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Tag: LCHF

Low Carb LDL- A Call for Reason

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

Health Benefits of Bone Broth

This week I am so excited to share with you a guest post from my friend and colleague Rachel Gregory, board certified nutrition specialist, strength and conditioning coach and creator of KillinItKeto.com. I hope to have more collaborative posts coming soon! If you enjoy this post, please let me know. -Bret

Health Benefits of Bone Broth

Bone broth is one of the most nutrient dense foods that you can consume. It’s rich in vitamins, minerals, and jam packed with nutrients that are rarely found in other common foods consumed nowadays. The reason for this is because the process of making high-quality bone broth utilizes parts of an animal that cannot otherwise be consumed, such as tendons, ligaments, bones, marrow, skin, and feet. When these animal parts are simmered in hot water for long periods of time, they release powerful nutrients like gelatin, collagen, amino acids, and tons of vitamins and minerals needed to optimize overall health and longevity.

 

Here are just a few of the common health benefits associated with bone broth consumption:

 

Bone Broth Health Benefits

  • Boosts Immune System
  • Protects Joint Health
  • Strengthens Bones, Teeth, Skin, Hair, and Nails
  • Aids in Hydration and Electrolyte Balance
  • Supports Gut Health

 

Boosts Immune System

 

Remember when you were a kid and your mom used to give you chicken soup if you were feeling under the weather? Well, it was for good reason! The broth in that soup contained vitamins and nutrients that your body needs when it’s trying to fight off a common cold or sore throat. Bone broth is like chicken soup on steroids (for lack of a better term). It not only contains large amounts of beneficial vitamins and minerals but is also packed with amino acids and collagen that help support immune system function and provide easily digested nutrients.

 

Protects Joint Health

 

As we age, the cartilage and connective tissues that make up our joints naturally begin to degrade and it’s very important to protect and restore these as best we can. Bone broth helps make this possible because it contains the very compounds that form connective tissues in our bodies – collagen and gelatin. You can think of collagen as sort of the glue that holds our bodies together and gelatin as the cushioning between our bones. Consuming real bone broth is one of the easiest ways to make sure you’re restoring and absorbing these essential building blocks needed to promote the growth of new cartilage and maintain healthy joints.

 

Strengthens Bones, Teeth, Skin, Hair, and Nails

 

The abundance of amino acids found in bone broth play a major role in helping to support bone mineral density and improve your body’s ability to grow and maintain healthy muscle tissue, teeth, hair, nails, and much more. Additionally, collagen is one of the most powerful anti-aging nutrients that forms compounds in your skin (such as elastin) that help to increase skin elasticity, maintain youthfulness, and reduce the appearance of wrinkles. Why spend hundreds (or even thousands) of dollars on supplements or skin rejuvenation treatments when you can make the ultimate anti-aging elixir right in your own home?

 

Aids in Hydration and Electrolyte Balance

 

One of the most common issues that many people face on a daily basis is the lack of proper hydration and imbalance of electrolytes within their body. Many of us have been taught that in order to replenish these electrolytes and stay hydrated, we need to be consuming sports drinks or adding squirts of processed chemicals to our water. This is completely false and can actually do more harm than good, especially when these products are jam packed with sugar and other unnecessary preservatives. Skip the processed junk and reach for nutritious bone broth that contains essential electrolytes like calcium, magnesium, and potassium that help to support proper hydration, cellular health, and so much more.

 

Supports Gut Health

 

Gut health is one of the most talked about issues in today’s society and there are millions of people who are struggling with a condition known as leaky gut syndrome. This condition occurs when the lining of the small intestine becomes damaged and causes bacteria, toxins, and partially digested food particles to “leak” into the blood stream causing increased inflammation and other problems within the digestive tract.

 

But what if there was a way to help protect the lining of the gut and prevent this “leakage” from occurring? Enter bone broth! The collagen and amino acids found in bone broth, particularly proline and glycine, are major players when it comes to healing damaged cell walls within your gut and reducing inflammation within the intestine.

How to distinguish between “real” and “fake” bone broth

 

It’s very important to understand that many of the broths and stocks that you find on your average grocery store shelf are NOT considered real bone broth. Most of those cartons and cans are filled with ingredients that have never even come in contact with real bones. Usually these products contain water, spices, and some type of preservatives or thickening agents – definitely not what you want!

 

Your best bet is to make bone broth at home because it saves money and ensures you are getting all the good stuff, minus the junk! (See below for how to make homemade bone broth). If you’re really pressed for time or don’t have access to the ingredients/cookware to make it at home, there are some brands like Kettle & Fire or Osso Good that you can purchase and are made from the real thing (bones!).

 

 

 

 

 

 

Homemade Bone Broth Recipe

Makes 4 to 5 quarts/Prep time: 10 minutes/Cook Time: 24 to 48 hours

 

I always cook a big batch and store it in individual containers in the freezer. When a recipe calls for bone broth, just defrost one container the night before in the refrigerator and you’re good to go.

 

4-6 large beef bones (about 4 or 5 pounds) or 1 whole chicken or fish carcass (with skin)

4 celery stalks, roughly chopped

1 large onion, cut into quarters

6 garlic cloves, smashed

1 bunch fresh parsley, rosemary, or other herbs of choice

2 tablespoons sea salt

1 tablespoon peppercorns

3 tablespoons apple cider vinegar

4-5 quarts water, or enough to fill the pot

 

  1. Preheat oven to 400 Fahrenheit
  2. In a large roasting pan or baking sheet, arrange celery, onion, and garlic in an even layer.
  3. Place bones on top of the vegetables and roast in the oven for 30 minutes.
  4. Remove bones and vegetables from the oven and transfer to a slow cooker.
  5. Add fresh herbs, salt, peppercorns, and vinegar. Pour enough water to cover the bones and vegetables.
  6. Simmer on low for 24 to 48 hours. The longer the broth cooks, the more nutrients will be extracted from the bones.
  7. Let the broth cool completely, strain it, and then store in glass containers with airtight lids in the refrigerator or freezer. Make sure to only fill the containers ¾ of the way full to allow room for the liquid to expand in the freezer and prevent containers from cracking.

 

Bone Broth Making Tips:

  • Add chicken feet and fish heads to boost the collagen and flavor of your bone broth.
  • Add Apple Cider Vinegar to help draw the nutrients out of the bones and other animal parts.
  • When possible, use animal products that are pasture raised and free of antibiotics and hormones.
  • The longer it simmers, the more nutrients will be extracted (aim for 48 hours).

 

Get more recipes by Rachel here.

Rachel Gregory, MS, CNS, ATC, CSCS, is a Board-Certified Nutrition Specialist, Athletic Trainer, and Strength and Conditioning Coach. Rachel is the Founder and CEO of Killin It Keto, LLC and creator of the 21-Day Keto Challenge. Get more recipes like this in her book, 21-Day Keto Challenge.

Lierre Keith — The Dark Truths Behind Veganism & Vegetarianism

This week, the Author of The Vegetarian Myth: Food, Justice, and Sustainability, Lierre Keith, joins me to dispel the three pillars vegetarians lean on to justify their dietary and lifestyle choices. Her book, published in 2009, is still widely discussed and referenced today. In this stirring discussion, Lierre reveals that just six corporations (who she calls grain cartels) own the world’s food supply and how they deceitfully market industrial by-products in the form of soy-based products, how global warming is NOT caused primarily by ruminants but rather by large-scale agricultural practices, and how modern agriculture is destroying our topsoil and our land in general. But she doesn’t stop there! She goes on to explain how proper use of grazing ruminants could actually be a solution to or environmental problems. That’s a message we all need to hear!.

 

What makes her story even more amazing is that Lierre was a practicing vegan for years. Luckily she realized she was slowly destroying her body by not consuming the vital nutrients necessary for good health. So, will going Vegan save your life and save the planet as is so widely believed? Listen to this podcast before you answer that question.

 

Key Takeaways:

 

[4:27] Why Lierre chose to go vegan.

[6:44] How the grain cartel used deceptive marketing to sell the industrial by-product of soy.

[12:01] The cult-like elements of Veganism.

[17:00] Will Veganism save the environment?

[26:21] Moving away from government subsidies and towards grass-based farms.

[32:13] Lierre describes the carbon sequestering process of soil and how global warming started.

[42:44] Lierre shares the moral dilemma brought about by her personal gardening experience.

 

Mentioned in This Episode:

Low Carb Cardiologist Website

Dr. Scher on Twitter

Dr. Scher on Facebook

Lierre Keith

The Vegetarian Myth: Food, Justice, and Sustainability

The Savory Institute

Eat Wild

Low Carb USA San Diego 2018 Recap

      

 

This year, I was lucky enough to attend (and speak at!) the Low Carb USA 2018 conference held in San Diego.

 

What conference! From the moment it started until the very last Q&A panel, this conference was packed with knowledge, energy and an amazing community. There is no way I can capture all the highlights, but here are my experiences from the conference.

 

Opening Comments

 

The conference began with Low Carb USA organizer Doug Reynolds welcoming everyone. He asked how many physicians or medical providers were in attendance, and approximately 60% of the hands in the room went up. That’s incredible! It shows how strongly LCHF lifestyle is making its way into mainstream medical practice. It may not be used by every doctor right now, but the tide is certainly moving that way, which I'm very excited about.

 

The Diet Doctor and Dr. Nasha Winters Blew Everyone Away

 

After Doug finished his welcome, the Diet Doctor himself, Dr. Andreas Eenfeldt kicked things off with The Food Revolution. He clearly outlined the obesity and diabetes epidemic we face as a society, and showed how LCHF is an easy and effective solution. As their motto says, they are "Making Low Carb Easy." His talk did just that. It was very motivating and educational, and I know people walked away ready to jump in.

 

 

Later that same day, Dr. Nasha Winters dropped some serious knowledge bombs about mistletoe, moonbathing, marijuana and more. If you haven’t heard Dr. Nasha speak, you have to seek her out. She is a powerhouse of information, of energy and of clear caring and compassion. I was fortunate enough to have recorded a podcast with her and it is definitely one of my favorites.

 

 

Concluding the First Day with Interviews

 

I spent the rest of the day running around doing my initial podcast interviews for my new upcoming project, The Diet Doctor Podcast. I am beyond excited to be part of this team! My initial interviews with Garry Taubes, Dr. Peter Attia, and a joint interview with Dr. Jeffry Gerber and Ivor Cummins really set the tone for how incredible this podcast is going to be. I will keep you updated when they are released.

 

Day Two of the Conference

 

Day #2 Was a powerhouse day! Starting with Peter Ballerstedt dispelling the environmental myths that ruminants are bad news for the environment. His talk shows how limited and short sighted that argument is, and it boggles my mind how pervasive it has become. Thanks Peter for setting the record straight!

 

 

Later that day Gary Taubes and Adele Hite led a discussion to help develop a defined standard of care for using a low carb diet in clinical practice. This is exciting. This is what our medical profession needs to safely and effectively initiate low carb lifestyles for our patients.  The goal is to educate all providers on the benefits and practical implications of low carb nutrition and help them help their patients. It doesn’t get much more powerful than that!

 

My Turn on Stage

 

Then it was my turn to speak, which was fun! I really enjoyed giving my talk on what the evidence says about LCHF diets and impact on our heart health. The question in the contemporary medical community is, “Is the LCHF diet harmful to our cardiovascular risk?” I think the evidence clearly answers that – NO!

 

 

Instead, we need to reframe the question and ask, “Is the LCHF diet beneficial for our cardiovascular risk?” There the answer is most likely yes. Reducing glucose and insulin, improving visceral adiposity, raising HDL, lowering TGs, improving LDL size and oxidation, reducing inflammation, lowering BP, reducing the need for medications, and more! LCHF does all these, and all these positively contribute to reducing our cardiovascular risk. It’s hard to imagine there is still debate about this.

 

The Interviewer Becomes the Interviewee

 

I then had the privilege of being interviewed by Vinnie Tortorich for his upcoming documentary Fat, and by Brian Sanders for his documentary Food Lies.  Seeing the overwhelming interest and the clear production quality encourages me that we will continue to see high-level documentaries exploring the benefits of LCHF.  The public needs a counterbalance to the overly dramatized and misleading documentaries that have populated this space to date, and Vinnie and Brian are both motivated to provide the answer.

 

The Low Carb Community

I could keep going raving about the speakers, but it's one of those conferences you need to attend to see the speakers for yourself. Instead, I want to finish by raving about the community. The energy and buzz from everyone attending was palpable.

 

Whether it was from individuals with a tremendous success story, newcomers eager to understand how their future may be different, or healthcare providers excited to start using these techniques with their patients, it was clear that lives were changing for the better. It is rare to see this level of excitement and energy at a medical conference. I knew right away this conference was unique, and this was going to impact everyone there.

 

In fact, a nutritionist I know came away so charged up that she immediately contacted me saying she "was ready to be part of something bigger!” She was ready to reach more people and help more people. That is exactly what a conference like this should do. Educate us. Inspire us. And help us take action. Bravo Doug Reynolds and the whole Low Carb USA staff. You hit this one out of the park.

 

Thanks for reading.

 

Bret Scher, MD FACC

www.LowCarbCardiologist.com

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

5 Reasons We All Should Fast, and 1 Reason Why We Shouldn’t

I wanted to write this article to address a question I hear often:

Do I need to Fast to Be Healthy?

 

In short, probably. But what exactly does that mean?

 

Thanks in large part to Dr. Jason Fung and others, intermittent fasting (IF) has emerged from the shadows of the health movement to now being discussed every day on social media, as if we have been doing it for decades.

 

And here’s the secret: We actually have been doing it for decades. In reality, it’s more like centuries.

 

Think of how we evolved. There wasn’t a convenience store, grocery store, restaurant, or fast food joint on every corner.  We had to hunt and forage for our food. That took time and was sometimes unsuccessful. The natural result, therefore was periods of eating interspersed with periods of fasting.

 

Modern society is a far cry from that evolutionary period, as we now have a 24/7 eating cycle with late night taco runs, vending machines and snacks available at a moment’s notice, and misguided advice that we need to eat every two hours to stimulate our metabolism and lose weight (awful advice with no scientific backing, mostly promoted by snack food companies).  We have plenty of reason to believe this constant eating cycle has contributed to our current obesity/diabetes/insulin resistance epidemic.

 

The good news is that we can reverse that trend. We can reverse it by bringing back fasts.

 

What exactly is fasting?

 

First we need to define what fasting means, and what time restricted eating means. Time Restricted Eating (TRE), means eating only in a specific time window, and not eating the rest of the day. For instance 18:6 means not eating for 18 hours straight, then eating over a 6-hour period. This can be 12:12, 16:8, 18:6 or even 22:2. They key is that you have an extended period of time each day when you are not consuming calories.

 

More extensive fasts, 24-72 hours or even longer, are really what we refer to when we say intermittent fasting. For this explanation, I will refer to extended fasts and TRE together as they have similar benefits. I will explore the differences and go into more scientific detail in a future post.

 

Here are the top 5 reasons we should all fast

 

1.    Fasting is the most efficient way to lose weight.

Forget the fat burning foods, forget the cleanses and detoxes. Not eating is the key to losing weight. But do it intermittently. That’s why it’s called intermittent fasting. Chronic calorie restriction doesn’t work long term since it forces our bodies to reduce our resting metabolic rate (RMR), thus stalling weight loss and increasing frustration. Intermittent calorie restriction, on the other hand, allows for weight loss without changing our RMR, the key to healthy and successful long-term weight loss.

 

2.    IF is a great way to lower insulin.

It just makes sense. If there is no food coming in, there is no need for insulin to rise. Insulin will stay at its low steady basal rate, and there will be no elevations or spikes. That keeps the area under the curve low, right where we want it. Low insulin means we can mobilize our fat stores, and possibly more importantly, it protects us from the harmful long-term effects of hyperinsulinemia.

 

3.    Intermittent Fasting is the key to longevity.

The one consistent finding in longevity research, from single cell organisms up to primates, is that calorie restriction works. But as we have learned from chronic calorie restriction experiments in humans, it’s not so clear cut. First, its miserable and most people would rather die younger that live longer with chronic calorie restriction. Agree?

Second, our bodies adapt to chronic calorie restriction and thus make it difficult to maintain the health benefits. Intermittent calorie restriction, on the other hand, has the promise of all the longevity benefits without all the baggage that comes with it. The fountain of youth only helps if we like how it tastes.

 

4.    It’s easy!

What’s easier than skipping breakfast? No planning, no shopping, no cooking, no cleaning. Simply walk out the door.  In our hectic everyday lives, we should welcome anything that takes less time and makes our lives a little easier. Fasting does exactly that. Just make sure you bring a water bottle with you wherever you go, and maybe some sea salt to put in your water. Stay well hydrated and enjoy the simplicity.

 

5.    There are many ways to make fasting work for you.

 There is more than one way to have a successful fast. As mentioned previously, 18:6 can work wonders for most people. For those who are more adventurous, a 72-hour water fast can have amazing results. And there is everything in between. Just follow the simple rules of staying hydrated, paying attention to how you feel, avoiding anything with calories, and even avoiding calorie-free sweeteners. The rest of the details can be individualized to fit your life and your goals.

 

The Top Reason Why You shouldn’t fast

 

Fasting can work wonders for most people, but it can also be dangerous for others. If you take medications for diabetes, hypertension or other medical conditions and you’re trying to fast on your own, don’t do it! Fasting can cause significant harm in these circumstances if not done with proper precaution. That doesn’t mean it can’t be done. In fact, it can still be incredibly beneficial. Just make sure you are working with an experienced clinician who can help coach you through it safely.

 

Here’s one last bonus tip.

 

Don’t give in to temptation once the fast is over.

 

How you break your fast can be just as important as how you fast.

 

  1. Break the fast with a small low carb snack such as bone broth
  2. Have your first meal an hour or two after your snack
  3. Resist the urge to “reward” yourself with high carb foods or junk food. Your gastrointestinal system isn’t ready for that. Plus, why work so hard to keep insulin low if you are just going to spike it when you are done? Stick to your usual, healthy, high quality low-carb fare.
  4. Resist the urge to increase your calorie intake to “make up” for the fast. If anything, the first 12 hours should have fewer calories than your usual eating pattern, slowly returning to normal (not supra-normal) over the next 24 hours.

 

Pretty easy, right? I am a big fan of simple, safe and effective. When done right, intermittent fasting hits all three criteria.

 

Is intermittent fasting right for you? It may just be.

If you are interested in Fasting, but are unsure where to start, or want to learn more of the benefits, my free Full Guide to Fasting E-Book is for you!

 

 

This E-Book discusses the benefits of fasting, an overview of different types of fasting, and a guide on how to fast correctly, so that you can see the best results.

Thanks for reading,

Bret Scher, MD FACC

Founder, Boundless Health

www.LowCarbCardiologist.com

 

 

 

Dave Feldman Challenges Everything We Think We Know About LDL Cholesterol.

Dave Feldman brought down the house yet again with a rousing presentation at Keto Con 2018. In his presentation, he postulated that a subset of LCHF individuals, which he terms Lean Mass Hyper Responders (LMHRs), are unknowingly changing the world of cholesterol.

 

Traditionally we are taught that any elevation of LDL cholesterol leads to heart disease. Not so fast, says Dave. In this episode, we discuss why this does not apply to LMHRs and what that means for LCHF individuals and what it means for the medical world as a whole. We also discuss how recent PCSK9i drug trials prove his point, even though contemporary medicine promotes them with an opposite conclusion. Sound confusing? Well, it isn't once you hear Dave explain his case.  

 

Once again, Dave brings his passion, his engineering mindset, and his intellectual honesty to the table for a rousing interview that is sure to cause a stir among old-school doctors and lipidologists. You don't want to miss this one!

 

How To Talk to Your Doctor About The LCHF and Keto Lifestyle

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

 

 

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.

    If you want to learn more about lipids and cholesterol, I recommend checking out my new dedicated cholesterol course: The Truth About Lipids.

  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 Autophagy.

    If you’re interested in Fasting and want to make sure you’re doing it correctly, download my free Full Guide to Fasting.

  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. To learn more about Low Carb and Keto, download this free E-Book:

 

 

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

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