dr. davis whats your take on brown rice? is it a good replacement for wheat? a cup full at mealtimes?

Dr Davis:  As you well know, not all of us can lower small LDL through carb restriction and wheat elimination to a level where small LDL is only say 30% of total LDL, a number low enough to perhaps get plaque regression. I have elimated all wheat, and eat low carb,have achieved HDL of 59, LDL of 45, NMR particle of 609, 57% of which remain small. Take Crestor and Zetia. Vitamin d measures at 60 and no thyroid issues.   My TRG's are only 28.  So, i think i am one that may have a CETP issue not responsive wholly to diet; if this drug works, it would most likely be of help to me and many others. The only way my particle count comes down is with drugs.  Not sure how i can go lower on the carb front given my only carbs now are veggies; no fruit or starch except teaspoon of Metamcuceil.  Any other natural ways to lower small LDL?

OK, I'm confused.  It sounds like this drug will increase the number of small LDL:

"This yields a several nanometer smaller LDL particle, now the number one most common cause of heart disease in the U.S."

But then, maybe not:

"CETP inhibition is really a strategy to reduce small LDL particles"

Dear Dr Davis,
what is your commentary about this new investigation which represents decreasing properties of whole grain food to ldl levels
http://jn.nutrition.org/content/140/12/2153.short?rss=1
Thank you in advance for your opinion
George

Dr. D.

I love your Blog. Keep up the good work.

A few years ago I would have been very excited about this new class of drugs. I am however not so sure this drug will be the super star people think it will be (despite being able to raise HDL so much).

According to Chris Masterjohn @ The Daily Lipid Blog, he believes that much of the benefit of HDL is because HDL transfers vitamin E to the endothelial cells and that CETP inhibitors actually decrease the transfer of vitamin E from other lipoproteins to HDL by about half.  

http://blog.cholesterol-and-health.com/2009/03/wherefore-art-thy-protection-o-hdl.html

Another recent statin study, with null results: http://www.ncbi.nlm.nih.gov/pubmed/21067805

My experience on the Paleo diet plus psyllium plus guar gum equals this drug.  My HDLs went from 35 to 91.

@ JCarey:

Paleo diet + psyllium + guar gum raises HDL?
Glad you hdl's are up..got any references or links for this?

This is my take Chris.

Paleo diet = increases HDL as a result of an increase of dietary fats.

Psyllium husk = lowers LDL by stimulating the conversion of cholesterol into bile acid.  It may also lower small LDL by controlling glucose levels by slowing digestion.

Guar gum = lowers small LDL by controlling glucose levels by slowing digestion.

It amazes me to no end that people have forgotten what the longest long term study has shown us about LDL.  1998 final Framingham data.  Those with the lowest LDL levels died the soonest and those with the highest levels lived the longest and yet we are still trying to lower LDL small large or medium sized.  Its the oxLDL that matter. Dr. Davis keep fighting the battle.  

Dr. K

I notice from the Merck statement that this drug did not reduce CRP like most statins.

A few responses:

Anonymous--It depends on individual carb sensitivity. Most people can tolerate small quantities, e.g., 1/2 per serving. Others (like me) cannot even tolerate this much without triggering a surge in blood glucose and small LDL.

Steve--You likely have what I call "genetic" small LDL, meaning a CETP variant. Niacin can help. Beyond this, we struggle. I've seen variable effects with more fats, phosphatidylcholine, medium-chain triglycerides, and milk thistle. We also lack endpoint data to tell us what a desirable level is. I believe, however, it is somewhere around 300 nmol/L.

Jim--In the first paragraph, I was referring to the small LDL-yielding effects of CETP and triglyceride exchange. Blocking CETP prevents this exchange from occurring.

thanks for the response dr. davis.

What I saw from the study was no real difference after 76 weeks in mortality or cardiovascular events. In fact there were 11 deaths in the anacetrapib group and 8 deaths in the control group.

I don't find that encouraging, but maybe it was too short term.

thank you Dr Davis for your recommendations.  I have tried Slo-Niacin and had great difficulty tolerating it at 1500/1000 mg doses. Felt much better when not on it.  Have tightened up my diet even more, eliminating fruit and cheese and Greek Yogurt.  Will see what next NMR brings.  Might add Niacin at low dose to existing regime.  My small LDL particle size at 20.6 is type A and small particles not to far off from the 300 you suggest despite the proportion of small LDL to total LDL being larger than optimal

Dr. Davis - can you comment on an article that Shane Ellison has written entitled "Hidden Truth About Cholesterol-Lowering Drugs"?

Within the article, Mr. Ellison provides the statement that low cholesterol is a bad thing, not a good thing and people with higher cholesterol are living longer.

Can you place this in context with regard to small LDL particles?

Steve,
I'm not Dr. Davis, but I also have difficulty with Niacin.  I also have high homocysteine.  These 2 things can go hand in hand.  For me, it's a methylation problem.  I'm an undermethylator, which means I have to supplement with TMG and a few other things.  You should get your Homocysteine checked, and if it is elevated, be very careful with Niacin, since Niacin can make it worse unless you supplement with TMG etc...

thanks Tyson:  Homocysteine level is in normal range,but near the high end, ie 10 vs. 12 being top of the range.  My understanding is that it elevates with age and i am pushing 60.  I also hear that a B complex vitamin might make sense.

Perhaps Dr. Davis may weigh in on the homocysteine issue with regards to treatment and Niacin use.

Don't get your hopes up for anacetrapib. Despite the researchers best attempts to hide it, the anacetrapib group had higher cardiac mortality, and higher overall mortality. So, do you care that some numbers changed, or that the drug increases the risk of death? I wrote an article on the subject on my blog: http://clintoncpr.blogspot.com/2010/11/anacetrapib-scam-improve-your.html

Considering alledged 400% increase in cardiovascular mortality rate....

http://high-fat-nutrition.blogspot.com/2010/11/anacetrapib-giggle.html

...I think I'll pass on this new wonder drug.

Dr. Davis,

I think total cholesterol should be 290, perhaps, and not 29?

I have started using the lipoprofile in my practice.  Patients with relatively normal lipid profiles are startled with the results.  Getting them to make any changes is another thing, but I will keep trying.

Teresa

I live in the UK under the National Health Service but I also  have private medical insurance. I know that neither my private medical insurance company, nor the NHS itself, know my cholesterol numbers - they are known only to the lab, my doctors and me. How is it that patient information, which should be confidential, is given to insurance companies ? I find that a very worrisome aspect of this.

I find it kind of strange how obsessed american doctors are with cholesterol levels, in my country (Iceland) this is not such a big deal.

It's almost as if the doctors in America are going out of their way to find something wrong with their patient so that they can treat it.

For example high cholesterol, thyroid disorders. I pretty much never hear people talk about those things here.

and when she refuses to do as ordered, her insurance company will find out about that, and will then terminate her coverage. Anybody want to make a bet? So much for privilege and confidentiality in the ole US of A.

Seems very odd, I've had health insurance fornforty years, and they've never given me any advice or indication that they read my lab results.

Some insurance companies routinely require physical examinations before they will write life insurance and are happy to find any reason not to write the insurance. Could this have been a life insurance company?

What do you think is the best line of defense for the patient? My husband has similar calculated LDL - 181, the rest of numbers are excellent and he is in a very good health at 50 years old. Blood pressure is excellent(115/65), pulse is 45 at rest, fasting BS is 76. Our doctor admits it, but recommends Lipitor anyway. Our health insurance is about to be changed and it makes me worry about perspective pressure from insurance people on my husband to take that Lipitor.

How does an individual give honest answers on health questionaires when applying for new or additional life or health insurance?  If they ask my PCP they would be told that I am low risk for heart attack.   If they look at my CT scan score they would see that I am in the 90th percentile - high risk.
These are hypothetical questions at this point but my inclination would be to base my answer on my PCP's opinion rather than my calcium score, in part because medical insurance does not cover CT scans (apparently because they don't consider them to be a reliable predictor of risk) and in part because I have taken steps to significantly reduce my risk.

Let's name names!  I have coverage by United Health Care through an employer.  I have gotten several letters in the past couple of years telling me I NEED this test, or that that test, to maintain my good health!  [However, never anything about the value of lipoprofile testing!]

I consider this an abhorrent practice, an invasion of my privacy, and totally reject their "advice".  Advice should be coming from my doctor, and in fact it is.  I don't need their nurse "case manager" nor this advocacy for excessive testing.

There's nothing like a letter from an insurance company to raise blood pressure!

madcook

It is very disturbing to me that 1) her health insurance has access to her medical records and 2) that a for-profit organization is getting involved in her healthcare. Having moved from Australia about five years ago, everything about American health care disturbs me. I trust no one; they all seem to be desiring a profit and therefore paperwork is their main concern, not patient care, health, or longevity.

My last test showed calculate LDL at 208, however the one from three months ago was "directly measured lipid" and showed 263 LDL direct, so might the calculated version be wrong in either direction?  I have pattern A and am FH.

I'm for naming names too!  I have Aetna health insurance through my employer. I don't get letters from them, but I get emails. Just today, I told my email program to automatically delete any further emails from the "Simple Steps to a Healthier Life" program. Plus whenever I sign into the online portal, I get nagged to have all kinds of tests, fill out questionnaires, and join health improvement programs.  I got so tired of the demand that I "fill out a health assessment questionnaire" I finally gave in, hoping it would be removed from the page. It just opened a new can of worms: now I have a half dozen new "suggestions" on my "to do list". Bah humbug!

I'm of the "live and let live" school.  Why go looking for trouble?  As long as I'm not having symptoms, I feel no need to undergo all of these tests.

Thank God my doctor is beginning to understand that I'm not going to be taking any of those Pharma-pushed poisons just because my lab results don't meet someone's criteria. Once again, I say Bah humbug!

Thanks for catching that, Teresa.

It is indeed an eye-opener, isn't it?

Anne and Kris--

Fascinating non-American perspectives.

Insurance companies have incredible info on us. I'm always surprised more is not made of this issue.

Remember: The more they know, the better they are at denying coverage.

Dr. Davis,

I didn't want to put this here (not sure if I could post it elsewhere) , but I thought you would find this interesting if you haven't seen it yet.

http://www.psychologytoday.com/blog/p-nu/201103/cardio-may-cause-heart-disease-part-i

RyanH

Anonymous1 said:
"I have coverage by United Health Care through an employer"
Ah, United. I have Oxford/United. '
Several years ago, when everyone at Oxford (and patients) worked toward a noble goal of "salary" for their CEO of 1.6 Billion a year, they sent me several letters suggesting that I have basic check up. I followed their suggestion. Then, I started to receive letters ... refusing to pay - 100% refusal. Each time, I had to call and ask nicely and politely: "Are you nuts?" They paid.

Though I am not in the habit of defending health insurers, I have found that they tend to provide a benign "you should speak to your doctor about . . ." kind of approach.

I often wonder, however, if at some point they start to be more coercive. Something like: "You should strongly consider a cholesterol-reducing drug. We anticipate that your premiums may be higher if you do not."

That would be scary.

Ah, I should have continued.
In a way, Oxford achieved their goal. What they paid was minimal, but they avoided bigger cost at that time.
They scared me to death - if they don't pay for what they send to ( with letters firmly printed) which is basic, stated officially in some book as my right, they probably won't pay for anything else. I neglected all symptoms and asked for medical attention when I really didn't have any choice (and in a slightly new climate)
I was diagnosed with two quite serious conditions - neither curable, but one was preventable and the other was at this time preventable to a degree. I mean the condition would be one only (the result of "bad" accumulation +genes?), less serious and correctable.

An insurance company has a tremendous incentive to reduce its costs and hence a great incentive to find out the truth. If they are not, it means that something is fishy. Why are insurers not commissioning their own studies? Are they not allowed to? Is it the regulators who are holding them back? Or are they actually stupid?

I have not had any insurers say they know what a patient's lipid numbers are, but they can pretty well tell from claims data what tests have been done, and what medications are prescribed.

We get faxes all the time recommending that meds be changed or weaned or made as needed rather than routine.  Yes, I know Mrs. Jones has been on an ulcer medicine for 6 months, and we should try to wean it.  What they don't know is that she won't change her diet and lose some weight, so maybe her symptoms would stop, and her symptoms get horribly worse without her ulcer medication.

Teresa

Dr. Davis,

Based on Claudia's numbers, I guess I should expect a letter from my insurance company and a prescription from my doc for a statin. I won't fill the scrip.

I'm 65, slim, eat VLC, and haven't been afraid of  saturated fat. But I just got my labs and TC was 476, HDL 146, Triglycerides 79 (I'd had wine with dinner--they're usually in the 30s), and LDL 314!!!

How worried should I be about these numbers?

Hey Dr. Davis,

At my last visit, my doctor mentioned my lipid numbers; but even he had to admit that my LDL (157) and TC (234) had improved (from 177 and 255), and the rest of my labs were all WNL. I generally eat low carb -- other than my recent indulgence in mini PB cups -- so I suspect that, as you indicated, the actual numbers are better than the official calculated numbers.

My doc didn’t try to prescribe any meds this time. But at other visits he’s tried to guilt me into following the accepted guidelines by telling me his “performance score” is determined by how well he adheres to those guidelines, including prescribing all the meds and tests recommended by the so-called experts for a patient of my age with my lab results.

I also fear that things are changing in this regard – and not for the better. Our government has now decided that we all must have insurance or pay a fine. If I refuse to follow the recommended guidelines, either my insurance company or my doctor, or both, may “fire” me. The truth is, I really don’t give a fig which entity it is (doctor, insurance company, or government panel) that tries to hector me into following guidelines promulgated by “experts” who believe in the lipid hypothesis. I simply choose to believe that I’m in charge of my body and that I get to determine whether to take a recommended med or have a recommended test.

As for insurance companies getting lab results, I don’t know whether the doctor’s office or Quest Labs has been feeding my results to my insurance company, but when I look at my online health info on the insurance company’s web site, all my lab results are listed. And I’m sure the company is basing at least some of its many recommendations on those results.

I must admit, having the results online makes it easy for me to keep track of them; but given the ease with which records can be hacked, I fear for my health privacy. And I resent the big brother attitude of the insurance company. I'm a well-informed, healthy adult. Treat me like one.

Just this past week, my insurance company (Aetna), which has paying for my test strips for the past year and a half, sent me a letter suggesting that I might have diabetes, and should talk to my doctor.

Hi Dr. Davis,

I spent the weekend reading your older posts about LDL. I guess I need to get a test done to determine my LDL particle number before my doc and I have a discussion. Thanks for posting that info in such detail on your blog.