What tests are MORE important than cholesterol?

In the conventional practice of early heart disease prevention, cholesterol testing takes center stage. Rarely does it go any further, aside from questions about family history and obvious sources of modifiable risk such as smoking and sedentary lifestyle.

So standard practice is to usually look at your LDL cholesterol, the value that is calculated, not measured, then--almost without fail--prescribe a statin drug. While there are indeed useful values in the standard cholesterol panel--HDL cholesterol and triglycerides--they are typically ignored or prompt no specific action.

But a genuine effort at heart disease prevention should go farther than an assessment of calculated LDL cholesterol, as there are many ways that humans develop coronary atherosclerosis. Among the tests to consider in order to craft a truly effect heart disease prevention program are:

--Lipoprotein testing--Rather than using the amount of cholesterol in the various fractions of blood as a crude surrogate for lipoproteins in the bloodstream, why not measure lipoproteins themselves? These techniques have been around for over 20 years, but are simply not part of standard practice.

Lipoprotein testing especially allows you to understand what proportion of LDL particles are the truly unhealthy small LDL particles (that are oxidation- and glycation-prone). It also identifies whether or not you have lipoprotein(a), the heritable factor that confers superior survival capacity in a wild environment ("The Perfect Carnivore"), but makes the holder of this genetic pattern the least tolerant to the modern diet dominated by grains and sugars, devoid of fat and organ meats.

--25-hydroxy vitamin D--The data documenting the health power of vitamin D restoration continue to grow, with benefits on blood sugar and insulin, blood pressure, bone density, protection from winter "blues" (seasonal affective disorder), decrease in falls and fractures, decrease in cancer, decrease in cardiovascular events. I aim to keep 25-hydroxy vitamin D at a level of 60 to 70 ng/ml. This generally requires 4000-8000 units per day in gelcap form, at least for the first 3 or so years, after which there is a decrease in need. Daily supplementation is better than weekly, monthly, or other less-frequent regimens. The D3 (cholecalciferol) form is superior to the non-human D2 (ergocalciferol) form.

--Hemoglobin A1c (HbA1c)--HbA1c represents glycated hemoglobin, i.e., hemoglobin molecules within red blood cells that are irreversibly modified by glucose, or blood sugar. It therefore provides an index of endogenous glycation of all proteins of the body: proteins in the lenses of the eyes that lead to cataracts; proteins in the cartilage of the knees and hips that lead to brittle cartilage and arthritis; proteins in kidney tissue leading to kidney dysfunction.

HbA1c provides an incredibly clear snapshot of health: It reflects the amount of glycation you have been exposed to over the past 90 or so days. We therefore aim for an ideal level: 5.0% or less, the amount of "ambient" glycation that occurs just with living life. We reject the notion that a HbA1c level of 6.0% is acceptable just because you don't "need" diabetes medication, the thinking that drives conventional medical practice.

--RBC Omega-3 Index--The average American consumes very little omega-3 fatty acids, EPA and DHA, such that a typical omega-3 RBC Index, i.e., the proportion of fatty acids in the red blood cell occupied by omega-3 fatty acids, is around 2-3%, a level associated with increased potential for sudden cardiac death (death!). Levels of 6% or greater are associated with reduced potential for sudden cardiac death; 10% or greater are associated with reduced other cardiovascular events.

Evidence therefore suggests that an RBC Omega-3 Index of 10% or greater is desirable, a level generally achieved by obtaining 3000-3600 mg EPA + DHA per day (more or less, depending on the form consumed, an issue for future discussion).

--Thyroid testing (TSH, free T3, free T4)--Even subtle degrees of thyroid dysfunction can double, triple, even quadruple cardiovascular risk. TSH values, for instance, within the previously presumed "normal" range, pose increased risk for cardiovascular death; a TSH level of 4.0 mIU, for instance, is associated with more than double the relative risk of a level of 1.0.

Sad fact: the endocrinology community, not keeping abreast of the concerning issues coming from the toxicological community regarding perchlorates, polyfluorooctanoic acid and other fluorinated hydrocarbons, polybrominated diphenyl ethers (PDBEs), and other thyroid-toxic compounds, tend to ignore these issues, while the public is increasingly exposed to the increased cardiovascular risk of even modest degrees of thyroid dysfunction. Don't commit the same crime of ignorance: Thyroid dysfunction in this age of endocrine disruption can be crucial to cardiovascular and overall health.

All in all, there are a number of common blood tests that are relevant--no, crucial--for achieving heart health. Last on the list: standard cholesterol testing.

Comments (8) -

  • stuart

    5/13/2013 12:56:55 AM |

    Great summary Dr. Davis.  You're the best!

  • Sol y Sombra

    5/13/2013 11:07:44 AM |

    Thank you for the useful information you provide, Dr. Davis. But I have a question: Does it really take 3-4 years to replenish vitamin D stores in the body?

  • Amy Crain

    5/15/2013 2:26:51 AM |

    Dr. Davis..
    My husband decided to give going gluten free a try after I read your book, and shared many things with him.  He has a number of issues.  HBP and taking meds.  Asthma, knee injuries with multiple surgeries over the years, and based on his lipid panel numbers, his dr. like you said, wanted to put him on a chol. reducer.  He went gf for a month, this past month, and just this week had his blood work done.  His LDL # went up from 146 to 164, and his HDL went from 45 to 47.   His Trig at least, dropped from 190 to 122,  So he now has in hand a scrip for atorvastatin (sp.?)..  Even though my husband would be considered a slender 48 year old, he has lost 6 pounds during this month of being wheat free.  I personally began a trek of losing weight a year ago by cutting wheat and sugar, and lost over 30 pounds, going from a size 12 to a 2.  I never had any blood work done, since I didn't have any health issues.  I was really hoping for better results for my husbands numbers so that we could provide a valid testimony to those unbelievers within our family.  I don't have your book memorized, but I've scanned through the blog posts and comments and found bits and pieces about numbers and how some people experience an increase like my husband Bill did.  Could you give me a bullet point laymen's version of the reason for the increase, if it's a concern, and if not, should he get the prescription filled like the dr. ordered so that he can then do the 3 month follow up to see if the med. worked for lowering the #'s?
    OR should I just go back and do some more reading like of the above post and reread the book?

  • Lowering cholesterol diet

    5/17/2013 3:10:25 PM |

    Hey there,

    thanks for the article. I would also like to know does Vitamin C plays any role in lowering cholesterol? I am thinking about writing a blog post about it so thank you in advance dr. Davis.

  • Geoffrey Levens, L.Ac.

    5/17/2013 8:23:48 PM |

    List makes great sense to me but one question arises: In light of recent research showing increased risks outside range of 20–36 ng/ml, do you anticipate any change in your recommendations as to Vitamin D blood level?
    J Clin Endocrinol Metab. Published online March 26, 2013. Abstract

    Thank you.

  • [...] between triglycerides and HDL, those improve with LCHF diet. You can start reading more here;  What tests are MORE important than cholesterol? | Track Your Plaque Blog  Lipid researcher, 98, reports on the causes of heart disease | News Bureau | University of [...]

  • Stephen in Jacksonville

    6/14/2013 9:20:30 PM |

    Tests are important, and I think that there are more people today who are interested in keeping track of their cholesterol levels. This is why I think we live in such a special time. We have access to more information than ever before, and now people can learn about high cholesterol risks without having to go to the doctor. In fact, I have found a number of sites that allow people to track their cholesterol levels online. Obviously, there are some people who may go overboard with access to this information, but I do think that there are plenty of benefits to be had.

Slash carbs . . . What happens?

Slash carbs . . . What happens?

Cut the carbohydrates in your diet and what sorts of results can you expect?

Carbohydrate reduction results in:

Reduced small LDL--This effect is profound. Carbohydrates increase small LDL; reduction of carbohydrates reduce small LDL. People are often confused by this because the effect will not be evident in the crude, calculated (Friedewald) LDL that your doctor provides.

Increased HDL--The HDL-increasing effect of carbohydrate reduction may require 1-2 years. In fact, in the first 2 months, HDL will drop, only to be followed by a slow, gradual increase. This is the reason why, in a number of low-carb diet studies, HDL was shown to be reduced.--Had the timeline been longer, HDL would show a significant increase.

Decreased triglycerides--Like reduction of small LDL, the effect is substantial. Triglyceride reductions of several hundred milligrams are not at all uncommon. In people with familial hypertriglyceridemia with triglyceride levels in the thousands of milligrams per deciliter, triglyceride levels will plummet with carbohydrate restriction. (Ironically, conventional treatment for familial hypertriglyceridemia is fat restriction, a practice that can reduce triglycerides modestly in these people, but not anywhere near as effectively as carbohydrate restriction.) Triglyceride reduction is crucial, because triglycerides are required by the process to make small LDL--less triglycerides, less small LDL.

Decreased inflammation--This will be reflected in the crude surface marker, c-reactive protein--Yes, the test that the drug industry has tried to convince you to take statins drugs to reduce. In my view, it is an absurd notion that you need to take a drug like Crestor to reduce risk associated with increased CRP. If you want to reduce CRP to the floor, eliminate wheat and other junk carbohydrates. (You should also add vitamin D, another potent CRP-reducing strategy.)

Reduced blood pressure--Like HDL, blood pressure will respond over an extended period of months to years, not days or weeks. The blood pressure reduction will be proportion to the amount of reduction in your "wheat belly."

Reduced blood sugar--Whether you watch fasting blood sugar, postprandial (after-meal) blood sugars, or HbA1c, you will witness dramatic reductions by eliminating or reducing the foods that generate the high blood sugar responses in the first place. Diabetics, in particular, will see the biggest reductions, despite the fact that the American Diabetes Association persists in advising diabetics to eat all the carbohydrates they want. Reductions in postprandial (after-eating) blood sugars, in particular, will reduce the process of LDL glycation, the modification of LDL particles by glucose that makes them more plaque-causing.

You may notice that the above list corresponds to the list of common plagues targeted by the pharmaceutical industry: blood pressure, diabetes (diabetes being the growth industry of the 21st century), high cholesterol. In other words, high-carbohydrate, low-fat foods from the food industry create the list of problems; the pharmaceutical industry steps in to treat the consequences.

In the Track Your Plaque approach, we focus specifically on elimination of wheat, cornstarch, and sugars, the most offensive among the carbohydrates. The need to avoid other carbohydrates, e.g., barley, oats, quinoa, spelt, etc., depends on individual carbohydrate sensitivty, though I tend to suggest minimal exposure.

Comments (20) -

  • Emily

    3/26/2010 4:17:02 PM |

    you forgot one more benefit- effortless wieght loss! at least for many of us...

  • Tony

    3/26/2010 4:28:57 PM |

    I've eliminated almost all sugar, and all refined grains, but I still  eat brown rice, oatmeal, and whole spelt bread. On my recent VAP test, my triglycerides were 78, HDL was 63, and my LDL was Pattern A (large, buoyant LDL). Also, my Cardiac C Reactive Protein was .84. I'm concluding that some whole grains are appropriate for me, and I use the blood glucose monitor to monitor postprandial glucose.

    By the way, thank you for all the info.

  • JustJoeP

    3/26/2010 4:47:04 PM |

    Dr. Davis, following your advice as well as several other clarion voices in the nutritional wilderness, over the last 9 months I went from:
    HbA1C 6.6, Fasting glucose 125mg/dl, BP135/85, LDL nearly 200, HDL below 30, body weight 245 (6ft tall, 40 in waist) on a mainly carb diet, to:

    HbA1C 5.5, Fasting glucose 105mg/dl, BP115/70, LDL nearly in 1/2, HDL above 65, body weight 204 (still 6ft tall, but a 33 in waist) on a very low carb diet.

    I've got 4 friends - all males in their 40s - who have also moved their personal numbers in these directions by greatly reducing carbs.  I'm trying to get my severely type II diabetic father to follow the same regimen, but his Medicare provided dietitian is fighting me every step of the way, with a diet based upon bread!  The struggle continues.

    Thank you for being a consistent, well informed, voice of reason.  You've helped more people than you know.  (linked to you here).  Be well.

  • Isaac

    3/26/2010 5:18:11 PM |

    And I'm so unimpressed with the lack of any good hard endpoint data associated with the insulin sensitizers and such.  These dietary options really need to be explored further but, sadly, won't so long as physicians aren't reimbursed for it.

  • Daniel

    3/26/2010 5:45:40 PM |

    I agree regarding fructose.  

    In people with impaired glucose tolerance, slashing starch too may indeed be beneficial.  But is there any evidence that slashing starch benefits people who have a healthy liver and pancreas?  In such people, I suspect slashing starch is just treating numbers and has nothing to do with health.  Otherwise, how do you explain Kitava, Peru, and Asia?

  • jandro

    3/26/2010 8:25:13 PM |

    Sometimes I think that the results given with these studies are mostly due to the reduction of grains (lectins) and refined sugar and not carbohydrates themselves. I want to believe it is as simple as reducing carbohydrates but it doesn't explain how populations like Kuna and Kitava have good health markers even though they eat a high carb diet. Dr. WD, do you have any ideas related to this specific topic?

    ** I am not debating the results of low carb (I personally do paleo), and if your metabolism is already damaged low carb is the only way, but what if it is not? (you were never obese, diabetic, started healthy habits at a young age, etc).

  • Anonymous

    3/26/2010 10:28:29 PM |

    Would these benefits also accrue to someone who does not get postprandial spikes in blood glucose on a low-carb diet - like the regular commentator "DrStrange"?

  • Ned Kock

    3/26/2010 10:57:59 PM |

    Actually, in the study reviewed in the post below, a 2-week replacement of refined carbs and sugars with dietary fat (mostly saturated) and cholesterol, led to a significant increase in HDL (14 percent increase in HDL from baseline for men).


    That was two weeks only.

    In my own experience, higher consumption of saturated fat and dietary cholesterol has immediate effects on HDL, and those effects are especially strong with elimination of refined carbs and sugars.

  • gindie

    3/26/2010 10:59:00 PM |

    Dr. Davis,

    You mentioned Vitamin D.  I just got tested, level is 14.  However, I get episodes of calcium-based kidney stones (every 3-4 years or so).  How do you treat such patients?

  • Anonymous

    3/27/2010 12:15:47 AM |

    One thing I don't understand is if all these benefits are independent or if they are all linked to glucose level.
    If a particular carbohidrate causes little glucose spike will it still cause the other poblems?
    Or if carbohidrate intake is followed by intense physic actvity which seems to take BG down does it still causes all the other problems?

  • I Pull 400 Watts

    3/27/2010 12:32:49 AM |

    Just letting you know, very nice post!

  • Kim

    3/27/2010 2:53:35 AM |

    I totally agree.  I continued to struggle with my cholesterol the first year or so on a low carb diet.  After 3 years, my HDL has gone from 40 to 87 and my LDL has improved.  My blood pressure also improved over time.  My triglycerides were never high, but are usually in the 35 range now.  It's an awesome thing!

  • Stan (Heretic)

    3/27/2010 3:50:02 AM |

    Welcome to Low Carb Dr. Davis!  From now on, your life will never be the the same


    In addition to what you have listed, which I can confirm in 100%, more beneficial effects will become apparent, such as:

    - self-healing of teeth with no need for dental intervention, and roughly twice as fast healing of broken bones.

    - healing of common cardiovascular diseases (arteriosclerosis, cardio myopathy and arrhythmia)

    - rapid self-healing of hepatic diseases (i.e post hep-C cirrhosis healed in 6 months),

    - improved kidney disease recovery (I heard of a patient  surviving on Optimal Diet without dialalysis with only 1/3 of 1 kidney left)

    - normalization of one's body weight (obese loose, underweight gain),

    - much stronger immune system (for instance, I never had a flu since yr 2000, before - twice a year)

    - stronger more benign reaction to stress, no more paralyzing panic, no more total body vascular contraction and probably related better resistance to cold temperature.  

    - no need to drink water frequently (fat metabolism releases water as an end product)

    - never feel hungry again, no need to snack, eating once or twice a day becomes the norm.   For me no breakfast, no supper, only lunch and dinner, typically.  

    - improved ability to hold breath longer when diving, generally we also naturally breath less frequently,

    - different (improved) mood, subtle changes in the way one thinks, solves problems and react to life events, as no doubts, you will find out...  8-Smile

    Stan (Heretic)

  • Lori Miller

    3/27/2010 1:59:21 PM |

    Daniel, I've tested my own blood glucose before and after meals and it's normal. However, I cut way back on all carbs a couple of months ago, and now eat around 47 grams of carbs per day. Results: I find that I don't need Sudafed or acid blockers at all now and I rarely take ibuprofin (an anti-inflammatory). The twinge in my shoulder and knee are gone. I've lost 10 pounds while working out *less.* I seldom get headaches, and when I do, they're mild. I also need a lot less sleep.

    Should anyone care for details, I've chronicled my experience in my blog.

  • Stan (Heretic)

    3/27/2010 3:26:56 PM |

    jandro - it is a very good question.  I wonder too but the studies I am reading (see for example Lancet. 1996 ) seem to indicate that carbohydrate reduction is beneficial in all cases, including healthy rural young populations.  

    I see it now in the same light as for example alcohol consumption: if you are healthy and young, a  harm may be minimal and some wine  (in moderation) may even provide you with some calories and micronutrients (i.e. resveratrol), but why bother consuming all that starchy and sugary plant food that we are not that well adapted for, that is useful only if we have nothing else to eat and that was probably meant for us only as a temporary food to get us over some rough periods of fauna decline.

      Since there is so little modern research done specifically on this subject we are still largely in the domain of hypotheses and theories. However not all that is speculative.  For example existing archaeological research does show us that paleolithic human diet consisted typically over 2/3 of meat!  We are talking about millions of years of human adaptation.


    Dr. Davis,  I forgot to add to my above list of benefits the following point:

    - reliable improvement (in almost every case) in treating the autoimmune diseases such as rheumatoid arthritis, asthma, eczema, psoriasis etc,

    - intestinal disease (Crohns, IBS , very high fat only!).  

    - Multiple sclerosis (not 100% especially if nerve damage is too advanced but improvement in most cases)

    There is a lot of patient cases (hundreds) of the above disease reported by Dr. Jan Kwasniewski, from his medical practice in the 1980-ties, described in his books, especially "Homo Optimus" and "Optimal Nutrition".  

    I think you will find those books extremely interesting, highly recommended.  


  • Ellen

    3/27/2010 8:03:15 PM |

    Um Heretic.. I think Dr. Davis has been low carb for quite a while now. No need to welcome him to something he's already quite familiar with Smile

  • jandro

    3/27/2010 10:55:06 PM |

    Stan, thanks for your response:

    I read the abstract of the study you link and don't see how it is related to what I mentioned. It is comparing a vegetarian population with one that eats around a pound of fish a day. Seriously, is there a question there as to which is healthier? I also don't think they are healthier primarily because they consume less carbohydrates, but rather because they consume a pound of fish a day compared to no animal fat/flesh in the other group.

    If you read my original post again you will notice I am not saying a vegetarian diet (in fact, I eat over a pound of meat a day), I am just questioning whether the true problem is carbohydrates or if it is lectins, assuming you have a generous amount of animal fat and protein. I personally eat around 20% carbs, mostly coming from tubers and squashes as I find fruits too sweet (I agree that fructose should be reduced). Generally eat one piece of fruit a day.

    I also don't see any evidence to your claim that humans are not adapted to plant foods. We are omnivores, and that's how we have succeeded. We are adapted to a diet similar to what equatorial hunter gatherers have, since we evolved in a similar environment. People bring many archeological references of sites located outside of Africa not realizing that the environment outside of Africa is nearly as new to us as grains are. Most HGs living in Africa have plant food present on their diet. The information you tell yourself claims 2/3 of our diet was meat, what happened to the other 1/3?

  • Anonymous

    3/29/2010 8:33:04 AM |

    And what if someone goes really lowcarb (mostly meat) and his LDL rises up to 500? No info on the the LDL size. The remaining bloodwork results are  really good. Is this something to be worried about?

  • scall0way

    4/21/2010 7:21:12 PM |

    Hmm, well I eliminated wheat and all glutens from my diet in January 2009. I eliminated sugar at the same time. I also eliminated high Omega-6 vegetable oils. I basically eat low carb. I love to use coconut oil. Smile I've lost over 100 pounds.

    But my cholesterol just goes UP and UP! At least total and LDL - HDL remains in the 58-62 range and triglycerides remain in the 60-70 range. But Total cholesterol went from 229 6 months ago to 279 3 months ago, to 280 today, and LDL went from 165 6 months ago, to 190 3 months ago, to 206 today.

    And I can't understand why! Of course my doctor is rabid to put me on stations and crazy with me that I refuse, and looks at me cross-eyed when I request an NMR/VAP test for LDL particle size.

    But it still bothers me that it continues to go up and up and up, as I feel like I'm doing all I can to lower it. I was also diagnosed with Hashimoto's 6 months ago and put on 50 mcg of Levoxyl. Then three months ago it was upped to 75 mcg. Today it was upped to 88 mcg.

    Slashing carbs eliminating the bad stuff sure is not helping my total numbers, which means a huge argument with the doctor every visit, and I hate to argue. :-(

  • julianne

    9/7/2010 1:42:40 AM |

    I'm so glad I found this post!. I've had a group of clients take on paleo eating as a 6 week trial, doing so has naturally decreased their carbs. I had each person do before and after blood tests and I was concerned that 80% had a reduction in HDL. They also had reductions in Triglycerides and LDL and blood pressure and significant weight loss - but couldn't figure this one out. Thanks so much for keeping us informed of what goes on for your clients, so I know what is happening with mine is normal.

    By the way here are some of the results in people's own words