11. August 2006 William Davis (0)
The recognition of the metabolic syndrome as a distinct collection of factors that raise heart disease risk has been a great step forward in helping us understand many of the causes behind heart disease.

Curiously, there's not complete agreement on precisely how to define metabolic syndrome. The American Heart Association and the National Heart, Lung, and Blood Institute issued a concensus statement in 2005 that "defined" metabolic syndrome as anyone having any 3 of the 5 following signs:





Waist size 40 inches or greater in men; 35 inches or greater in women

Triglycerides 150 mg/dL or greater (or treatment for high triglycerides)

HDL-C <40 mg/dL in men; <50 mg/dL in women (or treatment for reduced HDL-C)

Blood Pressure >130 mmHg systolic; or >85 mmHg diastolic (or drug treatment for hypertension)

Glucose (fasting) >100 mg/dL (or drug treatment for elevated glucose)


Using this definition, it has become clear that meeting these criteria triple your risk of heart attack.

But can you have the risk of metabolic syndrome even without meeting the criteria? What if your waste size (male) is, 36 inches, not the 40 inches required to meet that criterion; and your triglycerides are 160, but you meet none of the other requirements?

In our experience, you certainly can carry the same risk. Why? The crude criteria developed for the primary practitioner tries to employ pedestrian, everyday measures.

We see people every day who do not meet the criteria of the metabolic syndrome yet have hidden factors that still confer the same risk. This includes small LDL; a lack of healthy large HDL despite a normal total HDL; postprandial IDL; exercise-induced high blood pressure; and inflammation. These are all associated with the metabolic syndrome, too, but they are not part of the standard definition.

I take issue in particular with the waist requirement. This one measure has, in fact, gotten lots of press lately. Some people have even claimed that waist size is the only requirement necessary to diagnose metabolic syndrome.

Our experience is that features of the metabolic syndrome can occur at any waist size, though it increases in likelihood and severity the larger the waist size. I have seen hundreds of instances in which waist size was 32-38 inches in a male, far less than 35 inches in a female, yet small LDL is wildly out of control, IDL is sky high, and C-reactive protein is markedly increased. These people obtain substantial risk from these patterns, though they don't meet the standard definition.

To me, having to meet the waist requirement for recogition of metabolic syndrome is like finally accepting that you have breast cancer when you feel the two-inch mass in your breast--it's too late.

Recognize that the standard definition when you seen it is a crude tool meant for broad consumption. You and I can do far better.
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Your heart scan is just a "false positive"

Your heart scan is just a "false positive"

15. August 2006 William Davis (0)
I've seen this happen many times. Despite the great media exposure and the growing acceptance of my colleagues, heart scans still trigger wrong advice. I had another example in the office today.

Henry got a CT heart scan in 2004. His score: 574. In his mid-50s, this placed him in the 90th percentile, with a heart attack risk of 4% per year. Henry was advised to see a cardiologist.

The cardiologist advised Henry, "Oh, that's just a 'false positive'. It's not true. You don't have any heart disease. Sometimes calcium just accumulates on the outside of the arteries and gives you these misleading tests. I wish they'd stop doing them." He then proceeded to advise Henry that he needed a nuclear stress test every two years ($4000 each time, by the way). No attempt was made to question why his heart scan score was high, since the entire process was outright dismissed as nonsense.

I'm still shocked when I hear this, despite having heard these inane responses for the past decade. Of course, Henry's heart scan was not a false positive, it was a completely true positive. I'm grateful that nothing bad happened to Henry through two years of negligence, though his heart scan score is likely around 970, given the expected, untreated rate of increase of 30%.

The cardiologist did a grave disservice to Henry: He misled him due to his ignorance and lack of understanding. I wish Henry had asked the cardiologist whether he had read any of the thousands of studies now available validating CT heart scans. I doubt he's bothered to read more than the title. The cardiologist is lucky (as is Henry) that nothing bad happened in those two years.

Do false positives occur as the cardiologist suggested? They do, but they're very rare. There's a rare phenomenon of "medial calcification" that occurs in smokers and others, but it is quite unusual. >99% of the time, coronary calcium means you have coronary plaque--even if the doctor is too poorly informed to recognize it.
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Winning Through Intimidation

Winning Through Intimidation

31. August 2006 William Davis (0)
Do you remember the book, Winning Through Intimidation by author Robert J. Ringer?



In his 1984 bestseller, author Ringer details how to succeed in business by overwhelming clients and competition by appearing hugely successful and powerful. Rather than a business card, he'd hand out an elegant book to represent himself. He'd show up in a limousine to a meeting, even when he could barely afford it. He used these tactics, even when he was a small-fry, in commercial real estate and built a successful business following such techniques.

This reminds me a lot of what happens in conventional medical practice: The large and successful hospitals, filled with trained staff and technology, exude legitimacy and success. How can they possibly be wrong? Such overwhelming know-how and multiple levels of expertise mustbe right!

Let's be grateful that we do have access to such high-tech, capable care. Unfortunately, just as Mr. Ringer used deceptive practices to appear something he wasn't, this is also true in hospitals. Not all physicians have your best interests in mind. Their principal concern is how profitable your care can be for them--can you be persuaded to have your stent, bypass, etc.. After all, look around you: Aren't all this equipment and personnel impressive? Aren't you intimidated?

The patient that most recently drove home this issue for me recently was a smart and capable executive who came in for consultation. He had been told by his internist that a surgery (to replace his aorta, a HUGE procedure) was probably necessary. In my view, it was not--his process was simply not that far progressed. The risks for danger over the next several years was virtually nil. Unfortunately, this man, now confused and worried, sought an opinion from the chief of thoracic surgery (in the usual white coat and with professorial demeanor, I'm sure) in a major metropolitan hospital (in Chicago), who promptly rushed him off to the operating room.

The pathology report, cleverly not mentioned in any other of the hospital documentation, showed what I had suspected: this man had mild disease that wasn't even close to requiring surgery. But, with all that technology, $100,000 or so of costs, chief of surgery who looked the part, etc.--they must be right!

Robert Ringer's concepts only ring too true for hospitals and some of the unscrupulous physicians in practice. Don't allow yourself to be intimidated.
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Texas today, tomorrow . . . the world?

Texas today, tomorrow . . . the world?

10. March 2009 William Davis (0)
Texas state representative, Rene Oliveira, has introduced legislation that mandates heart scans for adults in the state of Texas.

Rep. Oliveira

A press release from the SHAPE Society ( Society for Heart Attack Prevention and Eradication) reads:

Assessment of heart attack risk on the basis of traditional risk factors alone such as high cholesterol and high blood pressure and so forth, while useful, misses many who are at high risk and also incorrectly flags some for high risk who are in fact at very low risk of near term heart attack; on the other hand detection of atherosclerosis by non-invasive imaging, as suggested by the SHAPE group, accurately identifies plaque and improves the ability to identify at-risk individuals who could benefit from aggressive preventive intervention while sparing low-risk subjects from unnecessary aggressive medical therapy," said Dr. P.K. Shah, Director of Cardiology at Cedars Sinai Heart Institute in Los Angeles, a leading member of the SHAPE Task Force who is also an active member of the American Heart Association. "Sadly, these vulnerable patients go undetected until struck by a heart attack, because insurance companies don't cover the newer heart attack screening imaging tests."


Rep. Oliveira, whose coronary disease was first uncovered by a heart scan and prompted a bypass operation, states:

"It is about time that we cover preventive screening for the number one killer in Texas, and take action to reduce healthcare costs through preventive healthcare. Right now, we are extending the lives of those who can afford the procedure while hundreds of thousands of Texans with hidden heart disease go undetected because of antiquated thinking. The time has come for this change."


Is this what we've come to? Since practicing physicians are either so entranced by the drug and procedural solutions to heart disease, do we need to resort to heart scan by legislation?

It does indeed appear that we've come to this point. Should this trend catch on, it will surely mean an upfront increase in healthcare costs to cover the expense of heart scans. But in the long run, it will mean reduction in healthcare costs--dramatic reduction--if heart scans prompt effective preventive action.
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LDL pattern B

LDL pattern B

18. July 2010 William Davis (17)
Here's a Q&A I stumbled on in the Forum of MedHelp, where people obtain answers from presumed health "experts."

Question:

My VAP test results in July 07 identified an LDL Pattern B.
Overall results:
Total 150
HDL 75
LDL 61
Trig 60
HDL-2 17
LP(a) 6.0
LDL Pattern B

Medications:
Lipitor 10mg
Zetia 10mg
Altace 10mg
Atenolol 50mg
Plavix 75mg
Aspirin 81mg

I had several heart attacks which resulted in CABG performed May 2000. I am a 53 year old white male , 6'1", 190 pounds, exercise every day, watch my diet and feel great. Everything looks OK except my LDL Pattern B. Is there any therapy to improve the Patten B?

Answer from CCF, MD:
Your results indicate an LDL pattern B, which generally indicates small atherogenic LDL particles which may cause increased risk for CAD. However, there are several problems with LDL patterning: 1) its unreliability (of LDL pattern testing ), 2) unclear clinical evidence regarding regarding the usefulness of LDL patterns and particle size. The majority of evidence regarding the progression of atherosclerosis is with LDL lowering and to an smaller extent HDL raising.

All available clinical evidence shows that any particles in the VLDL, IDL, or LDL range are atherogenic, and there is no evidence that whether belonging to pattern A or B one is more atherogenic than others.

Subclass studies have proliferated over the last few years, but many of these studies were funded or subsidized either by suppliers of the assays as a method to expand their use and move them into mainstream practice, or by pharmaceutical companies in an attempt to claim some advantage over other therapeutic agents.
Thus, current data on LDL subclasses are at best incomplete and at worst misleading, suffering from publication bias, and now given the recent results of the Ensign et al. study, unreliable.

Your LDL, and HDL are at goal. The Lpa level is still not clearly linked as a modifiable risk factor for CAD, although elevated levels are now know to be linked to stroke.

Continue with your present treatments: aspirin, plavix, ateonol and altace are all essential medications.


Wow. The extent of ignorance that pervades the ranks of my colleagues is frightening.

Contrary to the response, LDL particle size assays are quite reliable and accurate. I've performed many thousands of lipoprotein assays and they yield reproducible and clinically believable results. For example, eliminate wheat, oats, cornstarch, and sugars and small LDL drops from 2400 nmol/L to 893 nmol/L (NMR)--huge drops. If repeated within a short period of time, the second measure will correspond quite closely.

The data are also quite clear: Small LDL particles (i.e., "pattern B") are a potent predictor of cardiovascular events. What we lack are the treatment trials that show that reduction of small LDL results in reduced cardiovascular events. The reason for this is that small LDL research is not well-funded, since there is no prescription drug to treat small LDL, only nutritional means. Niacin (as Niaspan) is as close as it comes for a "drug" to reduce small LDL. But diet is far more effective.

Given the questioner's fairly favorable BMI of 25.1 and his history of aggressive heart disease, it is virtually certain that he has what I call "genetic small LDL," i.e., small LDL that occur on a genetically-determined basis (likely due to variants of the cholesteryl-ester transfer protein, or CETP, or of hepatic lipase and others).

Ignoring this man's small LDL will, without a doubt, consign him to a future of more heart attacks, stents, and bypass. Maybe by that time the data supporting the treatment of small LDL will become available.
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Comments (17) -

  • Ned Kock

    7/18/2010 5:14:33 PM |

    Hi Dr. Davis.

    Indeed, strange advice there. It seems that in terms of effects on arterial stiffness, compared with postprandial glucose levels lipids are not even on the radar screen:

    http://healthcorrelator.blogspot.com/2010/05/postprandial-glucose-levels-hba1c-and.html

    That is, as you have been pointing out all along, if one "eats to the meter", lipids tend to fall into place. For most people all it takes is to remove refined carbs and sugars from the diet. For others it means to remove some whole foods as well, such as potatoes and bananas.

  • Anonymous

    7/18/2010 6:54:08 PM |

    Dr. Davis- If the person in your post here has genetic small LDL, what are his options? Isn't he kind of stuck? If he lowers his already fairly low LDL too much more, won't he be oversuppressed? Can niacin lower (or convert, or whatever) the small LDL in "genetic" smLDL type, or should such a person just try to get their smLDL particles as low as possible? (even though they might always stay small?)

  • Anonymous

    7/18/2010 8:08:01 PM |

    Dr. Davis,

    What do you look at more, small LDL particles or average LDL size?  Over the period of a year, my small LDL particles have gone down to < 90 nmol/L from around 120 last year, but my average LDL size has decreased (though still pattern A) to 21.1 nanometers (from about 22.3 last year).  

    Thanks.

  • Anonymous

    7/19/2010 4:20:01 AM |

    Since it doesn't account for muscle or fat (i.e. athletic or sedentary), I wouldn't think BMI is a very good indicator of anything...

    Perhaps if the original poster had said his BODY FAT % is 25.1% then that can be evaluated as "favorable" or not.

  • Jim Purdy

    7/19/2010 4:26:43 AM |

    QUOTE:
    "eliminate wheat, oats, cornstarch, and sugars"

    Doctor Davis, based on your many previous posts,  I assume that this is good advice for everybody, not just the individual who asked the question?

  • Christian Wernstedt

    7/19/2010 7:05:11 PM |

    The person's trigs/HDL ratio is 0.8 which ought to indicate large pattern LDL.

    Is the discrepancy with the VAP test because of this person's genetics, or might some other factor be at play?

    Can we generally rely on the trigs/HDL ratio in people who are generally healthy with no signs of the metabolic syndrome?

  • Anonymous

    7/19/2010 11:21:35 PM |

    Christian Wernstedt, I thought that was odd too.  But then again, he is on a boatload of drugs that are designed to manipulate lipid numbers.  You can see that the drugs did indeed give him very low LDL, but seem to have done so by shrinking the particle size, thus the VAP pattern B.  

    So in the case of "great" lipid values here, it would seem they are not so great when achieved artificially by means of drugs.  He may have been better off with "high" cholesterol if it used to be large, fluffy LDL, especially if he had the high HDL and low triglycerides back then too.

  • Onschedule

    7/20/2010 12:35:40 AM |

    Christian Wernstedt,

    The comment Anonymous left is consistent with my experience. My father's LDL was in the 40s under "control" with statins. He died of a heart attack less than a week after passing a stress test. Reviewing his Berkeley lipid tests, he was solid LDL pattern B, though his trigs and HDL were enviable.

  • Anonymous

    7/20/2010 1:37:26 AM |

    i have a question as a neurosurgeon who completely thinks that Cholesterol is immaterial.  Do you Dr Davis as a cardiologist value the VAP or the HS CRP in your practice for true cardiac risk.  All my reading points to HS CRP......I am not sure that the VAP does anything unless you have a genetic predisposition.  Is this correct thinking or not?  Dr. K

  • Dr. William Davis

    7/20/2010 2:16:24 AM |

    Judging from the comments, a lot more conversation on small LDL is in order.

    It's actually quite simple, but the world floods us with misinformation hell bent on leading us towards statins and the small LDL CREATING low-fat diet.

    I will address these issues in forthcoming posts.

  • Peter

    7/20/2010 5:20:44 PM |

    If I want to find out my small particle number what test should I request.

  • Bob

    7/20/2010 8:48:26 PM |

    I am the original poster with the July 2007 blood test results. My April 2010 test results are as follows:
    Total = 129
    HDL = 79
    TRG = <45
    LDL = N/A
    non HDL = 50
    TC/HDL = 1.6

    Same meds 185 lbs.

    Am I killing myself with these numbers?

  • Anonymous

    7/20/2010 11:40:07 PM |

    Do you still have the small LDL pattern?

  • Bob

    7/21/2010 12:01:14 AM |

    Anonymous said...
    Do you still have the small LDL pattern?
    -------------------------------

    No, I have not had that tested since 2007- a university medical center performed that test and was not worried with the LDL pattern B results. No VAP tests since, only the standard lipid tests.

  • David

    7/21/2010 12:52:55 AM |

    @Peter-

    To find out your small LDL particle number, have your doctor order an NMR LipoProfile. You can also order these yourself without a doctor (very inexpensively) from places like privatemdlabs.com. You just order the test online, go to a local blood drawing station at your convenience, and look for the results to be emailed to you in a couple days. That's what I do. Super easy.

    David

  • Philip Barr

    8/2/2010 4:56:45 PM |

    Great thread in this blog. Bob, you have good advice here. I am also a big Niacin enthusiast and often use it in combination with a natural lipid lowering group of supplements: Triplichol + Niacin.
    Regarding your comment last month "Am I killing myself..." . You have to know that you are doing the best you can, and holding a positive mental attitude is extremely important as well. In my mind/body medicine fellowship we taught people stress management as well as doing the exercise and nutrition side. Weaving this into internal medicine has been rewarding.

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