Why small LDL particles are the #1 cause of heart disease in the US

Ask your doctor: What is the #1 cause of heart disease in the US?

Let's put aside smoking, since it is an eminently modifiable risk and none of those crazies read this blog anyway. What will your doctor say? Most like he or she will respond:

High cholesterol or high LDL cholesterol

Too much saturated fat

Obesity

Pfizer, Merck, AstraZeneca and their kind would be overjoyed to know that they can add your doctor to their eager following.

I'd tell you something different. I would tell you that small LDL particles are, by far and away, the #1 cause for heart disease. I base this claim on several observations:

--Having run over 10,000 lipoprotein panels (mostly NMR) over the past 15 years, it is a rare person who does not have a moderate, if not severe, excess of small LDL particles. 50%, 70%, even 90% or more small LDL particles are not rare. Over the course of a year, the only people who show no small LDL particles are slender, athletic, pre-menopausal females.

--In studies in which lipoproteins have been quantified in people with coronary disease, small LDL particles dominate, just as they do in my office. Here's a 2006 review.

--Small LDL is largely the province of people who consume carbohydrates, such as the American population instructed to "cut fat and eat more healthy whole grains." Conventional diet advice has therefore triggered an expllosion in small LDL particles.

--When fasting triglycerides exceed 60 mg/dl, small LDL particles increase as a proportion of total LDL particles. This includes the majority of the US population. (This ignores postprandial, or after-eating, triglycerides, which also contribute to small LDL formation.)

If you were to read the data, however, you might conclude that small LDL affects a minority of people. This is because in most studies small LDL categorize it as either "pattern B," meaning exceeding some arbitrary threshold of percentage of small LDL particles, versus "pattern A," meaning falling below that same arbitrary threshold.

Problem: There is no consensus on what percentage of small LDL particles should mark the cutoff between pattern A vs. pattern B. In many studies, for instance, people with 50% small LDL particles are called "pattern A."

If, instead, we were to set the bar lower to identify this highly atherogenic (atherosclerotic plaque-causing) particle at, say, 20-30% of total, then the number or percentage of people with "pattern B" small LDL particles would go much higher.

I see this play out in my office and in the online program, Track Your Plaque, every day: At the start eating a low-fat, grain-filled diet with lots of visceral fat ("wheat belly") to start, they add back fat and cut out all wheat and limit carbohydrates. Small LDL particles plummet

Comments (77) -

  • Bill

    9/15/2011 1:13:26 PM |

    But is there any real evidence that small LDL is a *cause* of heart disease? Correlation alone isn't sufficient, of course, and Chris Masterjohn has said that even the correlation largely disappears when traditional "risk factors" such as HDL, LDL, and triglycerides are added to the model.

    I ask in part because I am about to arm wrestle with my primary care doctor about my recent cholesterol panel:

    Total: 382
    HDL: 157
    LDL: 217 (calculated)
    Triglycerides: 39

    He's upset about the LDL, of course, especially since it's progressively risen over time (coinciding with dietary changes pretty compatible with TYP and including quite a bit of sat fat after years as a low-fat vegetarian). Naturally, he wants me to reduce my fat consumption and retest in four months, and I'm sure a statin drug recommendation will follow just as the sunset inevitably follows the sunrise.

    I am thinking of asking for a full lipoprotein panel, with the expectation that it will calm him down by showing 1) much lower real, measured LDL with my rock bottom triglycerides and 2) strong Pattern A LDL with my sky high HDL and low triglycerides.

    But I'm not certain if I can really make a convincing empirical case to him that Pattern A is benign with a high LDL. (I'm also hesitating after hearing Chris Masterjohn say that LDL particle size measurements are hugely dependent on the type of assay used and that as a result it's not clear what, biologically, any given result means until these methodological discrepancies are sorted out.)

  • Peter Silverman

    9/15/2011 2:41:59 PM |

    The article you cite says the number of LDL particles may be more important than the size.  Is that your experience?

  • Howard

    9/15/2011 3:02:31 PM |

    @Bill : Chris Masterjohn also mentioned in a recent podcast that the current measurement technology for LDL particle size is just not sufficiently accurate to be useful.

  • chuck

    9/15/2011 3:48:18 PM |

    what is your feeling on oxidized ldl?

  • chuck

    9/15/2011 3:52:16 PM |

    @howard
    yes, based on the hour to hour, day to day, week to week, and month to month natural fluctuations of lipids in the blood it is difficult to make any real judgements about cholesterol readings without doing multiple panels over a period of time.  the whole medical community seems to be screwed up in this respect.

  • Kathy

    9/15/2011 4:13:20 PM |

    I have no idea what Dr. Davis' response will be, but if you're interested in getting an NMR profile done on your own dime (and if there is a convenient location near you), check out directlabs.com for their September special.  An NMR profile will only set you back $79 (reg $127).  I've been waiting for this "sale" and am getting it done to show my own doctor.  Your health is ultimately in your hands - keep up the good fight!
    Best,
    Kathy

  • edward white

    9/15/2011 5:02:18 PM |

    Dr D,
    I totally agree small LDL is driven by excess carbohydrate intake and postprandial
    triglycerides. However there is a substantial subset of people whose small LDL
    is genetically driven. I believe you are aware of this phenomena.
    Please let these folks know what their options are to address this important issue!
    There can be a good deal of frustration when carbs and triglycerides are addressed but
    with little lowering of small LDL.
    Please help this substantial number of people out by outlining their options...
    Gib

  • Unix-Jedi

    9/15/2011 5:22:13 PM |

    Thanks for that information, Kathy.

  • cancerclasses

    9/15/2011 5:57:26 PM |

    It ain't good,  just ask Wikipedia.   From the Wiki page re 'Chronic endothelial injury hypothesis':
    "Once LDL accumulates in the subendothelial space, it tends to become modified or oxidized.[5] This oxidized LDL plays several key roles in furthering the course of the inflammatory process. It is chemotactic to monocytes; oxidized LDL causes endothelial cells to secrete molecules that cause monocytes to penetrate between the endothelial cells and accumulate in the intima.[6]

    Oxidized LDL promotes death of endothelial cells by augmenting apoptosis. Also, through the activation of collagenases, ox-LDL contributes to a process which may lead to the rupture of the fibrous plaque[7] Oxidized LDL decreases the availability of endothelial nitric oxide (NO), which, in turn, increases the adhesion of monocytes to the endothelium.[8] Moreover, NO is involved in paracrine signalling between the endothelium and the smooth muscle that maintains vascular tone; without it, the muscle will not relax, and the blood vessel remains constricted. Thus, oxidized LDL also contributes to the hypertension often seen with atherosclerosis."

  • Bob

    9/15/2011 6:12:21 PM |

    Test reply

  • cancerclasses

    9/15/2011 6:13:54 PM |

    Yes, French cardiologist Guy-Andre Pelouze MD. at the recent Ancestral Health Symposium said in his presentation "Paleodiet and atheroma: A Cardiovascular Surgeon’s Perspective" that:

    1. Native (the reduced form of) LDL cholesterol is NOT atherogenic, only the oxidized form leads to atheroma, atherogenesis & arterial plaque formation.

    2. Without oxidized cholesterol it's very difficult to have arterial plaque formation

    3. Anti-oxidants are ineffective in preventing atheroma.

    4. SDLDL easily enter the subendothelial space because SDLDL are less than 25 nm in diameter and the subendothelial space is 26 nm.

    5. Subendothelial space in humans is very different in humans than other mammals due to the large amount of smooth muscle in the arterial media below the the intima layer.

    And there's much more.  To see a video of Dr. Pelouze's presentation hosted on the Ancestral Health page at Vimeo just google 'vimeo, paleodiet and atheroma', then scroll to video number 33 in the right side box.

  • cancerclasses

    9/15/2011 6:42:38 PM |

    Do you REALLY believe that? We have the ability to measure the distance between the earth and the moon almost down to the millimeter, and certainly down to the centimeter. We have the ability to measure individual atoms with electron and other types of microscopy used in materials engineering and computer chip manufacturing.  Medical, biochemical & physiological textbooks are full of descriptions of the sizes of white and red blood cells, bacteria and viruses, etc. ad infinitum.  Do you REALLY think we lack the ability to measure SDLDL?  Don't be so ready to believe something just because somebody says something about it.  Use your own brain, put together everything you know and can learn on your own and connect ALL the dots before drawing a conclusion.  

    Furthermore, what's the point of a statement like that?  Should we just give up measuring and trying to understand how SDLDL causes atheroma just because ONE guy says we can't measure them to his degree of satisfaction?  Should we just give up worrying about what we eat, and what we are being sold as foods that are arbitrarily declared to be safe to eat by some anonymous bureaucrat at the FDA?  Should we just ignore the ever increasing incidence rates of cancer, heart disease and atherosclerosis that by all applications of observation and simple logic are known to be entirely due to the modern industrial foods diet in every society and the peoples that subsist on them?  

    I don't think so.  Homey don't play that anymore, at least this one doesn't.

  • cancerclasses

    9/15/2011 6:55:16 PM |

    @Bill,  Google and see this study: 'Detection of low density lipoprotein particle fusion by proton nuclear magnetic resonance spectroscopy'.    
    "Abstract: Recent evidence suggests that fusion of low density lipoprotein (LDL) particles is a key process in the initial accumulation of lipid in the arterial intima. In order to gain a better understanding of this early event in the development of atherosclerosis, it would thus be necessary to characterize the process of LDL fusion in detail. Such studies, however, pose severe methodological difficulties, such as differentiation of particle fusion from aggregation. In this paper we describe the use of novel methodology, based on 1H NMR spectroscopy, to study lipoprotein particle fusion."

  • Don

    9/15/2011 7:24:04 PM |

    Bill,
    You have no worry since your triglycerides are quite low and therefore your LDL particles are of healthy size.  Your correctly calculated LDL is only 161 using the Iranian formula (used if triglycerides low).  See LDL calculator here:
    http://homepages.slingshot.co.nz/~geoff36/LDL_mg.htm

    And never use statins, just cut carbs.
    Don

  • cancerclasses

    9/15/2011 7:34:54 PM |

    "About 80% of cholesterol is composed of fats and oils (Current Atherosclerosis Reports 2004). The
    majority of an arterial clog, 55%, comes from defective cooking oils, containing mainly damaged omega 6. Most of us unknowingly purchase these oils in the cooking oil section of the supermarket. These are the oils we fry with and the oils added to most packaged foods; both fresh and frozen.

    Here’s another shocker. It’s not the saturated fat —it’s the adulterated omega-6 from food processing that clogs arteries! Contrary to what we have heard for decades, it is not the saturated fat you eat that clogs your arteries! How do we know this? A 1994 Lancet article reported investigating the components of arterial plaques. In an aortic artery clog, they found that there are over ten different compounds in arterial plaque, but NO saturated fat. This means the bacon, eggs, cheese, steak, whipped cream, etc. isn’t the reason for a clogged artery. These natural saturated fats are actually good for you. You need them for body structure.

    With the consumption and transport of defective processed oils, LDL cholesterol acts like a “poison delivery system,” bringing deadly transfats and other ruined oils  into the cells. It is primarily the oxidized (adulterated) omega-6 that clogs the arteries, NOT saturated fat!"  

    For more just google 'Brian Peskin saturated fat' and read the day away to your heart's content.

  • Jack Kronk

    9/15/2011 8:37:50 PM |

    "just because somebody says something about it. Use your own brain, put together everything you know and can learn on your own and connect ALL the dots before drawing a conclusion. "

    lol. you must not know who CMast is.

  • cancerclasses

    9/15/2011 10:27:09 PM |

    Yeah, I do, and that's why I said that.

  • Dr. William Davis

    9/16/2011 2:40:13 AM |

    Hi, Gib--

    The strategies that reduce small LDL are the same whether it's genetically-driven or acquired. However, when (presumptively) genetically-driven, it's just harder and requires a more meticulous effort.

    We are now seeing more and more people achieve zero or near-zero small LDL with strict carb reduction. The big exception is apo E4 people, who can still struggle because of the peculiar physiologic effects of this pattern.

  • Dr. William Davis

    9/16/2011 2:42:32 AM |

    Big issue. Note that the real culprit in causing plaque may be glycated oxidized LDL.

  • Dr. William Davis

    9/16/2011 2:43:51 AM |

    Hi, Peter--

    No, I think that is wrong. It might be correct if small LDL is regarded in a dichotomous way, i.e., pattern A vs. pattern B. But, when viewed quantitatively, I believe the real culprit is quantity of small LDL.

  • Dr. William Davis

    9/16/2011 2:46:58 AM |

    No question: The various lipoprotein testing companies need to talk and standardize their definitions. But this does not invalidate the concepts.

    Chris Masterjohn is a very bright guy. But on this I disagree. I believe it is wrong to assume that triglycerides and HDL behave in perfect tandem with small LDL. While they do indeed correlate, they do not correlate perfectly and demonstrate independent behavior depending on postprandial phenomena and genetic factors like apo E and apo C.

  • Joyce

    9/16/2011 5:17:54 PM |

    This has nothing to do with LDL, but I don't know where else to ask this, so I'll dive right in.

    I am reading and enjoying your book Wheat Belly, but don't understand why you lump chia seed in with other non-gluten grains to avoid or minimize. .  In my mind it is closer to flax.  Chia is truly an oil-seed and not a grain according to Dr. Coates, the "father" of chia seed research.  I have used it generously, and feel it aids in weight loss.  Chia seed is high in protein and fiber and low in carbs.  Why are you telling us to avoid or limit it?  I feel it is healthier than flax even.

    Please, can you clarify your stance on chia?  I was very disappointed to read that in your book.  Other than that, I really enjoyed Wheat Belly, having avoided gluten for a few years now.

  • Joyce

    9/16/2011 5:33:17 PM |

    P.S.  According to calorieking.com website, 1 oz. raw chia contains 0 carbs and 1 oz. dried chia contains only 1 gram of useable carb.

  • Adriana

    9/17/2011 10:16:37 AM |

    Not everybody who has good HDL, good TG and eats a low carb paleo diet will have low small particle LDL numbers which is why an NMR LipoProfile is important.  People with gut issues, yeast issues,  H. Pylori or an otherwise compromised liver can have unhealthy LDL despite doing everything right on the diet front.  Getting to the root of these issues is critical to resolving it.

  • Dr. William Davis

    9/17/2011 1:23:49 PM |

    Thanks, Joyce. But I don't remember lumping chia with the bad stuff.

    In fact, as you point out, chia belongs with flaxseed as one of the few truly healthy, low-carb foods.

  • Joyce

    9/17/2011 1:45:31 PM |

    Dr. Davies, on p. 212 of your book, chia is lumped in with other non gluten grains.  Maybe in future editions, the publisher can remove that?

    Although I have been gluten free for years, my husband is finally going gluten free..ALL BECAUSE OF YOUR BOOK!  He has some health issues, so for that I humbly thank you.

    Also, his next Toastmasters speech will be on "Wheat Belly"...how about that!

    Thank you so much for a wonderful book.  Your recipes are awesome.  I look forward to a Wheat Belly cookbook!!!!

  • Linda

    9/17/2011 2:57:40 PM |

    There are so many well read and brilliant posters here that I am going to jump in and ask a question totally off topic. This is not Dr. Davis' area of expertise, so I hope others may help.
    I do believe I am dealing with a bone/heel spur. Too much treadmilling, trying to increase speed, etc. I have done research on the condition and I read that turmeric, taken 2-3 times a day, is helpful. I just recently began taking D3 as well, 5000 IU a day. Will the Vit D3 help as well?
    Any thoughts? No, I am choosing not to visit a doctor for a cortisone shot. I am using NSAIDS for the pain and that works very well.

  • nina

    9/17/2011 4:48:56 PM |

    I've just spotted this post.  Never tried chia and wonder what you thought.  Have your patients reported similar effects?

    Nina

  • steve

    9/17/2011 7:26:34 PM |

    We are now seeing more and more people achieve zero or near-zero small LDL with strict carb reduction. The big exception is apo E4 people, who can still struggle because of the peculiar physiologic effects of this pattern

    Could you go in to more depth as to what strict carb reduction menas?  Is it no more than 50grams of starchy carbs such as rice or potatoes, or 100Grams?  I am guessing it is individualized, but some range of restricitons with those who have been successful would be helpful.  
    I have always had a low level of Trigs- never higher tnah 75 even on a hi carb diet, and was surprised to find the NMR showing all small particles!  So Dr. Davis is right to say low Trgs not always indicative of having large LDL.  Switched to elimination of most carbs and totally changed the profile.  Only issue that is while i produced lots of particles with carb diet, i also produce lots of LDL particles with carb restriction.  Genetics i guess!  I am an ApoE 3/3, which was a surprise.  
    Thanks for the good work Dr. D.  Have gotten several to buy Wheat Belly.  It will have an impact!

  • Joyce

    9/17/2011 7:30:40 PM |

    Nina, I am not Dr. Davis (wish I had his knowlege!), and I hope he doesn't mind me jumping in here, but I leaned about chia a few years ago when I read a book by Dr. Wayne Coates on the subject.  Chia has definitely helped me lose weight.  It is very filling.  When mixed with fluids, the chia seeds expand, and they really help to fill you up.  I've found all sorts of wonderful chia recipes on the web - from Chia "Tapioca" to beverages, etc.  I mix  it into many foods.  I think it enhances their taste.  I feel the chia seeds help with weight loss because of their appetite suppressant potential.  I hope this helped, and my apology to the good doctor for hogging the thread.

  • PeteKl

    9/17/2011 10:24:07 PM |

    Your post doesn't provide a lot of info, but if I were to guess I would say your problem is more likely related to walking/running incorrectly than nutritional (assuming you are in reasonable physical condition).  The human foot wasn't designed to be encased in the heavily cushioned shoes we typically wear today.   As a result many of us don't know how to walk or run correctly.

    Some of the better shoe stores will video tape you on a treadmill.  Just seeing the tape may be enough for you to realize what you are doing wrong.  If that doesn't help, there are professionals who should be able to figure out what might be happening.  

    Also consider reading "Born to Run" if you haven't already (it's a good read even for non-runners).  It probably won't give you a direct solution, but it may give you some ideas on where to look.  Good luck.

  • Louise

    9/18/2011 2:10:34 AM |

    Dr. Davis,
       I am 56 and have a strong history of heart disease in my family. I have been eating low carb for a couple of years... ( around 60 gms carb per day average..no pasta, no potato, almost no grain)  My most recent lipid panel showed LDL of 140. HDL 81, Triglycerides 43, CRP 0.2. .  I requested a test to show size of LDL. My doctor declined to order this, saying all LDL is bad.  Instead I was sent for a heart scan  ( paid out of pocket) and my calcium score was 0.  
      So now I'm trying to lower my LDL by lowering saturated fat.  Hard to do when you eat low carb. I wonder if I might be one of those Apo E 4 types that you mention, so thought I should try,.
      Here are my questions:
         Can I test my LDL size myself, through a home test? Or should I try to find out if I have Apo E 4?
          Do I really need to lower LDL if my calcium score is 0?
    Louise

  • Bob Goldstein

    9/18/2011 4:02:36 AM |

    For the last year I have eaten zero fruit, zero grains, zero sugar. Have mostly eaten beef, occasionally eggs cooked in butter. Have done two VAP tests the last year. When I started a year ago, trigs were 115, now 142. HDL was 50, now 46. My LDL did show a change of going from pattern A/B to pattern A.
    Any ideas why a diet for a year devoid of fruit, sugar, grains, would show an increase in trigs, and a slight decrease in HDL. If I have Apo E4 would my ldl go from A/B to A.
    I have lost 25 lbs. in the past year. Could this be a reason my numbers seem to be off?
    Thanks,
    Bob

  • Dr. William Davis

    9/18/2011 3:44:29 PM |

    Hi, Bob--

    Yes, blood drawn in the midst of weight loss can be very misleading.

    Transient effects include increased triglycerides, reduced HDL, even much higher blood sugar. Thankfully, it all gets much better once weight plateaus for a couple of months.

  • Dr. William Davis

    9/18/2011 3:47:39 PM |

    Hi, Louise--

    Sad that you have to educate your doctor.

    I find it unacceptable that a nice person engaged in health is refused a simple, helpful test. Tell your doctor goodbye and find one willing to act as your partner and advocate in health, not an obstruction.

    Yes, you can test it yourself through services like PrivateMDLabs.com. My view is to 1) identify how much, if any small LDL there is, then 2) reduce small LDL with diet. If you have only large LDL, you will absolutely need an LDL particle number by NMR or an apoprotein B to know what the REAL value is.

  • Dr. William Davis

    9/18/2011 3:49:52 PM |

    Thanks, Steve.

    There are a number of posts on this blog that detail how to gauge individual carbohydrate sensitivity. The best way is to check 1-hour after-eating blood sugars. Second best: count carb with the cutoff being determined individually. Just go back over the past 6 months and you will find several discussions.

  • Dr. William Davis

    9/18/2011 3:51:17 PM |

    Hi, Joyce--

    Thank you!

    If chia is listed as among undesirable non-gluten grains, that was my error. Remember what Mark Twain said: "Don't read about health, else you might die of a typo."

  • nina

    9/18/2011 5:13:58 PM |

    Thanks for your response Joyce.  

    The part that fascinated me was the idea that chia triggers a drop in blood sugars without a pre-spike.  I can't find anything on the net about that and wondered if other people had similar experiences.

    Nina

  • Bob Goldstein

    9/18/2011 7:08:22 PM |

    Thanks for the reply Dr. Davis. I have a blood test scheduled six months from now, and hopefully I will see better numbers. My LDL shows pattern A so at least I did see one positive change.
    Love your blog. Have learned a lot and it was the reason I gave up grains and sugar. 1 full year, no cheats.

  • Annlee

    9/18/2011 10:41:56 PM |

    Consider also going barefoot as much as possible - around the house, etc. You don't necessarily have to run barefoot (unless you work into it *gradually* and choose to continue it). I've recovered from heel spurs with stretching my achilles, with emphasis on stretching the soleus, and letting my feet bear my weight without any props underneath. For stretches, Anderson & Anderson have a very good book - Stretching - available on amazon.com. You didn't develop the spurs overnight, and they won't clear that quickly, either. Be patient and work with your body.

    You may also wish to consider vitamin K2, very good for ensuring calcium deposition occurs in the correct locations.

  • Kira

    9/19/2011 6:52:43 AM |

    Hi Doctor Davis, I talked to your about a year ago and you were kind enough then to comment on my blood results saying there was nothing to worry about - according to the Iranian formula.  I would greatly appreciate if you looked at my new results, they scared my whole family, I certainly am not going to show to the family physician, and I don't even want to think about changing from paleo style of eating to some kind of low fat cholesterol lowering diet, and taking any drugs/supplements. But may be I have to? I am 36 y.o., 5'4 and weigh 104lb.
    Glucose 85
    VAP TEST:
    Lipids
    LDL Cholesterol 149!
    HDL 130
    VLDL 14
    CHOLESTEROL, Total 293!
    Triglycerides 48
    Non HDL Col (LDL+VLDL) 163!
    apoB100-calc 96
    IDL Cholest 4
    Remnant Lipo. (IDL+VLDL3) 12
    Sub-Class Information:
    HDL-2  35
    HDL-3  95
    VLDL-3  8
    LDL1 Pattern A 3.1
    LDL2 Pattern A 26.0
    LDL3 Pattern B  71.0
    LDL 4 Pattern B  31.4

    The ordinary, non-VAP Lipid panel shows:
    Cholest TOTAL 279 !
    Triglycerides 48
    HDL Cholest 144
    VLDL Cholest Cal 10
    LDL Cholest Calc 125 !

    Also, I can't understand how my vit. D can be so low - 29.0, when I have been sun tanning all summer here in Orange County, California, at peak hours. Is there anything that you know of that may inhibit the vit. D conversion from the sun?
    Again, I greatly appreciate any insight that you can give me on this situation...

  • Louise

    9/19/2011 4:52:38 PM |

    Dr Davis,
      Thank you for your reply.  For now, I found a lab I can go to and get myself tested. Two hours away.. (Oddly, I must leave NY state to get this done due to billing law.). I'm going to do this! Do you agree that my best choice is the NMR?

  • otterotter

    9/19/2011 5:43:51 PM |

    Hi Gib,

    Option 1 will be cutting the saturated fat and cholesterol from the diet in addition to cutting the carbs. I tried eliminating eggs and cheese and my total cholesterol down from 400 to 260. By adding back "one egg a day", it went back to 320 (that's the impact of the dietary cholesterol on me, confirmed twice). I am currrently trying to replacing all saturated fat with mono unsaturated fat (olive+canola), just want to see how big the impact is. I am also going to test coconut oil separately, it is a cholesterol-free plant based medium-chain saturated fat, there is a chance I might respond to it differently.

    Option 2 will be taking Statin drugs. I know it has side effects, but that's better than small dense LDL. Based on Dr Davis's previous response, for apoE, sometimes we have to go to Statin for the rescue. (My doc was pushing statin really hard on me, and I have been resisting that for the last year)

    otter

  • Joyce

    9/19/2011 5:50:45 PM |

    Dr. Davis, you are so funny.  We'll take your book....typos and all!  Now...how about a cookbook to compliment Wheat Belly/  PLEASE????

  • nina

    9/19/2011 7:41:34 PM |

    Sorry I missed the link:

    http://suzanneloomscreativity.blogspot.com/2011/09/lowering-blood-sugar.html

    Nina

  • PeteKl

    9/19/2011 9:24:31 PM |

    Hi Kira,

    Just out of curiosity, could you summarize your "paleo style of eating".  I have a good friend of mine who has similar numbers (low trigs, high HDL, high LDL).  I would describe her diet as "low-carb (no sugar, no grains), low-veggie (under 15%), high meat, high sat-fat (particularly cheese, eggs and coconut)".  Is your diet somewhat similar?  I would be interested to know how the two of you compare.

  • Dr. William Davis

    9/20/2011 12:36:46 PM |

    NMR is my preferred method, since it yields the LDL particle number, what I believe should be the gold standard.

  • Dr. William Davis

    9/20/2011 12:38:12 PM |

    Thanks for asking, Joyce! I've had very preliminary conversations with my editor, but nothing firm yet.

    In the meantime, in addition to the discussion on this blog, see the Wheat Belly Blog, where I will publish recipes one by one.

  • Dr. William Davis

    9/20/2011 12:41:39 PM |

    Hi, Kira--

    You have a surprising dominance of small LDL particles, despite your slender build and lifestyle (LDL 3+4 divided by "real" LDL). This is likely genetically-determined. The means of correcting this is beyond the scope of this blog, unfortunately. You might consider joining the discussion in the Track Your Plaque website.

    The vitamin D issue is common, an impaired or lost ability to activate vit D in the skin. It means doing it orally.

  • Adam

    9/20/2011 6:40:19 PM |

    Dr. Davis. I'm a type 1 diabetic who is on a low carb diet (mostly primal-esque) with only meat and veg. No fruit, no grains, no legumes. I lost 14 kgs in the first three months, then stabalized at around 89 kgs. Granted my fat is going down a wee bit as muscle mass increases (doing the slow burn exercises, plus HIIT training and martial arts). That is the background.

    The reason I'm posting here is confusion about cholesterol. I just got my latest results back from the lab, and they are the same. While my HbA1C is 5.3 (not bad), my cholesterol numbers don't look hot. Tryglicerides are fine (as I've stopped losing weight quickly), but HDL is low at 39, and LDL (doctor forgot to put in particle size check, but it cna't be that good as I'm a diabetic) was 150 on the spot. This was measured, not calculated.

    I take ~7k miligrams (or whatever the measurement is) of fish oil a day. Well, 7k of EHA/DHA, more in total quanity including inert substances. With my exercise, low carb diet, and fish oil supplements, how is it that my HDL are still so low? Any advice?

    Thanks!

  • Dr. William Davis

    9/20/2011 11:08:46 PM |

    Hi, Adam--

    How timely! See the next post after the one you responded to in which I discuss the transient effects of weight loss, including drops in HDL that rebound over time.

    Also, have you address vitamin D normalization? I aim for 60-70 ng/ml, which usually requires around 6000 units per day (gelcaps or drops only); the HDL-raising effect develops over a year or longer.

  • Adam

    9/21/2011 1:01:18 PM |

    Dr Davis,

    A pleasure to make your (virtual) acquaintance! My vitamin D, according to my last test (results came in yesterday, as I mentioned) levels are 59. A wee bit low, but not too bad, I think.

    I've been consistently 88/89kg for three months (I've been low carb/primal for 6 months total), so haven't lost any weight in the past three months, but still my HDL levels are very low. Do you have any suggestions?

    Cheers,

    Adam

  • Adam

    9/21/2011 1:03:52 PM |

    P.S. I'm pretty sure I've stabalized, as my triglycerides were at 29 or 39 (can't remember off hand, but pretty low). But still I had the low HDL and high LDL?

  • Dr. William Davis

    9/21/2011 9:37:43 PM |

    Hi, Adam--

    Of course, you are wheat-free, low-carb in addition to your vitamin D? Omega-3 fatty acids?

    Note that doing the diet and taking the vitamin D yield rises over 1-2 years. Patience is required.

    Consider a little red wine and dark chocolate, as well.

  • Adam

    9/22/2011 5:10:38 AM |

    Thanks for the response! Yes, I am completely wheat free (and was before I read your book, which was excellent). I am very low carb due to the diabetes. My HDL did go from 29 to 39 this last test (after 6 months), so I suppose, as long as maintaining this diet will continue to increase my HDL, I am ok. My concern isn't immediate gratification but more continuous improvement.

    I'll come bug you again in 3 months if my HDL doesn't continue to increase Smile

    Many thanks!
    ---Adam

    P.S. I've never been accused of not drinking enough red wine Smile While I've been beer free for 6 or 7 months now, I do go through ~2 bottles of red a week.

  • Adam

    9/23/2011 1:35:08 PM |

    Hah! Me too, because if my HDL doesn't start going up I'm gonna freak as I don't know what else to about my numbers. Diet is about as stripped down as it can be, and I'm exercising as much as is reasonable.

    --Adam

  • Kira

    9/24/2011 6:23:22 AM |

    HI Peter. I would say  that my diet could pretty similar, with the exception that I am still eating some low-glycmic fruit everyday (some cantaloup, grapefruits, berries) and eat lots of veggies.

  • Kira

    9/24/2011 6:29:11 AM |

    Dr. Davis, thnx for your reply. I understand this is a blog and it is hard to go into details here, but would you say that it is worth for me to try change this situation by changing the die to using less saturated fat? and would NMR test clarify anything?

    PS How do I further discuss this issue "by joining the discussion in the Track Your Plaque website"?

    Thnx AGAINSmile

  • ShottleBop

    9/25/2011 3:47:09 PM |

    My numbers are like Bill's.  I was diagnosed as pre-diabetic in February, 2008 (today, I'd have been diagnosed as Type 2; my A1c was 6.5, and my FBGs were 127 and 123).  Started low-carbing shortly after that:  cut out grains, starchy veggies, almost all fruit, all milk (still use heavy cream and eat cheese).   My most recent blood lipids (accounting for some variation, but roughly consistent in pattern over the past three years):

    TC:  381
    LDL (direct):  279 (291 calculated)
    HDL:  80 (was 40 at diagnosis)
    Trigs:  52

    (At diagnosis, my numbers were:
    TC: 281
    LDL (direct) 215
    HDL: 40
    Trig: 142)

    I lost 65 pounds in the first 9 months after diagnosis, and, since then, have regained approximately 25 pounds (mostly muscle).  Weight has been stable for months.  My doctor is talking statins, again--which I plan to continue resisting.  I have ordered an NMR test, and will see what it has to say about my particle size.

  • Dr. William Davis

    9/26/2011 12:39:56 PM |

    Hi, Shottle--

    Good plan. I wouldn't be surprised if NMR sheds an entirely different light on your values.

  • ShottleBop

    9/29/2011 4:23:57 PM |

    They drew the blood this morning.

  • Bob

    9/30/2011 11:14:10 PM |

    Dr. Davis, I had my NMR test and the doctor who looked at it suggests that I have familial hypercholesterolemia. My LDL-P 3158
    LDL-C 280 HDL-C 58, TGL 105, HDL-P 28.0 small LDL-P 1122,
    LDL 21.7, LP-IR-33. I have been on no carb, no sugar, no wheat, or fruit for the last 14 months. Have been eating fatty meat twice a day and also eggs. Before I started eating beef, I was eating low carb, very little sat. fat. I was eating a lot of skinless chicken breast, and canned salmon, veggies, nuts, fruit but almost no beef. My LDL according to the basic lipid test was a little high but not crazy high. My HDL was in mid 30's. and trigs were high. I changed to a high saturated fat diet to raise HDL and lower trigs. I have been taking 1 gram of fish oil 2X daily. Is it possible that the fish oil is having an effect on my LDL? Not sure what to do about my diet. Obviously I won't go back to sugar and wheat but what about all the meat I have been eating. Would it be better to go back to skinless chicken and egg beaters even if it means my HDL going down? Just not sure what to do. Doctor believes I am at high risk since my father died at age 62 of sudden death.
    Thanks,
    Bob

  • Dr. William Davis

    10/1/2011 1:48:14 PM |

    Hi, Bob--

    This is a tough situation that, unfortunately, cannot be remedied diet alone. I hate saying that.

    Like people with apo E4, familial heterozygous hypercholesterolemia people are fat sensitive. First order of nutritional business remains carb-restriction to minimize small LDL particles, but you can still show large increases in large LDL with fat intake. If apo E4 is present, too, then even something as great as fish oil can increase LDL measures. However, the dose of fish oil you are using is very small and not a likely factor.

  • Bob

    10/1/2011 2:57:34 PM |

    Thanks for the reply Dr. Davis. I know I won't go back to carbs and sugar, but what about beef. I have eaten almost nothing but beef the last 14 months. Would I be better off going back to skinless chicken breast? Egg Beaters, instead of eggs? Olive oil instead of butter? I know in the past when I limited saturated fat my HDL dropped to mid 30's.
    Bob

  • Dr. William Davis

    10/2/2011 2:46:17 PM |

    Hi, Bob--

    I think we could make a strong argument in favor of variety in diet and that includes meat sources. Yes, I think a broader range of meats (if you eat them; I don't want to sound like a bloodthirsty carnivore; I don't even like meat, personally) is better--fish, shellfish, fowl, pork, as well as eggs.

  • ShottleBop

    10/3/2011 10:02:47 PM |

    Results came back today:
    TC:  373 mg/dL (ref <200)
    LDL-C:  282 mg/dL (ref = 40)
    Trigs:  47 mg/dL (ref < 150)
    Large VLDL:  <0.7 (ref <=2.7)
    LDL-P:  1793 nmol/L (ref = 30.5)
    Large HDL-P:  14.2 umol/L (ref >=4.8)
    Small LDL-P:  146 nmol/L (ref  20.5)
    HDL size:  10.0 nm (ref >=9.2)
    VLDL concentration was too low to determine a size
    According to the interpretive information:
    My HDL-P (total) of 39.1 places me in the lowest category of risk (it is beyone "high")
    My small LDL-P places me well below the 25th percentile (while slightly higher than the "low" level of 117), and is indicative of lower risk for CVD
    My LDL size places me well above the 75th percentile, and well into Pattern A territory (75th percentile level is 20.6), and is indicative of lower risk for CVD

  • ShottleBop

    10/3/2011 10:04:16 PM |

    Correction:  My LDL-C was 282, vs. a reference of " 40"

  • ShottleBop

    10/3/2011 10:06:37 PM |

    I give up.  I am typing things in correctly, and the comment system is dropping words (maybe it's interpreting my use of "greater than" and "less than" symbols as markup code?).  My HDL-C was 82.  The reference level is greater than 40.  My LDL-C was 282; the reference level is less than 100.

  • ShottleBop

    10/3/2011 10:09:37 PM |

    I see it dropped more information than I thought at first.  No matter, the conclusion stays the same: except for my LDL particle number and concentration, all of my lipid values indicate that I am at lower (or much lower) than average risk of CVD.  Now if only my body takes that to heart . . ..

  • ShottleBop

    10/3/2011 10:16:32 PM |

    LDL particle size was 22.1
    HDL-P was 39.1 umol/L

  • Dr. William Davis

    10/4/2011 2:41:25 AM |

    Hi, Shottle--

    Your values highlight this tremendous void we have in knowing just what to do about nearly "pure" large LDL particles.

    In other words, you have lots of LDL particles, but they are nearly all the more benign large variety. What level of large LDL particles are "allowable" before they contribute to atherosclerotic plaque formation? Not known. My preference would be, given the extreme abundance of large LDL, to reduce with statin drug. I hate to say this, but this is the occasional exception in which I believe that statins might indeed be beneficial. This is not to be confused with the general and absurd overuse of the drugs, but an application for a very specific genetic variant.

  • Louise

    12/5/2011 10:58:49 PM |

    At last I have had an NMR.  Thank you for the suggestion of PrivateMDlabs.com.  I can recommend this
    to others who find their doctor unwilling to order tests.
    I am pondering my results, trying to figure out if they are okay, or if I need to cut back on fat now, or go lower with carb reduction. What are your thoughts, Dr Davis?
       LDL Particle Number  1091  ( IS this too high??)
        Small LDL - P    129
          LDL size     21
        Large VLDL - P   < 0.7
           Large HDL - P        12.1
            HDL size           9.7
          LP - IR score    11
    Triglycerides are 32  ( lower since I"ve gone completely
    grain free since my last lipid panel)

  • Dr. William Davis

    12/6/2011 5:26:54 PM |

    These values are excellent, Louise! The only less than perfect value is the large HDL, but this tends to drift higher very slowly.

  • GoodStew

    5/11/2013 1:56:57 AM |

    Seems particle size doesn't matter as much as particle number. According to Dr. Peter Attia, a particle is a particle.  More than 1000 is a risk factor whether they're small, medium or large and fluffy.

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"Friday is my bad day"

"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 |

    Kent,
    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).
    Renfrew

  • 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?

    Thanks,
    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....)

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