Sometimes small LDL is the only abnormality

19. July 2006 William Davis (0)
Janet is a 58-year old schoolteacher. At 5 ft 3 inches and 104 lbs, she had barely an ounce of fat on her size-2 body. For years, Janet's primary care physician complimented her on her cholesterol numbers: LDL cholesterol values ranging from 100 to 130 mg/dl; HDL cholesterol of 50-53 mg/dl.

Yet she had coronary disease. Her heart scan score: 195.

Lipoprotein analysis uncovered a single cause: small LDL. 95% of all of Janet's LDL particles were in the small category. What was surprising was that this pattern occurred despite her slender build. Weight is a powerful influence on the small LDL pattern and the majority of people with it are overweight to some degree. But not Janet.

How did she get small LDL if she was already at or below her ideal weight? Genetics. Among the genetic patterns that can account for this pattern is a defect of an enzyme called cholesteryl-ester transfer protein, or CETP. This is the exact step, by the way, that is blocked by torcetrapib, the new agent slated for release sometime in future (The manufacturer, Pfizer, is apparently going to sell this agent only packaged in the same tablet as Lipitor. This has triggered an enormous amount of criticism against the company and they are, as a result discussing marketing torcetrapib separately.)

Also note that Janet had a severe excess of small LDL despite an HDL in the "favorable" range. (See my earlier conversation on this issue, The Myth of Small LDL at http://drprevention.blogspot.com/2006/06/myth-of-small-ldl.html.)

With Janet, weight loss to reduce small LDL was not an option. So we advised her to take fish oil, 4000 mg per day; niacin, 1000 mg per day; vitamin D, 2000 units per day; use abundant oat bran and raw almonds, both of which suppress small LDL. This regimen has--surprisingly--only partially suppressed her small LDL pattern by a repeat lipoprotein analysis we just performed. We're hoping this may do it, i.e., stop progression or reduce her heart scan score.

The lesson: Small LDL is a very potent pattern that can be responsible for heart disease, even if it occurs in isolation. And, contrary to conventional thinking, small LDL can occur as an independent abnormality, even when HDL is at favorable levels.
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No need to re-invent the wheel

No need to re-invent the wheel

2. May 2007 William Davis (0)
I seem to be repeating myself lately, but I think this does bear repeating:

There's no need to re-invent the wheel when it comes to gaining control over your heart scan score.

The Track Your Plaque program is the most powerful approach known to help you gain control over your coronary atherosclerotic plaque and CT heart scan score, bar none. While 100% of people do not drop their score, more and more people every week are doing so. (One of the admitted weaknesses of the Track Your Plaque website is our failure to list more success stories; we're working on it.)

The basic program is quite simple:

--The Rule of 60 for lipids (LDL 60 mg/dl; HDL 60 mg/dl or greater; triglycerides 60 mg/dl or less)

--Identify hidden causes of plaque, esp. small LDL, Lp(a), and IDL, followed by specific corrective action

--Fish oil--minimum 1200 mg per day of EPA + DHA

--Normal vitamin D3 blood levels (We aim for 25-OH-vitamin D3 of 50-60 ng/ml)

--Normal blood sugar (<100 mg/dl)

--Normal blood pressure (<130/80)

--An optimistic attitude



Much of the other stuff--vitamin K, matrix metalloproteinase reducing strategies, flavonoid strategies, exercise-induced hypertension, etc.--are, for the majority, fluff. Their real role is in people who may have failed in stopping the rise of their heart scan score just doing the basics of the program.

If you neglect the basics, hoping to find some magic potion, I'm afraid the overwhelming likelihood is that you will fail. I've seen it happen time and again. Someone will come to my office with an extraordinary list of supplements--hawthorne, dozens of anti-oxidants, EDTA, concentrated flavonoid preparations, and on and on. Not only is it shockingly expensive to do this, it's also unnecessary and foolhardy. This kind of unfocused, hocus-pocus in the hopes of getting it right fail time after time.

The Track Your Plaque program, while not foolproof, is the best I know of. Stick to the basics and wander off when the basics fail. But there's extraordinary power in just achieving the basics.
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Some basic vitamin D issues

Some basic vitamin D issues

24. August 2008 William Davis (7)
The last post on vitamin D raised a number of basic questions among readers. So let me discuss some of these questions one by one. All of them raise important issues surrounding the practical aspects of managing vitamin D in your health.

Anne said:

I think it is important to stress that vitamin D supplementation needs to be continued long term.

I have met too many people who have been prescribed 50,000 IU of D2 for 8-12 weeks and then told to stop because their 23(OH)D went over 30ng/ml. I know one person who's doctor stopped and started the D2 3 times.

Thanks for pointing that out, Anne. Excellent point. I also see doctors do this with statin drugs: start it, check a LDL level which is lower, then think that you're done and stop the drug. What the heck are they thinking?

If vitamin D is not being produced by sun exposure and not obtainable through diet, continued supplementation is necessary, essentially for life.


Twinb asked:

How often you think Vit. D levels should be tested after the initial test is done, especially if the levels are drastically low?

We have used every 6 months in the office. Ideally, levels are in mid-summer and mid- to-late winter in order to gauge the extremes of your seasonal fluctuations. While most adults over 40 fail to fluctuate more than 10 ng/ml in the Wisconsin climate (and this summer, after an initial rainy season early, has been flawlessly bright and sunny, in the high-70s and 80s every single day for months), an occasional person fluctuates more widely. The only way to judge is to check a blood level.


Rich said:

Vitamin D dosage effects appear to be quite idiosyncratic.

Yes, indeed it is. Despite using crude rules-of-thumb, like taking 1000 units of vitamin D per 10 ng/ml desired (a rule I learned from Dr. John Cannell, which he offered fully aware of its inaccuracy), many people will surprise you and have levels that make no sense. Testing is crucial to know your vitamin D level.


Richard asked: Where do we get enough vitamin D wihout worring about laboratory tests?

Well, the entire point of the post was that you absolutely, positively cannot just take vitamin D blindly at any dose and hope that your level is ideal, no more than you can blindly take a dose of thyroid and know you have achieved normal thyroid levels. In my view, vitamin D blood levels are an absolute.


Another simple issue: Don't be afraid of vitamin D. It is, in all practicality, no more dangerous than getting a dark tan. (But, as many of you realize, getting a tan is no assurance of raising vitamin D if you are over 40 years old.)

Wouldn't it be great if someone developed a do-it-yourself-at-home skin test for vitamin D? I know of no effort to develop this, but it would be a huge advantage for all of us.
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Comments (7) -

  • Anne

    8/24/2008 2:06:00 PM |

    Ted wrote "I am a 64yr old male living in the UK. My skin is fairly tanned as I try to get as much full body sun exposure as is available here however I have also been taking 5000iu/daily for a couple of years now. When I was last tested my score was 147.5nmol/l 59ng/ml. I wonder if Anne's numbers are the result of a faulty test."

    I said to my endocrinologist that I thought the high test result I had, 384 nmol/L (153 ng/ml), was a lab error, but he was pretty sure it was correct. Maybe it's because I'm slim and can't store the D3 easily so I'll gain serum levels of it easily and lose it equally easily ? I contacted Dr Reinhold Vieth who has done a lot of research into D and he suggested I could have a hypersensitivity to D - if so, this will become apparent when I have my next test.

    Anne

  • Anonymous

    8/24/2008 7:32:00 PM |

    Great post

    If you have been taking 4000iu D3 daily for several months and then suddenly stop taking any, after a week would depression and lethargy be a side effect?

    Thanks

  • rabagley

    8/25/2008 4:14:00 AM |

    The most important thing to realize about Vitamin D is that your body has many ways to deal with excess quantities, and almost no way to deal with a deficiency.

    Once 25(OH)D gets above ~80ng/ml (which takes a LOT of vitamin D over a long period of time), your body begins to store Vitamin D in your fat cells.  The amount that can be safely stored in your fat is almost an order of magnitude larger than what is carried in your blood serum (equivalent of 500-600 ng/ml).  It takes a truly ridiculous amount of Vitamin D3 taken for a long time to saturate your fatty tissue.

    If you have sarcoidosis, which often causes problems with conversion of Vitamin D active forms in your body, supplemented Vitamin D will probably make your condition worse.  For everyone else, it is extraordinarily hard to overdose on oral Vitamin D supplementation.

    40,000 IU's/day for a month might cause problems for a normal person, but almost nobody will recommend more than 10,000 IU's/day (the same amount a young person's skin can make in 30 minutes of low-latitude, noonday sun).  Another number to be aware of is 4000 IU/day, which is the amount of Vitamin D that an average human body with normal levels of 25(OH)D will use up in a day.

    The RDA (at 400 IU's/day) is based on old science.  Completely ignore that number as worthless and dangerously out of date.  That amount will stop rickets and little else.  That's little help for bones, for cancer prevention, for steering calcium away from arterial walls, for all of the other things that Vitamin D will do in your body.

  • Anonymous

    8/25/2008 10:16:00 AM |

    I'm familiar with a couple chemists that tried to make a Vit.D home testing kit.  They looked up older TLC methods for making a Dkit that was similar to the home cholesterol kits.  They spent time on it, and  felt they had a result on one of the tests, but in the end decided it was going to take too much time to do right.  More time than they could offer, so the project was shelved.

  • moblogs

    8/25/2008 10:50:00 AM |

    Because I'm not ill I'm only really allowed vit D tests yearly (I would probably be seen as an NHS pest if I pursued it), but I'm taking 5000IU for the last year to see what this does to my unsupplemented level of 10nmol/L. I was prescribed 400IU and that only raised me by 11nmol/L to 21nmol/L, so in understanding the relative safeness of D, and how other family members respond to it (almost always needing higher), I don't feel like I'm playing Russian Roulette. I'm allowed a blood test late September though.

  • Anonymous

    8/26/2008 3:33:00 PM |

    This could be grist for another post (along the lines of how disastrously low the US RDA is for Vit. D):

    http://www.nytimes.com/2008/08/26/health/research/26rick.html?ref=health

  • Anonymous

    9/1/2008 6:01:00 PM |

    Dr Davis,

    Have you watched this video on vitamin D?

    http://www.youtube.com/watch?v=78CB21mKlXc

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