Lethal lipids

There's a specific combination of lipids/lipoproteins that confers especially high risk for heart disease. That combination is:

Low HDL--generally less than 50 mg/dl

Small LDL--especially if 50% or more of total LDL

Lipoprotein(a)--an aggressive risk factor by itself

This combination is a virtual guarantee for heart disease, often at a young age. It's not clear whether each risk factor exerts its own brand of undesirable effect, or whether the combined presence of each cause some adverse interaction.

For instance, lipoprotein(a), or Lp(a), by itself is the most aggressive risk factor known (that nobody's heard about--there's no blockbuster revenue-generating drug for it). Each Lp(a) molecule is a combination of an LDL cholesterol molecule with a specific genetically-determined protein, apoprotein(a). If the LDL component of Lp(a) is small, then the combination of Lp(a) with small LDL is somehow much worse, kind of like the two neighborhood kids who are naughty on their own, but really bad when they're together.

Interestingly, the evil trio responds as a whole to many of the same corrective treatments:

Niacin--increases HDL, reduces small LDL, and reduces Lp(a)

Elimination of wheat, cornstarch, and sugars--Best for reducing small LDL; less potent for Lp(a) reduction.

High-fat intake--Like niacin, effective for all three.

High-dose fish oil--Higher doses of EPA + DHA north of 3000 mg per day also can positively affect all three, especially Lp(a).

If you have this combination, it ought to be taken very seriously. Don't let anybody tell you that it is uncorrectable--just because there may be no big revenue-generating drug to treat it on TV does
not mean that there aren't effective treatments for it. In fact, some of our biggest successes in reducing heart scan scores have had this precise combination.

Comments (15) -

  • Jenny

    5/8/2009 12:22:00 PM |

    Isn't it time we stopped talking about "risk factors" which is a flaky idea invented by drug companies and often means "associations" and start talking about causes?

    In this case, a CAUSE of heart problems is probably glycosylation [permanent binding of glucose to the protein] of receptors used in lipid removal. That's why cutting back on carbs which lowers glycosylation helps.  

    The CAUSE explanation for why  wheat is an issue for many people is most likely that they have genes for mild gluten intolerance which leads to systemic inflammation. New genes have been discovered recently which are making many more people test positive for gluten intolerance, usually people with other autoimmune markers.

    Without those genes wheat behaves just like another glucose-source in the diet. I do eat wheat, just not much of it, but I keep all my carbs low and have very low Apo-A and very high HDL.

    I do occasionally hear from people with diabetes who are fat sensitive and whose insulin requirements and blood sugar go up not down on a high fat/low carb diet. That's probably another genetic error at work. It's rarer, but it does exist. For such people the cause profile may be different.

    It would be nice to know what's the cause behind the positive effects of the fish oil on heart disease. Any clue?

    As long as we stick with "risk factors" we can end up thinking that yacht ownership is a "risk factor" for wealth since studies have repeatedly shown that people who own yachts are more wealthy than those who don't.

  • prophets

    5/8/2009 1:23:00 PM |

    i have this pathology.  the causes are pretty clear, imo.  i take nicotinic acid, fish oil, etc.  unfortunately, i had to self-diagnose my condition because every cardiologist i saw was so fixated on low-ldl/lipitor-is-everything analysis.

    thx for the note.

  • Steve

    5/8/2009 2:13:00 PM |

    high fat intake is a surprise! are you saying high saturated fat or unsaturated fat from oily fish for example?  
    Does elimination of sugar mean not eating fruit?

  • Anonymous

    5/8/2009 2:31:00 PM |

    After reading your post about the use if niacin to improve low HDL, I started niacin.
    I just got my test results:In 6 months, I've gone from 42 to 79!
    I'm still waiting for the results from my vitamin d level and CRP, but I bet I'm not disappointed.
    Thanks again for great information.

  • Anonymous

    5/8/2009 2:33:00 PM |

    Oh, and my total cholesterol went up a little, to 211, but my tryglycerides are still very low (38), so I'm guessing my small dense LDL particles are very few.

  • Kurt

    5/8/2009 2:51:00 PM |

    I've been reading this blog with interest for the past week. I'm a 44 year old male who had my first coronary artery calcium scan. My doctor wanted to prescribe statins for my cholesterol (LDL 155, HDL 65, Triglycerides 78) so I decided to have a scan first. I was hoping my high HDL had kept my arteries healthy. My score was 42 (LAD 42, the rest were 0). I thought that was pretty good ("mild plaque burden," the test result said), but the doctor told me I was in the 85th percentile - only 15% of men in my age group have a higher score. I'm wondering, do you see any good news in my results? Thanks.

  • waxjob

    5/8/2009 10:29:00 PM |

    I've just read a Norwegian study that was recently cited in a cardiology journal that has found high HDL readings can be dangerous.
    I'm a 57 yr old male and this is my lipid profile:
    185 (TC)
    76 HDL
    103 LDL
    29 Triglycerides (TRG)
    My HDL is nearly as high as my LDL and my triglycerides are almost non-existant. Nobody in my family has ever had heart problems but my profile doesn't look like any of the other ones I see and I'm wondering if I should go back and ask to see a cardiologist for a follow up?

  • billye

    5/9/2009 1:32:00 AM |

    I am already taking 7000mg fish oil providing a little more than 2400mg EPA and DHA on a daily basis. What is your reference of north of 3000mg talking about, total fish oil or just EPA and DHA?.  You say high fat intake like niacin.  Did you also mean to infer that high fat animal protean and cheese could be helpful? My doctor stopped me from taking all Staten's and I already stopped sugar, wheat and high carbohydrates.

    Billy E.

  • Rick

    5/9/2009 3:06:00 AM |

    Dr Davis,
    Could you qualify the high-fat intake treatment a bit? Is any kind of fat effective? And presumably there are conditions for what the fat can be combined with, too?

  • David

    5/9/2009 4:00:00 AM |

    Saturated fat in particular is the most effective for increasing HDL, decreasing Lp(a) (by nearly 12% in one study), and decreasing sdLDL. One should note that saturated fat may cause an increase in calculated LDL, but this is inconsequential, as the LDL particles will be of the larger, fluffier, more benign type. Also, if triglycerides are decreased (as they would be -- oftentimes dramatically -- on a lower carb, higher saturated fat diet), of course calculated LDL will go up. According to the Friedewald calculation: LDL cholesterol = Total cholesterol – HDL cholesterol – Triglycerides/5. Therefore, if all you do is decrease triglycerides (a good thing, to be sure!), your LDL could go up! This is why the NMR is a much better way to track changes. It measures particle number and size instead of making a mere "calculation."

  • Anonymous

    5/9/2009 2:09:00 PM |

    Dr Davis:

    Would you comment or send a link to a comment about when you would do a calcium scan vs a full CTA for stratification of cardiac risk?


  • Anonymous

    5/9/2009 11:13:00 PM |

    David -  I would love to read more about this.  Can you point me to any studies where they have gotten these results.



  • David

    5/11/2009 4:02:00 AM |


    Certainly. Here's a study with all of the things I mentioned: Increased HDL, decrease in small LDL (increase in LDL particle size, which is good), and ~12% reduction in Lp(a) -- and all with a low-carb/high-fat (60%) diet.


  • Ricardo

    5/21/2009 3:03:51 PM |

    Dear Dr. Davis, I believe these recent studies tell us that LDL is not as bad as we were thinking. When shall we expect to see small LDL as a standard medical test/marker, and LDL discarded?

    1- http://www.journals.elsevierhealth.com/periodicals/jac/article/PIIS0002870308007175/
    2- http://astute.cardiosource.com/2007/vposters/pdf/275_Fonarow.pdf
    3- http://www.journals.elsevierhealth.com/periodicals/jac/article/PIIS0735109706004797/
    4- http://www.ncbi.nlm.nih.gov/pubmed/17134630

  • mongander

    8/17/2009 9:16:53 PM |

    My HDL just doubled from under 40 to 80.  Have been on niacin and also use 1 oz of 190 proof Everclear to dissolve supplement powders which I then add to hot cocoa.  My doc thinks the increased HDL was due to the alcohol.

    Coincidentally, at the same time my HDL doubled, so did my PSA.  Now I'm scheduled for a prostate biopsy.  I'm 70.