Ask your family physician what the number one cause for heart disease is, and he/she will likely reply "high cholesterol" without hesitating. Most Americans would answer the same. After all, the media overflows with discussions about cholesterol and how drugs can reduce it.
Just 30 years ago, small LDL was far less common because lifestyles were different and the technology for identifying small LDL was unavailable. Why the surge in the small LDL pattern? Two reasons: 1) The explosion of excess weight and obesity in the U.S., which triggers formation of small LDL particles, and 2) over-reliance on processed carbohydrates, especially wheat-based convenience foods, that increase expression of the small LDL pattern enormously.
Small LDL has climbed into first place as the number one cause of heart disease. (Number two: low HDL cholesterol.) Given current trends, as many as 80-90% of those with heart disease, 40-50% of the overall adult population may harbor this pattern.
Official agencies like the American Heart Association and the USDA have lost touch with the emergence of small LDL as a trigger for heart disease. The USDA Food Pyramid, for instance, advises American adults to eat 6-8 servings of grains per day. This advice is a sure-fire method to ignite expression of the small LDL pattern. The American Heart Association's Heart Check Mark program endorses products like Cocoa Puffs, Berry Kix and Cookie Crisp cereals and hundreds of other similar products as "heart healthy" that likewise act as potent triggers of the small LDL pattern.
It's also the same worn advice that has resulted in a nation drowning in obesity.
If you have small LDL and/or its frequent partner, low HDL, in my view it is time for reduction of wheat products and other processed carbohydrates, not some politically-correct silliness about increasing fiber by eating whole grains. Whole grains create small LDL! (Or, I should say, what passes as whole grains on the supermarket shelves.)
Small LDL is a big part of the explanation why some people with an LDL of cholesterol of, say, 130 mg/dl will have heart disease, while others with the same 130 mg/dl of LDL will not. When present, small LDL particles are much more likely to trigger atherosclerotic plaque formation. Estimates vary, but small LDL is estimated to increase heart attack risk at least three-fold.
How do you know if you have small LDL particles? There are several tell-tale signs: On a standard cholesterol panel, low HDL cholesterol (<40 mg/dl in men, <50 mg/dl in women) and high triglycerides (>100 mg/dl in men and women) can signal probable small LDL. (Small LDL can be present even when HDL and triglycerides are not in these ranges, though less commonly.) Excess abdominal weight and a diet over-dependent on processed carbohydrates, a frighteningly common situation, also provide clues. Unfortunately, the reality is that small LDL can occur even in the absence of any of these "red flags." Best of all, your doctor can specifically check for small LDL through "lipoprotein testing." You doctor can order this test, but must specify "lipoprotein testing" by one of three standard methods (see below).