Making sense out of lipid changes

Maggie had been doing well on her program, enjoying favorable lipids near our 60-60-60 targets (HDL 60 mg/dl or greater, LDL 60 mg/dl or less, triglycerides 60 mg/dl or less). Last fall, her last set of values were:

Total cholesterol: 149 mg/dl
LDL cholesterol: 67 mg/dl
HDL cholesterol: 73 mg/dl
Triglycerides: 43 mg/dl

The holidays, as with most people, involved a frenzy of indulgent eating: Christmas cookies, cakes, pies, stuffing, potatoes, candies, etc.

Maggie returned to the office 6 pounds heavier with these values:

Total cholesterol: 210 mg/dl
LDL cholesterol: 124 mg/dl
HDL cholesterol: 57 mg/dl
Triglycerides: 144 mg/dl

In other words, holiday indulgences caused an increase in LDL cholesterol, a reduction in HDL, an increase in triglycerides, an increase in total cholesterol.

What happened?

At first glance, many of my colleagues would interpret this as fat indulgence and/or a "need" for statin drug therapy.

Having done thousands of lipoprotein panels, I can tell you that, beneath the surface, the following has occurred:

--Overindulgence in carbohydrates from the goodies triggered triglyceride (actually VLDL) formation in the liver, released into the blood.
--Increased triglycerides and VLDL triggered a boom in conversion of large LDL to small LDL (since triglycerides are required to form small LDL particles) via cholesteryl-ester transfer protein (CETP) activity.
--Increased triglycerides and VLDL interacted with HDL particles, causing "remodeling" of HDL particles to the less desirable, less protective small particles, which do not persist as long in the blood, resulting in a reduction of HDL.

The critical factor is carbohydrate intake. This triggered a domino effect that is often misintepreted as excessive fat intake or a genetic predisposition. It is nothing of the kind.

I discussed this phenomenon with Maggie. She now knows to not overindulge in the holiday snacks in future and will revert promptly back to her 60-60-60 values.

Comments (9) -

  • Rick

    1/27/2009 4:37:00 AM |

    Wow. I hadn't realised that a short period of over-eating could trigger such big changes.

    Is there any danger from triglycerides going much below the target of 60?

  • Diana Hsieh

    1/27/2009 5:23:00 AM |

    Dr. Davis --

    What might cause a substantial rise in LDL, while triglycerides and HDL are lower than ever?

    Here's what happened with my tests over the last year and a half:

    ** Summer 2007, eating the standard American diet **
    Total Cholesterol: 266
    Triglycerides: 109
    HDL: 79
    LDL: 165

    ** Summer 2008, just a few weeks into my new diet (no processed foods, no grains, no sugars, no vegetable oils) **
    Total Cholesterol: 225
    Triglycerides: 63
    HDL: 72
    LDL: 140

    And now, January 2009 (same diet as before):
    Total Cholesterol: 341
    Triglycerides: 55
    HDL: 99
    LDL: 231

    My triglycerides and HDL are better than ever, but my LDL has gone way up.  I didn't overindulge over the holidays, but I was losing weight (slowly) when I got that latest test.

    I know -- thanks to your blogging -- that inferred LDL values are highly unreliable.  And I also know that there's a difference between small LDL (bad, caused by eating high carb) and the bigger, fluffier (okay) LDL.  The LDL number doesn't differentiate between those values.  Or might something else be the cause?

    My doctor wants to do a cholesterol recheck next month -- and I'm thinking that I ought to ask for a measured LDL value and a particle size test.  Does that seem reasonable to you?  

    BTW, my heart scan from six months ago is totally clear.  So I don't care how much my doc pushes, I absolutely refuse to go on any kind of cholesterol-lowering medication.

    Also, thanks to you, I got a vitamin D test -- and my values were excellent.  (I do supplement.)  Yeah!

  • Jenny

    1/27/2009 2:19:00 PM |

    Dr. Davis,

    While it is true that overindulging in carbs causes all the changes you cite here, if your patient really wants to stick with the program life-long, she'll do better learning how to carb up a bit at the holidays, and then correct afterwards, rather than getting into a lifestyle of self-denial that will build up an undercurrent of feelings of deprivation that will eventually blow her completely off course.

    I've been there, done that. Three family holiday seasons without eating any of our traditional foods left me depressed and miserable. Food is a complex issue with deep emotional roots.

    Something like a family death or a cancer diagnosis can trigger binges that derive from that deprivation and really derail the diet.

    I have found it much better to build in safety valves into the diet, here and there.  The lipids will recover very fast once she goes back to eating the low carb diet.  

    I've been doing a low carb lifestyle for going on 11 years now, and I attribute its success to the safety valves. Yes, I do gain a few pounds over the holidays, but I take them off in January.  

    The psychology of successful dieting is often to accept "good enough" rather than perfect. Perfect has a nasty way of ending up in disaster.

    If you doubt this, just read the low carb diet boards where for every person who has maintained perfectly for 5+ years there are 25 people back after catastrophic regains caused by being too stringent.

  • Alan S David

    1/27/2009 3:36:00 PM |

    Is it carbs in general or should we be more consciously eliminating the wheat and corn products?  
    I eat quinoa,oatmeal,  buckwheat,beans,brown rice, etc. Not to excess but as a part of my usual diet.
    Just wondering?

  • Grandma S.

    1/27/2009 4:51:00 PM |

    Question: I understand no wheat and what it does to the LDLs, but does that include potatoes? Thank you!

  • Anonymous

    1/28/2009 5:57:00 AM |

    Dr. Davis,

    I have a similar issue as Diana Hsieh.  

    My Total Cholesterol: 258
    Triglycerides : 60
    HDL : 61
    LDL- 181

    I've been on a low carb diet avoiding wheat, rice, starches, sugar, high fructose corn syrups and fruits for the last 6 months.  I've lost 35 pounds and reduced my triglycerides from 296 to 60.  Taking fish oil and slo-niacin. I have been eating alot of saturated animal fats (rib-eye steaks, baby back pork ribs, eggs) Is eating the saturated animal fat causing my total cholesterol to be too high?  Is total cholesterol above 200 dangerous if Triglycerides and HDL are in the 60's?

  • vin

    1/28/2009 10:11:00 AM |

    I am trying for last three years to get my HDL numbers high. So far without success. I have tried exercise and cutting out wheat but without significant improvement. I have now added 4000iu vitamin D. Will do a follow up blood test after about two months to see if HDL level increases.

    Any other tips?

  • Jmuls

    1/28/2009 12:34:00 PM |

    Dr. Davis,

    Is there often a direct correlation between low triglycerides and a greater proportion of large LDL particles?  Thanks

    - John

  • Trinkwasser

    2/8/2009 2:08:00 PM |

    Here were my lipids on a Heart Healthy (sarcasm) Diet

    Trigs 380
    HDL 25
    LDL 165

    Add simvastatin

    Trigs 185
    HDL 33
    LDL 75

    Here they are on a low carb diet with my BG more or less normalised
    (70 - 90 and postprandials mostly below 110 and seldom over 120)

    Trigs 39
    HDL 47
    LDL 105

    Adding more saturated fat

    Trigs 62
    HDL 55
    LDL 94

    Spot the reversal of HDL to LDL

    IME low carbing decimates the trigs and tends to increase HDL and LDL both, tinkering with the fat content and type adjusts the balance between these BUT there's a lot of individual variation as to exactly how this works. Some people just seem to have high LDL whatever they do, maybe a long term change from years of insulin resistance and hyperinsulinemia, maybe genes which would respond to a different balance of fat types in the diet.

    My #1 weapon has been BG testing

    which is deprecated in the UK. Lipid breakdowns are often unavailable and Full Lipid Panel is deprecated in favour of TChol which is pointless but cheaper. The money saving is probably to pay for the blanket prescription of statins, and it also serves to conceal the toxic nature of the diet

    here's the diabetic version

    I feel like part of a eugenics experiment