Extreme carbohydrate intolerance

Here's an interesting example of what you might call "extreme carbohydrate intolerance."

May is a 44-year woman who has now had her 7th stent placed in her coronary arteries. She lives on a diet dominated by breads, breakfast cereals, muffins, rice, corn products, along with some real foods.

Her conventional lipid panel and other lab values:

Total cholesterol 346 mg/dl
Triglycerides: 877 mg/dl
HDL cholesterol: 22 mg/dl
LDL cholesterol: incalculable
(Recall that LDL cholesterol is usually a calculated, not a measured value. The excessively high triglycerides make the standard calculation invalid--more invalid than usual.)

Fasting blood glucose: 210 mg/dl
HbA1c (a reflection of previous 60-90 days average glucose): 7.2% (desirable 4.5% or less)
ALT (a "liver enzyme"): 438 (about five-fold normal)

At 5 ft even and 138 lbs (BMI 27.0), May appears small. But the modest excess weight is all concentrated in her abdomen, i.e., in visceral fat.

By lipoprotein analysis via NMR (Liposcience), May's LDL particle number was 2912 nmol/L, or what I would call a "true" LDL of 291 mg/dl. (Drop the last digit.) Of the 2912 nmol/L LDL particles, 2678 nmol/L, or 92%, were small.

The bad news: This pattern of extremely high triglycerides, extremely high LDL particle number, low HDL, predominant small LDL, and diabetes poses high-risk for heart disease--no surprise. It earned her 7 stents so far. (Unfortunately, she has made no effort whatsoever to correct these patterns, despite repeated advice to do so.)

The good news: This collection is wonderfully responsive to diet. LDL particle number, small LDL, triglycerides, blood glucose, and HbA1c drop dramatically, while HDL increases. Heart disease will at least slow, if not stop.

It's amazing how far off human metabolism can go while indulging in carbohydrates, particularly a genetically carbohydrate-intolerance person. (Actually, I wouldn't be surprised if May's diet, as bad as it seems to you and me, still fits within the dictates of the USDA food pyramid.) The crucial step in diet to correct this smorgasbord of disaster is elimination of carbohydrates, especially that from wheat, cornstarch, and sugars.

Comments (26) -

  • john

    8/24/2010 9:57:22 PM |

    Wow, these numbers are wild.  It'd be great to see where they are in six months, assuming a change in diet.

  • Tuck

    8/24/2010 10:03:12 PM |

    Did you see the WSJ article today?

    "Giving Up Gluten to Lose Weight? Not So Fast"

    The last sentence is priceless:

    “Also, for dieters, going back to gluten after avoiding it can lead to stomach cramps, bloating, diarrhea and other symptoms, at least temporarily.”

    If an egg had that effect on you, they'd do a recall.


  • qualia

    8/24/2010 10:59:36 PM |

    great post! would be cool if you could pipe the links to your posts into your twitter account as well (there are online services), so that it can easier be forwarded by followers of you.

  • Anonymous

    8/24/2010 11:06:26 PM |

    The WSJ should give up the diet reporting and stick to what they (supposedly) know - financial news.  

    There's giving up gluten and then there's giving up gluten but maintaining a high starch alternative grain  GF diet.   Of course replacing one starch with another won't result in weight loss if one is overweight.  It's even possible to gain weight on such a GF diet.    

    Are people really silly enough to take diet advice from "creaky bones" Gwenyth Paltrow?

  • dan

    8/25/2010 1:01:04 AM |

    I watched the WSJ video.  It wasn't bad.  It was mainly ridiculing "gluten-free" imitation products.  The lady recommended eating natural foods that are gluten free.

  • Tommy

    8/25/2010 1:50:03 AM |

    I am completely baffled by some of the lipid panel numbers I see. She had 7 stents put in but there are many out there seemingly with no problems, with high numbers like that. Meanwhile I have eaten right and exercised seriously for the last 30 years, have never been overweight, always been in shape, had good lipid panel results but suffered a heart attack last year anyway. I just had bloodwork shortly before the attack and once again (as had been the case for years) I was told I was in perfect health. My triglycerides were good as was my CRP and my complete lipid panel. Actually any test I took ever, always produced good results. Even after my heart attack they couldn't get my heart rate up high enough in my stress test unless I ran longer and at the steepest incline. I'm still in great shape.....but I had a heart attack.  I never had a belly or bulge and still don't. 5'10" 169 lbs.  Go  figure.

  • 42

    8/25/2010 4:28:11 AM |

    My results after eight months: http://paleohacks.com/questions/9124/first-post-paleo-blood-work-results

    After 8 months and -50lbs  I can safely say that the std American flour/sugar diet is complete bullshit.

  • Lori Miller

    8/25/2010 4:36:29 AM |

    I bet that poor woman has forgotten what it's like to feel good. She'll surely feel better with an improved diet. I wish her the best.

    Re: WSJ article, I got a stomach ache that lasted two days the last time I ate a chocolate chip cookie made of wheat flour. That's some kind of "temporarily"!

  • Anonymous

    8/25/2010 5:58:01 AM |

    Lipids after two years of high-fat, moderate-protein, very low-carb eating:
    Total Cholesterol: 220, Triglycerides: 69,
    HDL: 98,
    LDL: 108.
    I think I'll carry on that way.

  • Anonymous

    8/25/2010 6:19:42 AM |

    After 7 stents and she still refuses to change her eating habits? I think that got my attention more than anything else in your report of this patient. I guess I am baffled on why people do not take charge of their health especially when expert advice is offered on a "silver platter".

  • Derek

    8/25/2010 2:11:31 PM |


    Sorry to hear that.  I guess it goes to show nothing is a guarantee.  No matter what we do, the chance is always there.

  • Jonathan

    8/25/2010 3:39:40 PM |

    Tommy, your case only goes to prove that cholesterol doesn't cause heart attacks.  
    There is something else causing CVD.
    Inflammation from Poly fat and grains seem the most plausible to me.

  • Tommy

    8/25/2010 4:04:49 PM |

    "Tommy, your case only goes to prove that cholesterol doesn't cause heart attacks.
    There is something else causing CVD.
    Inflammation from Poly fat and grains seem the most plausible to me."

    I had my CRP checked and it was below 4 just before my HA. After taking care of myself for the last 30 years and always doing well in every aspect I really felt backed against the wall afterward. My numbers are very low now (pretty close to 60's across the board) but all of this is more complexed than just numbers.

  • Dr. William Davis

    8/25/2010 5:05:28 PM |

    Hi, Tuck--

    That's great!

    It reminds me of the USDA's request for public commentary on the food pyramid revision, prefaced by "We don't understand why, after we tell people to increase consumption of whole grains, they keep on gaining weight and becoming diabetic."

  • Dr. William Davis

    8/25/2010 5:07:20 PM |


    Well said!

  • Jonathan

    8/25/2010 5:20:01 PM |

    "eating right" and "taking care of myself" only tells me you were healthy by your standards or by the governments standards.  Most of the people I hear say "I eat healthy" means they eat lower fat but mostly trans fat when they do.

    There has to be something causing your problem.  I would suspect what ever makes you extra hungry would be a possible cause.  Maybe it's too low cholesterol.  Agreed; very complicated.  Maybe it's just genetics.  Maybe there's something in the past 30 years that was not right but what?  A lot of maybes there.  Have you had a calcium score?

  • David

    8/25/2010 7:46:48 PM |


    Do you have Lipoprotein(a)? You sound to me like a textbook Lp(a) case. Better get it checked and address it.

  • Tommy

    8/25/2010 8:41:00 PM |

    Trans fat? nooooooooo...lol.
    No refined crap, no processed anything. Damn...I don't even eat ketchup(sugar)!! I consider AMA snobish about food intake. I had a conversation with a "heart healthy" dietitian from the hospital after my heart attack and she wanted me to have less than 50 g of fat per day (impossible). I told her I go by percentages of total calories consumed and explained it to her. She had no clue and didn't understand it in simplest terms. "Ok what if I wanted to consume more fat and just added non fat calories to my total intake....that would lower my percentage right? Uhhh....what? lol

    @ David
    I am thinking I may be LP(a) and I have been taking extra Vitamin D as well as a high dose of fish oil. Next cardiologist visit I will discuss Niacin as well as pattern B possibilities.

  • David

    8/26/2010 7:41:39 AM |

    Tommy, what about stress and sleep?  Stress is a killer...

  • Tommy

    8/26/2010 12:42:21 PM |

    David, that is my suspicion. It's complicated because a lot of things happened at once at that time. Through July and August I was under stress from problems at work combined with personal family issues. In September i went on a cruise an ate up a storm as well as drank more than normal gaining 14 lbs. (my prior good blood labs gave me confidence ..ha ha ha.) Then I came home, worked out hard and lost all the weight in a week. Then my grand daughter got sick and I was very stressed out about it while my work issues were still mounting. In October I had an argument in the morning before leaving work (I had been switched to an overnight shift)and was stewing when I went to sleep. I woke up a few hours later having a heart attack. The rest is history.

  • Ned Kock

    8/26/2010 2:50:39 PM |

    Hi Dr. Davis.

    These numbers are awful, but I think a point must be stressed regarding natural vs. industrial carbohydrate-rich foods. These numbers are not typical for normoglycemic folks who eat natural carbohydrate-rich foods.

    Avoiding natural carbohydrate-rich foods in the absence of compromised glucose metabolism is unnecessary. Those foods do not “tire” the pancreas significantly more than protein-rich foods do.

    Protein elicits an insulin response that is comparable to that of natural carbohydrate-rich foods, on a gram-adjusted basis (but significantly lower than that of refined carbohydrate-rich foods, like doughnuts and bagels).


    And nobody can live without protein. It is an essential nutrient. Usually protein does not lead to a measurable glucose response because glucagon is secreted together with insulin in response to ingestion of protein, preventing hypoglycemia.

  • Anonymous

    8/26/2010 10:33:29 PM |

    I definitely get the whole low-carb thing, but I think you always use the extreme cases to make your point.  Even dietitians would not recommend that much starch.  In fact, many of the "top" dietitians limit starch quite drastically in their meal plans.  They are not as ignorant as you think.  However, because they have clinical experience (which I know you have too), they know that draconian, restrictive diets do not work.  Therefore, they work starches in the diet a bit, so people don't feel "deprived."  Still they choose "better" starch options like beans (OMG LECTINS!!!).

    I do not believe for one second that the majority of people claiming to be eating according to the USDA guidelines are doing so within the correct caloric guidelines.  They are eating far too much and making terrible choices for starches to boot.  Portion control is tough obviously.  I think people who cannot master it may find low-carb useful because they eliminate starches/sugars outright and don't have to worry about serving sizes.  Plus, ketosis gives them a metabolic advantage allowing them to consume more calories and still lose weight.  It definitely is not an end all solution though.

  • Anonymous

    8/26/2010 10:37:29 PM |

    Also, they don't bad mouth carbs in the press because people being people would start avoiding things like vegetables.

    There is nothing inherently wrong with carbs.  We just have to eat them within reason.  Just like calcium for example.  Too much calcium is linked to heart attacks and prostate cancer.  But in moderate amounts, it is helpful.

  • stop smoking help

    8/27/2010 3:47:04 AM |

    Okay, I went my two weeks without wheat carbs. My results are purely non-scientific, but here goes. I lost 4 pounds, down to 156. I wasn't hungry at all. I didn't have any bread cravings like I thought I would. But I did have a hard time sleeping, for whatever reason.

    After my two weeks I had angel hair pasta and a hamburger on a wheat roll. My stomach was slightly upset for a couple of days once I started eating wheat carbs again - probably just a coincidence though.

    So I proved I could do it and I proved to myself that I wouldn't starve or go crazy without my bread. So, I think I'll be more careful about the wheat I put into my system. On the other hand, it looks like May needs to correct things and do it sooner than later.

  • scall0way

    8/29/2010 7:19:55 PM |

    Just goes to show ya. I'd *love* to weigh what Mary weighs - but it seems there is more involved that that. I just had an NMR test recently myself. Total LDL particle count was 2018. My doctor is freaked and says it's a horrible number. Every website I consult says it's a horrible number -though my small LDL is 212, only 10.6% of the total. But all the websites I consult say the total number is far more a risk factor than paticle size.

    But what were the HDL and triglycerides of the people with high particle counts. High like Mary's? My own HDL (measured just last week) is 66 and my triglycerides 49.

    But how do you get the particle number down? I've already been low-carb for four years, gluten-free for 18 months, avoid all sugars, take D3, magenesium, K2, 1500 mg niacin.

    Might it go down if I can get my thyroid normalized? That's one issue I'm still trying to work through with my doctor. Sheesh, the older I get the harder it gets. So many things to consider I sometimes wonder how anyone manages to stay alive for a few weeks - let alone many years for most of us.

  • Tommy

    8/30/2010 1:54:37 PM |

    So for people with existing coronary artery issues and Small particle LDL is it true that increasing fat (especially saturated fat) only makes this worse? If you go low carb you need to also be low fat?
    I read that "low fat" is bad for Pattern A but beneficial to pattern B.

    Dr. Davis?