Unforgiving small LDL particles

21. October 2011 William Davis (39)
Small LDL particles are triggered by carbohydrates in the diet: Eat carbohydrates, small LDL particles go up. Cut carbohydrates, small LDL particles go down.

A typical scenario would be someone starts with, say, 2000 nmol/L small LDL (by NMR) because they've been drinking the national Kool Aid of eating more "healthy whole grains" and consuming somewhere around 200 grams carbohydrates per day, including the destructive amylopectin A of wheat. This person slashes wheat followed by limiting other carbohydrates and takes in, say, 40-50 grams per day. Small LDL: 200 nmol/L.

In other words, reducing carbohydrate exposure slashes the expression of small LDL particles, since carbohydrate deprivation disables the liver process of de novo lipogenesis that forms triglycerides. Abnormal or exaggerated postprandial (after-eating) lipoproteins that are packed with triglycerides are also reduced. Because triglycerides provide the first lipoprotein "domino" that cascades into the formation of small LDL particles, carbohydrate reduction results in marked reduction in small LDL particle formation.

So let's say you are doing great and you've slashed carbohydrates. Small LDL particles are now down to zero--no small LDL whatsoever. What LDL particles you have are the more benign large variety, say, 1200 nmol/L (LDL particle number), all large, none small. You are due for some more blood work on Thursday. On Tuesday, however, you have four crackers because, what the heck, you've been doing great, you've lost 43 pounds, and have been enjoying dramatic correction of your lipoprotein abnormalities.

Your next lipoprotein panel: LDL particle number 1800 nmol/L, small LDL 700 nmo/L--substantially worse, with a major uptick in small LDL.

That's how sensitive small LDL particles can be to carbohydrate intake. And the small LDL particles can last for up to several days, since small LDL particles are not just smaller in size, they also differ in conformation, making them unrecognizable by the normal liver receptor. The small LDL particles triggered by the 4 crackers therefore linger, outlasting the normal-conformation large LDL particles that are readily cleared by the liver.

This phenomenon is responsible for great confusion when following lipoprotein panels, since a 98% perfect diet can yield dismaying results just from a minor indulgence. But, buried in this simple observation is the notion that small LDL particles are also extremely unforgiving, being triggered by the smallest carbohydrate indulgence, lasting longer and wreaking their atherosclerotic plaque havoc.
Tags :

Comments (39) -

  • ChrisB

    10/21/2011 3:45:39 PM |

    Great Article.  As I'm sure you know by now, I've been kind of a lipidpanelaholic since having a MI 2 yrs ago.  The hardest information to find is that of how long it takes for lipids to respond to diet changes and how sensitive they can be to even the smallest amount of carbs.

  • Howard

    10/21/2011 4:44:48 PM |

    Are you sure that sort of response is not due to gluten/gliadin/lectin/transfat? Four crackers doesn't sound to me like much of a carb load, but for a gluten-sensitive person like me, that could set off some inflammation.

  • Marc

    10/21/2011 7:08:35 PM |

    Dr. Davis,
    How does alcohol fit in to the above "equation"? Specifically wine.

    Marc

  • Sam Sinderson

    10/22/2011 12:12:39 AM |

    I have been on a wheat-free and carb restricted diet for about 7 weeks, and being concerned that I might be Apo E4, and therefor need to also limit saturate fat as you explained in an earlier blog, I asked my doctor to order a small LDL test.  No independent lab here that I consulted knew what that was, nor obviously did my doctor, since he just ordered "small LDL".  The local hospital lab finally found the following, which is what I will have blood drawn for tomorrow:
    Lipoprotein Fractionation Panel 1, Ion Mobility
    Which includes:
    Choesterol; HDL Cholesterol; Triglicerides; :Lipoprotein (a); Lipoprotein Fractionation Panel 2, Ion Mobility (LDL, Total; LDL, Medium and Small; LDL, VerySmall; HDL, Large; LDL Peak Diameter, LDL Phenotype)

    I hope that this is what I need.  Probably it is overkill, but in this case apparently my Medicare Advantage plan will cover it since it has been more than 3 months, since I had a simple panel done.

    Is there a simpler test for small LDL?  By the way the CPT codes are 80061, 83695, 83704

  • Fat Guy Weight Loss

    10/22/2011 4:41:38 AM |

    Sounds like cheat days may not be that good of an idea...

  • Dr. William Davis

    10/22/2011 12:39:39 PM |

    Yes, it does cast cheat days in a new light!

  • Dr. William Davis

    10/22/2011 12:45:11 PM |

    That's it, Sam.

    It shouldn't be that hard. The information is actually fairly straightforward and provides crucial information.

  • Dr. William Davis

    10/22/2011 12:51:45 PM |

    Hi, Marc--

    Alcohol does indeed slow or stop weight loss, especially if more than a serving or two are consumed. So it pays to minimize during a weight loss effort.

  • Dr. William Davis

    10/22/2011 12:56:34 PM |

    Probably not, Howard, since those components have not been associated with triggering of small LDL. The trans fat component can indeed trigger small LDL, but it seems to occur even with foods minus trans fats.

    However, I am impressed that gluten/gliadin/lectin rolled off your tongue!

  • STG

    10/22/2011 1:36:14 PM |

    The problem is carb creep. I experienced this a few months ago when I received the results of my HbA1c test. I was still in the prediabetic range and it was higher than the HbA1c test I had a few years earlier. I didn't get it? I thought I was consuming less carbs then I was. When I actually looked at my diet there were carbs creeping in: dark chocolate and small "safe starches" (e.g, potatoes, yams). Another factor that may have impacted my blood sugar was the stress of travel/visiting family during that three month time period. My understanding is that elevated cortisol levels can raise blood sugar. In any case, my recent HbA1c is in normal range. I think this is because I eliminated even small amounts of dark chocolate and "safe starches" (see Jimmy Moore's comments about safe starches).

  • jethro

    10/22/2011 2:01:01 PM |

    How low should we go in carbohydrates to avoid increasing small LDL?

  • Davide

    10/22/2011 3:01:26 PM |

    I'm not sure that wheat has this acute effect on everybody. In fact, I know it doesn't happen with me. I keep a close eye on my lipids and my small LDL particles remain "relatively" low despite the fact that I consume wheat/sugar products. Then again,  my blood sugar does not significantly rise after carbohydrates, so maybe that's why. If I eat a massive plate of pasta, a glass of fruit juice, and dessert, my blood sugar may (keyword, "may") rise to 120, if that, but then it goes down to about 80 about 45 minutes after the meal. No joke. In other words, I'm thinking this effect may have to do with the degree of people's volatility to rising blood sugars. Just a guess.

    Fyi, I'm the apo E/4 person who's LDL amount/particle number (226, 2,000) is extremely sensitive to saturated fats and thus I'm always lost in the conundrum of balancing fats with carbs. Difficult!

  • Teresa

    10/22/2011 3:05:34 PM |

    I know that if weight loss is involved, it can take a few months after weight stabilizes for lipids to normalize.  If minimal or no weight loss is involved, how long does it take?

  • Fat Guy Weight Loss

    10/22/2011 5:31:19 PM |

    With the example about 4 crackers would be as low as 10g carbs.  Curious of the overall effects of say 10g carbs of sweet potatoes....

  • Dr. William Davis

    10/23/2011 11:49:09 PM |

    Then it depends on which parameter you are talking about, Teresa.

    Small LDL requires just days to respond, while triglycerides require weeks to months, while HDL requires months to years.

  • Dr. William Davis

    10/23/2011 11:51:13 PM |

    Hi, Davide--

    No doubt: Individual tolerances to various foods, including carbohydrates, can differ. And the apo E4 person has a tougher time of it.

  • Dr. William Davis

    10/23/2011 11:53:40 PM |

    Unfortunately, Jethro, there's no quick and easy way to decide this, since individual sensitivity varies.

    Although imperfect, you can use HbA1c, an index of glucose and not of small LDL, to gauge whether you've been triggering higher blood sugars that often parallel the triggering of small LDL particles. You could, of course, obtain lipoprotein testing 48 hours after ingesting a known amount of carbohydrates, e.g., 20 grams, but that is logistically difficult.

    That all said, most people can get away with 15 grams carbohydrates per meal, while some can't tolerate more than 10, yet others do fine with 30+ grams.

  • Dr. William Davis

    10/23/2011 11:54:15 PM |

    Excellent point, STG! And I like the "carb creep"!

  • Barbara

    10/24/2011 12:14:06 AM |

    Did you see this, Dr. Davis?

    http://medicalxpress.com/news/2011-10-common-link-autism-diabetes.html

  • Teresa

    10/24/2011 1:14:14 AM |

    And it takes years to unlearn all the inaccurate stuff learned in school, and to find and learn the good stuff that is out there.  Thanks.

  • Stephanie

    10/24/2011 2:27:52 PM |

    How does one check to see if they are apo E4?

  • ChrisB

    10/25/2011 1:19:25 PM |

    How does it affect lipid results?

  • steve

    10/25/2011 10:52:06 PM |

    Dr Davis:  What is the small LDL profile for native populations that consume tons of of carbs and no signs of heart disease; also, the Japanese consume lots of carbs- easily 3 cups of rice per day which is about 120 carbs from rice alone.  Low level of CAD; what are their levels of small LDL.  I know for myself ApoE 3/3 that carbs do affect the small LDL level i have and in any event in the absence of a statin i produce tons of LDL particles large or small depending upon carb levels.  I believe genetics plays a large role.
    Thanks

  • Dr. William Davis

    10/26/2011 3:19:22 AM |

    No doubt, Steve.

    However, I'm unaware of lipoprotein assessment done to answer these questions. That would be interesting, however.

  • Dr. William Davis

    10/26/2011 3:21:50 AM |

    Yes, agreed, Teresa: New lessons to learn every day in this Information Age!

  • Dr. William Davis

    10/26/2011 3:23:44 AM |

    Thanks, Barbara. No, I hadn't seen this. But I'm not the least bit surprised!

    I find it wonderfully satisfying that the puzzle pieces are falling in place, just like that 1000-piece jigsaw puzzle we struggled to put together, with the last few pieces fit just perfectly!

  • Dee

    10/28/2011 1:57:49 PM |

    Dr. Davis,
    Have you heard or read about Lumbrokinase helping to lower small "a" particles?
    Just wondering.
    Dee

  • Tim

    10/28/2011 7:14:08 PM |

    Dr. Davis,

    There seems to be a lot of mention of the E4 ApoE genotype.  What about those of us that are E2/E4?  Any different instructions for us?

    Thanks.

  • Dr. William Davis

    10/29/2011 10:48:39 PM |

    With this very tough pattern, you are best following lipoproteins and glucose measures like HbA1c to gauge response to various dietary manipulations. The basic diet approach, however, is largely the same; it just may require some adjustments, e.g., fat intake.

  • Dr. William Davis

    10/29/2011 10:49:12 PM |

    Sorry, Dee, no info.

    Where did you hear this?

  • Dee

    10/30/2011 5:20:26 PM |

    Here is the quote.  Appently it just helps lower the LP[a]  and does not have any terrrble side effects.  I may try it, nothing else is working.  My little a is 43 and rising in spite of all I do.

    "The one nutraceutical that has shown promising clinical results in actually lowering Lp(a) is a lumbrokinase product made by Canada RNA Biochemical called Boluoke. Like its chemical cousin nattokinase, lumbrokinase is an enzyme that helps break up fibrin—a fibrous protein that helps form blood clots—to avoid too much clotting and keep blood flowing optimally."

    :

    Dee

  • Sam Sinderson

    10/31/2011 7:32:29 PM |

    I have my results.  My PCP reported these to me "for my records" with no further comment.  Maybe he can't interpret them?
    Total Cholesterol: 231 (My PCP surely would think this is high.)
    I find it strange that they did not report LDL direct, though perhaps it is not done because of the breakdown below.  
    Calculated LDL: 133 H MG/DL
    HDL: 85 Mg/dl  This is higher than I have ever had measured.
    Triglycerides: 64 Mg/Dl  Even Simvastatin only got it down to 84.  I conclude that I am not Apo E4.
    The range after \ below  is the range they cite, I presume, as normal.
    Lipoprotein Innocent: <10  NMOL/L \ <75  I presume this is a good result.
    LDL, Total: 2268 H NMOL/L  \ 440-1600
    LDL, medium and small: 651 NMOL/L \ 144-787
    LDL, Very Small: 277 NMOL/L \ 75-419
    HDL large: 9315 H NMOL/L  \ 469-5258
    LDL Peak Diameter: 227.5 Angstrom  \216.-234.3
    LDL Phenotype A  Pattern A     I believe this to be the preferred pattern, low small LD and Triglycerides.  Ref: Obesity (2009) 17 9, 1768–1775. doi:10.1038/oby.2009.146--Reversal of Small, Dense LDL Subclass Phenotype by Normalization of Adiposity
    Patty W. Siri-Tarino1, Paul T. Williams2, Harriet S. Fernstrom1, Robin S. Rawlings1 and Ronald M. Krauss1

    Does this calculate to large LDL = 2268-651 =1617 (Not including medium)?
    When should I do this test again?
    Comment?

  • Dr. William Davis

    11/1/2011 2:03:32 AM |

    Hi, Sam--

    The "pattern A" comment is misleading. About 40% of your LDL particles are small, too much.

    It means going back to the strategies to reduce small LDL, such as wheat elimination and limiting carbohydrate exposure. It is worth repeating about 2 months after weight has stabilized following a diet change.

  • Sam Sinderson

    11/1/2011 12:49:43 PM |

    I have been on a no-wheat, limited, very-low carb, diet now for 6 to 7 weeks already.  I cringe to think of what the numbers may have been before.  I initially lost about 12 pounds in less than 2 weeks to get to 148, I am 72-in tall, and have stabalized there by eating more high-fat non-carb stuff.  You say 40% small.  You must be using the medium and small (640) over total (2268) to get 40%.  Apparently medium and small includes the very small, which must be a fraction of small?  How long should it take for the very small to approach zero?  Isn't that the more important number?  I will be out of the country for 2 weeks.

    Thanks

  • Dr. William Davis

    11/2/2011 1:43:14 AM |

    Yes, exactly, Sam: Combine medium and small.

    Dietary and weight changes usually exert effects on small LDL within a few weeks, much faster than most other parameters.

  • pb

    2/6/2012 3:47:25 PM |

    Get a VAP test....this measures your small particle/large particle LDL.
    labcorp code 804500

  • pb

    2/6/2012 3:51:39 PM |

    I am going to try to get a VAP test.  No doctors know of it....only folks on the web.  Why?  It seems like a very important test to measure your LDL properly.  Can someone elaborate on this further?

  • Dr. William Davis

    2/7/2012 3:18:11 AM |

    Easy, Pb: There are no drugs--read: "no financial incentive"--to treat the abnormalities generally uncovered by lipoprotein testing like VAP. Thus, no push to get it tested.

Add comment

Loading
How did Cureality get its start?

How did Cureality get its start?

27. July 2014 William Davis (0)



In the Cureality program, we embrace information and strategies that empower you in health without drugs, without hospitals, without procedures. We convert your doctor from director of healthcare to your assistant in health. He or she is there when you need help, but you largely direct your own health future.

How did we gain the know-how, information, tools, even chutzpah to take on such an ambitious project?

It started around 10 years ago with the awkwardly named Track Your Plaque program. In fact, some of the current followers of the Cureality program are former Track Your Plaque members, having learned of the wonderful list of strategies that can be adopted to gain better control over, even reverse, coronary atherosclerotic plaque and risk for heart attack. They also learned that something special happens when you engage with other people with similar interests, all sharing ideas, insights, and resources to get the self-directed health job done. Over time, what started out as simply a source of better information for coronary health evolved into a self-directed coronary disease management program. We never set out to create something as wildly ambitious as a do-it-yourself-at-home coronary disease risk management program, but that is how it inadvertently turned out.

How we went from Information Provider to Health Empowerment Program

So we never intended to take on something so seemingly impossible as managing coronary risk on your own. But, because we armed people with such empowering, profound insights into better ways to manage their heart disease risk beyond “don’t smoke, cut saturated fat, be active, and take a statin drug”—the typical advice offered by doctors—they returned after an interaction with their doctors disappointed: doctors often declared such strategies unnecessary, or the doctor didn’t understand them—even when there were clear-cut clinical data already available to support their use. In other words, the patients—everyday people, not experts—knew more than their doctors. 

This flip-flop in the balance of knowledge made for some very interesting stories, like “Harold” (not his real name) who, having survived a heart attack and received a stent, was told by his doctor to cut his fat intake, eat more whole grains, exercise, take aspirin and a beta blocker drug, and reduce his cholesterol values with a statin drug. Upon learning all the additional information from the Track Your Plaque program, Harold returned to his doctor and asked “I’m not so ready to just go along with this idea of ‘reducing cholesterol’ to address heart disease risk. Because my goal is to gain as much control over coronary disease as possible, maybe even reverse it, I’d like to address some additional issues that I believe may be important. I’d like to have my advanced lipoproteins drawn to measure the proportion of small LDL particles I have, whether I have lipoprotein(a), an omega-3 fatty acid index and 25-hydroxy vitamin D level, and a thyroid assessment. Oh, and I believe I should also have an assessment of my inflammation status, perhaps a c-reactive protein and phospholipase A2, and my blood sugar status measured with a fasting glucose, insulin, and hemoglobin A1c.” Harold’s doctor was dumbfounded and speechless. Rather than reveal his ignorance, his doctor advised Harold that none of that was necessary, sending him on his way and telling him that he was fine.

But this left Harold with a sour taste in his mouth, having engaged in many online discussions with people who had followed conventional advice that resulted in more heart attack, more heart procedures—the conventional answers simply did not work. He also discussed his situation with people who had successfully obtained the additional information he sought, added it to their program and enjoyed dramatically improved health, including freedom from more heart attacks, heart symptoms, and heart procedures, as well as improved overall health. So Harold found an easy way to obtain the testing on his own. Within a couple of weeks, he returned to his online community and shared all his information. Within moments, he was provided useful discussion to help him understand the values, all leading to changes in nutrition, nutritional supplement choices, how and where to get the simple tools necessary, such as iodine and vitamin D supplements. He even entered his data, choosing which values he was willing to share with others, which remained private, allowing him to compare his own follow-up values several months later. Engaged in this process, self-directed but collaborative, he witnessed marked transformations in his health. Not only did he never again—over several years—ever re-develop heart symptoms nor require any more trips back to the cath lab, he lost weight, reversed a pre-diabetic sugar profile, improved his cholesterol values without drugs, got rid of the acid reflux symptoms he endured for many years, dropped his blood pressure to normal, enjoyed better mood, energy, and sleep. Slender, healthier, all accomplished without his doctor. 

Harold returned to his doctor for a routine follow-up. Slender, energetic, without complaints, on no drugs except the aspirin for his stent, the basic laboratory assessment his doctor ordered in front of him, his doctor admitted,” Well, I don’t know how you’re doing it, but these values look like a 20-year old substituted his blood for yours. They’re unbelievable. What drugs are you taking to do this?” “No drugs,” Harold replied, “I’m following a program to reverse heart disease, but it means doing some things that are different from conventional solutions.” His doctor closed their meeting with the signature response of doctors nationwide: “Well, I don’t understand what you are doing, but just keep doing it.”

Yes, Harold knew more about how to control heart disease than his doctor, more than his cardiologist. The cardiologist knew how to insert a stent or defibrillator. But deliver information that empowered Harold in all aspects of health from head to toe, while also dramatically reducing, perhaps eliminating, his coronary disease risk? As you now know, that is not what conventional healthcare does, nor is it interested in doing so, as it would relinquish control and threaten to cut off this hugely profitable revenue stream that drives “healthcare.”

Having managed to inadvertently create a self-directed coronary risk management program with such spectacular results and in probably one of the most difficult areas of all—heart disease—it became clear that a similar approach could be even more easily applied to many other areas of health, such as weight loss, bone health, cholesterol and blood pressure issues, diabetes and pre-diabetes, hormonal health, autoimmune conditions, and others. You can do it when empowered by safe, effective information, and supported by a community of sharing and collaboration. We don’t fire our doctors; they are there when we need them when, for instance, we get injured or catch pneumonia, or as an occasional resource. But doctors should no longer be able to get away with neglect, misinformation, or blindly directing you to the next revenue-generating procedure because you are empowered by the information and support you receive in Cureality.

As we get more effective in delivering this information and new tools to you, just imagine what we can accomplish in this new age of information and self-empowerment. The future for us is bright with ambitions for better interactive tools with Cureality expert staff, better ways to crowd source health answers, provide more engaging community conversation, all while the health insights that help accomplish our self-directed health goals get better and better. Each person that joins Cureality helps make this service more effective because your wisdom, insights, and experience are added to the collective knowledge. We are more powerful together than we are as individuals.

If you are already a Cureality Member, please add your comments and questions to the growing conversation. If you are not a Member, consider joining our discussions, as each new voice gets us closer and closer to better answers to take back control over health.
Tags :

Add comment

Loading