April 26

Playing The Numbers Game: HDL, LDL and Risk

5  comments

Mike wrote a blog piece a while back called “The Low Fat Hammer” about how entrenched the belief in the health benefits of the low fat diet remains in the minds of the media, the public, and (Heaven help us) in the minds of many doctors, despite the mountain of scientific evidence amassed to the contrary. In virtually every head to head contest that has pitted low fat against low carb, low fat has failed miserably across the board.

Study after study has shown the low fat diet to be a failure in treating obesity, in solving diabetes, in reducing blood pressure or in decreasing heart disease risk. Granted the low fat diet does offer some mild reduction in total cholesterol and LDL, but with the offsetting side-effect that it also lowers HDL and changes the type of LDL particle made from the healthier large, fluffy ones to the small, dense ones that promote atherosclerosis. So even that minor benefit–i.e., lowering total cholesterol and LDL, if those really were benefits, which looks more and more suspect by the day–would be a wash. And yet, still, many of my well-intentioned, fellow physicians across the country continue to prescribe the low fat diet for their patients with elevated cholesterol. And, as per drug company marching orders, when the low fat diet fails (which it surely will) they turn to their favorite cholesterol lowering drug. No matter what, they just gotta get those cholesterol numbers down. Never mind that it appears that those particular numbers don’t really mean much. As Mike pointed out in a recent blog, if a cholesterol number is important, it’s HDL, not LDL and not Total.

I am constantly amazed when I hear stories of healthy people–even women–who are counselled to take cholesterol lowering drugs to treat these numbers even when they’re accompanied by offsetting positives. For instance, a woman I recently learned about was wrestling with her doc’s recommendation of taking a statin drug because her LDL was 149. The kicker, however, was that her HDL (the good stuff, the one you want as high as possible) was a whopping 135!! As the study Mike wrote about in his blog pointed out, LDL and total cholesterol didn’t matter a whit in determining heart disease risk, but every 1 point increase in HDL correlated with a 1% reduction in risk.

For crying out loud, with a normal HDL reading for a woman being in the neighborhood of 50 or 60, how low is this woman’s risk? Seventy-five or 85% lower than average? If her triglycerides were also below 100 (and I’ll bet the farm they were) she’s really in good shape.

Would she benefit from taking a statin? I doubt it.

Would it harm her? Maybe not, but maybe so, since side effects (even very serious ones) are not uncommon for these drugs.

But shouldn’t she get that evil cholesterol down? Bear in mind that most of the cholesterol in the blood comes, not from the food we eat, but from production in the liver. Its manufacture is under the control of a particular enzyme that goes by the unwieldy name HMG Coenzyme A Reductase. Statin drugs work by inhibiting (or slowing down the activity of) this enzyme, with the end result being that the liver makes less cholesterol.

All fine and well, but could there be a better, less potentially toxic method to achieve the same end?

Yep. Since insulin stimulates the activity of this enzyme, and since a low carb diet reduces insulin levels, eating a low carb diet reduces the activity of this enzyme and reduces cholesterol production. And if the total number is still up higher than you like and this worries you (probably needlessly), why not try a dose of inositol hexanicotinate (a B vitamin marketed under the name No-Flush Niacin) instead? It’s been proven clinically to work well, is cheaper, and has fewer potential side effects.


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  1. Dr Eades,

    I have just found your blog along with your husband’s. thank you for posting to it (and regularly!), your information is quite helpful.

    I hope you dont mind me asking a question re: niacin, since you wrote about it here.

    my understanding is that niacin, when taken in excess, can be toxic to the liver. I also understand that inositol hexanicotinate is safer, albeit can still be toxic at certain amounts. can you say what amount you would recommend to someone who wants to lower cholesterol? also would you recommend liver enzyme testing after a certain amount of time?

    Im also interested in your opinion on niacinamide. I understand it is the safest (and please correct me if Im wrong) form of niacin and yet it does NOT offer any proven cholesterol lowering benefits. My question regarding this is not one about cholesterol, but since we are on the subject I thought I would ask: I have a B complex I would like to take but the niacin (as niacinamide) is 200mg.. I believe the upper limit for niacin has been set at 35 mg? what say you.. will it be safe for me to take this (in your opinion) daily.. and do you think it will cause increased appetite (ive read niacin deficiency causes a decreased one).

    yes maam.. im definitely one of those people who scours the internet for information.. an MD’s opinion (and especially yours) would be much better before I start this.. unless you think it would be better for me to discuss this with my personal MD.

    thanks so much..

    COMMENT from MD EADES: We’re delighted you enjoy the blogs and find them helpful.

    The liver toxicity of niacin you mention was related to use of a sustained-release or time-released form of niacin, not to the “No Flush” variety.

    It’s important to remember that the RDI is an amount of a vitamin or nutrient required to prevent disease. In the case of niacin, 14 to 16 mg a day is required to prevent pellagra. Amounts significantly larger than 35 mg have been used clinically to treat specific conditions without untoward consequences.

    As to specific recommendations for specific individuals, state-by-state differences in medical licensure laws preclude our answering specific medical questions via the internet. We feel the appropriate venue is to discuss these topics with your own physician.

    Since you have an interest in this topic, however, you might wish to pick up a copy of our book The Protein Power LifePlan, which contains a long discussion of niacin and cholesterol. The book is available from bookstores nationwide, through on-line book retailers, on this website, and in many public libraries.

  2. thank you for your reply 🙂

    Just yesterday I purchased The Protein Power LifePlan along with Protein Power: The High-Protein/Low Carbohydrate Way to Lose Weight, Feel Fit, and Boost Your Health-in Just Weeks from an online retailer.

    Ive been eating this way for a few years but think these will be great additions to my library… and my lifestyle.

    I am especially interested in your section on cholesterol and also understand there is a section on magnesium – Im very interested in that.

    again, thanks for your help (and support)

    COMMENT from MD EADES: You’re welcome! Read them in good health.

  3. It appears that when the total/HDL or LDL/HDL cholesterol ratio is favorable, the level of the lipids that compose the ratio on CHD risk has little influence.

    COMMENT from MD EADES: The more important number is probably the triglycerides/HDL ratio, at least as far as what good studies out of Harvard have shown to best correlate with actual heart disease endpoints–ie who will have a heart attack.

  4. My husband has been advised that his Total Chol. went from 194 on December 15, 2006 to 271 as of today (2/27/2007). The test was performed in the Doctor’s office on a machine labeled Cholestech LDX. Since December he has been cautious as to his diet and we eat very little red meat. He has the occasional egg and a Ben & Jerry’s ice cream bar maybe once a week. He has also been on Norvasc since December 15th and his pressure has not come down, per the office blood pressure machine. I have a real problem with this, and I feel he needs to have the Lipid Panel taken in a Lab setting. I feel the machine may have been off or something. I find it hard to believe that in the space of almost 2 months, that the Chol levels have all gone up rather than down and that his B/P has remained at the high level. 130/94.
    Can you speak to these concerns please.
    Thanks so much.

    COMMENT from MD EADES: Medical licensing regulators frown upon physicians offering advice to individual patients they have never seen via the internet, phone, or mail, but even if that were not the case, it would be imprudent to do so, since we can’t possibly have the complete picture of what’s going on with a patient.

    I can make a few general comments, however, and would recommend that if you have not done so, you might wish to read either of our major books (Protein Power and The Protein Power LifePlan) and the discussions in our blogs for more information about the causes of elevated cholesterol and what it means.

    In general:

    1) In our experience, on a low carb diet, cholesterol generally falls and lipid parameters, such as HDL, triglycerides and LDL pattern, improve markedly.
    2) Total cholesterol is a poor measure of cardiovascular risk.
    3) Serum cholesterol is not elevated by eating red meat, eggs, or fat, in the absence of a diet high in carbs. It is elevated by starch, sugar, and trans fats, primarily, but can be exacerbated by low magnesium levels, low iodine levels, low hormone levels, and a whole host of other causes.
    4) The causes must be sorted out by a knowledgeable physician who can examine and question the patient first hand and then treated in partnership with that patient.

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