Is LCHF Keto the right diet for you in the new year?

With New Year’s resolutions looming, many people are thinking about reinvigorating their health. In fact, 45% of people want to lose weight or get in shape as their New Year’s resolution.

The LCHF Keto diet has been quickly gaining momentum, and it is piquing a great deal of curiosity.

So, is this particular diet right for you? It may just be.

 

What are your diet goals?

Before selecting a diet, it’s important for you to define why you want to diet in the first place. Are your goals weight loss, general health, or a combination?

If you want to lose weight, reduce your hunger, enjoy your meals, and improve your metabolic health, then LCHF may be right for you.

 

Do you want to lose weight?

The primary reason most people go on a diet is to lose weight. As far as weight loss, low carb has you covered. Out of 60 studies comparing low carb to low fat diets, low carb had better weight loss in 30 and they were equal in 30. Low carb was inferior in exactly zero of these studies. That’s an impressive record, and definitely something to consider if weight loss is your primary goal.

But there is so much more to life and health than weight loss.

 

Do you want to reduce your hunger?

One main struggle in health and weight loss is how hungry we are and how much we need to think about food during the day. Studies show that following a LCHF diet reduces our hunger in the long-term. That means less worry about constant snacks, and less concern with needing to eat every few hours. In fact, LCHF works so well at curbing appetite that more people can practice time-restricted eating by compressing eating into a 6-8 hour window, which has indicated potential beneficial effects for longevity.

 

Do you want to improve your focus?

Food, especially the wrong food, can make us feel lethargic and unfocused. Many people report thinking more clearly and having better mental performance when on a low carb diet. The brain loves ketones, whereas carbs can cloud your thinking. Why not switch to low carb and see if your brain fog lifts?

 

Do you want to improve metabolic health?

A recent study showed that only 12% of Americans are metabolically healthy. Low carb diets are one of the fastest and best ways to improve metabolic health. Studies show it puts type 2 diabetes in remission, improves insulin resistance, reduces visceral fat, and improves overall metabolic health.

 

Do you want to decrease your cardiovascular risk?

Fat phobia is gone. Limiting carbs to real food veggies and eating plenty of healthy fats improves our cardiovascular risk profile. It reduces BP, reduces TG, increases HDL and improves the size and density of LDL, which all add up to a net improvement in cardiovascular health.

 

The main reason you should consider LCHF/Keto in the new year

You will love it!

No counting calories, no feeling hungry, no wild glucose swings and post meal crashes, no afternoon slump. With all of this research backing this diet, it’s definitely worth a try.

 

One last consideration

A note of caution, most people will do great. But not everyone reacts to this diet the same way, so you may want to consult a doctor experienced in low carb nutrition.

If you don’t already have a doctor to consult with or want to speak with one who specializes in Keto, I’m a professional who has extensive experience with LCHF diets and how they affect your health. If you’re just getting started, I recommend downloading my free LCHF/Keto starter tips e-book to get you on the right track:

 

 

 

If we can be of any additional service, please let us know!

Thanks for reading,

Bret Scher, MD FACC

A Guide to Keto-Friendly Meal Prep

 

Let's be honest. Changing our eating habits is hard. No matter how inspired and gung-ho we may feel when we first decide to go keto, inevitably, we will face temptations and frustrations. Whether you're brand new to the low carb or ketogenic diet or you've been following it for ages, adopting a meal prep habit can help traslate that initial enthusiasm into success. It can even save time and money along the way!

What is Meal Prep?

Meal prep is the practice of preparing a number of meals in advance, typically all at once on one day per week. I enjoy doing this on Sunday and trying to involve my kids as well! You can be flexible with this to fit your schedule. For instance, you can prepare and freeze an entire week of food, or make only certain meals or plan for only a few days at a time. 

Why Meal Prep?

It saves you time.

The more you prepare in advance, the less time you spend running to the grocery store, and my personal favorite, less day to day clean up! While yes, you prepare about the same amount of food, efficient meal prep typically relies on multitasking to significantly speed up the process.

It cuts your food bill, sometimes drastically.

Meal prep can save you a lot of money on food. How? Consider that the average U.S. consumer will dish out $5,400 on impulse purchases each year. Having a grocery list and sticking to it can dramatically decrease the likelihood that you will give into these types of impulse purchases. (anyone can make a list, but can you stick to the list? Seinfield reference anyone???) Also, preparing a week's worth of food at once makes it easier to buy in bulk, which is often more cost-effective. You'll also find it a lot easier to form your shopping list around sales when you're forced to plan in advance.

It helps you avoid impulse decisions about food.

When you're busy, it's very easy to give into carb-laden fast food temptations. When you're drained after a long day of work, you may think, Whi has time of energy to make dinner? That can lead to less healthy take out choices. Meal prepping helps you avoid this kind of impulsive decision because you'll always have a healthy meal ready for you at home. Just walk in the door, heat it up and viola, dinner is served.

It can facilitate your keto diet.

Since staying in ketosis depends on a certain percentage of macros each day, a meal plan can be invaluable. By planning your meals in advance, you can be certain that you won't get to the end of the day and realize you've gone way over your carb allotment. Meal prep makes it even easier to stick to your meal plan because you can reuse the same base components in multiple meals, making the macro calculations much easier. You're also less likely to deviate from a meal plan when the food is already in your fridge, ready to eat.

 

How to Start Meal Prepping

Getting Started

As with any lifestyle change, when you first start out with meal prep, it's important that you start slowly so that you don't overwhelm yourself. You don't need to prepare an elaborate menu with a different entreé each night. Instead, try the following steps to get acclimated to the habit.

  1. Start by picking two keto-friendly protein options that use different cooking methods. For instance, if one requires the oven, pick something that you can prepare stovetop for the other recipe. You may also pick a side dish or two if you'd like.
  2. Buy enough ingredients to make at least 3 servings of each recipe. You might also consider buying some extra meat and vegetables that you can prepare early and use throughout the week for lunches (think salads and lettuce wraps).
  3. Set aside enough containers to hold your meals for the week. You'll likely want to pre-portion the meals to keep your macros consistent, so you'll need one container per individual meal (Tip: glass is much better than plastic).
  4. On your chosen meal prep day, Sunday in my house, prepare your recipes. Be sure to prep your ingredients all at once and find ways to complete multiple tasks simultaneously. While your chicken is in the oven, for instance, you can be steaming or stir-frying some veggies.
  5. Cook any extra meat and vegetables as well, if you chose to purchase some. A slow cooker can be extremely useful here to free up your other kitchen appliances for your main recipes.
  6. Once you've finished cooking, portion out the meals into their containers. Consider freezing half of the meals to prevent any issues with spoilage. Put the extras into larger containers to portion out as snacks or side dishes.

Refining Your Routine

Throughout the first week, pay attention to the following questions:

  • Did I prepare the right amount of food? If you don't eat all the meals, consider cutting back. If you run out early or don't feel like you've saved yourself any time, consider preparing extra next time.
  • Am I bored with these meal options? If so, next time try preparing slightly different variations on the same recipe or add another entreé entirely.
  • Did meal prepping benefit me this week? Think in any terms you want: time, money, healthy decisions, etc.

It will take some trial and error to determine how often to meal prep and how much to prepare each time. Experiment with different schedules and menus until you are completely satisfied with the answers to these questions.

Keto-Specific Meal Prep Tips

Making meal prep work for any diet is all about planning, and keto is no different. The key is to prepare foods that will help you comply with the diet.

Add variety.

One of the main objections to meal prepping is that people don't want to eat the same meal over and over throughout the week. People who aren't following keto will often use a different carb with each meal to change things up. This isn't possible when following keto, unless you use alternatives such as spiralized or riced vegetables. If variety is important to you, consider one of the following ideas that take less time than adding a whole extra recipe to your prep day.

  • Prepare the same marinade, sauce, or seasoning, but use it on different proteins.
  • Stir-fry different combinations of vegetables with the same sauce or spices.
  • Portion your protein, vegetables, or both into sections and season each differently before baking or frying.

Don't skimp on snacks.

Pre-portioning keto-friendly snacks during your meal prep time can help ensure that you always have healthy options to keep you from dipping into the office candy jar, or in my case, snacking on the muffins and doughnuts in the doctor's lounge (I know that's absurd, but that is what they serve in the hospital!).

Label your food containers.

You should always label your food containers with the dish and date it was prepared. It's also helpful if you're following keto to mark the net carbs and other relevant macros in case you end up mixing and matching your recipes you can still stay on point.

With these tips, you should be well on your way to an efficient and effective meal prep routine. Once you see how much easier it is to follow the ketogenic diet with meal prep, you'll never go back.

 

Does Weight Loss Depend on Calories or Hormones?

 

Why do people have such a hard time losing weight? Anyone who has tried it before knows the challenges. It frequently goes one of two ways:

  1. Initial success followed by a stall and eventual regaining of the weight leading to frustration and giving up.
  2. Difficulty changing habits enough to see a meaningful difference. Life seems to get in the way to prevent success.

 

Let’s be honest. There are numerous ways to lose weight. You can hardly go on the internet without seeing an ad for a magic weight loss solution or the one food you need to finally burn that belly fat.

 

As long as we are being honest, let’s also acknowledge that those don’t work. Ever.

 

The seemingly elusive weight loss holy grail would look like this:

  • We can easily maintain for years if not decades- it’s enjoyable!
  • Helps us maintain a healthy weight- losing mostly fat while preserving muscle
  • Helps improve our overall health, longevity and health span

Low Carb vs Low Fat Diets

 

If you have read some of my prior posts, you know where I am going with this. I think a low carb high fat (LCHF) lifestyle is likely the closest thing we have to the holy grail.

 

This isn’t just my opinion. As presented by DietDoctor.com, there have been 60 studies comparing LCHF vs low-fat diets for weight loss. The running score board shows 30 wins for LCHF, 30 ties, and exactly zero wins for the low-fat diet.

 

I’m the first to admit nutritional science is messy and we have to be careful with interpreting the data. But when there have been 60 studies and a low-fat diet has not been more beneficial in a single one, that speaks volumes.

 

This leads us to the next question:

 

Why is an LCHF diet better for weight loss?

 

Some would counter: Does it matter why? If we know it works, people enjoy the lifestyle and feel good on it, and we have evidence that it improves diabetes, metabolic syndrome and cardiovascular risk factors, then what more do we need to know?

 

This is where the science gets murky regarding two theories for weight loss

 

1.    Calories in/Calories out.

This theory states that weight loss is a simple equation. Take in fewer calories than you expend and you will lose weight. If you burn 2000 calories in a given day, then it doesn’t matter if you take in 1500 calories of bread, pasta, soda, cake, cookies, or vegetables and steak. You will lose weight. Period.

 

2.    Carbohydrate-Insulin Model.

This theory states that the hormonal response to calories is more important than the absolute number of calories. Simply put, insulin resistance and hyperinsulinemia prevent us from losing weight. Insulin’s “job” is to shuttle glucose into cells and prevents us from breaking down our fat stores, thus impairing weight loss attempts.  By following a LCHF diet, we can lower insulin levels, improve insulin resistance, and allow our body to break down fat stores and lose weight in a healthy and sustainable way. Absolute calories matter little in this theory.

 

Studies Around LCHF Diets

 

A series of trials funded by NUSI recently caused waves of controversy regarding the mechanism of LCHF diets and the carbohydrate-insulin hypothesis.

 

The Ketogenic Diet Study

 

The first study published in 2016 investigated 17 overweight men and their response to two diets. For the first 4-weeks they ate a “high-carbohydrate baseline diet,” followed by 4-weeks of an isocaloric ketogenic diet. Each week they spent two days in a metabolic ward where investigators measured everything they consumed along with their resting energy expenditure.

 

In theory, if our insulin response is the primary driver of weight loss, then our resting energy expenditure should increase on a ketogenic diet as a reflection of breaking down our natural fat stores for use as fuel.

 

Here are the basic highlights of the study:

  • Subjects lost weight on both the control diet and the ketogenic diet
  • Fat loss continued but slowed after transitioning from baseline to ketogenic diets
  • Resting energy expenditure increased on the ketogenic diet by about 100kcal/day.

 

Now comes the interesting part. How do we interpret these results? Resting energy expenditure went up on the ketogenic diet, suggesting the carbohydrate-insulin model works, right?

 

Not so fast. The lead author of the study, Kevin Hall, concluded that his study disproves the CIM, claiming that the resting energy expenditure change wasn’t high enough. As part of their research protocol, they estimated the dietary change should have resulted in a difference of between 300 and 600kcal per day. So even though the trial “worked,” it fell short of expectations.

 

Kind of like if Amazon predicted a 20% revenue increase for the quarter. When their increase is only 15%, their stock price falls, even though their revenue still went up!

 

To be honest, this is where I tune out.  Switching to a ketogenic diet lowered insulin and increased resting energy expenditure. What’s wrong with that? That sounds like a good result to me.

 

The Healthy Low-Fat Diet Study

 

Which brings us to the second trial.  I wrote about this trial shortly after it was published, and will summarize it again here.

 

600 subjects were randomized to a “healthy low fat” or a “healthy low carb” diet (this was not a ketogenic diet as they ended up eating 130gram carbs per day). Both groups were advised to maximize veggies, minimize sugars and processed flour, minimize trans fats, and focus on nutrient dense whole food prepared mostly at home.

 

In the end, both groups lost the same amount of weight, and they saw no difference in genetics related to fat metabolism and insulin sensitivity. Does this also disprove the CIM and show restricting carbohydrates is of no value? Does it mean we can support drinking sodas and eating cookies as long as we keep our calories low?

 

This study compared a control diet is much healthier than what most Americans eat (remember, they still restricted sugars and flour and focused on home prepared nutrient dense meals), to a moderately low carb diet (not a very low carb ketogenic diet). In the end, it was not well formulated to answer the question of the CIM. But it does add to the ongoing score card of 30 wins for low carb, 30 ties, and zero wins for low fat.

 

Again, this is where I tune out of the debate.

 

I am a cardiologist. I care about what is going to help the client I am working with at that exact moment. These clients don’t live in metabolic wards where their meals are provided for them, and they don’t exist in study formats where they know they are under constant observation.

 

Dieting in the Real World

 

My clients live in the real world just like you. Thus, I care about what works in the real world.

 

In the real world, we cannot ignore human behavior and psychological responses to food. Robb Wolf’s book Wired to Eat is one of the best resources explaining the minefield we encounter on a daily basis, how carbohydrate rich foods stimulate our brain to crave more, how food companies purposely create foods we cannot resist, and how why we eat may be more important than what we eat.

 

In this environment, does your brain care if the carbohydrate-insulin model has scientific backing or not? No way. It just wants its reward centers triggered by the next chip/cookie/cracker.

 

Don’t get me wrong. How we interpret science is important.

 

As long as people feel calories in/calories out is the only answer, Coca Cola can keep promoting their sugar filled drinks and Nabisco can keep promoting their sugar filled snacks as part of a healthy diet, just so long as we exercise enough to burn the calories.

 

How has that worked for us so far? Just look at our obesity and diabetes epidemics to answer that question.

 

I strive to find a balance between the science and the practical question of what really works for most people.  Hunger, energy, mood, cravings and enjoyment are very powerful motivators. For that, I have found nothing more effective than an overall healthy lifestyle which incorporates a LCHF diet.

 

 

Thanks for reading

 

Bret Scher, MD FACC

www.LowCarbCardiologist.com

Is the Keto Diet Heart Healthy? 7 Reasons Why This Cardiologist Agrees

Is the Keto Diet Heart Healthy? 7 Reasons Why This Cardiologist Agrees

 

I am a board certified, card-carrying cardiologist, and I want my clients to eat more fat, more meat, more cheese, more eggs, more avocado, more, more, more.

 

For decades medical establishments have convinced us to eat low fat, higher carb diets. How has that worked for our health? Here’s a hint, we have record numbers of obesity, diabetes and dementia. Yet, as a cardiologist, that’s the party line I am supposed to support.

 

But I can’t. It’s just wrong, and I can’t support that line of thinking, not for a second.

 

Instead, I am a Low Carb Cardiologist. Here are the top Seven reasons why

 

 

              1-  Reducing Insulin is Essential to Health and Weight Loss.

 

Insulin is a hormone naturally secreted by the pancreas to help regulate blood sugar levels. Everything we eat (except possibly for 100% fat meals) causes insulin to rise. That is normal physiology. The problem occurs when our bodies become resistant to the effects of insulin, thus requiring our pancreas to make more and more and more insulin.

 

The problem? Insulin promotes fat storage, increase inflammation and oxidation, and can even help fuel the growth of cancer cells. Therefore, the healthiest approach is one which reduced the level of insulin to the lowest possible levels. As it happens, a Low-carb High-fat or ketogenic lifestyle (LCHF/Keto lifestyle) dramatically improves your body’s sensitivity to insulin, reduces the amount of insulin secreted, and it allows your body to naturally use your fat stores for what they are designed for: Break them down into energy! Once we see that we need to fight chronic elevations of insulin, it becomes obvious why a low-fat diet is harmful, and why a low carb diet is the true path to health.

 

2-    Eating Fat Improves Your Cholesterol!

 

Wait, what? Eating fat can improve my cholesterol? Sounds crazy, right? That goes against everything we have heard from the medical establishment. Notice I said “cholesterol.” I didn’t say the "bad" low density lipoprotein (LDL), I didn’t say the "good" high density lipoprotein (HDL), or any one specific type of cholesterol. We have over emphasized the solitary variable of LDL for too long. Total cholesterol to HDL ratio, Triglyceride to HDL ratio, lipoprotein size and density, insulin sensitivity, and other metabolic measures are more powerful predictors of cardiovascular health than just LDL.

 

Once again, we see that all these markers improve with a Low Carb High Fat (LCHF) lifestyle. The medical establishment needs to realize that we are more complicated than one lab value. The key is to look at the whole picture, and this picture dramatically improves with a LCHF lifestyle.

 

3-    Higher HDL is Associated with a Lower Risk of Heart Disease.

 

HDL is your friend, but drugs are not. Observational evidence has consistently shown that higher HDL is associated with a lower risk of cardiovascular disease. However, our healthcare establishment does not prioritize HDL for one simple reason- Drugs that raise HDL don’t make you healthier. Trial after trial has failed to show any benefit from drugs that significantly increase HDL. 

 

Instead, it’s the HDL-raising lifestyle that provides the benefit, not artificially increasing it with drugs. What’s the best lifestyle to naturally raise HDL? You guessed it. LCHF/Keto lifestyle. Add in some resistance training and you have your friendly HDL climbing the way it was meant to…Naturally.

 

4-    LCHF Leaves You Feeling Great, Leading to Healthier Decisions

 

What kind of health decisions do you make when you are fatigued, achy, and find it difficult to concentrate? That’s a rhetorical question, I already know the answer. When things look glum and we don’t feel well, it's far too easy to sit on the couch or reach for the chips and cookies. Compare those decisions to those you make when you are well rested, energetic, and seeing the world more clearly. For most people, the better you feel, the better decisions you make.

 

Guess what? The majority of people who change to a LCHF lifestyle feel better! It may take a few days or weeks, but in general, they feel more in control of their health, more energetic, and they are able to make better health decisions. I admit this is difficult to prove in a scientific trial. That is why we all should become our own n=1 scientific trial. How do you feel and how are your health decisions after going to a LCHF lifestyle? What matters most is what works for you, not what works for hundreds of people who are kinda-sorta like you.

 

      5-    Keto helps you with fasting.

 

Eating better helps you not eat. People who eat a high carb diet eat a lot, don’t they? They are always grazing and snacking. Our bodies go through the roller coaster of blood sugar and insulin spikes, making it a challenge to go 24, 18, or even 6 hours without eating. This creates a constant, unwavering supply of insulin in our blood stream.

 

Why is this harmful? For one, it promotes fat storage and keeps us from using our fat as fuel. Secondly, chronically elevated insulin can predispose to heart disease, strokes, cancer, dementia and other devastating health conditions. When people change to Keto, however, they realize they do not need to eat nearly as much or as frequently. Avoiding the carbs and increasing the fats keeps us full longer, and our bodies quickly adapt to longer periods without eating. The result? We can use our fat stores for what they were designed- a source of fuel! It also allows our body to maintain lower insulin levels, and also allows our cells to take care of their health chores, referred to as…..

 

6-    LCHF Promotes Health Through Increased Autophagy.

 

Autopha-What? In medicine we like using fancy words to make us look smart. Autophagy is a big word to describe cellular housekeeping. When we have low enough intake of carbs and protein, or when we do intermittent fasts, our bodies can take care of their “to do” lists.  That list includes breaking down weak or damaged cells, recycling the good parts and discarding the rest, and slowing down the processes that can lead to abnormal cell growth (i.e. excess proteins in Alzheimer’s disease, abnormal cancer cells etc.).

 

Admittedly, long term outcome studies evaluating fasting or LCHF and cancer or dementia risk have not been done. But, on the flip side, drug trials to prevent the same are showing no benefit despite hundreds of millions of dollars invested. If you asked me (which you sort of did since you are reading my article), I’d vote for autophagy as a preventative strategy any day. It makes good physiologic sense, and it is so easy to achieve.

 

7-    With Keto You Will Enjoy Eating Again!

 

That’s right. A way of eating that helps you lose weight, helps you feel better, improves your health and is actually enjoyable! No fake processed soy products, no cardboard tasting rice cakes. True, it also means no more candy, processed snack foods, doughnuts and danishes. But once you swear them off for a few weeks, and you are eating all the eggs, avocados, nuts, fish, steak, cheese etc. that you want, you won’t miss those old crutches any more. Let the enjoyment begin!

I could go on, but since it seems people like “7 Reason” articles, I will leave it at that. 

 

Now you know the secret: Look at the whole picture. Look for a lifestyle, (not a diet) that helps you feel better, increases your enjoyment, and still benefits your overall health.

 

Is LCHF/Keto the right lifestyle for you? It just may be. It is for me, The Low Carb Cardiologist, and it is for most of my patients and clients. Want to learn more about how LCHF lifestyle impacts your health? Visit us at www.LowCarbCardiologist.com

 

Thanks for reading

 

Bret Scher, MD FACC

Founder, Boundless Health

www.LowCarbCardiologist.com

 

ADDENDUM!! Since I have published this article, there has been a windfall of media buzz around low carb diets increasing our risk of heart disease or diabetes. Let's look at where that information came from.

1- A study force feeding mice excessive amounts of industrial omega 6 oils. You can guess what I have to say about that. The article was incredibly helpful, and I immediately stopped force feeding my pet mice industrial seed oils. Thanks goodness for that article. As for how it applies to humans eating real food that contain fat, there is zero correlation. 

2- Epidemiological study suggesting those who ate low carb (40% calories from carbs, which by the way is NOT low carb) as measured by two food journals over 25 years had a higher risk of dying. Oh and by the way, at baseline they were heavier, more sedentary, smoked more, and ate fewer veggies. Yet somehow they concluded it must be the low carb diet that "caused" the harm. Once again, it may not be bad science, but it sure was awful interpretation of the science. 

In light of those two studies and the hoopla surrounding them, has anything happened to change my mind about a LCHF/keto diet being beneficial for our overall health and our heart health?

Absolutely not.

We still need to individualize our care and our lifestyle for who we are and how our bodies respond. That is always the case regardless of our nutrition, our medications, our exercise etc. As long as we do that, then this cardiologist still believes that LCHF IS HEART HEALTHY!

If you liked this post, you'll love my free E-Book on Low Carb/Keto Starter tips to help you get started on your LCHF path!

Thanks for reading. 

Zero LDL vs Ketogenic Diet- Which Prevents Heart Disease?

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

Bret Scher, MD FACC

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