Low Carb Cardiologist

Virta Health continues to revolutionize the treatment of diabetes. And they are doing it while taking drugs away!

They recently released their study of cardiovascular risk data which, no surprise to me, shows significant improvement in patients’ risk profile. This impressive lifestyle study contrasts sharply with the other side of the coin- promoting drugs to drive LDL to a near zero level in the hopes of helping patients. That’s the other study I read last week, and I was much less excited about it.

Two wildly different approaches with wildly different magnitude of benefit. Let’s dig deeper to learn more….

The Virta Health Study:

The Virta Health trial enrolled subjects with diabetes, mean age was 54 years old, and they were obese on average with a BMI 40. After 1 year, they had the following results:

LDL particle number decreased by almost 5%,
Small LDL decreased by 20%,
Apo A1 increased by almost 10%,
TG decreased by 24%,
HDL increased by 18%,
TG/HDL radio decreased by almost 30%,
Large VLDL particles decreased by 38%,
CRP decreased by almost 40%,
The 10-year calculated risk went down by 11% ,
No change in CIMT, and
LDL-C went up by 10%.

EVERYTHING IMPROVED! Except for a small increase in LDL-C.

The first question this study forces us to ask, therefore, is should we care about the LDL-C? That is the only marker that went “the wrong” way, increasing 10%. But that is in the face of the LDL-P decreasing, the size of the LDL improving, and dramatic improvements in HDL and TG. All things that are likely protective against CAD.

Going all the way back to Dr. Castulli and the Framingham data, we know that LDL-C is a very poor predictor of CVD in the setting on high HDL. We also know that markers such as LDL-P and non-HDL cholesterol are better predictors of CVD than LDL-C.

So, in short, the answer is no. We should not be concerned with a 10% increase in LDL-C in this setting.

The second question is this. Does this data show that one year on a ketogenic diet is BENEFICIAL for heart health?

The original assumption within the medical community was that a ketogenic diet would be harmful and lead us to our grave (as many docs still believe).

The times they are a changin.’

Based on this data, the question has changed significantly. We should no longer concern ourselves with wondering if a very low carbohydrate, ketogenic diet could be harmful. The data is overwhelming that it is not. Instead, we need to ask if this diet protects us from heart disease.

Of course, we would need long term outcome data to show us that for certain. But in the absence of that, the most recent Virta Health data provides a strong vote of confidence that a very low carbohydrate ketogenic diet is likely cardioprotective.

That is my kind of medical science. Showing that lifestyle changes promote health. Clean and simple.

The Drug Trials- PCSK9i

The Virta Health study contrasts sharply with another paper I read recently, one that claims it is safe and beneficial to lower LDL as low as possible, the so called “Zero LDL hypothesis.”

I have to admit, I started reading with a heavy contrary bias. I wanted to rip it apart and find all the shortcomings in the paper. There were plenty, but I also have to admit that there are some very well thought out and well-argued points.

The general argument is that statins and PCSK9i are able to lower LDL to extremely low levels without documented significant adverse effects thus far. Therefore, there is no “floor” for how low we should drive down LDL.

Both statins and PCSK9i work by increasing the efficacy of LDL receptors, but they allow other compensatory mechanisms to remain functioning. For instance, the authors describe “back up” mechanisms for maintaining neuronal health, hormone synthesis, and even vitamin E transport (all of which are theoretical concerns with lowering LDL). They argue, since the back-up systems prevent adverse outcomes, and PCSK9i studies have gotten LDL down to 30, we can therefore safely drive LDL down to zero.

That’s a stretch that remains to be proven. However, the main question they fail to answer is this: Is worth the effort?

Once again, we see studies generating a tremendous amount of publicity and praise for underwhelming and conflicting results. Here’s what I mean:

The first big trial with PCSK9i was called the FOURIER trial. They enrolled patients with known cardiovascular disease and added PCSK9i or placebo to their current care. After 2 years, the PCSK9i drug reduced LDL by 60% to a median level of 30mg/dl (lower than any other major trial). The results? There was a small decrease in non-fatal heart attacks (1.2%), with absolutely no improvement in mortality. It did not save a single life.

The second trial that got even more attention was the Odessey trial. They enrolled individuals with a recent cardiac event and added PCSK9i or placebo to their standard care. After 2.8 years they lowered LDL by 61% to an average level of 53mg/dl. Again, there was a very small 1.5% reduction in a combined primary endpoint. In reality, this is negligible clinically even though it is statistically significant.

Where the trials differed, however, was that Odessey showed a very small reduction in all-cause mortality of 0.6%., whereas Fourier did not.

But here is where it gets complicated. What the press and mainstream cardiology societies don’t tell us is that because of the way the trial was structured, this is not a truly significant finding. It had a weakly positive p value, but since cardiac mortality was not decreased, it invalidated the all-cause mortality. Don’t worry. I don’t completely understand this part either. But I’m told that’s how statistics work in this case.

In summary, despite lowering LDL cholesterol to levels lower than we have even seen before with drug therapy, the benefits were underwhelming. If LDL was the true cause of heart disease, there should have been breath takingly dramatic benefits. Yet, one trial showed no improvement in all-cause mortality. One may have shown an improvement, but the trial can’t really claim that.

Yet somehow the conclusion is that now we should drive LDL down to zero. Where did that come from????

First Do No Harm

The belief that we should drive ldl to zero with drugs comes from the inherent bias in modern medicine: When it comes to drug therapy, “more is better,” and drugs are the best choice for treatment.

After all, the trials “proved” that the drugs were safe with no significant increase in adverse effects, right? Not so fast. Lack of side effects at 2 years is not very reassuring for a drug people will be on for decades. There is plenty of concern about long term effects of near zero LDL levels, even if the authors postulate ways the body will compensate. To counteract that concern, the benefits better be monumental.

After all, the medical oath is “First do no harm”. Not “First assume there will be no harm”.

And more importantly, just because we can treat LDL to near zero, doesn’t mean we should. If we aren’t helping people live longer or live better, then what are we accomplishing?

Instead of talking about zero LDLs, we should be talking more about Virta Health. They showed the ability to reverse one of the most common chronic diseases we face with simple lifestyle interventions. And they did it while improving cardiovascular risk factors and getting people off of their medications. In my eyes, that deserves a ticker tape parade.

My take home message: Lifestyle beats drugs. Commit to lifestyle change and the argument about reducing your LDL to zero is a non-factor.

What’s your take home message? Let us know your thoughts or if you have questions at www.LowCarbCardiologist.com

Thanks for reading

Bret Scher, MD FACC

Founder, Boundless Health

www.LowCarbCardiolgist.com

Is Alzheimer’s Disease Type III Diabetes? And Can it be Prevented?

By Bret Scher, MD

Alzheimer’s disease is one of the most devastating conditions in our country, and you may have the power to prevent it.

There is nothing more empowering than knowing you have the ability to prevent a chronic disease. Especially when some view that chronic disease as worse than death. While not all factors that lead to chronic disease is controllable (e.g., genetics), there are some diseases that you can protect yourself against. And one of those might be Alzheimer’s disease.

Alzheimer’s disease—which is the sixth leading cause of death in the U.S.—is a devastating condition that impairs your memory and ability to think. It progresses over time, eventually condemning an otherwise functional body to a life completely dependent upon care from others. It changes the lives of not just those affected by the disease, but their loved ones and caregivers as well.

In 2015 alone, approximately 15 million caregivers provided an estimated 18 billion hours of unpaid care to the 5 million Americans who suffer from Alzheimer’s disease. But the cost to families and to society as a whole cannot be measured in just dollars and cents. The emotional toll can also be enormous. The negative effects on caregivers can be vast, including:

Psychological distress
Impaired health habits
Psychiatric illness
Physical illness

To make matters worse, the number of people diagnosed with Alzheimer’s dementia is only getting larger and is expected to triple as baby boomers reach the at-risk age of 65 and older.

Paradigm Shift in Understanding Alzheimer’s

Modern medicine has struggled to find effective treatments for those who suffer from Alzheimer’s. The most effective medicines may slow the symptoms by a few months, but the inevitable progression always happens in the end.

A new paradigm shift, however, offers promise for methods to prevent and treat Alzheimer’s disease. The paradigm shift is that Alzheimer’s may be Type III Diabetes.

To understand this relationship, it helps to understand the basics about diabetes, blood sugar, and insulin. Insulin’s job is to signal cells to take sugar out of the blood and convert the sugar into energy. When a person has diabetes, the cells no longer listen to insulin, so the body needs to produce more and more insulin to get the message across.

As the efficiency worsens, the body can’t keep up, the blood sugar rises and diabetes develops. This causes two main problems:

Insulin levels rise sky high. Since insulin is a fat storage and pro-inflammatory hormone, higher levels equate to deterioration of overall health.
Blood sugar levels increase to dangerous levels. This can eventually lead to heart disease, vascular disease, kidney disease, vision loss, neuropathy, and other serious conditions.

It turns out that brain cells can become resistant to insulin as well, thus drawing a connection between diabetes and Alzheimer’s. The theory is that increased insulin and increased sugar in the brain leads to damage of brain cells and eventual dementia.

The Connection Between Alzheimer’s and Diabetes

Medical science is starting to explore the relationship between diabetes and dementia and is drawing a strong connection. One study, for instance, reviewed previous investigations of diabetes and dementia, accounting for over 2 million subjects. The study concluded that those with diabetes were 60 percent more likely to develop dementia.

While an association does not prove causation, it does raise an interesting potential link that deserves further exploration.

The next question is whether there is a reasonable explanation for why the two diseases might be related. And it turns out there is.

Another study demonstrated that individuals with type II diabetes are more likely to develop the same “brain tangles” that are seen in those affected with Alzheimer’s. It is thought that these tangles are directly responsible for the progressive cognitive decline. And they are present in both the brains of individuals with Alzheimer’s disease, and the brains of those with diabetes even in the absence of dementia.

How to Prevent Diabetes, and possibly Alzheimer’s

This emerging research could be discouraging news since the incidence of diabetes is on the rise, with an estimated increase from 285 million cases worldwide in 2010 to 439 million in 2030. The result could be an equal surge in new Alzheimer’s cases.

Or it could be encouraging news, since type II diabetes is almost entirely preventable with healthy lifestyle habits. Presumably, these same habits may help prevent Alzheimer’s as well.

In fact, a 2001 study in NEJM suggested that 90 percent of type II diabetes cases could be prevented with:

Proper exercise
Healthy eating
Not smoking
Maintaining a healthy bodyweight

Another study showed that a lifestyle program that included 150 minutes of weekly physical activity and a goal of 7 percent weight loss prevented diabetes better than the popular drug Metformin—an oral diabetes medicine that helps control blood-sugar levels.

Finally, a 2012 study followed 2,700 people over three years and found those who ate a diet higher in carbohydrates and sugars and lower in protein and fat were more likely to develop dementia.

This information shows that diabetes, and by extension Alzheimer’s disease, may be preventable by following a healthy lifestyle that includes these elements:

Exercise 150 minutes per week and remain physically active throughout the day
Maintain near ideal body weight
Eat a real-foods, vegetable-based diet with healthy fats
Avoid simple, refined carbohydrates
Avoid added sugars in food and drinks

A Healthy Lifestyle Is Necessary

Unfortunately, this is not hot-off-the-press news. These studies were published over 15 years ago, yet many people are still reluctant to adopt such healthy practices. In fact, one study of American adults found that only 2.7 percent of the subjects followed a truly healthy lifestyle.

The public shouldn’t need more inspiration to strive to be healthy, but knowing that Alzheimer’s disease and diabetes are likely preventable will hopefully be enough motivation to spark a revival for healthy lifestyles now and for decades to come.

Change doesn’t come easily, so start by making simple steps and find a support system that will help you adopt new ways of living.

Those in positions of influence (doctors, nurses, personal trainers, nutritionists, health coaches, chiropractors, and other medical professionals) need to actively educate society about the association between Alzheimer’s and diabetes.

If you fall into this category, it’s important to learn how to inspire individuals to adhere to healthy life habits, which may help prevent one of the most devastating conditions that touches the lives of tens of millions Americans every year.

Now that’s empowering.

Thanks for reading.

Bret Scher, MD FACC

Cardiologist, author, founder of Boundless Health

www.DrBretScher.com

ACTION ITEM:

Make 1 meal this week a Vegetable Based meal. Don’t have chicken with a side of veggies, or salmon with rice and a couple veggies. Make the basis of the meal veggies and add 4-6 oz. of high quality animal protein. Notice how it looks different, tastes different, and how you feel differently after you eat it. If you can do this, then you can increase it week after week until most of your meals are veggie-based. You will be amazed at how it improves your health and how you feel!

Tag: diabetes

Zero LDL vs Ketogenic Diet- Which Prevents Heart Disease?

Is Alzheimer’s Disease Preventable?

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