Lipoproteins, small LDL
I’ve discussed previously why cholesterol testing should have been abandoned decades ago as a crude, outdated, and nearly useless gauge of risk for heart disease. Sadly, that is one of the few tools your doctor has to address cardiovascular risk along with other useless practices such as cutting dietary fat and including “healthy whole grains” in your diet, ideas that got their origin from the absurdities of cholesterol testing.

But the real tragedy of cholesterol testing is not that it causes your doctor to dispense useless information, but that it took everyone’s attention away from the factors that really do cause heart disease. Focus on the real causes of heart disease and you learn that you can do plenty about such factors as insulin resistance, inflammation, bacterial endotoxemia, and triglycerides/VLDL particles. Another factor that is widely ignored yet a potent contributor to heart disease risk is small LDL particles.

As the name suggests, small LDL particles are small. But it’s not only about size. It’s also about the unique configuration of the particle that makes it unrecognizable to the liver.

Eat some fat and large LDL particles result. The configuration of large LDL particles and the protein, apoprotein B (apo B)–one apo B per LDL particle–are readily recognized by the liver and thereby cleared within 24 hours of their creation. Small LDL particles, however, have an altered configuration and thereby an altered conformation of apo B that the liver does not recognize well, allowing small LDL particles to circulate for 5 days or longer, allowing more time to do bad things such as enter the artery wall and contribute to atherosclerotic plaque formation. This is why eating a chicken sandwich, bagel, or bowl of ice cream on Monday will trigger formation of lots of small LDL particles that persist into the weekend.

In addition to their persistence in the bloodstream, small LDL particles also:

  • Are more prone to glycation and oxidation, making them more atherogenic (atherosclerotic plaque-causing)
  • Are more adherent to the structural tissues of arteries
  • Are more likely to trigger inflammation upon gaining entry into the arterial wall

If we were to examine the blood of people with coronary disease using NMR (nuclear magnetic resonance), the gold standard for analyzing blood lipoproteins (fat-carrying proteins), we would see that virtually everyone (except for smokers, who develop heart disease even without small LDL particles) has an abundance of small LDL particles. A typical small LDL value in someone with heart disease would be in the range of 1200-2400 mol/L (particle count per volume).

What causes small LDL particles? A number of factors:

  • Consumption of grains and sugars–Any food that fuels liver de novo lipogenesis, the liver’s conversion of sugars to triglycerides that yields increased VLDL (very low-density lipoproteins) in the blood leads to formation of small LDL particles. This is a big part of the reason why blood levels of triglycerides and VLDL are powerful risk factors for heart disease.
  • Insulin resistance–i.e., the body’s poor responsiveness to insulin
  • Inflammation–including that within coronary arteries
  • Endotoxemia–i.e., the entry of microbial byproducts into the bloodstream from dysbiosis, small intestinal bacterial overgrowth (SIBO), and small intestinal fungal overgrowth (SIFO). Preliminary evidence suggests that endotoxemia is a major factor contributing to heart disease.

How do you get rid or minimize small LDL particles? It’s easy, costs very little, and involves no pharmaceutical agents or procedures and thereby commands zero interest for practicing physicians.

To get rid of small LDL particles:

  1. Quantify small LDL particles via NMR–If you can measure something, you can track it to gauge whether or not you have been successful.
  2. Supplement the EPA + DHA of fish oil–since this reduces VLDL/triglycerides substantially, as well as disables bacterial lipopolysaccharide that causes endotoxemia
  3. Address other common nutrient deficiencies that plague modern people that contribute to insulin resistance–vitamin D, magnesium, iodine
  4. Take steps to cultivate a healthier microbiome–that includes a high-potency multi-species probiotic (accepting the deficiencies of modern probiotics), daily consumption of a fermented food, and including prebiotic fibers with every meal. You can go farther by adding some of our fermented yogurts such as L. reuteri or L. casei Shirota, made using my modified methods that increases bacterial counts to 200+ billion CFUs. And address SIBO and/or SIFO to further reduce endotoxemia.

(I would ignore the “goal” pictured in the photo above. Small LDL ceases to contribute to risk when reduced to 200 mol/L or less. Zero small LDL is actually readily achieveable.)

It’s really not that tough. Just by following my Wheat Belly/Undoctored programs, you can readily accomplish all of the above. While your doctor advocates statin drugs (that disrupt the microbiome and increase insulin resistance), a low-fat diet (that fuels de novo lipogenesis, causes small LDL particles, and promotes small LDL particle glycation), and is eager to schedule you for procedures, you have the power to eliminate risk for heart disease by rejecting conventional advice that actually contributes to heart disease risk.