"Friday is my bad day"

19. November 2011 William Davis (29)
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.
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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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Dr. Dwight Lundell on omega-3s and CLA

Dr. Dwight Lundell on omega-3s and CLA

7. September 2007 William Davis (15)


An interview with Dr. Dwight Lundell, cardiac surgeon and author of the new book, "The Cure for Heart Disease."


Dr. Lundell comes to us with a unique pedigree. He is a cardiothoracic surgeon practicing in the Phoenix, Arizona, area. Despite having performed thousands of coronary bypass operations, including numerous "off-pump" procedures earning him a place in the Beating Heart Hall of Fame and a listing in Phoenix Magazine’s Top Doctors for 10 years, more recently Dr. Lundell has turned his attentions away from traditional surgical treatment and towards prevention of heart disease and.

In particular, Dr. Lundell is a vocal advocate for omega-3 fatty acids from fish oil and conjugated linoleic acid, or CLA.

When I heard about Dr. Lundell’s unique perspectives, I asked him if he’d like to tell us a little more about his ideas. Here follows a brief interview with Dr. Lundell.



You’re a vocal advocate of the role of omega-3 fatty acids from fish oil in heart disease prevention. Can you tell us how you use it?

In my book, I recommend 3 g of fish oil daily. This would normally yield about 1000 mg of EPA and DHA depending on the concentration of the supplement. This is approximately the dose that reduced sudden cardiac death by 50%, and all cause death, by 25% in patients with previous heart attack.

In patients with signs of chronic inflammation such as heart disease, obesity, arthritis, metabolic syndrome or depression or in those patients with elevation of CRP, I would recommend higher doses, 2000 to 3000 mg per day of EPA and DHA. The FDA has approved up to 3400 mg for treating patients with severely elevated triglycerides.

I personally take a 2000 mg EPA and DHA per day because I have calcium in my coronary arteries.




Of course, in the Track Your Plaque program we track coronary calcium scores. Do you track any measures of atherosclerosis in your patients to chart progression or regression?

Carotid ultrasound with measurement of IMT [intimal-medial thickness] has been shown to be a good surrogate marker for coronary disease, as has vascular reactivity in the arm. CT scanning with calcium scoring is a direct marker of coronary disease. CT does not differentiate between stable or unstable plaque but there is no good noninvasive way of doing this.

The dramatic value of CT scan calcium scoring is to demonstrate to people that they actually do have coronary disease and to motivate them to make the necessary lifestyle and nutritional changes to reduce it. CT scan with calcium scoring is a direct way to measure the progression or regression of coronary artery disease. If there is a choice between a direct measurement and indirect measurement, always choose the direct method.

Every patient treated with CLA in my clinic, experienced significant reductions in C-reactive protein. These patients were also on a weight-loss program, so I can't prove whether it was the CLA or the weight-loss that improved their inflammatory markers. In the animal model for arteriosclerosis, CLA has a dramatic effect of reducing and preventing plaque. This has not yet been proven in humans.

Normally, when people lose weight 20% or more of the loss is lean body mass (muscle) this lowers the metabolic rate and frustrates further weight-loss. My patient, from teenagers to retirees, lost no lean body mass and continued to have satisfactory weight-loss when CLA was used as part of the plan.



In reading your book, your use of conjugated linoleic acid (CLA) as a principal ingredient struck me. Can you elaborate on why you choose to have your patients take CLA?

My enthusiasm for CLA is based on:

1) Safety?this is of paramount importance. Animal toxicity studies have been done, as well as multiple parameters measured in human studies, both of these are well reviewed recently in the American Journal of Clinical Nutrition (2004:79(suppl)1132s). CLA, a naturally-occurring substance, is not toxic or harmful to animals or humans. The only negative report is by Riserus in Circulation (2002), where he found an elevated c- reactive protein; however, he used a preparation that is not commercially available and not found in nature as a single isomer.

2) Effectiveness?also critically important. A recent meta-analysis [a reanalysis of compiled data] in the American Journal of Clinical Nutrition (2007; 85:1203-1211) demonstrated the effectiveness of CLA in causing loss of body fat in humans. The study also reconfirmed the safety of CLA.

Since we now know that atherosclerosis is an inflammatory disorder, any strategy that reduces low-grade inflammation without significant side effects would seem to be beneficial in the treatment and prevention of atherosclerosis. CLA not only has antioxidant properties, but it modulates inflammatory cascade at multiple points. CLA reduces PGE2 (in much the same way as omega-3) CLA also has been shown to reduce IL-2, tumor necrosis factor-alpha and Cox–2. It reduces platelet deposition and macrophage accumulation in plaques. It also has some beneficial effect in the PPAR [peroxisome proliferator-activated receptors, important for lipid and inflammatory-mediator metabolism] area.

Part of the effect of CLA may be because it reduces fat mass and thus the amount of pro-inflammatory cytokines produced by fat cells.

I reiterate and fully admit that CLA has not been shown to have any effect on atherosclerosis in human beings. However, the results in the standard animal models for atherosclerosis (rabbits, hamsters,APO-E knockout mice) are very dramatic.

From all I know, it appears that the effective dose for weight loss and the animal studies in atherosclerosis would be equal to about 3 g of CLA per day. The anti-inflammatory properties of CLA seem to work better in the presence of adequate blood levels of omega-3.



I’m curious how and why a busy cardiothoracic surgeon would transform his practice so dramatically. Was there a specific event that triggered your change?

The transition from a very busy surgical practice to writing and speaking about the prevention of coronary disease has not been particularly easy, but it has been very interesting. I can't really point to any specific epiphany, it was a general feeling of frustration that we were not making any progress in curing heart disease, which is what I thought I was doing when I began my medical career.

Of course, I enjoyed the technical advances, the dramatic life-saving things that you do and I did on a daily basis. American medicine is spectacularly good at managing crises and spectacularly horrible at preventing those crises.

The lipid hypothesis is old and tired, even the most aggressive statin therapy reduces risk of heart attack by about 30% in a relatively small subset of people. It's interesting that we're now looking at statins as an anti-inflammatory agent.


Thanks, Dr. Lundell. We look forward to future conversations as your experience with CLA and heart disease prevention and reversal develops!


More about Dr. Lundell's book, The Cure for Heart Disease can be found at http://www.thecureforheartdisease.net.


Note: We are planning a full Special Report on CLA for the Track Your Plaque website in future.
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Comments (15) -

  • Anonymous

    9/6/2007 8:46:00 PM |

    Do you know much about the diet he recommends to decrease inflammation and heart disease?
    Thanks!

  • Dr. Davis

    9/6/2007 9:56:00 PM |

    He uses a low processed carbohydrate diet. I'm afraid I did not get too far into that aspect of things with him.

  • Anonymous

    9/6/2007 11:22:00 PM |

    Thanks for the reply. I assume by "low-processed" you mean whole grains?
    Greg

  • Dr. Davis

    9/7/2007 1:45:00 AM |

    Although I read Dr. lundell's book, I remain unsure about how tightly he advises processed carbohydrate control. He is clear on minimizing sugars and sugar-equivalents like sodas and fruit drinks. However, on questions like some grains, I remain unclear.

  • Anonymous

    9/7/2007 10:20:00 PM |

    I was under the impression that CLAs only exist in animal products and that beef is particularly rich in CLAs.  I also understood that CLAs are a form of transfat, although perhaps a beneficial form, if there is such a thing.  Do you think that adding CLA is helpful for regression of plaque?  Does TYP recommend doing so?  If so, should the CLA be via a supplement and what dosage is typical?

  • Dr. Davis

    9/8/2007 1:07:00 AM |

    We are putting together a clinical trial to examine this issue. I don't have any preconceived notions over whether CLA will work or not. The animal data for reversal of atherosclerosis is fabulous, almost too good to believe.

    The human data on weight loss is, in aggregate, modestly promising. But will it reverse atherosclerosis in humans? We're going to try and find out.

  • Jill Doss

    6/5/2008 12:40:00 AM |

    It is my understanding that CLAs are a derivative of Parent Omega 6. I have read that the correct proportions are two parts omega 6 to one part omega 3.  This is referred to as Essential Fatty Acids (EFAs).  Lack of EFAs impede the use of oxygen and oxygenation is crucial to the miochondria of a cell.  I'm interested to see what your comments are on EFAs.

  • Anonymous

    1/8/2009 12:56:00 AM |

    Are you aware Dr. Lundell's medical license was revoked in 2008 by the Arizona Medical Board?  Go here to read about him: www.azmd.gov

  • David

    4/20/2009 1:08:00 PM |

    It's true.
    http://azmd.gov/GLSuiteWeb/Repository/0/0/1/4/97d47a09-71b9-4f30-8bfe-78428be876c4.pdf

  • Jim

    8/18/2009 4:38:47 PM |

    @anon & David,

    I didn't read the whole report of the deliberations, but from reading the first one, several observations can be made:
    -Dr Lundell had retired from thoracic surgery at the time of the hearings.
    -The hearings concerned complaints about certain high risk surgeries done by Dr Lundell, as they are done by all thoracic surgeons.
    -None of this has anything to do with a nutritional approach to halting and reducing CVD.

  • Anonymous

    1/9/2010 8:48:17 PM |

    Hi! How about fresh juiced carrots? It's hec of carbo thing but is it slow, fast, should I just eat vegetables and fruits and not juice them?

  • buy jeans

    11/4/2010 5:14:15 PM |

    In my book, I recommend 3 g of fish oil daily. This would normally yield about 1000 mg of EPA and DHA depending on the concentration of the supplement. This is approximately the dose that reduced sudden cardiac death by 50%, and all cause death, by 25% in patients with previous heart attack.

  • pammi

    11/9/2010 9:50:34 AM |

    Heart  disease is one of the most  dangerous disease which takes thousands of life every years all over the world. If we know its symptoms and Treatment for heart disease. We can prevent is to large extent.

  • MIKE

    8/11/2011 6:39:19 AM |

    I've been taking fish oil since 2005.Went to a cardioligist who wrote me out a script for lipitor after my cholesterol test was a little high.Being skeptical i then went hom and researched this horrible medication and realized i could take a much healthier,cheaper and much better alternative.Well that alternative was fish oil and i'm so glad i did my research first before blindly accepting my fate.

  • Brian

    11/24/2011 11:59:44 PM |

    Given the blood-thinning properties of fish oil, is it advisable to take it along with blood thinners such as Plavix or Coumadin?

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