What White Blood Cell Count Should We Shoot for?

At the start of my video What Does a Low White Blood Cell Count Mean?, you can see what it looks like when you take a drop of blood, smear it between two pieces of glass, and view at it under a microscope: a whole bunch of little, round, red blood cells and a few big, white blood cells. Red blood cells carry oxygen, while white blood cells are our immune system’s foot soldiers. We may churn out 50 billion new white blood cells a day. In response to inflammation or infection, that number can shoot up to a 100 billion or more. In fact, pus is largely composed of: millions and millions of white blood cells.

Testing to find out how many white blood cells we have at any given time is one of the most common laboratory tests doctors order. It’s ordered it hundreds of millions of times a year. If, for example, you end up in the emergency room with abdominal pain, having a white blood cell count above about 10 billion per quart of blood may be a sign you have appendicitis. Most Americans fall between 4.5 and 10, but most Americans are unhealthy. Just because 4.5 to 10 is typical doesn’t mean it’s ideal. It’s like having a “normal” cholesterol level in a society where it’s normal to die of heart disease, our number-one killer. The average American is overweight, so if your weight is “normal,” that’s actually a bad thing.

In fact, having excess fat itself causes inflammation within the body, so it’s no surprise that those who are obese walk around with two billion more white cells per quart of blood. Given that, perhaps obese individuals should have their own “normal” values. As you can see at 2:06 in my video, if someone with a 47-inch waist walks into the ER with a white blood cell count of 12, 13, or even 14, they may not have appendicitis or an infection. That may just be their normal baseline level, given all the inflammation they have in their body from the excess fat. So, normal levels are not necessarily healthy levels.

It’s like smoking. As you can see at 2:31 in my video, if you test identical twins and one smokes but the other doesn’t, the smoker is going to end up with a significantly higher white cell count. In Japan, for example, as smoking rates have steadily dropped, so has the normal white count range. In fact, it’s dropped such that about 8 percent of men who have never smoked would now be flagged as having abnormally low white counts if you used a cut-off of 4. But, when that cut-off of 4 was set, most people were smoking. So, maybe 3 would be a better lower limit. The inflammation caused by smoking may actually be one of the reasons cigarettes increase the risk of heart attacks, strokes, and other inflammatory diseases. So, do people who have lower white counts have less heart disease, cancer, and overall mortality? Yes, yes, and yes. People with lower white blood cell counts live longer. Even within the normal range, every one point drop may be associated with a 20 percent drop in the risk of premature death.

As you can see at 3:39 in my video, there is an exponential increase in risk in men as white count goes up, even within the so-called normal range, and the same is found for women. The white blood cell count is a “stable, well-standardized, widely available and inexpensive measure of systemic inflammation.” In one study, half of the women around 85 years of age who had started out with white counts under 5.6 were still alive, whereas 80 percent of those who started out over 7 were dead, as you can see at 4:05 in my video—and white blood cell counts of 7, 8, 9, or even 10 would be considered normal. Being at the high end of the normal range may place one at three times the risk of dying from heart disease compared to being at the lower end.

The same link has been found for African-American men and women, found for those in middle age, found at age 75, found at age 85, and found even in our 20s and 30s: a 17 percent increase in coronary artery disease incidence for each single point higher.

As you can see at 5:00 in my video, the higher your white count, the worse your arterial function may be and the stiffer your arteries may be, so it’s no wonder white blood cell count is a useful predictor of high blood pressure and artery disease in your heart, brain, legs, and neck. Even diabetes? Yes, even diabetes, based on a compilation of 20 different studies. In fact, it may be associated with everything from fatty liver disease to having an enlarged prostate. And, having a higher white blood cell count is also associated with an increased risk of dying from cancer. So, what would the ideal range be? I cover that in my video What Is the Ideal White Blood Cell Count?.

A higher white blood cell count may be an important predictor for cardiovascular disease incidence and mortality, decline in lung function, cancer mortality, all-cause mortality, heart attacks, strokes, and premature death in general. This is no surprise, as the number of white blood cells we have circulating in our bloodstreams are a marker of systemic inflammation. Our bodies produce more white blood cells day to day in response to inflammatory insults.

We’ve known about this link between higher white counts and heart attacks since the 1970s, when we found that higher heart attack risk was associated with higher white blood cell counts, higher cholesterol levels, and higher blood pressures, as you can see at 0:53 in my video What Is the Ideal White Blood Cell Count?. This has been found in nearly every study done since then. There are decades of studies involving hundreds of thousands of patients showing dramatically higher mortality rates in those with higher white counts. But why? Why does white blood cell count predict mortality? It may be because it’s a marker of inflammation and oxidation in the body. In fact, it may even be a biomarker for how fast we are aging. It may be more than just an indicator of inflammation—it may also be an active player, contributing directly to disease via a variety of mechanisms, including the actual obstruction of blood flow.

The average diameter of a white blood cell is about seven and a half micrometers, whereas our tiniest vessels are only about five micrometers wide, so the white blood cell has to squish down into a sausage shape in order to squeeze through. When there’s inflammation present, these cells can get sticky. As you can see at 2:20 in my video, a white blood cell may plug up a vessel as it exits a small artery and tries to squeeze into a capillary, slowing down or even momentarily stopping blood flow. And, if it gets stuck there, it can end up releasing all of its internal weaponry, which is normally reserved for microbial invaders, and damage our blood vessels. This may be why in the days leading up to a stroke or heart attack, you may find a spike in the white cell count.

Whether white count is just a marker of inflammation or an active participant, it’s better to be on the low side. How can we reduce the level of inflammation in our body? Staying away from even second-hand smoke can help drop your white count about half of a point. Those who exercise also appear to have an advantage, but you don’t know if it’s cause and effect unless you put it to the test. In one study, two months of Zumba classes—just one or two hours a week—led to about a point and a half drop in white count. In fact, that may be one of the reasons exercise is so protective. But is that just because they lost weight?

Fitness and fatness both appear to play a role. More than half of obese persons with low fitness—51.5 percent—have white counts above 6.6, but those who are more fit or who have less fat are less likely to have counts that high, as you can see at 3:47 in my video. Of course, that could just be because exercisers and leaner individuals are eating healthier, less inflammatory diets. How do we know excess body fat itself increases inflammation, increases the white count? You’d have to find some way to get people to lose weight without changing their diet or exercise habit. How’s that possible? Liposuction. If you suck about a quart of fat out of people, you can significantly drop their white count by about a point. Perhaps this should get us to rethink the so-called normal reference range for white blood cell counts. Indeed, maybe we should revise it downward, like we’ve done for cholesterol and triglycerides.

Until now, we’ve based normal values on people who might be harboring significant background inflammatory disease. But, if we restrict it to those with normal C-reactive protein, another indicator of inflammation, then instead of “normal” being 4.5 to 10, perhaps we should revise it closer to 3 to 9.

Where do the healthiest populations fall, those not suffering from the ravages of chronic inflammatory diseases, like heart disease and common cancers? Populations eating diets centered around whole plant foods average about 5, whereas it was closer to 7 or 8 in the United States at the time. How do we know it isn’t just genetic? As you can see at 5:38 in my video, if you take those living on traditional rural African diets, who have white blood cell counts down around 4 or 5, and move them to Britain, they end up closer to 6, 7, or even 8. Ironically, the researchers thought this was a good thing, referring to the lower white counts on the “uncivilized” diet as neutropenic, meaning having too few white blood cells. They noted that during an infection or pregnancy, when more white cells are needed, the white count came right up to wherever was necessary. So, the bone marrow of those eating traditional plant-based diets had the capacity to create as many white cells as needed but “suffers from understimulation.”

As you can see at 6:26 in my video, similar findings were reported in Western plant eaters, with an apparent stepwise drop in white count as diets got more and more plant based, but could there be non-dietary factors, such as lower smoking rates, in those eating more healthfully? What we need is an interventional trial to put it to the test, and we got one: Just 21 days of removing meat, eggs, dairy, alcohol, and junk affected a significant drop in white count, even in people who started out down at 5.7.

What about patients with rheumatoid arthritis who started out even higher, up around 7? As you can see at 7:03 in my video, there was no change in the control group who didn’t change their diet, but there was a 1.5 point drop within one month on whole food plant-based nutrition. That’s a 20 percent drop. That’s more than the drop-in inflammation one might get quitting a 28-year pack-a-day smoking habit. The most extraordinary drop I’ve seen was in a study of 35 asthmatics. After four months of a whole food plant-based diet, their average white count dropped nearly 60 percent, from around 12 down to 5, though there was no control group nor enough patients to achieve statistical significance.

If white blood cell count is such a clear predictor of mortality and is so inexpensive, reliable, and available, why isn’t it used more often for diagnosis and prognosis? Maybe it’s a little too inexpensive. The industry seems more interested in fancy new risk factors it can bill for.

I touch on the health of the rural Africans I discussed in How Not to Die from Heart Disease.


For more on fighting inflammation, see:

In health,

Michael Greger, M.D.

PS: If you haven’t yet, you can subscribe to my free videos here and watch my live presentations:

What Happens When Pregnant Women Eat More Animal Protein

Are high-protein diets during pregnancy healthful or harmful? That question was answered about 40 years ago in the infamous Harlem Trial of 1976: a “randomized controlled trial of nutritional supplementation pregnancy, in a poor black urban population in the United States.” The study, which I discuss in my video The Effect of Animal Protein on Stress Hormones, Testosterone, and Pregnancy, “was begun when protein was commonly assumed to be deficient in the diet of the poor.” Had researchers actually analyzed their diets before they started, they would have realized that this wasn’t true, but why let facts get in the way of assumptions? So, the researchers split poor black pregnant women into three groups, each receiving one of the following treatments: (1) an extra 40 grams of animal protein a day, which is essentially a couple cans of Ensure, (2) an extra 6 grams of animal protein, or (3) no extra protein. Then they sat back and watched what happened. The high-protein group suffered “an excess of very early premature births and associated neonatal [infant] deaths, and there was significant growth retardation” in the babies who survived. More protein meant more prematurity, more deaths, and more growth retardation, which you can see reflected in the chart at 1:00 in my video.

What’s more, animal protein intake during pregnancy has been associated with children becoming overweight later in life and getting high blood pressure. The “offspring of mothers who reported eating more meat and fish had higher systolic blood pressure” in adulthood. This was part of another failed dietary intervention trial in which mothers were advised to eat a pound of meat a day. The increased weight gain and high blood pressure may be due to the obesity-causing chemical pollutants in the meat supply, as I’ve discussed in my video Animal Protein, Pregnancy, and Childhood Obesity, or the animal protein-induced rise in the growth hormone IGF-1. Or, it could be due to a steroid stress hormone called cortisol.

As you can see in the chart at 2:01 in my video, a single meal high in animal protein can nearly double the level of the stress hormone in the blood within a half hour of consumption, much more than a meal closer to the recommended level of protein. When subjects are given a meal of crab, tuna fish, and cottage cheese, the stress hormone level shoots up. If they’re instead given some barley soup and a vegetable stir-fry on rice, the stress hormone level goes down after the meal, as you can see at 2:27 in my video. Imagine eating meat-fish-dairy meals day after day. Doing so “may chronically stimulate” our stress response axis “and increase the release of vasoactive hormones” that could increase our blood pressure. And, all that extra cortisol release has been linked to increased risk for elevated blood levels of insulin, triglycerides, and cholesterol.

When men on a high-protein diet, “such as meat, fish, poultry, egg white,” were switched to a high-carb diet of bread, vegetables, fruit, and sugary junk, their cortisol levels dropped about a quarter within 10 days. At the same time, their testosterone levels shot up by about the same amount, as you can see at 3:09 in my video. High-protein diets suppress testosterone. That is why, if men eating plant-based diets begin to eat meat every day, their testosterone levels go down and some estrogens actually go up, and that’s why bodybuilders can get such low testosterone levels. It’s not the steroids they’re taking. If you look at natural bodybuilders who don’t use steroids, there is a 75 percent drop in testosterone levels in the months leading up to a competition. Testosterone levels were cut by more than half, which is enough to drop a guy into an abnormally low range, as you can see at 3:47 in my video. It’s ironic that they’re eating protein to look manly on the outside, but it can make them less and less manly on the inside. And, from an obesity standpoint, in general, a drop in testosterone levels may increase the risk of gaining weight and body fat. What does cortisol have to do with weight?

There’s actually a disease caused by having too much cortisol, called Cushing’s syndrome, which can increase abdominal obesity. Even in normal women, though, chronic stress and chronic high cortisol levels can contribute to obesity. What’s more, if they’re pregnant, high-meat and low-carb diets may increase cortisol levels in the moms, which can lead to inappropriate fetal exposure to cortisol, which, in turn, can affect the developing fetus, resetting her or his whole stress response thermostat and leading to higher cortisol levels in later adult life. This can have serious, life-long health consequences. Every maternal daily portion of meat and fish was associated with 5 percent higher cortisol levels in their children as much as 30 years later, though green vegetable consumption was found to be protective. Higher meat consumption, such as three servings a day compared to one or two, was associated with significantly higher cortisol levels, but eating greens every day appeared to blunt some of that excess stress response, as you can see at 5:12 in my video.

As well, the adult children of mothers who ate a lot of meat during pregnancy don’t only have higher stress hormone levels, they also appear to react more negatively to whatever life throws at them. Researchers put them through the Trier Test, which involves public speaking in front of a panel of judges, following by a live math exercise. You can see in my video at 5:36 a chart comparing the stress hormone responses in those whose moms ate less than two servings of meat per day, about two servings a day, or about two to three servings a day. Note that before the test started, the cortisol levels of the two groups eating less meat started out about the same, but their exaggerated cortisol response was laid bare when exposed to a stressful situation. The real-world effects of this are that after that sort of test, when people are given their own private snack buffet with fruits and veggies versus fatty, sugary, comfort foods like chocolate cake, guess who may eat less of the fruits and veggies? Those who have high chronic stress levels. “Cortisol has been implicated as a factor in motivating food intake” even when we aren’t really hungry.

It’s no surprise then that a woman’s animal protein intake during pregnancy may lead to larger weight gain for her children later in life—and maybe even for her grandchildren. “Remarkably, recent evidence suggests that the long-term consequences of adverse conditions during early development may not be limited to one generation, but may lead to poor health in the generations to follow, even if these individuals develop in normal conditions themselves.” Indeed, the diet of a pregnant mother may affect the development and disease risk of her children and even her grandchildren. Ultimately, these findings may shed light on our rapidly expanding epidemics of diabetes, obesity, and heart disease.


Whoa, there was a lot to unpack! Rather than break it up, since so much of it was tied together, as you could see, I compiled everything into this one, heftier piece. You may want to read this a second time and watch the video to absorb it all.

For more on how a woman’s diet during pregnancy can affect her children, see Maternal Diet May Affect Stress Responses in Children and Animal Protein, Pregnancy, and Childhood Obesity.

Protein is such a misunderstood nutrient. For more information, check out:

In health,
Michael Greger, M.D.

PS: If you haven’t yet, you can subscribe to my free videos here and watch my live presentations:

Proof that Lifelong Cholesterol Reduction Prevents Heart Disease

“It is well accepted that coronary atherosclerosis is a chronic progressive disease that begins early in life and slowly progresses over several decades” before symptoms arise. However, the average age in cholesterol-lowering drug trials is 63; therefore, people have already been exposed to a lifetime of circulating LDL cholesterol. It’s no wonder pharmaceutical therapies typically reduce cardiovascular disease risk by only 20 to 30 percent.

We know LDL, the so-called bad cholesterol, plays “a central role” in the “initiation, development, and progression” of our number-one killer. In fact, more than 100 prospective studies involving more than a million people have demonstrated that those with higher LDL levels are at higher risk.

“It seems reasonable to assume, therefore, that if lowering LCL-C [cholesterol] levels beginning later in life can slow the progression of advanced atherosclerotic plaques…then keeping LDL-C levels low, beginning much earlier in life” might prevent our arteries from getting clogged in the first place. A reasonable assumption, certainly—but let’s not just assume.

“It would be…unethical to set up a controlled clinical trial in which young adults with elevated serum cholesterol levels were treated or not treated over their lifetime”—just as we couldn’t ethically set up a study in which half the young adults are made to start smoking to see if smoking really does cause lung cancer. That’s where observational studies come in. We can follow people who already smoke and compare their disease rates to those who don’t.

It was aroud 40 years ago when the president of the American Heart Association tried to argue we should all stop smoking even though there were no randomized controlled trials. You can see a copy of the “Presidential Address” entitled “The Case for Prevention of Coronary Heart Disease” to the AHA’s 47th Scientific Sessions at 1:34 in my video. Those who smoke have a higher risk of heart attack, and the more we smoke the higher the risk. After we stop smoking, our risk drops. The same can be said for high cholesterol.

Young men 18 through 39 years of age were followed for up to 34 years, and their cholesterol levels, even when they were young, predicted long-term risk of heart disease and death. Men in their 20s and 30s who have a total cholesterol just under 200 have a “substantially longer estimated life expectancy”—around 4 to 9 years longer—than those with levels over 240.

“Evidence from observational studies, however, [is] vulnerable to confounding” factors. Eating a diet that is plant-based enough to lower cholesterol below average, for example, may add years to our lives regardless of what our cholesterol actually is. Ideally, we’d have a long-term, randomized, controlled trial.

Nature may have actually set one up for us. Each of us, at conception, gets a random assortment of genes from our mother and our father, and some of those genes may affect our cholesterol levels. Just like there are rare genetic mutations that result in unusually high cholesterol levels, there are rare genetic mutations that lead to unusually low cholesterol levels, “provid[ing] an ideal system in which to assess the consequences of low LDL cholesterol levels independently of other factors that may modify disease progression,” such as confounding diet and lifestyle factors.

Starting at 3:14 in my video, you can see what I mean. About 1 in 40 African Americans have a mutation that drops their LDL cholesterol from around 130 down toward more optimal levels. Now, this group didn’t eat healthy to get achieve that drop. It’s just in their genes. More than half had high blood pressure and there were a lot of smokers and diabetics in the group, yet those with genetically low LDL levels still had a significant reduction in the incidence of coronary heart disease even in the presence of all those other risk factors. How significant? How much less heart disease? A remarkable 88 percent of heart disease was simply gone.

The astounding finding was that the risk of heart disease in these individuals was reduced by more than 80 percent, whereas the same 20- to 40-point decrease in LDL from drugs only reduces risk around 30 percent. Makes sense, though, because the folks with the mutation had low levels their entire life. They didn’t simply start taking a pill when they were 60.

“The magnitude of the effect of long-term exposure to lower LDL-C [cholesterol] concentrations observed in each of these studies represents a threefold greater reduction in the risk of CHD,” or coronary heart disease, compared to drug treatment started later in life. (As an aside, for all of my fellow research nerds, check out that p value shown in my video at the 4:30 mark. You’d have to do arourd a quintillion studies to get that kind of result by chance!)

“Therefore, a primary prevention strategy that promotes keeping LDL [cholesterol] levels as low as possible, beginning as early in life as possible, and sustaining those low levels of LDL [cholesterol] throughout the whole of one’s lifetime has the potential to dramatically reduce the risk of CHD,” coronary heart disease.


If you don’t know your cholesterol level, you should get it checked—maybe even starting in childhood. See my video Should All Children Have Their Cholesterol Checked? to learn more.

What if you do get tested and your doctor tells you not to worry because your cholesterol’s “normal”? Having a “normal” cholesterol level in the society where it’s normal to drop dead of a heart attack (the number-one killer of men and women) is not really such a good thing. See my video When Low-Risk Means High-Risk.

Check out Optimal Cholesterol Level and What’s the Optimal Cholesterol Level? to find out where you should be.

What if your doctor tells you your LDL is large and fluffy? See my video Does Cholesterol Size Matter?.

In health,
Michael Greger, M.D.

PS: If you haven’t yet, you can subscribe to my free videos here and watch my live presentations: