Cholesterol belly

Kate posted these “before” and “after” values for her cholesterol panel, i.e., values from before her wheat elimination, then values after elimination. Her experience helps illustrate a number of important issues that surround lipid/cholesterol testing. I thought it would be interesting to take her numbers apart to understand them.

I had read Wheat Belly this last summer as we were traveling in our motor home. Well, we were in South Carolina visiting my daughter. Both my husband and I read Wheat Belly and thought: Yep, we’re gonna do this, and we did. Do you have any idea how hard it is to make a change like this when you’ve stocked up your motor home with all of the “other” foods!!??

So we acted in faith and got rid of all of our ‘old stuff’ and, sorry to say, carted it over to my daughter’s house who was happy to have it. We started our full-on gluten-, wheat- and grain-free life.

It was unreal: Each day my little tummy went down and inches started to go away. We started this in August. It’s December 27th and I had my blood work done about a week and a half ago, as I do every December. I was SO excited about it that I just had to come back and blog and well, say “hi” to Dr. D! And to say my sister is gluten-free, my son and his wife and my granddaughter are the latest to go gluten-free (and this one is a miracle!!) and several friends of mine are doing it.

OK, back to the blood work. Here it goes:

December of 2011, December 2012
Total Cholesterol: 234, Total Cholesterol: 210
Triglycerides 121, Triglycerides 81
HDL 69, HDL 85
LDL 141, LDL 109

Now the lab results says both [cholesterol values] are high but what I see is the wonderful difference between these numbers. I am thrilled. And it’s all from NOT consuming gluten. I’m 6′ tall and weigh 170 and am in pretty darn good shape for a 62-year old gal!!

All I can say is, it works. Dr. D said it would and it did and I am thrilled. And it’s a piece of cake, well, you know what I mean, to do this.. it’s now a lifestyle that I care NOT to cheat.

Thanks for posting your numbers, Kate, and sharing you and your family’s experience. Let’s try and make sense of these values:

Triglycerides
Kate’s triglyceride level dropped from 121 mg/dl to 81 mg/dl, a very nice reduction. This is due to the reduction in liver de novo lipogenesis, the conversion of the rapidly-digested carbohydrate of wheat, amylopectin A, into triglyceride-containing particles like very low-density lipoproteins, or VLDL.

Think of triglycerides in VLDL as the first domino: Once there are excess triglycerides as VLDL particles, they interact with other blood particles, especially LDL particles, in turn enriching LDL particles with triglycerides. This leads to a series of reactions in the bloodstream that cause the formation of small LDL particles. So Kate’s very nice reduction in triglycerides means that she is forming fewer small LDL particles. While conventional wisdom says that small LDL particles do not form until triglycerides are 150 mg/dl or greater, in real life this is absolute nonsense: It is true that a triglyceride level of 150 mg/dl is associated with flagrant excess of small LDL particles, but you can still have oodles of small LDL even with lower triglycerides. The contribution of triglycerides to forming small LDL particles essentially ceases when triglycerides are reduced to 60 mg/dl or less. (So keep on going, Kate: Aim for the ideal triglyceride value of 60 mg/dl or less by further slashing carbohydrates. Also, consider supplementing omega-3 fatty acids from fish oil, e.g., 1800 mg per day of EPA + DHA, the most effective way to reduce triglycerides after wheat/carbohydrate reduction.)

HDL
HDL is protective against heart disease, stroke, even cancer. In general, the higher the HDL, the better.

The excess de novo lipogenesis that yields excess VLDL particles characteristic of wheat consumption also affects HDL particles. HDL particles, like LDL, become enriched in triglycerides and become smaller, less protective, particles. Also, the excess triglycerides cause degradation of HDL, reducing the quantity persisting in the bloodstream. Thus, wheat-eating humans have lower HDL levels. As Kate’s experience demonstrates, lose the wheat and HDL goes up, often way up. (HDL cholesterols of 70, 80, 100 mg/dl are everyday events.) While she started with a favorable HDL, she now has a spectacular HDL level that is likely mostly of the beneficial large variety.

LDL cholesterol
I call conventional LDL cholesterol fictitious LDL cholesterol. This is because this value is calculated–yes, calculated–from the Friedewald equation developed in the 1960s by Dr. William Friedewald:

LDL cholesterol = total cholesterol – HDL cholesterol – triglycerides/5

It is meant to estimate the quantity of cholesterol within the low-density fraction of lipoproteins in the bloodstream. Problem: The original Friedewald equation relied on several assumptions, including the assumption that the amount of triglycerides and cholesterol in ALL LDL particles was the same. In those of us following a wheat-free diet with limited exposure to junk carbohydrates, the triglyceride content of LDL particles is much lower, making the Friedewald equation invalid.

In a practical sense, it means that Kate’s Friedwald-calculated LDL cholesterol of 109 mg/dl likely overestimates the real LDL value. If Kate were to have her doctor draw, for instance, an NMR lipoprotein panel, she would see that her real LDL was something like 70 mg/dl (i.e., LDL particle number of 700 nmol/L, for those of you familiar with NMR lipoprotein panels). Or, if an apoprotein B were to be obtained, it would likely be something like 60-70 mg/dl–a very favorable value. So Kate does NOT have a high LDL cholesterol, just the misleading appearance of 109 mg/dl by the invalid calculation. Had an NMR LDL particle number or apoprotein B been obtained at both “before” and “after,” Kate would indeed have witnessed a drop in all these measures. While her fictitious LDL cholesterol also dropped, some people experience the opposite: an increase in fictitious LDL, but truly concealing a drop in the superior measures.

Total Cholesterol
Total cholesterol is a useless, outdated value for a number of reasons.

First of all, total cholesterol is too crude a marker for anything. Yes, it is a crude statistical marker in a large population, but a useless predictor at the individual level. Total cholesterol should have gone the way of frontal lobotomies long ago.

Second, you can see by the Friedewald equation that, if the equation were solved for total cholesterol rather than LDL cholesterol, it would be become:

Total cholesterol = LDL cholesterol + HDL cholesterol + triglycerides/5

Note that a rise in HDL–something good–is unavoidably accompanied by a rise in total cholesterol–something presumed to be bad. In other words, total cholesterol would be misleading. Conversely, some stress that drops HDL, say, by 20 mg/dl would reduce total cholesterol by 20 mg/dl–once again, misleading. Total cholesterol is an absolutely useless value that has no business being measured or reported in modern healthcare.

Kate has done a wonderful job of transforming her lipid/cholesterol panel and reducing or eliminating her risk for cardiovascular disease–but not for the reasons often cited. The drop in triglycerides, the rise in HDL, and meaningless drop in fictitious LDL cholesterol that conceals a genuine reduction in LDL particles–it’s all good with wheat elimination . . . but it has nothing to do with cholesterol.

This entry was posted in Cholesterol, Lipids, Small LDL particles. Bookmark the permalink.

124 Responses to Cholesterol belly

  1. Jeanine says:

    I hope you get a response. Your post is compelling: following WB but your doctor is steering you in a different direction because of your geno type. i also hope you post the results from the June testing. Best wishes and hope results indicate that you can continue with WB.

  2. Janet Dodge says:

    No need to repost Kate’s numbers, I see them here now! TY, Janet

  3. Great job Kate!

    I am struggling with my cholesterol… Have been eating a lot of fruits and I even started blog about it.

    Since I am a very slow person, I tend to need more time for things… so I am just starting with my fitness plans… will see how that works out! :)

  4. Nic says:

    I’m also considering eliminating wheat from my diet. Never easy to do as it is such a staple, but Kate’s results are food for thought. The more I read about the benefits of eliminating wheat, the more convinced I am that it’s worth a go, especially since eating wheat products often leaves me feeling bloated. I guess that’s a sure sign that my body isn’t too keen on it.

  5. Malcolm says:

    Hello Dr. Davis:
    I live in Canada and I am wondering whether it would be possible for me to obtain a NMR Lipoprotein blood test. The test is not available in Canada. The U.S. labs do not accept clients from Canada. Perhaps my physician in Canada could arrange to send you a blood sample, which you would in turn send for analysis (I could pre-pay the cost to you).

    Best regards,

    Malcolm

    • Dr. Davis says:

      No, please don’t do that, Malcolm. I have no way to actually run the test, nor do I want to be involved in a process that your doctor should manage for you.

      Getting this done in Canada is indeed a problem. Have you contacted the company, Liposcience? They are the most likely to be helpful. Please let us know what you learn.

  6. Malcolm says:

    Hi Dr. Davis:

    I’ll be getting in touch with LipoScience this week. Gotta say I am not enthused about some things on their Web site, such as their advice on eating…

    “Eat more whole grains, fruits and vegetables. Eating more of these foods, like whole-wheat pasta, beans, nuts, berries, spinach and broccoli, are good for your heart. Limit your red meat — like steak and hamburgers — eat fish at least once a week and lean turkey or chicken without the skin. Use olive oil or canola oil in place of butter. Avoid fried foods or those meals served with heavy sauces.”

    Malcolm

    • Dr. Davis says:

      Yes, their dietary advice is absolute nonsense. It reflects their willingness to fight some battles, but not others.

      That’s how it goes in life, eh?

  7. Kelly says:

    Please shed some light on what is going on with my 6 year old. They took a baseline level for cholesterol last year, and her total cholesterol was 222 (132 LDL, 67 HDL, Triglycerides 100). They were concerned, and we modified our already presumably healthy all organic diet. After a year (last week) she was retested: Her new results total 270! (LDL 168 HDL 94, Triglycerides 40). Doctors are so shocked and baffled by the spike in LDL, and the dramatic lowering of the other numbers that they are sending her to cardiology at Children’s hospital. She has a minimal amount of organic wheat in her diet, which we will be removing, but someone please try to explain these numbers to me and how I can explain to conventional medicine why we shouldn’t necessarily be alarmed, because I’m totally freaked out right now!

    Thanks!

    • Dr. Davis says:

      No freak out required, Kelly, just smarter doctors.

      To understand this situation, I would suggest:

      1) A full lipoprotein panel, e.g., NMR lipoprotein analysis, HDL Labs lipoprotein analysis, Spectracell, Berkeley HeartLab panel, or VAP–NOT cholesterol testing, a crude screening test. Be sure the one you choose includes lipoprotein(a).

      2) An apoprotein E genotype test–This will help explain unusual dietary responses.

      I doubt any of these issues were considered. My colleagues (cardiologists) are NOT generally helpful with these issues unless they specifically take an interest, which is true of about <1% of cardiologists. If your son sees a pediatric cardiologists, the most common response is “cholesterol is too high, he needs a statin drug” despite the fact that a crude screening test that is notoriously unreliable was the basis for the decision.

  8. Sifter says:

    Seems to be incorrect that only small LDL is harmful. The following study suggests both small and ‘big, fluffy’ LDL is harmful. Would appreciate Dr. Davis’s response to the following pubmed study:

    LDL particle subclasses, LDL particle size, and carotid atherosclerosis in the Multi-Ethnic Study of Atherosclerosis (MESA).

    Mora S, Szklo M, Otvos JD, Greenland P, Psaty BM, Goff DC Jr, O’Leary DH, Saad MF, Tsai MY, Sharrett AR.

    Abstract
    BACKGROUND:
    Previous studies showing that smaller low-density lipoprotein (LDL) size is associated with greater atherosclerotic risk did not adequately control for small and large LDL particle correlation.
    METHODS AND RESULTS:
    We studied the association of lipoproteins measured by proton nuclear magnetic resonance spectroscopy with carotid intima-media thickness (IMT) in apparently healthy individuals (N = 5538, 38% White, 28% African American, 22% Hispanic, 12% Chinese). Small and large LDL particle concentrations (LDL-p) were inversely correlated (r = /-0.63, P < 0.0001). Controlling for risk factors but not for LDL subclass correlation, LDL size and small LDL-p separately were associated with IMT (-20.9 and 31.7 microm change in IMT per 1-S.D., respectively, both P < 0.001), but large LDL-p was not (4.9 microm, P = 0.27). When LDL subclasses were included in the same model, large and small LDL-p were both associated with IMT (36.6 and 52.2 microm higher IMT per 1-S.D., respectively, both P < 0.001; 17.7 and 11.6 microm per 100 nmol/L, respectively). LDL size was not significant after accounting for LDL subclasses and risk factors (P = 0.10).
    CONCLUSION:
    Both LDL subclasses were significantly associated with subclinical atherosclerosis, with small LDL confounding the association of large LDL with atherosclerosis. Future studies of LDL size should account for the strong inverse correlation of LDL subclasses.

    "However, after accounting for their inverse correlation, both LDL subclasses showed highly significant and independent associations with IMT, with a greater difference in IMT per large LDL particle compared with small LDL."

    http://www.ncbi.nlm.nih.gov/pubmed/16765964

    • Boundless says:

      > … did not adequately control for …

      Are there ANY lipid studies that adequately controlled for diet?

      • Sifter says:

        I don’t believe it said anything about not adequately controlling for diet. It said ‘did not adequately control for small and large LDL particle corelation’.

        • Boundless says:

          > I don’t believe it said anything about not adequately controlling for diet.

          It didn’t. My point was that the study you reported is complaining about inadequate controls in other studies, but itself probably doesn’t adequately control for what is arguably elephant in the lipid lab: diet.

    • Dr. Davis says:

      The bulk of data suggest that small, oxidation-prone, glycation-prone is a much more atherogenic beast than large LDL. This study is just one among many.

      We do indeed need better data, particularly real outcome studies (myocardial infarction, mortality), not just surrogate studies. But the surrogate study data on the whole suggest that small LDL particles are the worst kind.

  9. Sifter says:

    Thank you Doctor.

    It is difficult for the layman to discern between the legitimacy of the ‘inflammation’ side of things, i.e. Dr. Sinatra, Dr. Davis, many others… and the ‘lipid hypothesis’ camp of Drs. Esselstyn, Ornish, the Brown and Goldstein study, and many others. The only thing I seem to be able to discern in terms of overlapping agreement is more veggies, less refined sugar. The issues of sat. fat, PUFAs and grains seem to be huge points of contention between both ‘camps’.
    In the pursuit of dietary Truth….. Sifter

  10. Karen says:

    Dr. Davis,
    I have been wheat free for 1 year now and would like your advice. I went to get my lab results today from my Dr. and he wants me to go on Cholesterol medication. I am a 54 year old female in excellent health with the exception of high blood pressure which is under control with medication. My lab results are as follows:
    Total Cholesterol: 258
    HDL: 75
    Triglycerides: 52
    LDL-Cholesterol: 173 (previously it had been 159
    Chol/HDLC Ratio: 3.4
    Non HDL Cholesterol: 183
    Glucose: 100
    I do have a history of heart disease on my father’s side.
    I would really appreciate your advice as I am scheduled to have labs done again in 8 weeks.
    Thank you so much!

  11. Karen evans says:

    Dear Dr. D,

    I am thrilled to say I have been wheat free since Dec. 4th 2012. In that time I’ve dropped 40 Lbs. feel TREMENDOUSLY better and gone from a size 16 to 6. My journey has been amazing and it all started with your book. I’ve read Good Calories, Bad Calories, The Great Cholesterol Myth! & now Cholesterol Clarity in which you were a contributor. But – having had this success I’m still greatly frustrated about my cholesterol numbers and the fact that I’m still fighting with my doctor about taking a statin. I don’t seem to have had the success in this area that others have and I admit I still don’t understand all of these elements of the blood.

    My numbers as of 8-23-13 taking no statins:
    Triglycerides = 121mg
    LDL = 193
    RCHOL/HDL = 5.82 Ratio
    HDL = 45
    Total Cholesterol = 262

    I have cheated not at all and eat close to no carbs – only those in veggies. And, I also take meds for hypothyroid. Any insights?

    Thank you for everything you’ve taught me. I appreciate it more than I can ever say. You gave the control back to me over weight and nutrition.

  12. I was shocked when my Doctor told me that my bad cholesterol was high. I exercised a lot and ate well (at least I thought I did). But I wasn’t eating cholesterol busting foods. But embracing the ‘Trawler Diet’, I lowered
    my bad cholesterol in just 12 weeks.

  13. Malcolm says:

    Now What?

    I got the results of my detailed lipoprotein analysis from Spectracell Laboratories. My question to Dr. Davis is – Now what should I do?

    I am a 64-year old male, slim, 152 lbs, 6′ tall, fit, exercise regularly and have been on Wheat Belly for two years. My carbohydrate intake is still high by Wheat Belly standards, about 100 grams/day. I could bring that down to 50 grams per day by eliminating my daily orange, apple and several carrots.
    I know I have coronary artery disease based on a 64-slice CT scan done in July 2010, which revealed blockages up to 60% and a calcium score of 479.
    The report I got from Spectracell breaks the results into 3 simple categories: Green = Normal, Yellow = Borderline, Red = Abnormal or higher risk.
    In the lipoprotein analysis my total LDL particles were 1052 (abnormal). They advise a number under 900, or even 700 if there is known coronary heart disease. My total HDL particles, non-HDL particles, and large buoyant HDL2b were all slightly in the red (abnormal) zone.
    The good news is my small dense “LDL III” and “LDL IV” were OK. The cutoff for LDL III is 300 (mine was 275) and LDL IV should be under 100 (mine was 72). Remnant lipoprotein at 142 was also normal (the cutoff is 150).
    My biomarkers and other risk factors were good. Lp(a) was 15.3 (well below the cutoff of 30). My hsCRP was 1.0 (AOK) and insulin and homocysteine were in the normal range.
    In the lipid panel they flagged my LDL of 161 as very high, well above their cutoff of 130. HDL was borderline at 43. Triglycerides were good, measuring 75. But non-HDL-cholesterol (calculated) at 170 was high (should be under 160). Total cholesterol was 213 (borderline high).
    Spectracell is pretty bullish on using Niacin therapy. I have experimented a few times with niacin (the proper fast-acting form called nicotinic acid – 1500 mg/day) for 3 month intervals, and it works wonders with my cholesterol numbers. It does drive my homocysteine up (from 8.5 to 10.5), and tends to raise uric acid, GGT and blood sugar a bit. Based on my tests, niacin lowers my total cholesterol to 160, drops LDL to 100, and raises HDL to 50. It even drops hsCRP at bit.
    I am considering 3 options:
    1. Resume niacin therapy
    2. Reduce my carbs to 50 (eliminate the fruit and carrots)
    3. Ease up on my fat consumption (e.g. boil eggs instead of frying, take the skin off the chicken, etc.)
    Would you favour option 1, 2, or 3? Or should I do all of them?

    Best regards,

    Malcolm

    • Dr. Davis says:

      See the “My particles are bigger than your particles” chapter in the original Wheat Belly book, Malcolm, for your answers.

      • Malcolm says:

        Dr. Davis:

        Thanks for your response. I did re-read the chapter in your book. Based on what I read, I won’t worry about lowering my fat consumption, but will focus on cutting out the fruit.

        I am still perplexed about why my VLDL and triglycerides and dense particles are all AOK, yet the LDL particle number and Apo B values are in the high-risk range.

        Any thoughts on that?

        Best regards,

        Malcolm