Dr. Davis

    11/13/2007 10:08:00 PM |

    This blog and the accompanying website, www.trackyourplaque.com, are intended to focus on coronary issues.

    However, I have been seeing aortic valve disease actually improve with vitamin D. Please see my blog post, Valve disease and vitamin D at http://heartscanblog.blogspot.com/search/label/Valve%20disease%20and%20vitamin%20D.

  • buy jeans

    11/3/2010 10:15:10 PM |

    When studying the coronary arteries of people who died, he observed that people commonly had plenty of atherosclerotic plaque lining the artery wall, yet it did not necessarily impinge on the artery "lumen," or the internal path for blood to flow.

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