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

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!


TAGS:  dear mark

About the Author

Mark Sisson is the founder of Mark’s Daily Apple, godfather to the Primal food and lifestyle movement, and the New York Times bestselling author of The Keto Reset Diet. His latest book is Keto for Life, where he discusses how he combines the keto diet with a Primal lifestyle for optimal health and longevity. Mark is the author of numerous other books as well, including The Primal Blueprint, which was credited with turbocharging the growth of the primal/paleo movement back in 2009. After spending three decades researching and educating folks on why food is the key component to achieving and maintaining optimal wellness, Mark launched Primal Kitchen, a real-food company that creates Primal/paleo, keto, and Whole30-friendly kitchen staples.

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22 thoughts on “Dear Mark: Really High HDL, More Heart Disease; Low-Salt For Grandpa?”

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  1. 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 way too much salt.

    All that said, salt is necessary for good health. Actually, it’s necessary for life itself. Just because less salt is sometimes better doesn’t mean that no salt is a good idea. I’ve known two people who almost died because they tried to strip all the salt from their diets.

    Most of us here cook from scratch, which means we probably don’t eat an overabundance of salt. The other thing is, salt to taste instead of blindly following a recipe. Use a salt shaker when cooking instead of pinching salt between the fingers (as the professional chefs do). Salt shakers with relatively few holes automatically cut down on the amount of salt we put on our food.

  2. 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.

  3. 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.

  4. 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 😉

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

    1. Thanks for the link. I’ve just searching about the salt and found that iodine is added to salt to combat lack iodine in the diet which can lead to thyroid disease and the growth of goiter. It is not there gratuitously, although if you know that your diet includes plenty of iodine there is no need to add more in your salt. However, iodine in salt did drastically decrease the incidence of goiter in the US.

  6. 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 (but can be fun), especially if you’ve melted some butter over it.

    I think the secret is stripping out the cruft and then adding flavor back in when the natural taste of the food just isn’t enough. Works for me.

  7. 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.

  8. Hi Mark,

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



    1. 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 will take up this fascinating subject in more detail.

  9. 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.

    1. 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.

  10. 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. 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 to go on a low-sodium diet is an excellent excuse to give up grains altogether. And remember: a low-sodium diet is not a zero-sodium diet. If you give up grains, cheese, processed food and legumes, you’ll automatically slash your salt intake to a considerable degree, so you can use salt where it’s truly indispensable – meat, fish and soups.

  12. 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. The head cardiologist in the department recommends a coronary calcium test. If it comes back zero (hopefully considering my low C reactive protein score and pattern A LDL) then I should just roll with my oddball numbers and not sweat the elevated LDL.

    So how did my HDL go from the usual 110 range and my LDL from the usual 100 range to these numbers? By adding meat to my diet after 30 years of being a lacto/ovo vegetarian. That's the big change. Go figure.

    It's also funny how your perception of numbers changes in relation to other numbers. When my HDL was 110, that seemed amazingly high. Now that it's 138, 110 just sounds OK. When my LDL jumped from 98 to 223 after a four month binge on fatty meats (like pulled pork every day and for snacks too!) that sounded dangerously high. But when I brought it back down to 176 just by backing off the fatty meats and adding a gram of oat fiber to my diet, 176 sounds pretty – even though it's way higher than the baseline of 98.

    Someone once said that numbers aren't a disease, they only indicate probabilities based upon a standardized population. How it plays out for any individual varies wildly.

  13. 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…

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