Meet Mark

Let me introduce myself. My name is Mark Sisson. I’m 63 years young. I live and work in Malibu, California. In a past life I was a professional marathoner and triathlete. Now my life goal is to help 100 million people get healthy. I started this blog in 2006 to empower people to take full responsibility for their own health and enjoyment of life by investigating, discussing, and critically rethinking everything we’ve assumed to be true about health and wellness...

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September 11, 2017

Dear Mark: Really High HDL, More Heart Disease; Low-Salt For Grandpa?

By Mark Sisson

Inline_DM_07.03.17For today’s edition of Dear Mark, I’m answering two questions from readers. They were excellent this week. The first one comes from Sarah, who’s a bit puzzled by the recent paper in which people with the highest HDL levels died earlier than those with lower levels. What’s going on, and is more HDL actually bad? Last but not least, how should a reader approach a doctor who wants to put Grandpa on a low-salt diet? Is there any literature or information he can present?

Let’s go:

Hi Mark,

I just read this article in the NY Times about how really high HDL levels are linked to greater risk of heart attacks. What’s going on here? Isn’t HDL supposed to be good?


Very interesting study.

Before we tackle your question, let’s establish what HDL particles actually do:

They intercept and neutralize oxidative stressors in the blood.

They regulate coagulation.

They reduce inflammation.

They inhibit platelet aggregation.

They deliver cholesterol to the liver for processing and to organs like the testicles and ovaries for conversion into steroid hormones.

These are established mechanisms, by the way. And they’re all “good things.” Avoiding clots, lowering inflammation, limiting oxidative damage to the endothelium, making sex hormones? What’s not to love? More HDL, please.

If that’s true, how can higher HDL be linked to more cardiovascular mortality?

Remember that production of HDL is a dynamic process. The body doesn’t just make HDL for the hell of it, nor does it make a set number of HDL particles irrespective of what’s going on in and outside the body. HDL has a very specific set of skills. When HDL’s services are required, the body makes more.

This means that very high HDL could indicate a need for high HDL. What does HDL do, again?

It could mean elevated platelet aggregation. Maybe you’re boosting HDL production to prevent a clot.

It could mean you’re in danger of atherosclerosis. A major role of HDL is to protect LDL from oxidative damage and prevent the atherosclerosis that would otherwise result. In one study, putting mice on a high omega-6/omega-3 ratio diet increased HDL—probably because the lopsided O6/O3 ratio was making the LDL more vulnerable to oxidative damage—but failed to prevent atherosclerosis.

HDL doesn’t have superpowers. It doesn’t always finish the job or prevent the malady from befalling you. Sometimes the clot happens, the atherosclerosis proceeds, the LDL particle oxidizes.

HDL is both an indicator of risk and an agent of protection against risk. Firemen put out fires, but that doesn’t mean you want a fire truck showing up in front of your house at 3 AM. That would be bad news, even though the guys manning it are fine, upstanding, invaluable members of the community.

In the original study, HDL followed a U-shaped mortality curve. Low HDL and extra-high HDL were both associated with more all-cause mortality (dying from any cause). Plain old “high” HDL was associated with the lowest risk, as you’d expect. High is enough to handle incoming threats. You can respond quickly and upregulate production when needed.

Next, John asks:

Hey Mark, My grandpa’s doctor wants him on a low-sodium diet. He can’t add salt to any food. He can eat food that already has salt though. I know you can’t give medical advice but maybe you could give me some suggestions for how to talk to the doc about it.

Thanks, John

Humans have a real craving for salt. It’s one of the few specific appetites we have. The craving doesn’t disappear. He’s going to seek out salt, and he’ll get it. Restricting adding his own salt to food and allowing “pre-salted” food will only drive him into the corpulent embrace of processed junk. That wouldn’t be so bad if it weren’t loaded with sugar, grains, and industrial seed oils. But it is, so it is. What would doc rather have Grandpa eat—a salted-and-peppered ribeye or a pack of low-sodium cupcakes?

It crazy that it’s even a debate.

Most adults are forced into low-salt diets to improve their blood pressure. Those lab markers—already fraught with major reliability issues—must tick down. They’re everything.

Yet they don’t work well in most people. Some people with salt-sensitive hypertension definitely can benefit from salt reduction. Asian and African Americans see bigger benefits to blood pressure than other groups. Others are lucky to get a few points in the other direction. Better than nothing, but nothing to write home about. And that’s without taking into account the other hints that salt restriction may have other, unwanted effects.

In healthy men and women, a low-salt diet increased insulin resistance compared to a higher-salt diet.

In hypertensive patients, low-salt reduced blood pressure by a few points while worsening triglycerides, LDL, and stress hormones.

In adults, eating under 3 grams of sodium (just over a teaspoon of salt) or between 6-7 grams of sodium (more than 2 teaspoons) led to more strokes and heart attacks than eating between 4-6 grams of sodium.

Sodium restriction may also increase stress hormones.

One study even established the important role of chloride (from such famous works as “sodium chloride”) in host immunity. Our white blood cells use chloride to produce a chlorine-based microbicide—bleach, essentially—that targets infectious microbes. Infections become really dangerous the older you get. Chloride-based microbicide is invaluable, and so is the salt which carries its precursor.

Maybe Grandpa needs the low-salt diet. Maybe the supposed benefits outweigh the ignored deficits. Talk to the doc, come prepared, and find out for sure. Oh, and ask what he or she thinks about sugar as the primary driver of hypertension.

That’s it for today, folks. Thanks for reading! Be well and leave some thoughts down below!

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21 Comments on "Dear Mark: Really High HDL, More Heart Disease; Low-Salt For Grandpa?"


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13 days 49 minutes ago
Some additional thoughts regarding salt… Processed foods, fast foods, and restaurant foods can contain considerably more salt than what most of us would cook with from scratch at home. This is because salt covers up the fact that shortcuts have been taken in the preparation, sometimes to the point that such foods have little flavor of their own. Anyone who has ever watched TV chefs cook knows they throw salt into whatever they’re making literally by the handful. And we’ve all seen people who routinely salt their food before they even taste it. These things can all add up to… Read more »
13 days 27 minutes ago

To the salt question – read The Salt Fix by by Dr James DiNicolantonio. The author is a cardiac specialist and debunks the salt myths and gives clear guidance.

12 days 22 hours ago

Hi Mark, what’s your opinion on epitalon for longevity and low-dose (1-3 mg) nutritional lithium for a balanced biochemistry?

Of course, take up these topics as thought experiment. Thanks, a science lover.

12 days 22 hours ago

Love these three-dimensional answers to one-dimensional questions.

Why the human obsession with simple explanations for complex phenomena?

Scale weight: up = bad, down = good. Except when it isn’t.

Hormone X: in “reference range” good, outside “reference range” bad. Except in this case, and that case…

People who see one or two pieces of the puzzle think they see the whole thing. Especially if they built a career around those pieces.

It’s only as we accumulate more pieces… and more pieces… that we start to realize the puzzle is very large indeed.

At least we picked up a few corner pieces from Mark 😉

Susan B.
Susan B.
12 days 20 hours ago

Good questions – and good answers. Thanks, Mark, this is very elucidating.

12 days 20 hours ago

Yes, I agree.

Himanshu Gupta
12 days 20 hours ago

Thanks for the tip mate. I was searching this all day and I am glad I found your blog.

Bookmarked it 🙂

Matt B
Matt B
12 days 17 hours ago

Here’s a good article on the salt issue. Might be worth a read before speaking to the doctor again or, even better, send him/her the link.

12 days 16 hours ago
The salt thing is interesting. Most of us here would know exactly how much salt we’re consuming since we love making our own food, or when we shop we buy foods with simple ingredients where the dietary components are obvious. Some days I have trouble getting more than a teaspoon of salt, despite my food tasting just the way I like it. Training your body out of added sugar and flavor enhancers sensitises your taste buds and decreases your need for such stimulation. Steam a head of broccoli and it’s quite naturally sweet. A small sprinkle of salt isn’t necessary… Read more »
Wesley Lofton
Wesley Lofton
12 days 11 hours ago

I would agree with sugar being the cause of hypertension. My mother eats slot of sugar and pastries and she struggles with high blood pressure. Though it’s hereditary in my family, I can still see the connection.

12 days 9 hours ago

Hi Mark,

For next week, any guidance on poop? Parameters on size, consistency, colour, texture, regularity? And flatulence? 🙂



11 days 23 hours ago
I’m not Mark, but from what I’ve read, it should have form to it but be fairly soft. Size will vary. Color should generally be medium brown (think peanut butter) but can vary depending on what a person eats. Regularity also varies from person to person. (For me regularity means daily.) Flatulence could mean IBS or it could simply be that certain foods don’t agree with you. Lastly, there’s probably no such thing as “normal” poop. As long as you aren’t frequently constipated and don’t have chronic diarrhea, you probably have nothing to worry about. Maybe, as you requested, Mark… Read more »
11 days 8 hours ago

Thank you Shary

11 days 18 hours ago

Probably a loaded question, but how high would be considered “too high”? As a 55 y/o female, I recently had results of LDL= 140, HDL= 102. I know other factors are involved, but just curious as to your off-the-cuff response.

10 days 13 hours ago

I generally hover around 110, but currently my HDL is 138 and my doctors aren’t worried about it. With an HDL of 102, if your triglycerides are low, your LDL is most likely pattern A, the big fluffy kind that everyone wants. If you want to go deeper, ask for a CARDIO IQ ADVANCED LIPID PANEL. It gives you the real story on what’s going on.

11 days 13 hours ago

I adore salt! But, I don’t eat any processed foods (other than the Primal Kitchen avocado mayo) and I don’t eat sugar. I put a shake or two of salt in my green smoothie, I have salty sardines for lunch. For dinner I eat a big salad with homemade dressing (which has salt in it), grilled fish or moose (seasoned with salt and pepper) and sometimes roasted veggies (also lightly salted). My blood pressure is very low.

I agree with others that when you stop eating processed foods and sugars you don’t really have to worry about seasoning with salt.

11 days 5 hours ago
Eating a low-sodium diet might be warranted in certain diseases pertaining to the kidneys. The “right” way to go about it – *if* you really need to limit your salt intake – is to eat a lot of vegetables and some fruit. Most veggies, especially when roasted, are flavourful enough not to need salting. And of course fruits don’t need to be salted either. Certain kinds of organ meat are also flavourful enough on their own – or with veggies, think liver with onions – to require only minimal salting. Grains and grain flours are generally too bland, so having… Read more »
10 days 16 hours ago
I have what the head cardiologist in my doctor’s office as a “complex lipid abnormality”. Currently my HDL is 138, LDL 176, TG 43 My LDL is pattern A and really big and fluffy. Same with my HDL.Big and fluffy. My C Reactive protein levels are really low (0.4 mg/L) Lipoprotein (a) is a really low <10 nmol/L My doctor said I hold the record in his office for both highest HDL and total cholesterol. He said I'm such an outlier that there is very little information on what my numbers mean because people like me aren't included in studies.… Read more »
6 days 16 minutes ago

from a strictly evolutionary discussion though how would salt have been needed in hunter gatherer societies? We’ve got to be the only mammals that salt our food/natural diet…

5 days 6 hours ago

S. Boyd Eaton and other high-profile researchers of the Paleolithic era maintain that the sodium intake of our ancestors will have been very low, barely more than three-quarters of a gram:

“Preagricultural humans are calculated to have consumed only 768 mg of sodium, but fully 10 500 mg of potassium each day.”

1 day 7 hours ago

So what is the best level for HDL? After reading some of the comments below mine are “low” at 2 mg/dl