If you’ve read Don’t Die Early, you know the book explains in great detail the failings of the Lipid Hypothesis, the dangerously inaccurate model that proclaims that having “too much cholesterol” causes heart disease. Don’t Die Early explains that the real factors that combine to form heart disease are glycation (elevated blood sugar), inflammation, oxidation, and damagingly small LDL particles. These four factors are overwhelmingly more relevant to one’s risk of heart disease than simply measuring total cholesterol, or even measuring the quantity of LDL (the wrongly labeled “bad cholesterol”).
Examining these four factors, however, begs the question do they all contribute equally to heart disease? In other words, can one or more of these factors be less of a worry if others are in check?
I’ve posed this question to a number of forward-thinking cardiologists and studied the work of various researchers and the answer is a definite “maybe.” And the “maybe” points at lipids.
On one end of the spectrum are folks like cardiologist William Davis, author of the Wheat Belly series of books and founder of the Track Your Plaque online community. Dr. Davis firmly believes that one’s lipid subfractions (the size and characteristics of the lipid particles) are a significant factor in heart disease. Echoing Dr. Davis is professor of biochemistry James P. Otvos, who believes so strongly that lipid subfractions are a principal factor in heart disease that he founded the company LipoScience, a company specializing in performing lipid subfraction analysis.
If I were so bold as to guess, I would say that Drs. Davis and Otvos fall on the “all four factors are equally important” end of the spectrum. This is the position I take in Don’t Die Early, where I advocate that people facing coronary artery disease address all four factors with as much vigor as possible.
On the other end of the spectrum, are the cardiologists who think that lipids are all but irrelevant in the face of the other three factors. If a person controls glycation, inflammation, and oxidation, they argue, there is very simply no need to worry about lipids.
Not at all.
For example, in a conversation I had with cardiologist Dr. Dwight Lundell on the role of advanced lipid testing, Dr. Lundell offered his opinion that “Lipid testing is stupidity and advanced lipid testing is advanced stupidity.” When I asked if a person who already had heart disease and who was already aggressively working to lower blood glucose levels, reduce inflammation, avoid oxidation would be well served to also try and optimize lipid subfractions, Dr. Lundell responded that the role of lipid particles is so minimal in the face of the other three factors that it’s meaningless to chase lipids.
In other words, it’s not worth chasing the 1% when you need to be worrying about the 99%.
Similarly, I have met with cardiologists who no longer even perform cholesterol testing whatsoever on their cardiac patients. None. At all.
Clearly, cardiologists such as these fall into the “lipids are not a factor” camp, preferring that their patients instead focus on reducing glucation, inflammation, and oxidation.
So, which is it? Is heart disease an equal product of glycation, inflammation, oxidation, and lipid subfraction characteristics or is it just about glycation, inflammation, and oxidation?
In other words, do the factors of heart disease look like this?
Or like this?
Personally, I don’t think this is an answerable question. Even if we could quantitatively assess, in real time, the role that each factor is playing as heart disease progresses (a feat that’s logistically infeasible and undoubtedly beyond today’s technology), I think the influence of these factors almost certainly varies from person to person.
I think the more important point to take from this discussion is that there’s no reason to obsess about lipids. If their role in the formation of cardiac plaque is at most 25% of the cause and might be virtually irrelevant, we are far better worrying about the other 75 to 99%: glycation, inflammation, and oxidation.
Fortunately, lifestyle decisions that control blood sugar and reduce and reverse inflammation and oxidation are also likely to sway one towards more favorable lipid patterns. Those grains you’re avoiding in the name of blood glucose levels and inflammation are also shifting you towards a large, less dense LDL pattern. By avoiding vegetable oils and other “heart healthy” oils so that you minimize omega-6 intake and the inflammation it causes, you are also improving your lipids.
Accordingly, it’s quite likely that even if we choose to focus on the other three factors and “ignore” the lipid question, we’re still improving our lipids.
Which gives even more reason to relax about your lipids..
Whether lipids are <1% or as much as 25% of the problem, there’s no denying that the bigger potential benefit comes from controlling your blood sugar, reducing inflammation, and lowering oxidation in your body.
In other words, don’t get tunnel vision on your lipids and ignore the bigger picture.
 “Forward-thinking” in this context means a cardiologist who already recognizes that the Lipid Hypothesis is hogwash and who focuses on preventing heart disease instead of just prescribing statins to lower the patient’s LDL and waiting around until a bypass or a stent is required.