First up, an email from Robert, who'll become a medical doctor in under a week. He must be completely thrilled, eh?
Just wanted to say hello. I’ve been a regular reader for several months now and thought I should take a moment to introduce myself. My name is Robert and I will be an MD in about six days. I’ll be starting an internal medicine residency in Reno, NV in July. I am both excited and nervous about starting, nervous largely because my patience with “modern” medicine is in rapid decline and I have three years of attending physicians to deal with. Yes, Richard, all of the doctors I have worked with personally approach health and nutrition in as mindless a manner as you think and often rant about.
I know, Robert, and isn't it the damnedest thing? Here you spend all that time, money and effort — all the while enduring an enormous burden in terms of mental and physical stress and fatigue — and it would certainly be an appropriate reward to be held in the sort of superman high esteem doctors have traditionally and often deservedly been held.
But I think it's safe to say that owing to the Internet, with its legions of people like me who deal in facts, logic and principles — and not so much in titles, degrees and positions — that we're in a situation where the gig is up. Doctors have largely squandered the goodwill they've earned over a century of hard, dedicated, lifesaving work. Thankfully, there are a growing number of docs like your very-soon-to-be self who have come to see the light. It's going to be an uphill battle for a long time.
For instance, Tim, another reader, sent me his lipid panel for comment. Though I don't expect you to comment, Robert, I have an idea that you would interpret it far differently from Tim's doctor. So, as frustrating as it is, this is a step in the right direction. There's that.
February, 2008, 225 lbs, years on the Standard American Diet:
LDL (calc) 91
July, 2008, 160 lbs, through calorie counting, semi starvation, yet semi-low carb:
LDL (calc) 68
Been going Paleo(!) since Sept 08, intermittent fasting, 3 days a week lifting hard efforts, sprints, eating tons of meat! Actually heading down the road for 90 days of meat only (2+ weeks in right now) so I did another panel:
May 1, 2009, 170 lbs, more muscle!
LDL (calc) 137
Should I be concerned of the rise in Total and LDL? From what I've read on your blog, Dr. Eades, and other sources, I don't think so. I am more fearful of the 145 total number (cancer! etc) than the 226! But my doctor is of the opposite opinion.
His doctor is of the opposite opinion, but why? Has the doctor been reading Eades, Davis, Sears, Briffa, or the many others out there and concluded that they are wrong? I doubt it. Tim's doctor is probably what I now refer to as a "regurgitator," i.e., as applied to the medical profession: someone who is trained to expertly diagnose and treat in accordance with conventional "wisdom," right or wrong. My non-medical opinion is that we ought to be cheering his great success in improving his health in a way that reflects every well done study and observation of this sort of thing I've seen.
For example, his C-reactive protein was .3 (a "BTW" in another part of his email), where "normal" is < 3 mg/l. This is a strong marker for inflammation — the very thing that small, dense LDL acts upon to cause heart disease. Also, the ratios they have given Tim are of Total/HDL, which remain steady, as his HDL went from 60 to 82 (all the while you hear great cheering amongst the ignorant masses when someone goes from 45-50 and credits oatmeal or Cheerios). Normal for that ratio is 4-6, because grain and sugar eaters have such miserably low HDL. Ideal is 2-3. Mine was 2.1, so was my wife's, thereabouts, so there's three data points on that for Paleo: IDEAL.
The more important ratio by far, in my opinion, is Trigs/HDL. This is one of the biggest associations with cardiovascular disease (CVD). Again, grain and sugar eaters have abysmally low HDL (the thing that carries oxidized LDL out of your arteries and back to the liver for recycling) combined with elevated triglycerides, which is dissolved fat in the blood. Yes, ironic, isn't it? You want low levels of circulating fat in your blood? Replace grain and sugar with fat in your diet and the very first thing that will happen is that your Trigs (fat in your blood) drop precipitously. Guaranteed.
Tim went from a decent level of 109 ("normal" is considered < 150, but that's only because it's based on normal for grain and sugar eaters) to a whopping low of 34. Of course, he did it by replacing crap in his diet (grain and sugar) with real food like animals and their fat.
Now, in case you're suspicious about the veracity of this Trig/HDL ratio being of prime importance, there's a lot out there. How about this, a 1990 (!) interview with then director of the massive, long-term Framingham Heart Study, Dr. William Castelli.
"There's a subgroup of people who have an HDL under 40 and triglycerides over 150," he explains. "These people have galloping proression of their cholesterol deposits, which will eventually lead to heart disease, and the average physician is not picking it up."
You can read the whole interview.
So, what did Tim's Trig/HDL ratio do while progressing from SAD to Paleo? It went from 1.8, which is on the very low side of ideal (< 2), to .4, which is on the screaming bleeding high side of ideal. Mine is also .4, so is my wife's, thereabouts, so three more data points for ya. Tim achieves a 4.5 magnitude improvement on his Trig/HDL ratio.
I wonder what Cheerios would have done for him.
But that's not all. His LDL is calculated, and rather than rehashing the pitfalls of calculated LDL, I'll just refer you to my 2-part series: What Do You Think You Know About LDL Cholesterol? (part 1; part 2). For another reference, here's how LDL ought to be measured: NMR LippoProfile.
But what can we glean from the information provided? Well, it turns out that the Trig/HDL ratio is a reasonable marker for LDL particle size. Remember, and you can find out more here, but small & dense LDL particles are the real danger. Guess what else? grains and sugar give you a profile where most of your LDL is small and dense, while a high fat (natural, i.e., animal) diet gives you LDL that's large and fluffy, which is inversely associated with CVD, so far as I can tell.
RESULTS — Clinical characteristics, pharmacological therapies, lifestyle, and prevalence of diabetes-related complications were similar in both patient groups. LDL size correlated negatively with plasma triglycerides (TGs) (R2= 0.52) and positively with HDL cholesterol (R2=0.14). However, an inverse correlation between the TG–to–HDL cholesterol molar ratio and LDL size was even stronger (R2= 0.59). The ratio was >1.33 in 90% of the patients with small LDL particles (95% CI 79.3–100) and 16.5% of those with larger LDL particles. A cutoff point of 1.33 for the TG–to–HDL cholesterol ratio distinguishes between patients having small LDL values better than TG cutoff of 1.70 and 1.45 mmol/l.
Let's unpack this, and by the way, while this may look incomprehensible to many of you, do know that a couple of years ago it would have been to me too. I can only encourage you to persevere. You can develop an ability to pretty well understand this stuff. Yes, consult a doctor (hopefully one like new-doc Robert), but go in knowing and understanding what you're talking about. If a doctor is ever offended by your accumulated knowledge and insistence on questions and clear explanations, you need to find a new one.
- LDL size correlated negatively with plasma triglycerides: higher Trigs = smaller LDL particles (bad)
- …and positively with HDL cholesterol: lower HDL = smaller LDL particles (bad)
- However, an inverse correlation between the TG–to–HDL cholesterol molar ratio and LDL size was even stronger: the ratio is even more important, i.e., the higher the ratio, the smaller (badder) the LDL particles. Stunningly striking: 90% of those with small dense LDL (bad bad bad) had a Trig/HDL ratio greater than 1.33.
So, what's an average Trig/HDL ratio? I don't have time to look up averages and verify sources, but let's just assume an "on the edge" level for both Trigs (150) and HDL (40).
That's a whopping ratio of 3.75, well above that 1.33 "cutoff"!!! So, if you present to your medical professional with better-than-"normal" triglycerides of 149 and HDLs of 41, he's going to give you a big high 5, and tell you you're on the right track. He's probably not going to even measure your C-reactive protein to determine inflammation markers, nor your Lipoprotein(a), or even homocysteine. And Tim? Before his transformation? Even with a very moderate Trig level by "normal" standards, he had a ratio of 1.8, well over that 1.33 "cutoff" between likely (with 90% confidence) small dense LDL and large fluffy. And now, at .4? Fergettaboutit. He's going to have an NMR per a subsequent email, but I can already tell you what it's going to show.
[Late edit: Note that as commenter below, GoEd, has correctly pointed out, that 1.33 ratio is based on European units for Trigs and cholesterol, i.e., mmol/l instead of mg/dl. That would all be fine and good, but Trigs and cholesterol convert differently. Dumb mistake, as I've made these conversions a number of times. So, at any rate, the ratio for Trigs and cholesterol based upon mg/dl is about 3.0, not 1.33. So, still, our example of a "normal, excellent" profile at a ratio of 3.75 is still well above the cutoff, albeit not quite as dramatically as I first implied.]
Though it is probably achievable to have a a small percentage of small LDL on a standard diet, I'm far more certain that it's going to be far easier accomplishing it on a paleo-like diet.
Afterthought: Tim has VLDL measurements, and the only thing I know is that lower is better. However, I've no idea how they are measured, how reliable they are as a marker, or any relevant studies. If an astute reader can educate me and the rest of us, please do so — with my sincere gratitude.