Can we be certain that elevated LDL (Low-density lipoprotein) particles have no meaning and can be completely ignored?
Can we be certain that all LDL particles are deadly and need to be treated to microscopically low levels?
So, what do we do?
I have seen countless second opinion consults and enrolled numerous clients in my Boundless Health Program who have this exact question. What’s the deal with LDL? Do we worry or don’t we?
Life is much easier when it is black and white, good and bad. I, however, believe in looking for the nuance and trying to understand things a little deeper.
But first, let’s back up a little.
What is LDL and LDL-P?
Cholesterol can be a complex topic that we frequently oversimplify, which I am about to do. In brief, LDL is known as the “bad” cholesterol, the cholesterol that is found in plaque buildup in our hearts. But the truth is that LDL is not inherently bad. In fact, LDL has a purpose in our bodies as part of our immune response and as a fuel and vitamin delivery mechanism to name a few. If vascular injury and inflammation are present, then modified LDL may invade vessel walls and participate in a cascade of events leading to plaque buildup and an eventual heart attack.
LDL-C is a measure of the total amount of cholesterol in our LDL lipoproteins. LDL-P is the total number of the LDL lipoproteins. Studies show that LDL-P is a much better marker for CVD risk than LDL-C. As an analogy, the number of cars on the road matter more than the number of people in the cars.
What are the risks of LDL-P?
On the one hand, trials in the general population show that elevated LDL-P is a risk factor for cardiovascular disease (CVD). This includes a combination of observational trials, genetic mutation trials (mendelian randomization), and drug treatment trials.
All things being equal, based on these trials alone, we should want our LDL-P to be low.
But does LDL alone cause heart attacks and death? Or are there other factors involved?
Of course there are other factors involved in CVD. Vascular injury and inflammation being the two most prominent factors.
Can lowering our LDL-P have risks greater than the potential benefits for certain populations?
Absolutely. Since primary prevention statin trials show we have to treat over 200 people for five years to prevent one heart attack with no difference in mortality, it seems reasonable that certain populations will experience more potential risk than reward.
The Low Carb High Fat Reality
How many LDL or statin trials have specifically looked at individuals on a healthy, real foods, LCHF diet?
None. Not a single one.
How many LDL or statin studies have looked specifically at red headed, left handed boys born the second week of March?
None, at least to the best of my knowledge.
This seems glib but bear with me.
Is there any reason to think a red headed, left handed boy born the second week of March would behave any differently than everyone else in these LDL studies? Not really. Especially if they are eating a standard American diet or a low -fat diet as was almost exclusively studied in every cholesterol or statin trial.
Here’s the more important question. Is there reason to believe individuals on a healthy, real foods, LCHF diet would behave any differently than everyone else in the decades of lipid and statin studies?
There absolutely is reason to believe they may behave differently. There is not clear proof, but there is plenty of reason to suspect it.
Think about the benefits of a LCHF lifestyle.
- Lowers inflammation
- Reverses insulin resistance
- Naturally raises HDL and lowers TG
- Converts majority of LDL particles to larger, more buoyant particles
- Lowers blood pressure
- Reduces visceral adiposity
Could these create an environment where an elevated LDL is less of a concern?
It sure could.
To be clear, I openly acknowledge that we do not have definitive proof that we should have no concern with LDL in this situation. In my opinion, this is a specific scenario that the existing trials simply do not address one way or the other.
So, it seems we have two choices.
- Since we don’t have any proof we can ignore LDL in this setting, we plug the numbers into the 10-year ASCVD calculator and start a statin if the risk is above 7.5%, or we ask the individual to change their lifestyle in hopes the LDL will come down.
- If the individual is enjoying multiple health benefits from their lifestyle, and they are rightly concerned about the potential risks of statin therapy, then we can follow them for any sign of vascular injury or plaque formation, or any worsening of their inflammatory markers or insulin sensitivity. In the absence of any potentially deleterious changes, we can reason that the risk is low, and the benefits of living the healthy lifestyle may outweigh the risks.
The “problem” is that the second option requires a detailed discussion of the risks and benefits. It requires close monitoring and follow up. It requires us to think outside general guidelines and consider everyone as an individual with their own unique circumstance. These are qualities that our current healthcare system sorely lacks. Yet that is the exact care that each individual deserves.
What do we do in the meantime?
I hope someday soon we will have definitive long-term evidence that a high number of large buoyant LDL particles along with elevated HDL, low TG and low inflammatory markers is perfectly safe.
Until that day, we will have to continue to talk to our patients. To see them as individuals. To weigh the lifestyle benefits with the possible risks. That includes seeing the risks in real numbers- not quoting a 30% benefit with statin therapy. Instead, having a real discussion that statins may reduce your risk a heart attack by 0.6% with an increased risk of muscle aches, an increased risk of diabetes, and a potential increased risk for cognitive and neurological dysfunction.
And we will have to understand that the answer won’t be the same for each person. And we can be OK with that.
So, do you have to worry about your LDL? I don’t know. But I welcome the opportunity to explore the question and reach the best answer for you.
Do you have questions about what your lipids may mean for you? What they mean when taken in the context of your lifestyle and overall health picture? If so, you may want to learn more about my Health Coaching Consult.
Thanks for reading,
Bret Scher, MD FACC
16 thoughts on “Low Carb LDL- A Call for Reason”
Thanks for this. It’s good to read about a medical professional who actually considers this and doesn’t follow the marketing.
I follow a LCHF real food diet, and in mid 40s I’ve reversed a lot of the bad I could see starting in my 30s. I have CVD in my family history so it’s always great to see that at least someone is thinking of how does this change things.
My boss started taking statins recently as directed by his doctor, but is defiantly not eating as well (it’s all low fat type diet). I was not even aware of the side effects and risks you mentioned at the end of the article! I shall pass his along to him.
What are your thoughts when you have an ultrasound for Pain in the stomach area and it comes back with a fatty liver?
my chloresterol numbers went way out of wack also doing the LCHF diet for two years. Didn’t loose a lot of weigh but did loose inches and felt good!
Fatty liver should be taken very seriously and discussed with your doctor. The most common causes are too much alcohol and too much sugar intake. But your doctor can help you determine if that is the correct diagnosis and what other tests or interventions are needed.
I have been on a LCHF Diet (Under 50g carbs 70% fat) for 6 months, stabalized my weight at 150lbs (5' 10") Excercise 2 hours per day.
Before LCHF Diet LDL 184 HDL 60 TRI 64………. After LDL 183 HDL HDL 55 TRI 53.
Not much of a change in HDL or TRI. After LCHF Diet I also had an NMR, LDL-P 2409 HDL-P 27.8 Small LDL-P 837.
I have a CAC Score of 979 ……….. I feel great on a LCHF Diet and have no CVD symptoms, but it seems that I'm in a category that isn't recieving the LCHF benefits, and I'm forced to consider if it may actually be harmful. I'm sure there must be others in a similar predicament.
Hi Phil. Thanks for sharing your story, Yes, I have seen many others in a similar situation. Interetsingly, not all have the same outcome. That is what I enjoy most about working with individual clients, each one is unique!
But there is another possibility. That precisely such a group that would have high LDL and higher than average HDL and low TG and without CVD. And that such a group was precisely ignored in the main studies, maybe even suppressed in the data that originally established the statin/LDL guidline all along. Isn't that the point of many in the LC community?
Very good point Randy.
I have heard some prominant people in the LCGH world state that if you have a high Calcium score a statin can reduce your risk of an event. I've been on a statin since my stent in 2009 and my cac score has gone though to 1000 in 2017. I don't know what it was in 2009 when I had my first of 2 stents….But it doesn't appear to have helped at all.
Hi Ken. One important concept about CAC is that statin therapy has been shown to increase the score. There are theories as to why this happens, but the consistent take home is that once someone is on a statin, CAC becomes much less useful to follow. Plus, the scanner cannot tell the difference between a stent and natural calcium in an artery so will confuse the two. You should discuss it with your doctor, but it may be that CAC is not the best test for you.
during my last annual (late November 2018) my doctor commented on "coppering" of the veins in the back of my eyes. this concerned him and he wants me to do a fasted blood test now (which i did) and again in 3 months. and in that three months he wants me to cut back on my bacon, eggs, cheese and (good) butter.
i've never hear and can't find anything online about "coppering" veins. is this something to be concerned about?
thank you for taking the time to write your posts.
Hi John. I am sorry but I am unfamiliar with “coppering of the veins” as well. I would suggest asking your doc for better clarification.
If following your option 2 above, what lab or other tests would you be running, and how often?
Hi Lauren. I take a very individualized approach with my patients. We follow some combination of advanced lipid tests, inflammatory markers, measures of insulin sensitivity, coronary calcium scores CIMT, and others depending on the specific situation. The labs can be every 3months or more, the CAC usually 3-5 years, and the CIMT every 6 months or so. Since this is all outside the guidelines and a “new” area of investigation, it has to be an individualized approach. Sorry I can’t be more specific!
I have high LDL and Lp(a) and was also told I have family history of high cholesterol as well as CVD and several gene variants (SNP’s) that may indicate Familial Hypercholesterolemia. I am concerend what I can be doing right now to help myself as I understand this is a life threathening situation. What do you recommend?
Hi Stephanie. I understand your position. It can be incredibly anxiety provoking to hear “bad news” and be unclear what to do about it. Unfortunately I cannot comment specifically on your case with a full consult. If you are interested you can sign up for a health coaching consult on my website. In general, I can say that my opinion is that anyone identified as high risk should see a specialist familiar with advanced lipid testing and treatment, and someone who is willing to look at the whole picture as well and not focus only on lipids. You may want to ask your doc for a referral to a specialist that fits that description. I am happy to help if possible.
Fantastic Thread ! I have been enjoying your blog posts ❤️