Atherogenic dyslipidemia; Tchernof 2013

From Tchernof 2013

“Atherogenic dyslipidemia” simply refers to the abnormal lipoproteins (fat-carrying proteins) in the bloodstream that lead to the accumulation of atherosclerotic plaque in arteries such as the coronary arteries. This phenomenon has little to do with cholesterol but plenty to do with the particles in the bloodstream that develop with diet and other factors.

I stumbled on this helpful graphic (above) while thinking about the effects of visceral fat, i.e., the deep abdominal fat that encircles organs such as the liver, intestines, pancreas, etc. that is known to be a powerful source of risk for type 2 diabetes, cardiovascular disease, dementia, and cancers. In this graphic, the left panel displays the normal situation, while the right panel displays the abnormal situation of having excess visceral fat.

In the normal situation associated with low-risk for these health conditions in the left panel, note that blood markers such as:

  • Triglycerides and VLDL particles are at low levels. I define an ideal level of blood triglycerides as 60 mg/dl or less. Because VLDL particles track perfectly with triglycerides, the triglyceride value on any standard cholesterol panel is a reliable index of VLDL. VLDL particles are both direct causes of heart disease as well as a factor that leads to formation of small LDL particles.
  • LDL particles are large and usually associated with “normal” levels of LDL cholesterol. (Although it is not uncommon for LDL cholesterol to be high, even though this pattern is associated with low cardiovascular risk, reflecting the unreliable and inaccurate nature of the LDL cholesterol value.) Large LDL particles are readily recognized by the liver and thereby cleared from the bloodstream in <24 hours.
  • HDL particles are also large and believed to be more protective.

In this low-risk situation, lipoproteins don’t lead to accumulation of atherosclerosis in arteries and thereby do not lead to heart disease.

In comparison, when there is excess visceral fat that causes resistance to insulin and inflammation, as illustrated on the right panel, then:

  • Triglycerides and thereby VLDL particles are increased, contributing to increased atherogenicity (accumulation of atherosclerosis in arteries) and potential for events such as heart attack, development of angina, and sudden cardiac death.
  • Increased small LDL particles. Recall that small LDL particles persist in the bloodstream for 5-7 days, since smaller particles partially conceals the apoprotein B recognition protein, making it less likely to be cleared by the liver. Note that, despite an increase in the worst particle of all, small LDL particles, this is not reflected in cholesterol values. In fact, it is common for LDL cholesterol to go down when small LDL particles develop, concealing the fact that a high-risk pattern is present.
  • HDL particles become small and less protective.

I share this to drive home just how useless, even misleading, cholesterol values can be. High LDL cholesterol can actually reflect low risk, while low LDL cholesterol can conceal high risk. Imagine just how deceptive this can be: What if the gas gauge on your car showed empty when the gas tank was full, but showed a full tank when truly empty—it would be useless. Well, that is how cholesterol measures are: virtually useless as indicators of cardiovascular risk. And, as I often say, the real tragedy of cholesterol testing is that it takes everyone’s focus away from the real causes of heart disease.

It all fits together. A low-fat diet rich in “healthy whole grains” leads to low HDL that are small and non-protective, lots of slow-to-clear LDL particles, lots of triglycerides and VLDL particles, increased insulin resistance, increased blood sugar, increased blood pressure, increased measures of inflammation like C-reactive protein, and an epidemic of weight gain and obesity. Yes: dietary guidelines and most doctors CAUSE health problems while providing the appearance of coming to your rescue with silly strategies like statin cholesterol drugs, blood pressure, and anti-inflammatory drugs.

The solution? Find a doctor who understands that cholesterol testing is outdated and should no longer be used and instead uses a method such as NMR lipoprotein analysis that reports VLDL, number and size of small LDL particles, and number and size of HDL particles. Even better, address issues such as insulin resistance and inflammation that also play roles, and address vitamin D, thyroid, and blood glucose status. Gain these insights and you will also come to appreciate that you are provided huge control over cardiovascular risk using strategies such as diet, addressing common nutrient deficiencies (vitamin D, omega-3 fatty acids, iodine, magnesium) that impact insulin resistance and inflammation, and the gastrointestinal microbiome. Do you now appreciate how derelict the healthcare system can be if the only concern is “high cholesterol”?