So, basically one can't eat carbohydrates at all, nor dairy products, nor too much animal fat. So what are you supposed to eat?

Very interesting post Dr. Davis.

And that is one more reason to replace refined carbs and sugars in one's diet with saturated fat and dietary cholesterol, which significantly contribute to a shift from Pattern B to A in LDL particles.

By the way, the usual term that I normally see is "apolipoprotein", but they may be a bias in the literature I have been reading.

This is really interesting but I only understand about 1/2 of it.  Can you break it down a little for the lay person. I am following your tweets and find them really insightful...  I would love to share more with my followers but none have the background to figure this out and how it relates to our habits. Thanks for making me reach...

Great science on the risk of small LDL particles. Now I wish our health care system made the tests easier to get. An NMR costs twice as much at my doctor's office than if I get blood drawn on my own, and my expensive insurance plan won't pay for it either way.

This is interesting;

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The nonenzymatic glycation of LDL is a naturally occurring chemical modification of apolipoprotein (apo)-B lysine residues by glucose. Once glycated, LDL is only poorly recognized by lipoprotein receptors including the LDL receptor (LDL-R), the LDL-R–related protein (LRP), and scavenger receptors. Glycated LDL (gLDL) is a preferred target for oxidative modifications. Additionally, its presence initiates different processes that can be considered “proatherogenic.” Thus, LDL glycation might contribute to the increased atherosclerotic risk of patients with diabetes and familial hypercholesterolemia. Here we investigate whether lipoprotein lipase (LPL) can mediate the cellular uptake of gLDL. The addition of exogenous LPL to the culture medium of human skin fibroblasts, porcine aortic endothelial cells, and mouse peritoneal macrophages enhanced the binding, uptake, and degradation of gLDL markedly, and the relative effect of LPL on lipoprotein uptake increased with the degree of apoB glycation. The efficient uptake of gLDL by LDL-R–deficient fibroblasts and LRP-deficient Chinese hamster ovary cells in the presence of LPL suggested a mechanism that was independent of the LDL-R and LRP. In macrophages, the uptake of gLDL was also correlated with their ability to produce LPL endogenously. Mouse peritoneal macrophages from genetically modified mice, which lacked LPL, exhibited a 75% reduction of gLDL uptake compared with normal macrophages. The LPL-mediated effect required the association of the enzyme with cell surface glycosaminoglycans but was independent of its enzymatic activity. The uptake of gLDL in different cell types by an LPL-mediated process might have important implications for the cellular response after gLDL exposure as well as the removal of gLDL from the circulation.
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http://diabetes.diabetesjournals.org/content/50/7/1643.abstract

And this;

http://diabetes.diabetesjournals.org/content/49/4/597.abstract

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Atherosclerosis is the major complication of diabetes. Accumulating evidence indicates that lipoprotein lipase (LPL) produced by macrophages in the vascular wall may favor the development of atherosclerosis by promoting lipid accumulation within the lesion.

We previously demonstrated that high glucose stimulates in vitro murine and human macrophage LPL production.
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I'm still not sure about the whole high triglycerides and chylomicrons in the absence of high glucose, though. Carbohydrate seems to make cells fat. Liver cells, muscle cells, fat cells.

Macrophages and smooth muscle cells?

Is fructose especially bad in contributing to the glycation of Apo B?  I have read in several sources that fructose creates ten times as many advanced glycation end-products (AGEs) as glucose.  I wonder if it is also similarly implicated in the Apo B glycation process.

I think it would be much more clear and less "inflammatory" to differentiate between "refined carbohydrates" like flour products, and sugars, etc. vs "unrefined, complex" carbs like those in whole, intact grains (not wheat IF you are sensitive to it and as much as 70% of population or more are fine with it)(Don't forget, doctors mostly see the ones that are ill, not the ones that are healthy), legumes, sweet potatoes, etc.  To jump from avoiding flour products to replacing those calories w/ sat. fat is a big step and leaves much out!  What happens if you replace bagels w/ whole, cooked millet for example?

The only way to control it is to have  a diet that is low on cholesterol. This is the only solution that can be followed for the results to appear.

So, I'm paleo/ primal, with good amounts of coconut oil for my fat. I just had a full lab analysis with my Dr. yesterday and turns out that my Cholesterol is high at 268. Triglycerides were ate 60, HDL at 86 & LDL 170.

Thank God he was Paleo as well, so I did not have to hear a speech about modifying my diet. What he did say, however, was that in correlation to my other readings (High Platelets and White Blood Cell counts, low RBC, Hemoglobin and Hematocrit as well as low iron saturation) shows my body is fighting a parasite/ infection of some sort, causing obvious inflammation to fend off the 'critter'.

I was immediately worried, since all naysayers to my high amounts of fat-ingesting diet always think that I will have high cholesterol.

I will watch with avid curiosity as to this correlation to my infection (most likely my dental carries) and my cholesterol. Sometimes, full homeostasis or the lack-thereof, may show us a better picture in the whole, grand scheme of things.

Dr. Davis, do you know if an increase in glycosylated LDL due to hyperlipidemia could result in altered (possibly lower) blood glucose readings?

I'm looking for cholesterol test that differentiates the LDL number into glycated- and non-glycated LDL

A similar experience happened to me. In my case I had a stroke, a triple bypass on my left coronary artery, a stent the size of Rhode Island on my right coronary artery, all preceded by v-tach.

It was a near death experience and surprizingly enough, I never had a heart attack. I am in my mid-50's and very fit when this happened and it wasn't until my final meeting with my Heart Surgeon where he asked, "how did this happen?"

Not one Doctor previous to that asked me why I had heart disease. I had an answer yet nobody bothered to ask.

I refuse to take a statin. When medicine has an answer for LpA I will be all over it!

Awesome essay, Dr. Davis.

Question: How could this be improved upon via Medical Education? It appears to be a deeply-seated cultural problem, aside from the prevailing financial reasons for why we treat instead of prevent:

"In other words, the prevailing community standard is to stent, bypass, prescribe statin. It is not to understand why the disease occurred in the first place, correct the causes and minimize or eliminate any future danger or need for procedures."

In other words, is there a cultural / professional development approach to (partially) attacking this problem; or, is our maligned financial landscape the sole culprit that must be changed?

Thanks,

Brent

My fiance's dad is being treated in a similar matter. Unfortunately, he won't listen to her or info that I've found and modify his diet much. He also seems highly sensitive to Niacin so won't take it all anymore. Fish oil and Vit. D3 are no starters as well. It really saddens me how people could make simple inexpensive changes and improve their health and yet they don't due to lack of information or unwillingness to believe or make change.

This is exactly my story. I'm 49, heart attack and stent in rca in May, script for 80mg lipitor and plavix. Heart Association diet, etc. and see me again in 6 months. When I googled lipitor, I ended up here eventually. Thank God. A goldmine of information and advice and pointers to many other resources. Thanks Dr.Davis for providing this service to the public. It should be required reading for anyone in cadiology, and all their patients as well. One day when time permits I'll post my entire experience, maybe it will help someone else. Thanks again.

OMG! that's not good. why most people heart disease is the problem? I think this kind of disease will happen to those people who are working in offices and no limit in oily foods.

Absolutely!   There is a very simple and effective defense against this kind of new medieval "culture" you have described - science and reason.

I am surprised how little of that is being used or taught.

Stan (Heretic)

This totally rings true with many and/or most of my personal experiences with the medical profession. Many doctors seem to be only interested in treating the symptoms, not getting at the underlying root causes.  When I've pressed them on the issue of cause, I've gotten vague answers along the lines of "sometimes these things just happen, and you have to learn to live with it" (direct quote from an ophthalmologist recently).  It's hard to determine whether they don't care, or don't know, and won't admit it.  
I wish there were more sources available online such as Ratemds.com where you could get info on a doctor before you see them - it seems I can be better informed about the company coming to clean my carpets, than the doctor who may hold my life in their hands.

Hi, Brent--

I think that change needs to come from several directions, including changes in education and attitude.

However, I believe that the quickest way to change the system is for patients themselves to agitate with their doctors and express their dissatisfaction with their care. The system still supports 2nd and 3rd opinions and free-market access to doctors who try to do better.

I was on that merry-go-round. Age 54 and had my 1st stent. My cardiologist came into my room and told my husband "I fixed her." Funny, he did not say that when he did #2, #3 and #4 stent. He did once mention that my heart reblockage was probably due to inflammation, but no one was looking for the source. Not surprising I went on to have bypass.

I have noticed that doctors seem to be focused on diagnosis. They want to give a name to the disease and then there are evidenced based treatments to do and prescribe. What is missed is looking for underlying causes. CAD may be a diagnosis, but it does not reveal anything about what might have caused it. When my doctors looked at my heart, they saw a plumbing problem. When I started looking at my heart, I found low vitamin D, low B12, low folate, low B6, hypothyroidism, hypertension, insulin resistance, gluten sensitivity, belief that trans fats were safe, low fat/high carb AHA diet and probably low EFA's. Slowly I am figuring out how to truly improve my health.

Physician are rewarded for procedures. There is little money in counseling a patient about diet and lifestyle. Nutrient levels are rarely tested. Patients too often want the quick fix and are unwilling to make lifestyle changes.

Forgive me for this--but what is heartbreaking are the infants and children I transcribe consultation letters for.  And this is for a large Eastern children's hospital, pediatric cardiology department.  The doctors are true believers, are genuinely interested in helping their young patients, and deal with heart disease and anatomical problems, but still the families are referred to the dieticians and the low-fat diet.  Some conditions are prescribed Gatorade and salty snacks like pretzels...carbs, but perhaps some electrolytes in fluid and/or fluids and just plain salt might help (I am only a transcriptionist, obviously not a doctor) but I transcribe consultation after consultation where I wonder what lies ahead for these youngsters when the heart disease you address here piles onto their congenital problems because of the dieticians and cardiologists' take on how to treat.  They have saved many an infant or young child though but that is not the whole picture.

A friend who was moving Labor Day weekend in 2004 developed chest pain and tachycardia and so presented to the emergency room and there was narrowing in two vessels (do not remember which ones), was stented (the cardiologist even went so far as to call the Italian cardiologist who had stented before in an awkward junction of vessels to get advice before he proceeded).  So my friend ended up with two stents and lost the house she was moving into, so I offered to have her stay with me.  She then suffered a heart attack---right at the stent where the "awkward junction" was.  So what caused this heart attack?  In my lay opinion, the cardiologist's approach to treatment is partially to blame here, but legally his treatment was up to the community standard of care.  My friend and I parted when I moved to another state but as much as i talk to her about sugar--she is addicted to cake and sweets, takes more drugs then I know anyone takes, has ignored the Vitamin D Cure I sent her, the Carlson's fish oil I sent, and the Carlson's Vitamin D3 I sent.  She is on statins/2, pain killers galore (I wonder why she hurts), antihypertensives/2, but she is on Armour thyroid.  Still thinks that cardiologist knows what he is talking about.  I have tried.

I went for a cardiology workup as I have some blockage in one artery. I was prescribed Crestor, and told to eat some tuna once in awhile.  Not even close to what I know to do already, thanks to the Track Your Plaque web site information.

Dr. Davis,

PLEASE stop stereotyping dietitians as if we were all Stepford bots programmed to relay the same canned information.  Would you not take offense to me categorizing you as a typical doctor who knows nothing about preventative care, prescribes medications only offered to him by pharm reps, and adheres to everything the AMA decrees?

Perhaps instead of blasting us, you could encourage dietitians to build on their knowledge and training base by providing some resources?  Maybe offer seminars?  Research?  

Also, how do you expect us lowly dietitians to make radical changes when the cardiologists and other docs we work for have limited knowledge and certainly no support for dietary intervention and non-pharm therapy?

Hi, Tara-

You are absolutely correct.

A good friend of mine is a dietitian. She eats no wheat, cornstarch, or dairy. She's slender and has corrected a complex lipid abnormality with her diet.

So there are good dietitians and there are plenty of "Stepford bots." Sadly, most are the latter.

I absolutely agree that my colleagues are failing miserably in delivering intelligent preventive nutritional care. So don't yell at me; yell at my colleagues and your colleagues.

Hospitals employ dietitians. How many dietitians are willing to go out on a limb to buck current,dated, nutritional recommendations?
Wheat? C'Mon! They must go with the flow.

There is a similar "neglect" following treatment that may be quite widespread.  I was treated for depression and after the prescription medications were over, I was 25 lbs heavier.

I asked the prescribing psychiatrist what to do to get the weight off, and he said, "Go on some kind of diet, I suppose".

I then and now consider this response inappropriate and inadequate and unprofessional.

Same here in Sydney. MI in June, five stents then discharged with paltry dietary advice and the usual list of poisons. Only by searching the web was I able to find sites like this and advice that made sense. Needless to say its over the counter treatment all the way for me now.

Still unsettling having to steer a course on my own. None of the medicos I've spoken to have been willing to consider a programme for being healthy, they just want to treat me

Super informative wriitng; keep it up.

At last! Someone who unedrsatnds! Thanks for posting!

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