Risks for coronary disease 2008

According to conventional thinking, there are identifiable risks for coronary disease and heart attack. These risk factors are:

* smoking
* high blood pressure
* high blood cholesterol and excessive saturated fat intake
* diabetes
* being overweight or obese
* physical inactivity

I'd agree with all the factors listed (though I would argue about the importance of high blood cholesterol and saturated fat; they are not as important as commonly made to be.)

Is the list complete?

From the unique perspectives gained in the Track Your Plaque program, I'd offer a significantly different list. Trying to stop or reduce coronary atherosclerotic plaque and heart scan scores makes you a whole lot smarter about what works and what doesn't work.

So, in addition to the risk factors listed above, I would add:

* Small LDL particles--Lots of small LDL particles is MORE important than high LDL.
* High blood pressure with exercise
* Excessive wheat intake and other processed carbohydrates--An issue of explosive importance today. Wheat creates large numbers of small LDL particles, among other adverse effects.
* Vitamin D deficiency--Among the most powerful risks I know of. It belongs at the top of the list.
* Vitamin K2 deficiency
* Low HDL cholesterol
* Blood sugar >100 mg/dl
* High triglycerides--While some argue about whether triglycerides are a risk that behaves independently of patterns like low HDL, they are neglecting the potent force of this risk. Sure, it occurs in tandem with low HDL (usually, though not always), but it is a factor that can leave you with risk even when HDL is raised to healthy levels.
* Lipoprotein(a)--It is eminently, positively crystal clear that lipoprotein(a) is a powerful risk for heart disease. The lack of a profitable treatment keeps it hidden in the shadows.
* Pessimism--Be happy, do better. Be a constantly angry, frustrated, complaining sourpuss and you are more likely to succumb to heart disease, cancer, or other undesirable fate.

These are the risk factors that we address through the Track Your Plaque program, a list that yields a far more powerful and comprehensive approach to control over coronary plaque/atherosclerosis, sufficient to achieve reversal in many (though not in all) instances.

I view the list of conventional risk factors as a "no brainer" list. Sure, smoking is a risk factor. But there are virtually no smokers in the Track Your Plaque program. If you smoke, you clearly don't care enough to engage in a high-intensity prevention program like this.

Saturated fat? Perhaps, but the battlefield of heart disease is riddled with the bodies of those who employed this as their sole strategy and failed catastrophically.

Diabetes, hypertension, and overweight all represent a continuum of risk; the solutions offered in the conventional scheme (i.e., low-fat diet, etc.) make these patterns worse, not better.

The conventional response to heart disease risk is trapped somewhere in 1973 and has not changed in over 30 years. Heart disease continues to be a growth industry for hospitals and the pharmaceutical and medical device industries. The "official" organizations continue to deliver an antiquated, outdated message.

If you want heart disease, follow the American Heart Association diet. If you want established heart disease to get worse, follow the American Heart Association diet. If you want diabetes or, if you already have diabetes or pre-diabetes, if you want it to worsen and develop organ damage (eyes, kidneys, nervous system, etc.), then follow the American Diabetes Association diet. USDA food pyramid? Loosen your belt!

The list of conventional risk factors for heart disease is woefully inadequate. If that is as far as your prevention program takes you, heart disease will not be controlled or prevented. At best, it might be slowed; at worst--and more likely--it might be accelerated.

Comments (27) -

  • Ross

    1/1/2008 11:13:00 PM |

    From the two lists you've provided (and the critical caveat about dietary cholesterol and saturated fat), it seems so simple to reduce my risk of heart problems.  Lose weight on a carb-restricted diet (I've lost 25 pounds towards a 35 pound goal so far) and:

    1) blood pressure falls
    2) blood glucose, insulin, and diabetes risk falls
    3) triglycerides fall
    4) HDL rises
    5) LDL composition improves
    6) Lp(a) falls
    7) Athletics are easier and more enjoyable.
    8) I feel better about my appearance (anti-pessimism).

    How in the world can anyone still say that low-carb (high-fat) diets are bad for you or increase your risk of heart disease, heart attack, or stroke?

    And yet, this is what I keep hearing over and over and over again.  

    I'm learning to not talk about my diet (cooking eggs in butter, drinking whole milk, etc.) because almost everyone who hears me describe how I'm losing weight gets very defensive about the established advice to cut fat in order to lose weight.  All of my assurances that the science doesn't actually back up the US Government's (or the AHA, ADA, etc.) position fall on deaf ears.  The fact that I'm losing weight and getting regular blood tests to verify progress on cholesterol and some inflammatory markers seems to have no effect on anyone.

    Shutting up and just improving my own health seem to be the best way to keep the peace.  Sigh.

  • chickadeenorth

    1/2/2008 2:29:00 AM |

    Dr D what are your thoughts on the chol ratios ?It used to be thought that it was more significant.
    You're right on with those thoughts mentioned about AHA and ADA.

  • Dr. Davis

    1/2/2008 12:03:00 PM |

    Hi, Chickadee-
    I find that the standard numbers like total cholesterol and LDL very limited in predictive value. Ratios like total cholesterol to HDL are simply manipulations of these basic numbers. They improve predictive confidence for heart disease and heart events, but they are simply statistical manipulations. If you are using lipoproteins (e.g., NMR), you've already far surpassed the limited value of these ratios.

  • MAC

    1/2/2008 12:22:00 PM |

    Wonder if you have ever seen this study where rye turned on certain genes that prevent diabetes, control blood sugar, and wheat and oats and potato had the opposite effect and turned them off?

    American Journal of Clinical Nutrition, Vol. 85, No. 5, 1417-1427, May 2007

    I don't know if you can infer from this that oats and potatoes may be just as bad as wheat but it was interesting.

    Also, I know you have blogged about some HDL subfractions having issues as well. Is that a consideration as well? Article: Sizing up your HDL. http://www.menshealth.com/cda/article.do?site=MensHealth&channel=health&category=heart.disease&conitem=c31a99edbbbd201099edbbbd2010cfe793cd____

  • wccaguy

    1/2/2008 1:43:00 PM |

    Hi Dr. Davis,

    What a fantastic post to start off the New Year.

    I see that Vitamin K2 has now made the short list.  I'd noticed that you were talking about it more recently.

    Do you think this has the potential to become another "D3-like" sleeper for risk control?

    Thanks for all you do.

  • g

    1/2/2008 4:03:00 PM |

    Can't the rest of the world catch up to your progressive pace Dr. Davis?

    Obviously you enjoy figuring out and solving puzzles. Have you seen National Treasure yet?
    Dr. Davis, y-o-u are our National Treasure.

    As Heart Hawk says it... 'Jack, Smack and WHACK that Plaque!'

    I like that... kinda Tony Soprano-style *ha ha* Smile

    Happy New Year to you and your family and all the TYP-ers and Early Adopters!  

  • Dr. Davis

    1/2/2008 6:01:00 PM |

    Hi, MAC--

    Interesting. I wonder if rye deserves a reconsideration. I have to admit that I've dismissed rye since it nearly always occurs as part of wheat-containing products. Perhaps this was throwing out the "baby with the bath water" sort of issue.

    HDL sub-fractions are indeed something we pay attention to, though the therapeutic efforts to correct them are virtually the same as those that correct small LDL.

  • Dr. Davis

    1/2/2008 6:04:00 PM |


    The more I use vitamin K2, review what data exists, and observe its effects, the more I am convinced there is a real effect here.

    However, K2 does not appear to exert the broad array of benefits that D3 does, such as resolution of winter blues, metabolic syndrome, increased HDL, drops in blood sugar, decreased inflammatory responses, etc. K2's effects are more confined and narrow.

    I'm hoping this preliminary experience holds. I think it may have been responsible for heart scan score reduction in a couple of people, but it's often hard to know when people are doing multiple things all at once.

  • Anonymous

    1/2/2008 6:48:00 PM |

    I know you were reading "Good calories, bad calories" and wonder after reading that if you still feel saturated fat is bad?

  • Dr. Davis

    1/2/2008 6:59:00 PM |

    I loved Mr. Taubes' book.

    However, I am not prepared to endorse the full embrace of saturated fat. I am going to go back to the original literature before I (re-)make up my mind on this issue. I'm well aware of the arguments on both sides of the issue, but there's nothing like the real sources.

  • MAC

    1/3/2008 12:23:00 AM |

    How is it that the focus is still on total LDL and not the size of the LDL particles? The inverse relationship between HDL and triglycerides per Taubes book was presented in 1961.

    I was a test subject in the early 80s for Quaker Oats research to claim that eating oats would lower your cholesterol and even then my blood work came back with sub fractions. So over 25 years ago they were interested in these subfractions.

    Second question. If you have bad subfractions of HDL do you always have bad subfractions of VLDL and vice versa? As you have indicated the therapeutic efforts to correct  both are the same. Just curious.

  • Dr. Davis

    1/3/2008 12:34:00 AM |

    In my view, lipoprotein testing is an absolutely crucial part of determination of risk for heart disease. The reasons for its lack of use by practicing physicians are several, but principally 1) complexity, 2) no big bucks for promoting any specific treatment from a drug company.

    Lipoproteins do tend to travel in "packs". HDL subclasses do follow LDL subclasses which follow VLDL--they do tend to track together, though they can also diverge.

  • wccaguy

    1/3/2008 6:22:00 AM |

    Hi Dr. Davis,

    I don't take issue with you often, if ever, but I must object to your point that lipoprotein testing and analysis is "complex" and that's a reason why practicing physicians don't do it more often and/or effectively.

    You've made this point before and it struck me that this point was wrong and I figured out how to show that it was wrong but then forgot about it.  Your making the point again jogged my memory.

    I'll bet you that I could explain generally how lipoprotein subfraction distributions impact risk of CAD to my 10 year old daughter and a few of her friends (all 5th graders) and they could understand it and explain it's importance.  

    Admittedly, the explanations wouldn't be on a par with what one would expect from an adult with a scientific bent.  I'm hoping that you wouldn't insist that their explanations would need to be on a par with a practicing physician for me to demonstrate the point.

    The point is that it's NOT difficult to grasp the concept that lipoprotein subfraction distributions have an extremely significant impact on CAD risk.

    I must insist that you cease and desist making this point or you will force me to make a video that I post on the web showing some young teens explaining the importance of lipoprotein subfraction testing and analysis.


  • Dr. Davis

    1/3/2008 1:31:00 PM |

    You know, it took over 20 years for the cholesterol concept to be incorporated into daily clinical practice of the average primary care physician, despite enormous marketing budgets from the drug companies.

    Lipoprotein testing, I agree, is really not that complicated. Just a few months of education and someone could diagnose and treat quite confidently. It is, however, a significant hurdle to a primary care physician dispensing flu vaccine, prescriptions for arthritis, doing pap smears, treating colitis, etc., just one more new thing to learn among many.

    I believe that the new generation of "lipidologists" will be a practical solution, since my colleagues, the cardiologists, are too focused on the next exciting procedure and the primary care physician is spread too thin. It's also the reason why I've gone straight to the person most interested in lipoproteins--you and other readers--to provide this information.

  • Anonymous

    1/3/2008 2:18:00 PM |

    In your list of risk factors, what do you mean by "high blood pressure with exercise"?  Do you mean that blood pressure is high only during exercise or that blood pressure is high even though you exercise?  
    Thanks for a great blog.

  • wccaguy

    1/3/2008 2:56:00 PM |

    Dr. D.

    I think your last response really begins to get to the heart of the problem.

    Wikipedia says that "cardiology is the branch of medicine pertaining to the heart and the vascular system of the human body."

    I didn't read the whole Wikipedia entry on the subject, but I'm pretty certain that "next exciting procedure" is not descriptive of any limitation of the subject matter that it might be assumed cardiologists should be expected to know something about.

    Seems to me you're right in pointing out that Primary Care Physicians are spread thin and can't be faulted too much for not knowing detailed treatment nuances of every disease.  Even for them, however, one would think there would be greater interest in treatment of the single most significant cause of death in the US and most of the industrialized world.

    But it's also understandable that Primary Care Physicians have expected to be able to look to their cardiologist colleagues for leadership in promotion of the best treatment regimes for CAD.

    In my view, the problem is that cardiologists, in general, have utterly failed to provide the kind of knowledge leadership the current state of the science of lipoproteins ought to require.

    I'm not certain about what kind of doctors run the AHA and the ADA but if they are run primarily by cardiologists then I'd be hard pressed not to come to the conclusion that the general failure of this profession is even more massive for all the reasons you find fault with those organizations.

    I think THAT is what is so hard for all of us to fathom:  How could it be that such a large and seemingly smart and educated group of people fail to "get it", about diet at the ADA and the AHA, about lipoprotein education leadership for the colleagues, etc.

    Given the tragic consequences of that general failure, is it possible even to argue that there is another group of white collar professionals who have failed more than the cardiologists?

  • Dr. Davis

    1/3/2008 9:46:00 PM |

    Hi, Kate--

    I'm referring to blood pressure measured during a stress test. It's too difficult to assess your own BP while exercising. It has to be done by someone else in the midst of exercise, meaning a stress test. However, this effect can be an important "coronary risk."

  • Dr. Davis

    1/4/2008 1:26:00 AM |


    It is dismaying, I agree.

    I do feel that my colleagues have been sidetracked by the promise of financial gain, probably no different than the mortgage lenders making unwise sub-prime loans, stockbrokers churning accounts for commissions, pharmaceutical manufacturers inflating drug prices in the U.S. while charging far less in more cost-conscious countries.  

    It's the profit motive, alive and well. It is through conversations like this that help all of us break out of the profit-driven bounds of the conventional approach.

  • moblogs

    1/5/2008 9:12:00 PM |


    Someone posted an article with a similar finding in one of your earlier posts.
    If this is true, it's absolutely astounding that statins could simply be pricey analogues of cheap-ass (pardon my French) vitamin D.

    I also believe calcium channel blockers used for epilepsy, which clearly simply block calcium from entering the desired part of the body, could be replaced by D. Instead of blocking calcium, it's probably best to ensure proper metabolism.

  • Anonymous

    1/6/2008 10:39:00 PM |

    We know that wheat intake is not good for people with lots of small ldl, what about psyllium ? Is it good bad or indifferent as far as small ldl partcles ?

  • Dr. Davis

    1/6/2008 11:21:00 PM |

    Indifferent: psyllium reduces all LDL particles, regardless of size.

  • Anonymous

    1/8/2008 7:24:00 PM |

    Dr. you mention high blood pressure with excercise as a risk factor and then go on to say that this is something that would be found out during a stress test. My question is surely everybodies blood pressure raises during excercise what level would be "high" for someone during this stess test ?

  • Dr. Davis

    1/8/2008 9:47:00 PM |

    "High" depends on the level of exercise on a formal exercise "protocol". However, we use a crude cut-off of any BP >170/80 as clearly high.

  • Red Sphynx

    1/9/2008 9:08:00 PM |

    Dr Davis,

    Good list.  But I was wondering about some other factors that others list that don't appear either in your list or the conventional one:
    * Inflammation - as measured especially by C-reactive protein, or other measures.
    * Advance glycation endproducts (AGE) as measured by pentosidine, skin autofluorescence, etc.  Sure it correlates with blood sugar, but other factors (antioxidant status, fructose in the diet, dietary intakes of oxidized oils) throw the correlation off.

  • Dr. Davis

    1/10/2008 12:14:00 AM |

    Yes, good point.

    We do address inflammation, but only occasionally does it emerge as something that requires specific action, e.g., suppression of matrix metalloproteinase. Otherwise, all the steps we take to correct the other factors also correct inflammatory responses.

    AGE's are a fascinating issue, but not one we've specifically addressed for purposes of plaque reversal.

  • Anonymous

    4/26/2008 6:39:00 PM |

    Dr. Davis,

    Wanted to make a friendly suggestion.  I have been printing pages from your blog to hand out to others.  
    I was thinking if possible to do, it would be helpful if there was a "print button" for blog posts.  Also it would be good for the printed  page to have your web sight highlighted somewhere on the print.

  • Daniel

    2/16/2010 6:54:20 PM |

    Dr D,

    First time reader and I am excited to see a cardiologist that is actually standing up for correct Western Medicine. I have a question about this post ( a year late I know), but wanted to discuss. You state "* High blood pressure with exercise" as being another problem. In one of the comments you stated that this can be under 170/80. I have been treated with beta blockers and thiazidines to reduce my BP. It's been "working" for 10 years now, yet I was severly overweight. Recently I started to eat a grain free diet under the Primal Blueprint method and amped up real totally body fitness. I lost about 40 lbs since and feel amazing.

    Recently I went back to my cardiologist and began discussion about lowering my dosages since I get winded and shortness of breath during my workouts.

    Anyways, I asked the Dr. to lower the meds and then told me that I was going to die if I stopped taking them. Told me to eliminate caffeine, and sodium to lower it. Said I needed to eat more vegetables.

    Can you explain why BP would not lower with proper diet and 6 days of exercise a week for almost a year?