"It's genetic"

17. November 2008 William Davis (17)
At 53, Sam had been through the wringer with heart disease. After his first heart attack at age 50, he'd undergone four heart catheterizations, 5 stents, and, most recently, a bypass operation. He came to us to see if there was a better solution.

After hearing Sam's story, I asked,"Did your doctors suggest to you why you had heart disease?"

"Well, they said it was genetic, since my father went through the same thing in his early 50s, though he died after his second heart attack at age 54. They said it was bad luck and nothing could be done about it."

Though Sam's case is more dramatic than most, I hear this argument every day: Risk for heart disease is genetic.

It's true: There are indeed multiple reasons for inheriting causes for coronary heart disease, genes that heighten inflammatory responses, oxidative responses, modify lipoprotein particles, increase blood pressure, etc. There has even been some excitement over developing chromosomal markers for heightened risk.

That's all well and fine, but what can we do about it today?

In practical life, many inherited genetic patterns can be expressed in ways that you and I can identify--and correct. They are not chromosomal markers, but end products of genetic patterns. (Although there are indeed identifiable chromosomal markers, they have not yet led to meaningful treatments to my knowledge.)

These readily identifiable patterns include:

--Lipoprotein(a)--Clearly genetically transmitted, passed from mother or father to each child with a 50% likelihood, then you onto your children if you have it.

--Small LDL--Although small LDL is amplified by high-carbohydrate diets and obesity, it can also occur in slender people who do not indulge in carbohydrates --i.e., a genetic tendency. Or, it can be a combination of poor lifestyle magnifying the genetic tendency for small LDL.

--Low HDL--Particularly the extremes of low HDL below 30 mg/dl. (Although, interestingly, I am seeing more of these people, though not all, respond to vitamin D replacement. Perhaps an important subgroup of low HDL people are really Vitamin D Receptor (VDR) variants.)

--ApoE--Two variants are relevant: ApoE2 and ApoE4. In my experience, it's the E2 that carries far greater significance, though the data are somewhat scanty. ApoE4 people are more sensitive to the fats in their diet (greater rises in LDL with fats; thus, some people advocate a tighter saturated fat restriction with this pattern, though I am not convinced that is the best solution), while ApoE2 people are exceptionally sensitive to carbohydrates, develop extravagant increases in triglycerides, and are very diabetes-prone with even the most minimal weight gain. If two "doses" of the E2 gene are present (homozygotic), then the tendencies are very exagerrated. E4 people are also subject to greater likelihood of Alzheimer's, though it is not a certain risk in a specific individual.

--Postprandial disorders--We use the fasting intermediate-density lipoprotein (IDL) as an easy, obtainable index of the ability to clear after-eating byproducts of meals from the blood. Increased IDL has been related to increased coronary, carotid, and aortic aneurysmal disease.

--Hypertriglyceridemia-i.e., increases in triglycerides, While not all forms of high triglycerides confer risk for atherosclerosis, many do, particularly if associated with IDL, small LDL, increased LDL particle number and/or apoB.


There are more, but you get the point. There are clear-cut genetically-transmitted reasons for greater risk for cardiovascular disease. Some, like lipoprotein(a), yield very high risk. Others, like increased triglycerides, yield mixed levels of risk.

Importantly, all of these patterns--ALL--are identifiable and are treatable. Treatment may not always be the easiest thing, but they are treatable nonetheless. While lipoprotein(a), for instance, is the most difficult pattern to correct in the above list, I remind everyone that our current "record holder" for reversal of plaque and heart scan scores--63% reduction--has lipoprotein(a) that we corrected.

If you've been told that your risk for cardiovascular disease or coronary plaque is "genetic" and thereby uncorrectable and hopeless, run the other direction as fast as you can. Get another opinion from someone willing to take the modest effort to tell you precisely why.
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Comments (17) -

  • steve

    11/18/2008 2:58:00 PM |

    all excellent points,but the question is: how do you find someone who will tell you why?  Most will look at advanced cholesterol testing and based on that prescribe a statin and a low fat diet.  Speaking of diet, it is unclear how much sat fat you think acceptable on a daily basis.  It is nice to say it is ok to have and we have gone overboard in its elimination, but unfair not to then say how much in your view is ok

  • Anonymous

    11/18/2008 4:25:00 PM |

    Thank you, thank you, thank you... I'm still trying to convince my dad that his lifestyle is still important after his idiot cardiologist told him it was all genetic and all he could do it take meds and hope for the best... I hate when docs downplay diet and exercise.  Ugh!

    On another note, I've been told that because I have ApoE 4 I should not consume alcohol or take fish oil.  What do you know about that?

  • vin

    11/18/2008 4:25:00 PM |

    My grandmother, who died 20 years ago at the age of 85, used to say "it is god's will" whenever someone died young (or old). It is what the modern day cardiologist now puts it down to genetics.

    That is progress over the last 100 years.

  • Jessica

    11/18/2008 7:14:00 PM |

    I think the potential that Vitamin D has relating to heart health is significant.

    Although I'm not the best at verbalizing why this is the case, when I learn a condition is "genetic" and it tends to strike later in life, I think, "but you've had that gene your entire life. Why is it that NOW it's expressing itself?"

    Genetic predispositions to conditions may explain why someone has a condition, but it doesn't explain why the condition occurs when it does.

    Could it be that identifying and correcting D deficiencies early in life will provide our cells (DNA) with the power to continue suppressing genes that should never be expressed?

  • Anonymous

    11/18/2008 7:59:00 PM |

    I think you missed one of the biggest "genetic" factors: crappy living habits: junk food, no exercise. These pass down from generation to generation too. But, like some of the others you mentioned, these conditions are treatable.

  • Anonymous

    11/19/2008 12:03:00 AM |

    www.amocare.com is a free service that has hospitals located in the U.S. that perform heart surgery for around 70% the cost of the price of the average cost. American Medical Outsourcing will help you with the entire process of the treatment. Heart bypass surgery usaly cost $45k-$55k. with AMO, the cost is around $10k-$13k. Go to www.amocare.com for more info.

  • Anonymous

    11/19/2008 4:01:00 PM |

    I'm curious as to why you approved the comment of the amocare spammer?

  • Katherine

    11/20/2011 6:08:47 PM |

    About six months ago I started eating a paleo lifestyle.  Since then I've had two cholestrol panels.  After two months, my LDL was 180.  Four months later, my LDL was 290.  HDL is 68 and Trigs are 41.  I've also lost about 10-14 pounds.  My dad has high cholesterol (LDL) and my grandmother on my mom's side had a heart attack at 66 and died.  I've recently had a FH test and I'm awaiting the results.  Now after reading this, having having a test run on the ApoE4 seems like a good idea as well.  Would the ApoE4 be appropriate?  Was the FH test a waste of time?

  • Dr. William Davis

    11/21/2011 1:38:03 PM |

    Both can be helpful, if only to confirm whether there is a genetic basis or not.

  • Katherine

    11/24/2011 2:16:31 PM |

    Dr. Davis,
    You've said "ApoE4 people are more sensitive to the fats in their diet (greater rises in LDL with fats; thus, some people advocate a tighter saturated fat restriction with this pattern, though I am not convinced that is the best solution),"  What do you think is the best solution?

  • Dr. William Davis

    11/25/2011 2:10:35 PM |

    Because the majority of apo E4 people have extravagant numbers of small LDL particles triggered by carbohydrate consumption, I still advise first eliminating wheat and slashing carbs.

  • Gene K

    11/25/2011 4:21:21 PM |

    I am apo E4/3, and I was able to bring down my small LDL particles to under 90. My daily carb consumption includes a small cup of dark berries, hummus, non-starchy vegetables (broccoli, eggplant, cauliflower, zucchini), and natto. I saw a big drop in small LDL particles after I greatly reduced consumption of oils (olive oil specifically), but I don't know whether this change alone had a role in causing the reduction of my smLDL.

  • Gene K

    11/25/2011 4:27:53 PM |

    (cont'd) As far as fats, I don't eat red meat, but plenty of fatty fish and lean poultry plus an egg every day. Tons of yellow mustard (turmeric), too.

  • Dr. William Davis

    11/27/2011 2:15:58 PM |

    HI, Gene--

    I believe the best way to view this is that oils/fats amplify LDL particles in all its forms. If in the presence of carbohydrates, oils/fats will increase small LDL because it is the dominant form.

  • Katherine

    11/28/2011 8:50:14 PM |

    I have eliminated wheat and eat about 30 total carbs a day while my LDL is 289.  I am actively losing weight which is sounds like may have influenced my numbers.  Is the Apo E4 associated only with increased LDL's or is it with elevated Trigs as well?  My Trigs are 37.

  • Ronnie

    12/13/2011 3:16:58 AM |

    My doctor tested me for ApoE without telling me and mailed me my results....I'm a 3/4.  My LDL-P was 1206, Triglycerides 115, HDL-C 72, sdLDL 37 mg/dl.  I'm 60, female, thin (5'2" 109 lbs), have exercised my entire life, non smoker, occasionally drink one glass of white wine.  Parents never had heart disease although I have a sister with CAD which I always chalked up to poor lifestyle habits (terrible diet, sedentary).  I never expected this and I'm not handling this news well at all.  While some people may want to know their ApoE genotype, I wasn't one of them.  I greatly resent my doctor doing this test without consulting me first and the way I received the results through the mail.   I have no idea what to do this information.  Do I consult with a geneticist, a cardiologist or a lipid specialist?

  • Robin Michael

    5/1/2013 5:50:50 PM |

    Dr. Davis,

    I joined TYP specifically because my Heart Diagnostics Lab results (taken before I started Wheat Belly plan) showed my to be APOE E4 3/4 genotype.  My other numbers: total cholesterol=154, LDL-C=85, HDL-C=56, Triglycerides=58. On Lipitor generic 10mg, Lisinopril 20mg and Amlodipine 5mg. I find the WB plan to be easy, but am moderately high fat diet including labne for breakfast, eggs for lunch with avocado, sour cream, and fish/chicken and salad/green vegetable for dinner. Carbs are limited to less than 50g per day. I generally cook with olive oil, and sometimes toasted sesame oil. I eat very little fruit, limited my intake to a few berries in the morning, a plum or half an apple at lunch.

    Do you recommend lowering my fat intake? Anything else?

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