Lipoprotein Checklist: Small LDL
TYP SITE
Small LDL
Just like people, LDL particles vary in size and structure. The size of the LDL particle makes a crucial difference in whether or not it contributes to coronary plaque.
While all LDL particles, regardless of size, contribute to heart disease and atherosclerotic plaque growth, small LDL particles are much more likely to do so. That's because small LDL particles more readily enter and adhere to the artery wall, induce oxidative damage, and ignite inflammatory responses. Small LDL particles escalate heart attack risk up to 6–fold, as compared to large LDL.
Small LDL is more likely to be present when HDL is <60 mg/dl, though some people with high HDL levels may still have small LDL. Small LDL occurs with any level of LDL cholesterol, high or low. LDL cholesterol of 130 mg/dl, for instance, can be all large particles, all small particles, or, most commonly, some mixture of the two.
Because triglycerides are a necessary ingredient for the body's production of small LDL, reducing triglycerides is among the effective strategies for reducing small LDL. Fish oil may work by this route.
Small LDL is much more common when pre-diabetic patterns are present, such as high blood sugar (=110 mg/dl), low HDL, high blood pressure, large waist size, and increased inflammation (C-reactive protein). However, a rare person may have small LDL cholesterol particles even when pre-diabetic patterns are not present and body weight is ideal. This represents a strong genetic tendency that may not fully respond to treatment. Thankfully, this is unusual.
The majority of people with small LDL particles enjoy a vigorous response to the following strategies.
Small LDL is reduced by:
* Niacin in doses of 500–1500 mg is an effective method of reducing or eliminating small LDL. Niacin also raises HDL, increases large HDL, reduces VLDL and triglycerides, and modestly reduces total LDL. When used in combination with statin agents, there is a profound reduction in heart attack risk. The preferred forms are prescription Niaspan® and over-the-counter Slo-Niacin®, the safest and best tolerated. Immediate-release niacin can also be taken safely, provided it is taken only twice per day. Total daily doses of >500 mg should only be taken under medical supervision. Avoid nicotinamide and "no-flush niacin" (inositol hexaniacinate), neither of which have any effect whatsoever.
* Fish oil—The omega-3 fatty acids in fish oil reduce triglycerides and VLDL, and thereby reduce small LDL, since triglycerides are a necessary ingredient to produce small LDL. Fish oil, 4000 mg per day, is a good starting dose (providing 1200 mg EPA+DHA); higher doses should be discussed with your physician, though we commonly use 6000–10,000 mg per day without ill-effect. Flaxseed oil, while beneficial for health, does not correct lipoprotein patterns.
* Weight loss to ideal weight or ideal BMI (25). If achieved with a reduction in processed carbohydrates, the effect will be especially significant.
* Reduction in processed carbohydrates—especially snacks; wheat-flour containing foods like breads, pasta, pretzels, chips, bagels, and breakfast cereals; white and brown rice; white potatoes. The reduction of high- and moderate-glycemic index foods is the factor that reduces small LDL. Small LDL particles are therefore a major problem that develops when someone follows a low-fat diet. For this reason, we do not advocate low-fat diets like the Ornish program. Reducing your exposure to wheat-containing snacks and processed foods is an especially useful and easy-to-remember strategy that dramatically reduces small LDL particles.
* Raw nuts—Raw almonds and walnuts, ¼–1/2 cup per day, modestly reduce small LDL. Dry roasted (with no added hydrogenated oils or other unhealthy ingredients) exerts the same effect.
* Oat products—The soluble fiber, beta glucan, most plentiful in oat bran, can modestly reduce small LDL. Oatmeal (though not instant) is a second choice. Three tablespoons of oat bran per day provides full effect. Oat bran can be used as a hot cereal; added to yogurt, cottage cheese, and other foods; and as "breading" for fish, chicken, and other baked meats. Using oat products in place of wheat products is an effective strategy to substantially reduce small LDL. Beta glucan can also be taken as a nutritional supplement; a total of several thousand milligrams (e.g., 2000–4000 mg) are required per day, preferably spaced out into two or three doses.
* The thiazolidinediones (Actos®, or pioglitazone, and Avandia®, or rosiglitazone), usually prescribed for pre-diabetes or diabetes, can reduce small LDL by 30%. However, these agents are accompanied by weight gain.
* The fibrate class of prescription drugs (fenofibrate, or Tricor®, and gemfibrozil®, or Lopid) reduce small LDL significantly. The effect is approximately half that achieved with niacin.
Track Your Plaque target: <10 mg/dl small LDL
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