What Does My Cholesterol Level Mean?

Depending on how you look at it, cholesterol can be an incredibly simple topic, or an incredibly confusing one. Contemporary medicine teaches that cholesterol is “bad” and should be low. That seems pretty simple, right? Get it tested, if it’s high, start a drug to lower it. 

Times have changed. Now, cholesterol is much more complex, and we all need to be armed with knowledge before we sit down with our doctors to evaluate our cholesterol levels.

Here is my guide to you and your doctor for evaluating your cholesterol.

1. Understand the difference between Total Cholesterol (TC) and high density lipoprotein (HDL) and low density lipoprotein (LDL)

If you doctor is referring to your total cholesterol (TC) and is making decision based on your TC— Run, don’t walk. Run away and find another doctor. TC is comprised of low density lipoprotein (LDL), so-called “bad cholesterol” even though it isn’t bad. High density lipoprotein (HDL), so-called “good cholesterol”, and remnant cholesterol (VLDL and IDL). Initial studies in the 1960s and 70s looked at TC and risk of cardiovascular disease (CVD) and found a weak association.  That was prior to when scientists learned how to measure LDL and HDL.

Studies then looked at the individual lipoproteins (i.e. LDL and HDL) and found the higher the LDL, in general, the higher the risk for CVD. And the higher the HDL< the lower the risk of CVD. So, while talking about TC was cutting edge in the 60s and 70s, it is woefully outdated today. That is why if your doctor is still evaluating and treating TC—Run!

2. Does Your Doctor Know Your TC to HDL and TG to HDL Ratios?

If your doctor does not know your ratios, this is another reason to run away and find another doctor (We are doing lots of running here, bonus exercise!) Studies in the early 2000s and more recently have shown that total cholesterol to HDL ratio (TC:HDL) and triglyceride to HDL ratio (TG:HDL) are BETTER predictors of cardiovascular risk than isolated LDL, TC or HDL.

By incorporating TG and HDL into the analysis, these ratios incorporate the impact of remnant cholesterol and track with insulin resistance, both strong predictors of CVD. These ratios are calculated from a standard lipid profile, so they do not require any special testing or special labs. They are widely available for everyone to see. So if your doctor is not using them to evaluate your lipids, it’s time to find a new one.

3. Understanding a Familial hypercholesterolemia (FH) diagnosis

Familial hypercholesterolemia (FH) is a diagnosis that requires (wait for it…) a family history! As the name suggests, it is an inherited condition passed from generation to generation. All too often, doctors will see an LDL level over 190 and make the diagnosis of FH. If your doctor makes that diagnosis that based on level alone without a family history, run!

There is a well-accepted scoring system, The Simon Broome Criteria, to help determine if someone has FH. This equation factors in age of diagnosis, absolute level of LDL, in addition to family history of early onset hyperlipidemia or early onset heart disease. It makes a big difference if you have FH or not. Don’t let your doctor label you as having FH without applying the full criteria. Just wait for the look on their face when you respond, “What was my Broome score? Did it confirm I have FH?” and hope you don’t hear crickets.

4. What is Advance Lipid Testing?

Advance lipid testing may be helpful. And it may not. Advanced lipid testing can tell us the size, density, and inflammatory characteristics of our lipoproteins. This can help further risk stratify the potential danger of our lipids. For instance, small, dense LDL tend to correlate more strongly with CVD, whereas so-called pattern A LDL (the larger, less dense version) does not correlate as well.

Here is the interesting part. Those with high TG and low HDL almost uniformly have small dense LDL and increased inflammation. Conversely, those with low TGs and high HDL have Pattern A, larger less dense LDL. Are you starting to see a pattern? Low TG and high HDL=good. High TG and low HDL=bad.

Sometimes, however, there can be variation in this equation. Therefore, I usually suggest people get advanced lipid testing one time to see if their results correlate. If they do, then you can just follow your ratios to predict your advanced results. Why not get them all the time? They are frequently not covered by insurance and can be expensive.

5. Interpret your lipids in context

Lipids don’t exist in a vacuum. They exist in your body, so it’s important to take into account what else is going on in your body. Insulin resistance and inflammation can directly affect your lipids and increase your risk in general. Hypertension, obesity, and family history of heart disease also play crucial roles in determining your risk.

Therefore, if your doctor checks only your lipids and bases decision on those labs alone—Run! Instead, you should get a hsCRP, Hgb A1c, fasting glucose, insulin and HOMA-IR, BP measurement, family history assessment, and complete history. This is the context in which your lipids should be evaluated. Not alone in a vacuum.

6. Why test a risk factor that may be related to CVD risk when you can test the disease itself?

Good question, right? To truly know what your lipids mean to you, you also need to know if you have evidence of CVD. Coronary artery calcium scores and Carotid Intima Media Thickness (CIMT) are two easy, relatively inexpensive tests, that you can get to show you whether or not you have current evidence of CVD. The presence or absence of disease significantly impacts the risk of lipid levels.

So, What Does Your Cholesterol mean to You? It depends.

It depends on many factors, and only by evaluating ALL of those factors can you truly know what impact your lipids may be having on our health. Anything short of this evaluation is an inadequate and antiquated approach to lipids.

Now you are forewarned and forearmed, and you can walk into your doctor’s office ready to ask the important questions and help guide the workup so that you can know what your cholesterol means to you.

Thanks for reading, and as always, please let us know If you have any comments or questions.

Bret Scher MD FACC

Founder, Boundless Health

www.LowCarbCardiologist.com

Are you interested in trying a Low Carb-High Fat/Ketogenic lifestyle? If so, great.

Are you looking to your doctor for support in this diet? If so, tread gently.

The medical community has engrained false beliefs that LCHF lifestyle is dangerous to your health. We can blame it on Ancel Keys. We can blame it on an over emphasis on LDL-C. We can blame it on Big Pharma. We can even blame it on the rain!  Whatever the reason, you may not get a warm and receptive response from your physician.

But there is hope. Here are my top 6 Tips on How to Talk to Your Doctor About The LCHF/Keto Lifestyle.

1.    First, ask for your doctor’s opinion about LCHF

Doctors are people too. How would your spouse react if you said, “I’m no longer taking out the trash/doing the dishes/making dinner. It doesn’t work with my personal philosophy of house chores and we are going to change this. Now.” I hope you have a comfortable couch, cause that’s where you will be sleeping.

Picture instead, “Hi Honey. I was thinking that we may want to reassign some of our house chores to help things get done better and more efficiently without putting too much strain on either of us. What do you think about that? Do you have any thoughts how you would like to change things?” That sounds better, right?

The same approach applies to your doctor. Just don’t start by calling your doctor honey. That’s just awkward. Don’t say, “Hey Doc, I’m going LCHF and need you to order x, y and z blood tests on me now and again in 6 months, and help me get off my meds.” Instead, try a kinder, gentler approach. “Hi Doc. I was thinking of ways to be more proactive about my health. What I have done thus far has not worked as well as I have liked. I have heard a lot about LCHF as a way to lose weight, reduce insulin levels, improve blood glucose control, and feel better. I was thinking of trying it. What do you think about that?” You may not immediately get the answer you want (for instance, I am still taking out the trash every week), but you have opened the lines of communication in a much less confrontational way, which can set you up for success as we discuss other tips below.

2.    Measure the effects of Keto on your body with a medical trial

If your doctor is hesitant about you trying LCHF/Keto, suggest a 3- or 6- month trial. Establish what you want to monitor (here’s an eBook I created to help you get started: 10+Medical Tests to Follow on the LCHF Diet). Check what you would like to monitor at baseline and then at the 3-6-month mark. Emphasize you want to experiment to see how your body responds, and that you want his/her expertise in helping analyze the labs to help you progress safely.

Also, if you are on medications for blood pressure, blood sugar or lipids, you will want their guidance with these. Emphasize how you want him or her on your team to help you on your journey and temporary experiment. It is hard to resist when someone genuinely wants your help and thinks you can play a role in their improvement!

3.    Show them your results!

Don’t gloat, don’t brag, but make sure you follow up with your doctor and tell them everything you feel and have measured. Do you have more energy? Less stiffness or inflammation? Are your pants fitting looser? And of course, follow up on all the labs to look at the whole picture. You will be surprised how often your doctor will then turn to you and ask you what you have been doing. If they have the time, they will likely say “Tell me more about that.” Yes! This is your opportunity to teach them the power of LCHF/Keto. Then, when the next patient comes around, they won’t be as resistant, and may even start to suggest it themselves. The patient becomes the teacher!

4.    Find a doctor who will listen

Our healthcare system is messy. No question. We don’t always have freedom to choose our own doctors. But that doesn’t mean it is impossible to change. Here is a hint: If your doctor isn’t open minded enough to try a self-directed experiment with you, what else are they close minded about? Maybe it is time for a change anyway.

It may not be easy to find a doctor with an open mind who takes your insurance, is geographically desirable, and who is accepting patients, but there are some tricks you can use. Look for a doctor who has been in practice more than seven years, but less than 20 years. In my experience, this is the critical “open minded” window. They have been in practice long enough to be confident in their own skills and are willing to stray from “what everyone else does.” On the other hand, they have not been in practice so long that “That’s the way I have always done it” becomes the reason for their care.

Look for doctors with interests in prevention, sports medicine, or integrative medicine. These suggest more interest in health and less interest in the standard “pill for every ill” medical practice. Lastly, people are developing lists of Keto-friendly doctors online. While these may be small at present, they are growing quickly and hopefully can help you find the right doctor for you. 

5.    Seek online Keto support

Numerous online sites exist to help you with you transition to a LCHF lifestyle. I have built my blog and Low Carb Cardiologist Podcast to provide information and support on those who are embarking on their healthy lifestyle journeys, with a lot of information about Keto and LCHF.

Some other sites I recommend are DietDoctor.com, 2KetoDudes podcast, and Ketovangelist podcast, to name a few.

6.    Take control of your own healthcare journey

As nice as it is to have your physician on board with your health decisions, it is not always needed. As Brian Williamson from Ketovangelist said to me on his podcast, “If your doctor is more interested in your health than you are, then you are in trouble!” I agree with that sentiment, and I encourage everyone to be the driver in their own healthcare. You can still choose to try the LCHF lifestyle even without your doctor. Look for a reputable second opinion doc who is willing to help open lines of communication between you and your doc. That is one of the services I enjoy providing the most. Since I speak the same language, I can usually help someone start the conversation with their doctor.

In addition, online sites such as WellnessFx.com allow you to get your blood drawn and seek consultations with health care providers (Disclaimer: I am one of those providers and get paid for my services. Another disclaimer: I love doing it). If you go this route, I encourage you to then bring your results back to your doctor (See number 3 above). You can now become the teacher, young Jedi.

There you go. With these six simple tips and resources, you will be well on your way to safely adopting a Keto lifestyle. Doctors are people too. Just like everyone else, we like to be needed, we like to be helpful, and we don’t like being told what to do. I just need to remember that the next time my wife “needs” me to clean the toilet….

Thanks for reading.

Bret Scher, MD FACC

Founder, Boundless Health

www.LowCarbCardiologist.com

Dr. Scher’s six-month program has been helping me make progress on my health journey. I started the program five months ago after I decided to get more serious about my health and reduce my coronary heart disease (CHD) risk by making healthy diet and lifestyle changes.

The program is not only providing me with excellent video and written content that helps me progressively realize my health goals with effective plans of action, but also individualized attention via email and with monthly video calls with Dr. Scher. I’m grateful for this individualized attention and for Dr. Scher’s insights and suggestions. His advice has honored my preference to continue following a low-carbohydrate lifestyle and has helped me select appropriate macronutrient targets such as daily intake of carbohydrates and protein based on my goals and his review of my medical history and lab test results.

Ken Carrillo
Chemical Engineer

We hear the words Heart Healthy a lot, especially when it comes to our nutrition.

By now, you’re likely used to seeing cereals with the “heart healthy” moniker. Is it really heart healthy? We all too frequently refer to foods as “heart healthy”, or we say that our doctor gave our hearts a “healthy” checkup.  

It all sounds nice. But what does it mean? How do we define heart health?

How does LDL Cholesterol affect Heart Health?

Unfortunately, most of our current definitions center around LDL cholesterol concentration.  While LDL cholesterol plays a role in heart health, it by no means defines heart health in totality.

In fact, in many cases it is the least important factor.

Our healthcare system has simplified things too much, so as a result we focus on one bad guy, one demon to fight. In reality heart disease is caused, and made more likely to occur, by a constellation of contributing issues.

Elevated blood sugar, elevated insulin levels, inflammation, high blood pressure, poor nutrition, and yes, lipids all contribute to heart health.  It does us all an injustice to over simplify it to one single cause.

What food is heart healthy?

Our superficial definition of cardiac risk is how industrial seed oils containing polyunsaturated fatty acids (PUFAs) became known as “heart healthy.”

Studies show that they can lower LDL. But they can also increase inflammation and have no clinical benefit and even increase risk of dying. According to our simplified definitions, that doesn’t stop them from being defined as “heart healthy.”

 That’s right! Something that increases our risk of dying is still termed “heart healthy.”  How’s that for a backwards medical system?!

Same for blood sugar. If you have a diagnosis of Type 2 Diabetes (DM2) that is a risk for cardiovascular disease. If you don’t have the diagnosis, you are fine. That ignores the disease of insulin resistance that can predate diabetes for decades and increases the risk of heart disease and possibly even cancer and dementia.

Cereal can also be called “heart healthy” as they may minimally lower LDL. But is that a good thing if they contain grains that also worsen your insulin resistance and metabolic syndrome? I say definitely not.

Time has come to stop this basic, simplified evaluation and start looking at the whole picture.

How Low Carb High Fat Diets Improve Heart Health

Low carb high fat diets have been vilified as they can increase LDL. But the fact of the matter is that it does so only in a minority of people. The truth is that they can improve everything else!

These diets reduce blood pressure, reduce inflammation, improve HDL and triglycerides, and reverse diabetes and metabolic syndrome! Shouldn’t that be the definition of “heart healthy” we seek? Instead of focusing on one isolated marker, shouldn’t we define heart health by looking at the whole patient?

Only by opening our eyes and seeing the whole picture of heart healthy lifestyles can we truly make an impact on our cardiovascular risk and achieve the health we deserve.

Join me in demanding more. Demand better.

Thanks for reading,

Bret Scher, MD FACC

In the fall of 2018, I was diagnosed with Type 2 Diabetes. I was educated enough to know that there was something I could do about it and set out to change the path I was on by adopting a low carbohydrate/Ketogenic Diet to control my blood sugars. Fortunately, it worked right away- but soon after I discovered that I had some red flags on my cholesterol test results. There is a history of Cardiovascular disease in my family and I was disappointed that I might have to yet again make diet changes but was willing to do what was best for my whole health. After an appointment with a local Cardiologist, I felt somewhat confused about how to move forward. I wanted more information and not just a prescription.

I contacted Dr. Scher for a consult because I wanted to confer with someone who not only understood my condition but who could also give me the latest and soundest advice on how I might treat it and move forward in the best way for me as an individual- not as a statistic. I needed someone who came from a low carb perspective as well as a medical background. My interaction with him was positive, informative and went a long way to making me feel like I could make informed choices without the black and white thinking of well-meaning physicians. He sees the WHOLE person and not just one aspect of their health. Wellness is a journey- and having Dr. Scher along the way is a great way to make the trip!

Lisa K.