90% small LDL: Good news, bad news

Chris has 90% small LDL particles.

On his (NMR) lipoprotein panel, of the total 2432 nmol/L LDL particles ("LDL particle number"), 2157 nmol/L are small, approximately 90% (2157/2432).

Bad news: Having this severe excess of small LDL particles virtually guarantees heart attack and stroke in Chris' future.

Good news: It means that Chris potentially has spectacular control over his lipoprotein and lipid values, achieving statin-like values without statin drugs.

Typically, extravagant quantities of small LDL particles are accompanied by low HDL, high triglycerides, and pre-diabetes or diabetes. Chris' HDL is 26 mg/dl, triglycerides 204 mg/dl; HbA1c 5.9% (a reflection of prior 60-90 days average blood glucose; desirable 4.8% or less), fitting neatly into the expected pattern.

Chris' pattern tells me several things:

1) He overconsumes carbohydrates, since carbohydrates trigger this pattern.
2) He likely has a genetic susceptibility to this effect (e.g., a variant of the gene for cholesteryl ester transfer protein, perhaps hepatic lipase). Only the most gluttonous and overweight carbohydrate consumers can generate this high a percentage small LDL without an underlying genetic susceptibility.
3) Provided he follows the diet advised, i.e., elimination of all wheat, cornstarch, oats, and sugars, he is likely to have an extavagant drop in LDL particle number. Should he achieve the goal I set of small LDL of 300 nmol/L or less, his LDL particle number will likely be around 500 nmol/L. This translates to an LDL cholesterol of 50 mg/dl . . . 50 mg/dl.

In many people, this notion of taking statin drugs for "high cholesterol" is an absurd oversimplification. But it is a situation that, for many, is wonderfully controllable with the right diet.

Comments (11) -

  • Might-o'chondri-AL

    3/4/2011 5:10:09 PM |

    Patient dropping total LDL particles from 2432 nmol/L to 500nmol/L is an impressive goal. The posting is a prediction however.

    It would be instructive to hear
    clinical data on ratio of patients who have actually achieved that degree of LDL reduction. A busy private practise isn't a research project, so that's probably impractical to compile.

  • Anonymous

    3/4/2011 6:09:15 PM |

    FWIW, my NMR lipid profile following about 16 months of Eades/Harris protocols (more the latter than the former).

    My doc almost had a heart attack Smile She is focused exclusively on the LDL-C and the TC #'s. I have of course refused any statin.

    LDL-P 1450  Borderline-High 1300-1599

    LDL-C  208   Very High > 189

    HDL-C   85

    Trigs      65

    Total    306

    HDL-P   47.6

    Small LDL-P   131

    LDL size   21.9

    HDL-P  of 47.6 >34.9 (probably on the order 99%ile = lower CVD risk)

    Small LDL-P 131 estimated 33%ile (lower CVD risk)

    LDL size of 21.9 large (Pattern A = 23.0 lowest CVD risk)

  • Dr. William Davis

    3/4/2011 6:49:31 PM |

    Hi, Might--

    Actually, we've accomplished drops like this many, many times.

    As you point out, the experience is retrospective and therefore difficult to attribute (in a scientific way) to any one treatment strategy. But I can tell you, having done this many times, wheat elimination in the setting of a low-carb restriction accomplishes such drops as a rule.

  • Anonymous

    3/4/2011 11:18:09 PM |

    I believe I fall into this category relative to wheat products.  I have started eating oat bran rather than oatmeal for my morning hot cereal and avoiding carbs.  

    While the scale doesn't reflect any real weight loss I am less bloated and actually feel slimmer after a few weeks of wheat elimination.  I was a strict WHOLE WHEAT person prior as that was what the AHA recommended.  I have been told that I have a hereditary condition which causes high LDL and low HDL.  Statins give me such muscle pain and fatigue that I have stopped them.  I do take Enduracin daily and will get my levels checked again.  I wondered about OAT BRAN and what the thoughts are regarding consumption of OAT BRAN.  I have a 1/2 cup of hot oat bran each morning.

    Suggestions or comments welcomed.

  • Craig Newmark

    3/5/2011 2:57:16 PM |

    Question for Dr. Davis:

    I'm 54 and have labs similar to Chris, including a very high proportion of small LDL particles.

    But I recently had a cardiac calcium test at a reputable facility and the score came back . . . 0.

    I have been, and expect to continue, doing better on my diet and exercise. But if the LDL doesn't change much--all of my other results have responded at least some to my change in lifestyle--am I still virtually guaranteed to have a stroke or heart disease?

    Thanks in advance.

  • Might-o'chondri-AL

    3/6/2011 5:56:02 PM |

    Small LDL has to get acted on by an "immunological complex" to become an actual problem. Inflammation is a non-precise way of describing how the immunological complex gets to form.

    My understanding is that
    small LDL does not "guarantee" a
    cardio-vascular disaster. Blood tests for specific inflammation markers are a way to monitor the degree to which the body might
    be generating the immunological complex risk factor.

    Magnesium is absolutely vital to prevention in this dynamic. It is capable of disassociating the molecule of oxidized small LDL from absolutely locking with any circulating immunological complex.

    But, the magnesium has to be on the scene shortly after the two "bad" parts first connect (bond). Magnesium can't come along too much later and neutralize (sunder) the undesireable bond described above.

    Of course keeping down the "inflamation" (immunological complex) in the first place is also important. This is where having robust circulating levels of active vitamin D on the job, all of the time, is relevant.    

    A low level of calcium laid down indicates, in my premise, that magnesium has been doing it's job (knocking down problem reaction). It does not neccessarily mean the body is free from risky inflammation (immunological complex).

    Age re-models most of us; our health is not a steady state with constant variables. Risk factors Doc's deals with clinically, and warns us about, become more relevant.

  • Anonymous

    3/10/2011 12:06:28 PM |

    Dr. Davis, what would be a reasonable time frame for Chris to achieve the goal of LDL-P = 500?

    Also, if Chris meets his goal(s), correct to think that the guarantee of a stroke or heart attack has been stymied?

  • High LDL

    5/3/2011 7:50:01 PM |

    I've just received my lipids back:
    Total cholesterol : 357
    Trigs:                            63
    HDL                              93
    LDL                              251
    Apo-B                         165

    I am hypothyroid and my T3 is low on the range.  Also am on an extremely low carb diet (following Dr. Richard Bernstein's way of eating) and am Type 2
    (no meds/no insulin).

    Any suggestions how to get the LDL down?  Also do you have a list of lipid panel blood work that I could have done?

    Thank you so much.


  • Damien

    5/14/2011 8:54:30 AM |


    like Maxie55,

    I too follow Dr Bernstein and am Type one diabetic.. my lipip panel is almost identical to yours Maxie55;  fantastic TG/HDL ratio but LDL over 200...

    very interested how i may be able to get the LDL down....?

  • Frustrated

    8/23/2011 8:04:22 PM |

    Dr. Davis,
    I have spent the last 5 months eating a diet that completely eliminated all wheat products. It was very low carb, and consisted of relatively high protein (eggs, grass fed beef, grass fed raw cheese, oily fish, chicken), good level of olive oil, walnuts, fish oil (3 mg per day), raw vegetables, little bit of fruit.  So I had good amount of monounsaturated fat as well as saturated fat from eggs and grass fed products. My recent NMR showed:
    LDL-p. 2,800
    Small LDL particle 1700
    Small HDL particle 20
    HDL-C 40
    LDL-C 114
    Trigs. 224
    Total chol 208
    So I was disappointed. Where have I gone wrong?  No wheat and sky high LDL-p and 1700 small LDL paticles.

  • Dr. William Davis

    8/24/2011 1:50:39 AM |

    Hi, Frustrated--

    Why don't I make this post the topic for a full discussion?

Cath lab energy costs

Cath lab energy costs

In honor of Earth Day, I thought I'd highlight the unexpectedly high carbon costs of activities in hospitals, specifically the cardiac catheterization laboratory.

A patient enters the cath lab. The groin is shaved using a plastic disposable razor, the site cleaned with a plastic sponge, then the site draped with an 8 ft by 5 ft composite paper and plastic material (to replace the old-fashioned, reusable cloth drapes). A multitude of plastic supplies are loaded onto the utility table, including plastic sheaths to insert into the femoral artery (which comes equipped with a plastic inner cannula and plastic stopcock), a multi-stopcock manifold that allows selective entry or removal of fluids through the sheath, a plastic syringe to inject x-ray dye, plastic tubing to connect all the devices (total of about 5 feet), and multiple plastic catheters (3 for a standard diagnostic catheterization, more if unusual arterial anatomy is encountered).

All these various pieces come packed in elaborate plastic (polyethylene terephthalate or other polymers) containers, which also come encased in cardboard packaging.

Should angioplasty, stenting, or similar procedure be undertaken, then more catheters are required, such as the plastic "guide" catheters that contain a larger internal lumen to allow passage of angioplasty equipment. An additional quantity of tubing is added to the manifold and stopcock apparatus, as well as a plastic Tuohy-Borst valve to permit rapid entry and exit of various devices into the sheath.

Several new packages of cardboard and plastic are opened which contain the angioplasty balloon, packaging which is usually about 4 feet in length. The stent likewise comes packaged in an 18-inch or so long package with its own elaborate cardboard and plastic housing.

At the conclusion of the procedure, another cardboard/plastic package is opened, this one containing the closure device consisting of several pieces of plastic tubes and tabs.

If the procedure is complicated, the number of catheters and devices used can quickly multiply several-fold.

By the conclusion of the procedure, there are usually two large, industrial-sized trash bins packed full of cardboard, plastic packaging, and discarded tubing and catheters. The trash is so plentiful that it is emptied following each and every procedure. None of it is recycled, given the contamination with human body fluids.

That's just one procedure. The amount of trash generated by these procedures is staggering, much of it plastic. I don't know how much of the U.S.'s annual plastic trash burden of 62 billion pounds (source: EPA) originates from the the cath lab, but I suspect it is a big number in total.

So if you are truly interested in reducing your carbon footprint and doing your part to be "green," avoid a trip (or many) to the cath lab.

Comments (6) -

  • Anonymous

    4/23/2009 8:05:00 AM |

    Dr. Davis,
    Isn't a catheter used for an angiogram?  I thought an angiogram is a necessity before surgery for an aortic abdominal aneurysm?  What are the other alternatives if catheters make so much rubbish?  Just wondering since my mother is considering having surgery for her AAA and needs to have an angiogram first.
    Josephine Keliipio

  • Anonymous

    4/23/2009 2:19:00 PM |

    Dr. Davis doesn't answer questions posted to his blog any longer. He announced this some time ago.

    I think the point of his little story about being green is to avoid having to have such a procedure done in the first place. I don't believe he is suggesting that you ask the Hospital to recycle all the left over rubbish from such a procedure. At the rate of pay of those people, they'd probably have to charge you a couple of hundred dollars to sort everything out that could be recycled..  Frown

    I am only a lay person but I believe there is no alternative (less rubbish producing that is) to the procedure your Mom needs done. Don't worry about the trash and focus on your Mom's outcome instead.

    Good luck with your Mom's procedure.

  • Anonymous

    4/23/2009 5:10:00 PM |

    Catheter angiogram is no longer needed to demonstrate arteries, especially arterial anatomy in the abdomen, extremities,head and neck, including, carotids and intracerebral arteries, arteries in the arm or legs. There is now, an alternative, non-invasive. This consist of CT, CTA, or even better, without radiation an MRI,MRA. The only indication for catheter angiogram is if there is plan for angioplasty, or placement of a stent.
    No one or nobody should be subjected, to a catheter angiogram, in this day and age.
    I hope this helps.

  • Jonathan Selwood

    4/23/2009 5:55:00 PM |

    Dr. Davis,

    Much obliged for the post.  It provides me with a wonderful counter to claims that a grain-based diet has less of an environmental impact.

    Wheat=Heart Disease=Medical Waste


  • Anonymous

    4/24/2009 9:41:00 AM |

    Anonymous #2,
    Thanks for your comment about angiograms. I am still learning about this procedure and am glad to know that there may be other alternatives. My mom had no plans for a stent or an angioplasty but it seems that angiograms are the standard for elderly patients electing to fix AAAs. Anyway, lots of questions to ask the cardiologist when we see him again in a few weeks. Josephine

  • jean

    4/25/2009 5:53:00 PM |

    Mmmm...stay out of the surgical ICU also, if you can help it. We generated on average 3-4 large cans of waste per room (14) per shift (12hr) per day. Efforts to separate out recyclables were futile. And let's not even get into hand washing. This was in 2000. I hope things have improved.