Dr. Scher’s one-on-one Consultation was extremely valuable in my search for advice about cardiovascular health on a low-carb diet. During our discussion, I learned that interpreting lab results using the standard reference ranges can be misleading for anyone on low-carb or keto. He helped me better understand my test results and develop effective strategies to improve my cardiovascular health through nutrition and exercise. Dr. Scher is a good listener and a pleasure to work with. He is an excellent preventive cardiologist with a deep understanding of lipidology and metabolism, and the issues and challenges specific to a low-carb lifestyle.

Gabriel B.

Can we be certain that elevated LDL (Low-density lipoprotein) particles have no meaning and can be completely ignored?

Certainly not.

Can we be certain that all LDL particles are deadly and need to be treated to microscopically low levels?

Certainly not.

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.

1. 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.
2. 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

Despite what the sugary beverage and processed snack food companies want us to believe, all calories are not created equal.

A new study from Harvard shows that individuals following a low-carbohydrate (20% of total calories) diet burn between 209 and 278 more calories per day than those on a high-carbohydrate (60% of total calories) diet. So the type of calories we eat really does matter.

The New York Times: How a low-carb diet might help you maintain a healthy weight

This isn’t the first study to investigate this topic, but it is likely the best.

The current study was a meticulously controlled, randomized trial, lasting 20 weeks. Even more impressive, the study group provided all the food for participants, over 100,000 meals and snacks costing $12 million for the entire study! This eliminated an important variable in nutrition studies — did the subjects actually comply with the diet — and shows the power of philanthropy and partnerships in supporting high-quality science.

After a run-in period where all subjects lost the same amount of weight, participants were randomized to one of three diets: 20% carbs, 40% carb, or 60% carbs, with the protein remaining fixed at 20%. Importantly, calories were adjusted to stabilize weight and halt further weight loss, thus making it much more likely that any observed difference in calorie expenditure was not from weight loss, but rather from the types of food consumed.

After five months, those on the low-carb diet increased their resting energy expenditure by over 200 calories per day, whereas the high-carb group initially decreased their resting energy expenditure, exposing a clear difference between the groups. In addition, those who had the highest baseline insulin levels saw an even more impressive 308-calorie increase on the low-carb diet, suggesting a subset that may benefit even more from carbohydrate restriction.

Why is this important? It shows why the conventional wisdom to eat less, move more and count your calories is not the best path to weight loss. Numerous studies show better weight loss with low-carb diets compared to low-fat diets, and now studies like this one help us understand why.

Our bodies are not simple calorimeters keeping track of how much we eat and how much we burn. Instead, we have intricate hormonal responses to the types of food we eat. It’s time to accept this and get rid of the outdated calories in-calories, calories-out model, thus allowing for more effective and sustainable long-term weight loss.

Originally Posted on the Diet Doctor Blog 

Can you find a more polarizing topic than statins? One article says they are miracle drugs that should be given to everyone. Then you turn the page, and you read how they are poison and you should stay away from them no matter what.  How can one drug cause such differing views? And which should you believe?

The statin debate has intensified ever since the 2013 ACC/AHA cholesterol treatment guidelines increased the number of people without heart disease who “should” take a statin to 43 million Americans. That is for primary prevention, meaning the individual has never had a diagnosis of cardiovascular disease, never had a heart attack, and never had any type of a heart problem.

As you can imagine, this has been a windfall for the drug companies. But are we healthier and better off as a result? That is unknown.

The problem is understanding the bias of whoever is writing the story.

Subtleties of Science

But wait, you say. Won’t the science tell us if statins are good or not? Isn’t it an objective fact if they are good for us?

Not so fast. Beauty is in the eye of the beholder, and so is the application of science.

Are you getting advice from someone who believes prescribing more medicine is better? Or someone who believes a more natural lifestyle is better? 

Are you reading a report sponsored by the pharmaceutical company that paid for the research?

Or are you getting advice from a scientist who is more focused on statistical benefits, or someone who is more concerned with the potential benefit for the one individual they are taking care of at the moment?

It is a confusing sea of conflicting information, and you have to find which approach resonates more with your beliefs and your life.

The Three Keys

Regardless of who you are and your beliefs, I promised you the three most important things you need to know about statins. Here they are:

1. All statin studies are worthless! That’s right. All statin studies that have been done to date are worthless and don’t apply to anyone who follows healthy lifestyle principles.
2. Statins will not prolong your life. Not at all. Not for a single day.
3. Statins DO reduce your heart attack risk, by about 0.7% over 5 years.

All of a sudden, statins don’t seem so powerful, do they? Let’s go deeper into these points to learn why.

1-All Statin Trials Are Worthless

When designing a trial, you have to decide what your control group is going to be. You have to show that the drug is better than something. The key is defining what that something is.

Therein lies the problem. In order to show beneficial effects, primary prevention statin trials need thousands of subjects, studied over years. That is very expensive to do. The vast majority of trials, therefore, rely on drug company funding.

Do you think they are going to fund a trial that makes it easier or harder to show a benefit? Of course, that was a rhetorical question.

Pharma companies don’t have an interest in your health and wellbeing. Their priority is to their stock holders and their bottom line. They are going to sponsor trials that are most likely going to benefit them.

How does this make the trials worthless? They compare statins to “usual care.” That means a brief, and ineffective attempt to educate people about healthy nutrition and physical activity.

In addition, the specific nutritional guidance that was used has always been a low-fat diet. As we now know, what does a low-fat diet usually include? Lots of sugars and simple carbohydrates. What does that diet do? Increase your risk of obesity, diabetes, inflammation, and eventually heart disease.

That’s setting the bar pretty low to show a benefit from statins. And that is exactly what the drug companies want.

What we need is a control group that is involved in a comprehensive lifestyle intervention program. A program that helps participants get regular physical activity. Helps them eat vegetable based, real food, low in added sugars and simple carbs, and high in natural healthy fats.

Since that is the way we should all be living, THAT is what the control group should be. I guarantee you, the results would be far different compared to the standard control groups used to date.

That is the trial the drug companies never want to see and will never fund. And that is why all statin trials to date are worthless.

If you can focus on proper lifestyle interventions, using healthy foods, physical activity and stress management as medicine, then we have no idea what effect, if any, statins would have. But I assure you it will be minimal if any benefit.

2-Statins Will Not Prolong Your life

You read that right. For people who have never had heart disease before, the multi-billion dollar drug won’t help you live longer. The overwhelming majority of primary prevention trials involving statins show no difference in overall mortality between those who took the drug and those who did not.

That surprises a lot of people. Statins are promoted as if they are wonder drugs that save lives left and right. That’s good marketing and good PR. Reality is far different.

If they don’t help you live longer, they must increase the quality of your life, right? Nope. In fact, 30-40% of people on statins will experience muscle aches and weakness causing them to exercise less and decreasing the overall quality of their lives.

So, if they don’t help us live longer, and they don’t increase the quality of our lives, why do we take them????

3-Statins DO Reduce Your Heart Attack Risk

If the news was all bad there wouldn’t be any debate about their use. But the truth is that statins do reduce the risk of heart attacks, and that is why in some cases it may be beneficial for you to take one.

But the big question is: How much do statins reduce your heart attack risk? The answer is not as much as you would think. Considering the recommendations keep getting more and more aggressive for statin therapy, you would think statins would be immensely powerful at reducing heart disease risk.

In reality, they reduce the risk of a heart attack by 0.7-1.5% over 5 years. That means you need to treat 66-140 people for 5 years to prevent one heart attack.  (as an aside, for people with pre-existing heart disease, so called secondary prevention, you need to treat approximately 40 people for 5 years to prevent 1 heart attack and 85 people to prevent 1 death)

When presented like that, it should certainly temper the enthusiasm for statin therapy. Again, it may still be the right choice for some people, but given the potential risks and side effects, I would hope for a much greater benefit.

Better Than Statins

A common response is that statins are “the best we have to offer” to reduce one’s risk of cardiovascular disease.  If you are talking about a drug manufactured in a laboratory, then that would be correct. But what else are options?

It turns out following a Mediterranean eating pattern with vegetables, fruit, fish, legumes, and lots of nuts, olive oil and avocados reduces the risk of cardiovascular events as well. For something as simple as nutritional choices the benefit must be much less than a statin, right?

That is what the drug companies would want you to believe. In reality, you need to “treat” 61 people with the Mediterranean diet for 5 years to reduce 1 cardiovascular event (a “combined endpoint” of stroke, heart attack or death).

To be fair, you cannot compare one trial to another as they have very different populations studied, and the outcome measures are different. So, it is not scientifically fair to say, “The Mediterranean diet has been proven to be more beneficial that statins.”  That would require a head-to-head trial. Unfortunately, that trial is unlikely to ever happen.

But it makes for an obvious answer when asked “If statins aren’t all that helpful, what else can I do to reduce my risk of cardiovascular disease?

• Follow a real food, vegetable-based, Mediterranean style diet, low in sugar and high in healthy fats.
• Maintain a physically active lifestyle.
• Exercise with some form of moderate cardio exercise, resistance training and higher intensity interval exercises.
• Practice stress reduction techniques.
• Don’t smoke.
• Manage your other risk factors such as diabetes and high blood pressure.

If you can follow these healthy lifestyle principles, you will be doing far more for your health than any pill you could take. And the best part? The only side effects are having more energy, feeling more empowered, and reducing your risk for chronic diseases.  Sounds like a good trade off to me!

Thanks for reading.

Bret Scher, MD FACC

Cardiologist, author, founder of Boundless Health

www.DrBretScher.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