LDL size and Heart Disease (small dense vs large "fluffy") | Dr. William Cromwell
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- Опубліковано 22 тра 2024
- Is it safe to have high LDL as long as it's large and "fluffy"? Is LDL size a key determinant of risk?
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References:
1-jamanetwork.com/journals/jama...
2-pubmed.ncbi.nlm.nih.gov/15296...
3-www.ahajournals.org/doi/epdf/...
4-europepmc.org/article/med/104...
5-www.ahajournals.org/doi/10.11...
6-academic.oup.com/jcem/article...
7-www.ahajournals.org/doi/10.11...
8-www.sciencedirect.com/science...
9-www.lipidjournal.com/article/...
Disclaimer: The contents of this video are for informational purposes only and are not intended to be medical advice, diagnosis, or treatment, nor to replace medical care. The information presented herein is accurate and conforms to the available scientific evidence to the best of the author's knowledge as of the time of posting. Always seek the advice of your physician or other qualified health provider with any questions regarding any medical condition. Never disregard professional medical advice or delay seeking it because of information contained in Nutrition Made Simple!.
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0:00 Intro
1:40 Small LDL is associated with risk
3:48 LDL size vs number
7:09 ApoB, lipoproteins and risk
9:16 Eliminating confounders
11:22 Genetic lessons
14:25 Small LDL keeps bad company
15:25 Summary & Takeaways
Incredibly clear communication by him without oversimplifying. You may have competition...
I know that you were just joking, but I'd like to say that in pursuit for truth, there shouldn't be competition, but cooperation. 🙂
So many people are still attached to the belief that you don't have to be concerned with LDL as long as they are large particles. It's definitely gonna take some time to change this common misconception.
Most people have no idea that there is difference type of LDL particles. 😂
It’s not a misconception. An interaction term for the LDL size phenotype must be added to the multivariate adjustment model with both subtractions which gives a clear picture that lbLDL are not associated with ASCVD in the absence of genetic perturbations.
Just bc Cromwell and Gil say it, doesn’t mean it’s gospel.
doi:10.1097/MOL.0000000000000824.
@@AZ89231 Cromwell said size is not irrelevant, and it's a factor, so that seems consistent with what you're saying. Cromwell also said a high number of large particle size is not good. It does not appear to me that you're refuting that. As far as I can tell, the abstract of the reference you provided does not refute that in any manner. I did not read the full paper though.
Plus, it is very sad to hear the word "significant" in the matter of total less than 2% in overall.
@@AZ89231One study does not invalidate all meta-analysis.
7:32 over 90% of ApoB particles are LDL [however in a previous video, the same expert said that in most people LDL-C doesn't track well with ApoB, unless your LDL-C is very high or very low, so i'm left a little confused as to which one i should test, also considering that idk the ideal ApoB ranges.].
7:41 here are the more atherogenic ApoB particles (the bigger ones are less atherogenic).
11:08 small and large LDL particles are equally atherogenic [this seems to contradict what i wrote in the line above].
11:20 the LDL in familial hypercholesterolemia is large [and not oxLDL, i might add], yet the people with such condition have early events and cardiovascular disease.
11:59 we used to think that small was worse than large.
12:31 large and small are equally associated with heart attack, stroke, and events.
Regarding your first question, I could not find when he said the LDL-C doesn't track well with ApoB for most people, can you give me the timestamp from the other video? The only reference I remember and could find was him explaining that if you have a high amount of Triglyceride Rich Remnants, that this was the cause for the discrepancy between ApoB and LDL-C as it relates to risk, but this was not typical.
LDL and LDL-c are two different things. LDL is the number of LDL particles,LDL-c is the amount of cholesterol inside these LDL particles. If you want the most accurate one-measure apoB and the lab usually has the intervals for that. Quick google search says less than 100 mg/dL( some other sources say 40-120 mg/dL) is good. The lower the better.
@@nichtsistkostenlos6565 the video is titled "What causes heart disease? | Dr. William Cromwell" and the part on the discordance between LDL-C and ApoB starts at 10:05.
@@nichtsistkostenlos6565 i have found the part of the video you're looking for but for some reason my comment reply isn't publicly visible :( oh, this one reply is visible! let me edit it real quick: the information you're looking for starts at 10:05 (in that other video by Gil with the same expert).
LDL-C refers to the cholesterol content carried by the apolipoproteins, whereas LDL-P refers to the number of LDL particles.
In most people, apob tracks well with ldl-p
Dr Cromwell is amazing at breaking down this complex topic! I'm not a clinician nor a statistician but even I could follow his nuanced explanation.
One of the best clear and concise summaries of particle size, particle number, and interactions as it relates to CVD risk. Thanks.
Covering every excuse from their book! Good job!
I am super early!
Love from an other (soon to be) dietitian from Greece!
Keep up the great work mate for both the public and us scientists all around the world!
Thank you for covering this important and misunderstood topic, Gil.
A clear concise explanation of a very complex topic. Reinforces the importance of lowering Ldl and Apo B.
Best nutrition channel in the world
Great video! Many thanks for this Dr Carvalho
Thank you for the amazing content Gil! The part about FH is really interesting too.
Thank you for covering this topic in great detail 😊
Excellent video! This was very interesting.
Thanks for explaining this topic.
This is a video everybody eating low carb/keto/carnivore needs to see. Influencers in that area only showing people half of the information, despite it is nothing incredibly new, comming to dangerous conclusions. There has been boycotting of statins, mistrust in primary care providers and their advice, self interpretation of blood test results if you look at the comments of such videos. Difficult to see, yet ineffective discussing with those people. Half truths are extremly dangerous. Thank you for this video, an honour to hear from such an expert that my understanding of the topic is not wrong.
I have a question though that has not been answered in this interview. In what cases does the determination of particle size sense in order to not overlook elevated risk, when you have somebody witout risk factors? As Dr. Cromwell was explaining the idea to look at particle size was given by the fact that there are individuals without otherwise detectible risk factors having myocardial infarctions.
Family history would come to my mind. In diabetics and insulin resistance you would have elevated TG, so that would give a hint at small particle size, thus not needing advanced lipid testing? Or am I wrong in that regard?
Sorry but I don't see anything disproving low carb diets. Listen carefully at 14:34. If you focus on the problem of metabolic syndrome (in other words, talk about the obesity epidemics rather than familial hypercholesterolemia), then indeed what happens is a huge amount of small dense LDL. And if the problem is insulin resistance, then fasting and low carb are proven ways to solve it.
@@southern842
You misunderstand me. Not saying it is a gimmick. I did low carb myself for a time.
I‘m against spreading medical misinformation. Every diet has a downside. You need to know what it is to counter balance it and to estimate the risk vs benefit going on such diets.
You can adjust the fats in low carb if you find your LDL-C rising to much.
It also might not be the diet that is causing high LDL-C, a big part is genetics. But with the misinformation out you simply might dismiss it as harmless not listening to your doctor about it.
We are also talking about long term consequences of high LDL-C, not short term, arteriosclerosis develops over decades. Short time elevated LDL-C is not that tragic, long term is. If you read about the critique on low carb you will find exactly that, the worry about long term effects.
It is also an option to do a diet long term + taking medication to counteract the negative effects of high LDL-C.
The worst thing to do is ignoring a problem by just talking it away as if it does not exist.
@@southern842 people improve when they stop overeating, stop eating ultra processed foods, and stop drinking alcohol. If low carb is the best way for someone to stick to these things, that's great! But at the end of the day, regardless of your diet, if your healthcare provider flags something in your blood work you should probably do something about it (including getting a second opinion if needed).
@@markotriesteThe entire country of Switzerland is proof against low carb 😂. They eat bread 5 meals a day and give zero F's. Low rate of obesity and diabeetus. Difference is they have real bread. Low carb is an American thing. We don't have real bread here, it's more like an industrial foam 😢
Great video Gil, thanks
Good info, Doc and Doc
Thanks for a great video!
Pairing with a creator with a very good ability to explain complex statistical topics (like 3Blue1Brown or Stand-up Maths, for example) to explain the suppressor variable effect would be fantastic. There wasn't enough time in this conversation to dive into it but I think presenting the exact way that that it affected the particle size analysis would be fascinating and help people really come to a personal and complete understanding of this subject. Some might wave this explanation off as that the extra analysis isn't honest and just serves to let the researchers arrive at the conclusion they wanted to arrive at. That's not the case, but bringing the viewers to a place where they can really internalize why that extra analysis is necessary would really solidify the point and the message. Also, math is awesome!
Definitely the most concise and understandable explanation I’ve heard of why risk tracks with number versus size, as well as how the confusion over particle size got started in the first place.
Gill, I appreciate the scientific rigour in all your videos and your passion to improve scientific communication. I strongly feel it would be much better if you use a professional camera to shoot your videos and also change the display picture of the youtube channel which is very over exposed and you are not at all visible.
That was very good, thank you. Although baffling not even a mention of Lp(a), even when discussing the most concerning ApoB containing particles. Lp(a) certainly should have been included.
Fantastic explanation of a very confusing subject. Sure wish he would have also addressed the added risk of the dreaded Lp(a) particles. Maybe a great follow up topic?
Excellent presentation. My doctor is one who still believes large particles are less concerning than small. I've been reading several studies on cholesterol, but most seem to concentrate on cardiovascular outcomes. I would love to have you address overall mortality in relation to cholesterol levels.
I'd have liked to have his opinion on the cholesterol paradox, ie the fact that low ldl is associated with higher mortality, especially in older people. Is it really fully explained by the fact that diseases that lead to death tend to lower cholesterol? (reverse causation )
Yes, unless you have outcome data to the contrary
Yes, and why do most heart attack and stroke victims have normal or low ldl levels.
Its not the size that matters, its how you use it. Thanks doc for the reassurance. 😂
I got the impression that you wanted to say that LDL is not that significant unless you are insulin resistant, suffering from metabolic syndrome or are diabetic. You kind of hinted at that but maybe I'm reading to much into it. Enjoying your videos. Thanks.
14:15 he just says that a lot of ldl is bad no matter the size. And about metabolic issues was that some of them are associated with high LDL. You misstated the point
Labcorp offers LDL particle (LDL-P) tests. But what numerical ranges in particle size and number are we supposed to refer to when interpreting our results and assessing possible risk? Dr Cromwell seems to have numerical sizes and ranges in mind associated with risk…how can we learn what those ranges are? (or appear to be at this point in time based on the current state of research?)
When Dr Cromwell talks about one particle blocking another, is he referring to a testing error or a data analysis error? He seems to say it's a data analysis error. I thought the test LDL-P results are very straightforward: a direct count and size measurement is provided with no ambiguity and that's it. What am I missing here?
Can you get Dr. Cromwell to comment on how he currently treats elevated Lp(a) levels as there is no approved drug to lower that LDL type . Thank you.
High lp(a) risk (above 100mg/dl) is addressed by crushing ApoB via diet and statin even in absence of other risk factors as per European Heart assoc consensus statement
Is there a partially empty bottle of whiskey on the desk behind Cromwell?
Looks that way. Moderate drinking helps the heart. The brain is a different story (cerebral hemorrhage).
Hi Gil, what do you think about Dr Gregor’s science based book How not to die? Lots of meta analysis.
We already know that our LDL lab results really measure LDL-cholesterol: the cholesterol within the particles. It's used as a sort of proxy, to guess at particle numbers. It doesn't measure particle numbers. Is this really a useful number, when particle count is what truly matters? Is ApoB the only useful number available, and why isn't it used routinely? By the way, the latest research has clearly shown that LDL-cholesterol does NOT directly cause cardiovascular disease. I believe Dr. Carvalho has a video on this.
Is testing for particle size useful if you have a low LDL level? Mine is calculated to be 39 mg/DL. Total cholesterol is 120 mg/DL, and HDL is 61 mg/DL.
Hello. I understand cholesterol goes up in those with Hashimoto's diease mainly due to non diet related issues; apparently mechanism for which is not clear(?). I would really like it if discussions/ another video could be made addressing heart health and other symptoms like brain fog, fatigue etc be addressed even whilst being on thyroxine and having correct lab test results. Thank you.
I would be interested in this as well.
At the moment I’m trying to lower my LDL and will be measuring my ApoB after revamping my diet to a Hashimoto diet Mediterranean style. I’ll also retest my antibodies to see if by chance it made a difference.
Small dense (damaged) ldls are typically damaged via glycation and/or oxidation. It cannot bind to receptor so stays in body with nowhere to go. Typically seen with high triglycerides.
Sdldl is a Hallmark of metabolic syndrome
I heard Niacin (B3) can lower LDL. Is it True? Then why we still need Statin?
Dr Cromwell and Gil talk about APOB in terms of particle number but my understanding is that APOB is expressed in mg/dl which is a measure of weight and not a measure of particle number. Where as LDL particle is measured in terms of nmol/L which is a true particle count. Am I understanding that correctly? So I have seen blood results where particle count is high but APOB is low. This seems to be indicative of a large concentration of small particles. i/e weight is low (APOB) but particle number is high (LDL particle count). So I am still a bit confused when he says the important factor is particle count and the important value is APOB. When APOB is not measure in these terms (from what I understand).
Sounds like yet another blood test that adds to the medical bill.
Can the patient let it wait until they are referred to a lipidologist?
So not part of the screening panel?
Why did people start differentiating between different LDLs if typical laboratory blood exams don't separate such in the first place?
If someones total cholesterol is high but everything else is fine, (hdl high, ldl fine but on the higher cusp), would thid be affected by health polyunsaturated fats? My mother does not eat meat or processed foods just rarely chocolate and cakes....no butter but olive oil
my trig - 41mg/dl, ldl - 96mg/dl, hdl- 69mg/dl, small dense ldl - 49mg/dl. Am doing low carb diet.....can low saturated fat diet help to reduce small dense ldl?
It's been decades since my last stats class in grad school and I'm trying to wrap my head around his explanation of small LDL "hiding" the effect of large LDL. Is he saying that when you look at small LDL, it's clear that risk increases as the number of particles increases, but if you then add the number of large particles into the analysis, on top of the small ones you've already included, the risk factor doesn't go up much, because most of the risk has already been accounted for by the small particles? Whereas if you look at the correlations separately, the increase in risk is the same whether the particles are large or small?
Would really love to know his thoughts on Lp(a).
Me too
Me 3! Mine was 380 nmol/L last time I checked. It was 243 nmol/L last June, 293 in September, and last time I checked in April it was 380. No telling how high it is now. Getting new blood work done tomorrow.
From his examples, it seemed the risk from large LDL came from genetic conditions. Are there differences in the causes and remedies of large LDL as opposed to small particles? And if I am understanding correctly, we are still concerned with particle numbers, not total cholesterol, so if the cholesterol is a little higher but in fewer particles because they are large, it is lower risk than the same amount of cholesterol in a larger number of small particles?
Very informative video. But I am not sure I heard an answer to Gil's very good question: what about a person who has a high number of particles but has an ApoB in the healthy range? Based on Dr Cromwell's analysis, it sounds like he is saying that ApoB is not a helpful predictor for that individual. Or did I misunderstand what he said?
Unless I'm terribly mistaken, your ApoB number IS the number of particles in circulation. There's exactly ONE ApoB protein attached to each particle. If your ApoB number is within the healthy range your risk of cardiovascular disease is low.
@@paulmaxwell8851 So you are saying that the hypothetical I described is impossible? I don't know enough about this to know if that is so. That is the source of my confusion.
All ldl particles have apob, an lpa has the same one apob plus one lipoprotein a it’s the only difference
I have recently learned of oxidized triglycerides and how many studies about their atherogenety were performed. I wonder why there is no mention of them in atherosclerosis cause discussions like this? Are they irrelevant or debunked?
So, all LDL particles are atherogenic, but some more than others, and the fewer of both, the better?
No - all LDLs are equally atherogenic
@@nanduthalange77367:40, is VLDL not LDL? "VLDL not so much." I'm still sticking with what I said unless someone clarifies this. Also I did not say "equally."
It appears that he is saying the small particles seem to be worse because there are too many of them, and the bigger ones seem worse because they are equivalent to a few small particles.
I think until they don't explain the mechanism of action of how these particles interact with and enter the artery walls, it is all a mathematical model.
No we do not know that. All are dangerous, but we have yet to understand exactly how relatively dangerous each is. @@nanduthalange7736
@@rsalehi6568 He said the larger ones, VLDL and chylomicrons "not so much because they're so large they don't get into the artery wall."
Mine are small, friendly, smoochy and bouncy … friendly ldl particles are not atherogenic as it would be considered rude.
What about low ApoB and LDL and higher sdLDL-C
8:05 So LDL are danergous because they are small enough to get under the inner layer of the artery wall?
I think I just had a "A HA" moment that helps me tell these *DL's apart.
it's a question of ""Foam cells, also called lipid-laden macrophages, are a type of cell that contain cholesterol. These can form a plaque that can lead to ... " and how particle sizes pro[de]mote this trigger mechanics,"
TriGlycerides are just as good a proxy for metabolic [insulin] disease as any other.. This idea of confounders [supressor variables] obscuring causation might mean something to him, but to me it is only the cross correlation that is confounding his hand waving argument. Mathematically these are the eigenvalues of the co-variance matrix of paramenters [ this is distinct from Factor Analysis yet more multivariate calculus]
What's the variability between people in distribution of LDL particle sizes? Can you affect it in a meaningful way via diet, exercise, drugs?
With LDL-c fixed one could have particle count several times lower by making their particles bigger in diameter. If the particles are balls (probably not, more like discs?), doubling their diameters would give 8 times more storage of LDL-c per particle, i.e. 8 times fewer particles for the same amount of total LDL-c.
Maybe that's why carni crowd says their stratospheric LDL-c is fine cause they believe they have *that* much bigger particles, so their 480mg/dl LDL-c is really equivalent in risk to usual 60?
ETA: I saw your video on not-dr Berg who went through his wifes labs and it wasn't pretty so I guess keto is not the answer here.
👌
Haven’t you posted this before ? The bottle of,scotch is still on his desk.
That's a digital background, there are a few places in the video where the effect breaks up around the left side of his body (looking at the screen, so his right arm). Watch between the 12-13 minute marks.
My ldl is 180 and Apob 120 .. . Which one to believe ?
I like my pillows like my LDLs: large and fluffy! 😆
LDL is an opsonin, meaning it prepares a bacterium to be eaten by a phagocyte. LDL is part of the immune system and goes up during infection. Once you input this missing factor, infection, then everything makes sense.
Now go learn the difference between LDL and LDL-c ;-)
Small or large, both are bad. OK. Understood. This is a good new actually as it is simpler like that 😂.
Thanks for all your work and all your interview. Your channel is great. It helped me to really understand my conditions (I am eating in a balanced way but due to familial hypercholesterolemia, I have high ldl/Hdl) and find simple actions to lower my LDL in the healthy range and avoid (for the time being) statins.
👍👍👍👍👍
Glad i found you, Sir.... so good and in depth 👌
uhhh it's almost quantum mechanics 😀
At 7:28 Dr. Cromwell says the following
"Of all the ApoB particles our body makes, over 90% are LDL"
So, does that mean for most people (who aren't currently tested for ApoB), that our ApoB test result will usually be a little below or a little above our LDL level result?
Currently with a LDL of 40, it would seem of little value to test my ApoB which would probably track closely to my LDL results.
I believe this is a repeat.
All I know is eating a diet high in saturated fat is not good for you and that will do for me
One thing you should probably know is that some people can have the healthiest diet and exercise regimen available and still have high LDL-C/ApoB and be high risk for heart attacks due to genetic factors. Good to know your cholesterol numbers, most notably triglycerides, LDL-C, ApoB, and LP(a), so you know whether you're at risk regardless of your own specific dietary interventions.
Is that a bottle of scotch?
More single ingredient carbs and less fat is the answer.
Single ingredient carbs? First time hearing this phrase. Does this mean whole carbohydrates or something else?
@@MmartinLI think they mean like oatmeal but it's a confusing term because white sugar is also a single ingredient carb.
The only type of fat that seems to increase the presence of blood serum atherogenic particles are saturated fats. The amount by which that occurs in saturated fat seems to vary by person a lot, but PUFAs and MUFAs are not implicated in any of the literature that I'm aware of.
Whole foods carbs. Basically whole grains and potatoes. McDougall style high carb plant based diet.
Any carb that's one ingredient. That automatically includes all fruits. One ingredient starches too like potatoes, sweet potatoes, peas, corn, oatmeal, whole wheat pasta, etc. White rice and white wheat pasta are also ok
So size doesn't matter, but kinda does? 😵
Size matters a bit because small means you have more actual particles and more likely to have other metabolic issues but having elevated ldl where they are large is also bad.
Basically get ldl levels to a good amount and dw much at all about size
I love your content but I'm distracted by how much you look like Joe Strummer. But I have decided to stay rather than go.
Which will burn down your house... Large fires or small fires? 😜
Kaiser does not even test for this many years after I asked for them. All they will test is Lp(a) along with regular cholesterol.
You can check prices online to order your own tests. In some areas they have discounted labs prices and they’re fairly reasonably priced.
Unfortunately, that is how I found out about my autoimmune. I had to order my own test . Needless to say I switched doctors.
I wish you would go back to the basics of eating. Its nutrition made simple but the topics keep getting more complicated. My doctor isnt going to run any of these tests for me so doesnt help me with my health. But talking about what to eat each day and basics of food and nutrition will help me. So please go back to the simple part of the name, its getting to complicated and there are lots of videos out there about all the stuff that we cant control or get are doctors to test. It was better when you first started.
But before you go jump on the statins, just get your absolute risk looked at with a heart scan
CAC score doesn't measure soft plaque though. That's the most dangerous plaque.
All LDL is atherogenic.
This should be the food pyramid
Vegetables
Fruits: all fruits are good
Single ingredient starches: potatoes, sweet potatoes, grains, legumes. If more than 1 ingredient, then no meat, dairy, eggs, nuts, seeds, chocolate, oil of any kind, artificial colors, flavors, additives, preservatives, fortified vitamins and minerals ( especially iron) gmo ingredients, (modified corn starch, HFCS,) and other mysterious ingredients. Organic is better for wheat, corn, and oats.
-- Please give me your opinion --
Is cholesterol (nearly) not uptaken from peripheral cells from (all) lipoproteins?
This is what I conclude from the above paper (see below).
Am I right?
--------------------------------------------------------------------------------------------------------------------------------------
In the paper:
*Physiological Bases for the Superiority of Apolipoprotein B Over Low-Density Lipoprotein Cholesterol and Non-High-Density Lipoprotein Cholesterol as a Marker of Cardiovascular Risk*
you can find following statements:
"What physiological process is served by the cho-
lesterol that was exported from the liver within VLDL
particles and returned as VLDL or LDL particles? Is this
just a futile cycle of cholesterol or could it be that cho-
lesterol and CE are essential elements to form VLDL
particles? Alternatively, could it be that at least in cer-
tain circumstances VLDL particles also export excess
cholesterol from the liver? These are questions without
answers at present."