What you need to know about cholesterol—Total and LDL

Found on: http://www.wheatbellyblog.com/2017/10/need-know-cholesterol-total-ldl/

This is an area in which I will be guilty of oversimplification. But even oversimplified, it will vastly outstrip your doctor’s focus on total cholesterol, LDL cholesterol, and statin drugs. Unfortunately, most doctors have fallen for the marketing disguised as statin drug “research” paid for by the drug industry. Statin drugs do indeed provide a very small benefit—but with substantial health (and financial) costs.

The Undoctored Wild, Naked, and Unwashed strategies address these issues quite aggressively. For example, wheat/grain elimination reduces triglycerides dramatically, often by several hundred points (in mg/dL); raises HDL cholesterol over time; and reduces or eliminates one of the most powerful causes of heart disease—small LDL particles. Omega-3 fatty acids from fish oil reduce triglycerides, removing the distorting effect of excessive triglycerides on other lipoproteins and reducing heart disease risk. Cultivation of bowel flora likewise reduces triglycerides and improves insulin response, along with reducing cholesterol values (via increased growth of bacterial species that yield bile salt hydrolase enzymes that prevent intestinal cholesterol reabsorption). In other words, the basic Undoctored strategies improve the values on the standard cholesterol panel dramatically. Some people, however, are left with higher total and LDL cholesterol values, so it is important to understand several issues surrounding these two values.

Total cholesterol is virtually worthless, as it includes HDL cholesterol. If HDL goes up (as it nearly always does on the Undoctored program) by 40 mg/dL (which is great), total cholesterol will also go up by 40 mg/dl, but many doctors try to “treat” this rise with statin drugs, which makes no sense whatsoever. There is no useful information in total cholesterol, so this outdated value should be ignored. (Personally, my HDL cholesterol used to be 27 mg/dl when I was in my thirties and following a vegetarian lifestyle while jogging five miles a day. My HDL is now 94 mg/dl—nearly four-fold higher–eating a grain-free, low-carb, high-fat diet along with the collection of Undoctored strategies such as fish oil and vitamin D. Because my HDL increased by nearly 70 mg/dl, it means my total cholesterol includes 70 mg/dl of HDL and most doctors, “educated” by marketing rather than real science, would try to treat this change.)

LDL cholesterol is usually not even measured; rather, it is calculated from the other three values (total cholesterol, HDL, triglycerides). The calculation is outdated (over 50 years old), based on crude and inaccurate assumptions, and is unreliable. It also ignores variation in LDL particles— size, duration of persistence in the bloodstream, potential for oxidation (since oxidized LDL particles are especially bad), etc. For these reasons, I call LDL cholesterol “fictitious LDL,” since it is wildly unreliable. On this lifestyle in which we sharply curtail carbohydrates (which modifies lipoprotein composition), it becomes even more unreliable, essentially invalidating the calculation.

We therefore turn to superior methods to quantify LDL particles and measure their size. (See Appendix D of the Undoctored book) Small LDL particles—by far the worst (they persist much longer, are more prone to oxidation, and are more adherent to artery walls to form atherosclerotic plaque)—are triggered by consumption of carbohydrates; large LDL particles—more benign, persisting for a much shorter period of time, less oxidation-prone, less adherent—are caused by fats. Among lipoprotein testing methods, I believe that the NMR method is the best choice for accuracy and provides the most information. A typical NMR lipoprotein test result in someone with heart disease risk would be: total LDL particles 1,800 nmol/L (the units signify number of particles per volume) and small LDL particles 900 nmol/L—meaning that 50 percent of all LDL particles are the undesirable, heart disease–causing small variety caused by grain and sugar consumption, reduced dramatically with their elimination. Other methods, though distant second choices, are to measure apoprotein B (apo B)—since each LDL particle contains one apo B molecule, which therefore serves as a virtual count of LDL particles—or direct LDL measurement. However, both apo B and measured LDL provide no indication of size and therefore do not suggest a dietary solution to correct the excess of small LDL particles, nor do they reveal the full extent of risk posed by small LDL particles.

The goal is to minimize small LDL particles (no higher than 20 percent of the total), while the goal for total LDL particles is not yet worked out, as it is not clear whether large LDL particles even contribute to heart disease risk (particularly in the absence of inflammatory phenomena) and at what level. Stay tuned to Undoctored conversations for clarification of this issue.

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