"Friday is my bad day"

At the start, Ted had a ton of small LDL particles. His starting (NMR) lipoprotien values:

LDL particle number: 2644 nmol/L

Small LDL: 2301 nmol/L

In other words, approximately 85% of all LDL particles were abnormally small. I showed Ted how to use diet to markedly reduce small LDL particles, including elimination of wheat, limiting other carbohydrates, and even counting carbohydrates to keep the quantity no higher than 15 grams per meal ("net" carbs).

Ted comes back 6 months later, having lost 14 pounds in the process (and now with weight stabilized). Another round of lipoproteins show:

LDL particle number: 1532 nmol/L

Small LDL: 799 nmol/L

Better, but not perfect. small LDL persists, representing nearly 50% of total LDL particle number.

So I quiz Ted about his diet. "Gee, I really stick to this diet. I have nothing made of wheat, no sugars. I count my carbs and I almost never go higher . . . except on Fridays."

"What happens on Friday?" I asked.

"That's when I'm bad. Not really bad. Maybe just a couple of slices of pizza. Or I'll go out for a big custard cone or something. That wouldn't do it, would it?"

That's the explanation. Your liver is well-equipped to recognize normal, large LDL particles. Large LDL particles therefore "live" for only a couple of days in the bloodstream. But the human liver does not recognize the peculiar configuration of small LDL particles, so it lets them pass--over and over and over again. The result: Once triggered by, say two slices of pizza, small LDL particles persist for 5 days, sometimes longer.

So Ted's one "bad" day per week is enough to allow a substantial quantity of small LDL particles to persist. While a fat indulgence (if there is such a thing) pushes large LDL up, the effect is relatively short-lived. Have a carbohydrate indulgence, on the other hand, and small LDL particles persist for up to a week. It means that Ted's one "bad" day per week is enough to allow his small LDL particles to persist at this level, preventing him from gaining full control over coronary plaque.

It also means that, if you have blood drawn for lipoprotein analysis but had a carbohydrate goodie within the previous week, small LDL particles may be exaggeratedly high.

Comments (29) -

  • yuma

    11/19/2011 4:45:34 PM |

    This is scary! One bad day sets you back a week.
    I limit my carbohydrates (zero grains, no more than 25 grams of sugar) to no more than 100 per day. How low should I go?

  • Jeff

    11/19/2011 8:44:09 PM |

    Dr. Davis, I think we need some clarification on "carbohydrates" -such as which sub-group, sugars (of which there are also sub-groups), starches (more sub-groups), and fiber (more sub groups) need limits. Obviously, sugars are of top concern, with starches following close behind. But arent some of the fiber carbohydrates desirable?

  • Jeff

    11/19/2011 8:45:36 PM |

    I think your website clock is off by twelve hours.....

  • Mary Titus

    11/19/2011 10:58:44 PM |

    How would this affect triglycerides, Dr. Davis.

  • Might-o'chondri-AL

    11/20/2011 4:24:33 AM |

    Hi All-
    Got server error where this belongs, so...about lamestream media hype of vitamin D & fibrilation here is the study's own press release - they only worry about D over 100ng/ml.
    Quote:  "... Dr. Bunch and his colleagues examined blood tests from 132,000 patients in the Intermountain Healthcare database.Patients did not have any known history of atrial fibrillation, and all had previously received a vitamin D assessment as part of their routine care. Patients were then placed into categories to compare levels of vitamin D: low (less than 20 nanograms per decilter), low/normal (21-40 ng/dl), normal (41-80 ng/dl), high/normal (81-100 ng/dl), and excess (more than 100).Patients with vitamin D levels in the normal range were compared with other groups to assess their risk of developing atrial fibrillation.
    In patients with low, low-normal, normal and high-normal levels of vitamin D there was no increased risk of atrial fibrillation.  However, in those with excess levels of vitamin D there was a significant increased risk of atrial fibrillation.  Atrial fibrillation risk was two and a half times greater in patients with excess levels of vitamin D compared to those with normal levels."

  • Teresa

    11/20/2011 2:42:29 PM |

    Thanks for bringing that up, Al.  I had heard of the study, but hadn't gotten around to looking it up.  

    Two and a half times higher risk of atrial fibrillation may not be as much of an increase as it sounds.  It depends on how many people were in the group, and what the real numbers are.  I found this on WebMD:  http://www.webmd.boots.com/heart-disease/news/20111118/high-vitamin-d-levels-linked-to-heart-condition

    The risk of a-fib in those with normal levels of vit D was 1.4%.  With high levels, it was 3.8%.  It isn't that much of a difference, and not as significant as it would be if the risk went from say 10% to 25%.  It is also not as significant if the group number is very small, but we don't have that information.  

    I also found this note on a case study in which a-fib stopped after starting vit D.  Go figure.  http://www.ncbi.nlm.nih.gov/pubmed/2379840

  • Dr. William Davis

    11/20/2011 3:53:11 PM |

    Triglycerides tend to go up, Mary, though not with the same magnitude as small LDL particles.

  • Dr. William Davis

    11/20/2011 3:57:27 PM |

    Hi, Jeff--

    The problem with the fiber is that it comes with digestible carbohydrate. It means that a slice of white Wonder bread triggers small LDL, but so does a cup of quinoa, millet, or buckwheat, all fiber-rich grains.

    Got to be careful: We can't fall for the same logic that has fooled generations of nutritionists: If something bad for you is replaced by something less bad and there is apparent benefit, lots of the less bad thing is good for you.

  • Dr. William Davis

    11/20/2011 3:58:35 PM |

    Wow, that's a lot, Yuma.

    It varies with individual carbohydrate sensitivity, but most people tolerate 15 grams per meal well without postprandial rises in blood glucose or triggering of small LDL.

  • STG

    11/20/2011 4:26:57 PM |

    Dr. Davis:
    It amazes me how some nutritionists  (e.g., ADA or AHA  based) and diet book writers encourage people to cheat on their diets without considering the health impacts. Clearly a mixed message when one is told to make changes, but then told that they can ignore the dietary changes once a week or on special occasions or holidays.

  • Dr Matti Tolonen

    11/21/2011 11:44:07 AM |

    Hi doc, are you sure you have the right units (nmol/l)? Hwere in  Europe, the target for LDL is less than 3 mmol/l which would equal to 3000 µg/l (not nmol/l).

  • Dr. William Davis

    11/21/2011 1:39:01 PM |

    Hi, STG--

    Yes, it is amazing. I have done so many lipoprotein panels (tens of thousands) that I see patterns that a casual observer would not see. This is a substantial, though underappreciated, effect.

  • Jim

    11/21/2011 2:11:19 PM |

    Great post Doc! That really brings the message home.

  • Jeff

    11/21/2011 3:43:08 PM |

    Actually, I am questioning how much do we ned to be concerned about the carbohydrate content of things like green peppers or onions? Flax seed has a nearly all-fiber carb content, doesn't it? What's a safe daily target for total carbohydrate intake, and how should we do the math, if any?

  • Kent

    11/21/2011 4:18:48 PM |

    Knowing that high postprandial glucose levels cause an increase in small ldl particles. And we know that carbohydrates, especially wheat, significantly raise post prandial glucose levels. Would it make sense that Ted could cheat on Fridays with a carb load and still drop his particle score just by exercising after being bad if it kept his glucose levels from spiking?

  • Renfrew

    11/21/2011 10:19:10 PM |

    exercising after "cheating" (eating carbs) MAY work, especially for people who still have enough residual beta cells left in their pancreas and not much insulin resistance. But often exercise is counterproductive because the exercise raises cortisol levels which in turn release blood sugar from the liver. This can only be determined by tight blood sugar measuring (pre/post exercise).

  • Dr. William Davis

    11/22/2011 3:16:41 AM |

    Hi, Jeff--

    It varies, but most people can do well with around 15 grams carbohydrate grams ("net" carbs, meaning total carbs minus fiber) per meal.

  • Dr. William Davis

    11/22/2011 3:17:26 AM |

    This has never been studied, Kent, but I suspect that exercising will only partially blunt the effect, not eliminate it.

  • steve

    11/23/2011 2:36:27 AM |

    Dr Davis:
    Where do you come out regarding the "safe starch" debate on the Jimmy Moore website?

  • Lindas

    11/23/2011 2:47:10 AM |

    Can anyone (or Dr. Davis)  tell me what they include in their 15 gr. carb meals?  how many carbs per day total,,,,SNACKS ETC? does this cause ketosis?  I've been trying to eat right,  however, at 8:30 PM my blood sugar was 112. is that bad or ok?  I'm a 61 year old woman. my calcium score 4/11 was 206. thank you

  • Dr. William Davis

    11/25/2011 2:13:48 PM |

    Sorry, Steve, I'm not familiar with that term.

    If you are referring to amylose, the form of carbohydrate that is less efficiently digested, it will boil down to blood sugar consequences of a specific amylose-containing food.

  • Dr. William Davis

    11/25/2011 2:15:10 PM |

    Hi, Lindas--

    I aim for blood sugar to stay below 100 mg/dl--all the time, including after meals.

    Ketosis can occur, though usually not. Eat vegetables, nuts and nut meals, oils, olives, avocados, meats, cheese. Plenty to eat without wheat and limited carbs.

  • Chris Buck

    11/26/2011 5:09:38 AM |

    Can I add vegetables does not include potatoes, corn, and rice - just to be clear.

  • Dr. William Davis

    11/27/2011 2:16:38 PM |

    Yes, correct. They will trigger small LDL if consumed in anything but the smallest portion size (e.g., more than 1/2 cup).

  • steve

    11/28/2011 6:18:55 PM |

    Dr Davis:
    The "safe starch" discussion is related to rice and potatoes being "safe starch" according to the writers of the Perfect Health Diet, The Jaminets.

    1/2 cup serving per meal X3 = 1.5 cups per day.  If three meals consumed in a day and zero at one meal could you eat 1 cup at one meal, and 1/2 cup at another and still be ok from an overall perspective?
    Are you advocating zero rice, potatoes as well as wheat and other starches?
    How is the level of acceptable maximum small LDL?
    Which would you find more acceptable for a person with CAD with normal weight, thryroid, D?
    LDL 2200
    small 200
    HDL 69
    The above with no statins; or
    LDL 650
    small <90
    HDL 60
    The above with statins
    Both with virtually zero starch
    Is zero starch healthy?  Will zero starch induce thyroid issues?
    Meat, chesse, fish, veggie diet healthy ok for those who cannot eat nuts?

    Wheat Belly sound advice; I have recommended it to several who have  gotten the book

  • STG

    11/29/2011 3:19:21 AM |

    Dr. Davis:
    What population develops small LDL--your patients, anyone who eats carbohydrates, individuals with defective glucose metabolism (e.g., prediabetic, diabetic, insulin resistant)?

  • Dr. William Davis

    12/1/2011 4:22:34 AM |

    Yes and yes. It is truly ubiquitous with few modern people escaping it.

  • Dr. William Davis

    12/1/2011 4:27:04 AM |

    Hi, Steve--

    The triggering of small LDL tends to be dependent on the contents of a single meal. It does not necessarily mean zero carbohydrates, but staying below the threshold for provocation, which can be approximated by checking a 1-hour postprandial glucose: If any rise above the pre-prandial level is seen, then there is potential for provoking small LDL.

    There is no confident answer to which is better. But, given the apo E4-driven or other abnormal metabolic pattern with the LDL particle number of 2200, I would opt for statin, much as I hate to say it.

  • Amos

    12/7/2011 7:25:33 AM |

    I'm not familiar with American blood sugar levels....what on earth would it mean to keep blood sugar under 100, in Canadian terms?  (I've been given a target of 4-7 before meals, and 7-9 after meals....)