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Jun 26

Cholesterol Endgame?

Something exciting is happening.

There’s a special group of people that may be answering one of the most powerful medical questions of our time.

The Hypothesis

A hypothesis was made several decades ago, well before I was born. This “Lipid Hypothesis” suggested cholesterol in the blood independently caused heart disease.

From Wikipedia:

The lipid hypothesis is a medical theory postulating a link between blood cholesterol levels and occurrence of heart disease. A summary from 1976 described it as: “measures used to lower the plasma lipids in patients with hyperlipidemia will lead to reductions in new events of coronary heart disease”.[1] Or, more concisely, “decreasing blood cholesterol… significantly reduces coronary heart disease”.[2]

More cholesterol, more heart disease. Simple.

It has since morphed and changed a bit. Now some point to Low Density Lipoproteins as the problem (LDL-P, the “boats”) while others still insist it is the cholesterol found inside them (LDL-C, the “cargo”). Regardless, if you have a lot of LDL-C, you likely have a lot of LDL-P, so it is pretty much the same for most people anyway.

This is “deadly” and “needs immediate treatment” to lower the LDL-C/-P with prescription drugs. Even with the newer guidelines putting less emphasis on LDL, there’s no lack of insistence by doctors around the world on taking drugs to lower it when at high or even moderate levels. In fact, what was considered high has been continually dropped (from 130 mg/dL to 100, and now to 70). Naturally, this has resulted in more and more drugs prescribed.

Case Closed… or is it?

Last year we had a massive Consensus Statement from the European Atherosclerosis Society. In very declarative language, they state the evidence is quite overwhelming and clear: LDL is the bad guy.

Interestingly, this appears to be in the wake of many papers that are pointing to several new channels with higher associations to CVD such as Remnant Cholesterol, something I’ve written about here before.

In fact, even this EAS statement didn’t get very far before it got a paper that sought to show its many problems from the Karger group, A Critical Review of the Consensus Statement from the European Atherosclerosis Society Consensus Panel 2017.

There’s even been a quiet subtraction of LDL as a target for treatment in the new guidelines from 2013 AHA/ACC.

So what’s going on here? Is LDL a problem or not?

HDL High and Triglycerides Low? Then No, LDL Does Not Appear to be a Problem

When looking at only LDL, then one can find a weak correlation with CVD/CHD. But when looking at LDL alongside HDL and triglycerides (TG), it becomes nearly meaningless. HDL & TG together are just a far stronger measurement compared to LDL alone.

Over the last 4 months, I’ve been pinging LDL-lowering experts, organizations, and social media at large for studies showing high LDL is giving high CVD to normal, non-treated people who have high HDL and low triglycerides. Can’t find any studies. Not one. I even turned it into a hashtag campaign on Twitter: the #LCCholesterolChallenge. Or you’ve seen the graphic I’ve posted to help attract attention to the challenge.

Instead, I’ve found compelling studies that show the opposite — that high HDL and low triglycerides are associated with low CVD and low all-cause mortality.

Take this Framingham Offspring study, where I even marked it up to showcase where I (and many other hyper-responders) stood in the risk category. (Colored markings and overlay mine)

In other words, if you grab everyone who had a moderately low TG (less than 100), a moderately high HDL (more than 40 for men, 50 for women) — then even if their LDL was above 130, their risk was nearly identical to someone with LDL of below 100 (0.7 and 0.6, respectively).

But it gets better…

In this observational cohort study of 2906 men aged 53 to 74 years free of IHD at baseline, we see this relationship in perfect display. (Colored markings mine)

You see how on the left we have people with an LDL of 170 or less vs those with an LDL of 170 or more? That’s literally just 20 mg/dL away from one of the two criterions for a diagnosis of familial hypercholesterolemia! In other words, and LDL of 170 will likely get your doctor talking to you about multiple drugs to lower your cholesterol.

Yet there it is in black and white — the group on the left is nearly the same as the group on the right. If you’re in the dark grey bar with HDL of 57 or more and a TG of 97 or less, you’re at nearly identical risk for ischemic heart disease whether above or below LDL of 170. But worse, if you’re hanging out in the white bar and take your lipid-lowering drugs to drop below 170 with no change in your HDL of 46 or less and TG of 142 or more, you’ve made effectively zero impact.

So Why Doesn’t the Medical Community Focus on HDL and Triglycerides?

Good question. I wish I knew the answer.

Sure, there’s plenty of fodder for the cynical answer here: there isn’t a pharmacological solution to it. And yes, there appears to be some support for this given all the trials that chemically alter the lipid system to bring up HDL and reduce LDL, such as CETP inhibitors, have failed spectacularly. But weirdly, this has led to a new train of thought insisting maybe HDL isn’t so beneficial after all. (Note: I couldn’t possibly disagree more with applying the assumptions of a population who had their lipid systems chemically altered through drugs to that of the general population without supporting evidence.)

Enter the Lean Mass Hyper-responder

About a year ago I wrote about this emerging profile that was becoming very central to my research. It represents a kind of endpoint to very high fat-adaption as shown in higher circulation of VLDLs, resulting in high LDL. As a class, these individuals have the highest LDL-C and LDL-P of everyone in the low carb community.

Yet they defy expectations of what we’d imagine with high LDL — the insulin-resistant, junk food couch potato. Rather, they are typically lean, fit, and have very low fasting insulin. Many of whom insist this is the best they’ve ever felt and performed in their life. I see their bloodwork on a near daily basis and it is stunning how many of them have great metabolic markers, extremely low inflammation, CIMT, and CAC scores.

I called this profile “Lean Mass Hyper-responder” (LMHR) and I had no idea how just how many of them there were when I wrote the article. Now I know they are a sizable population in the low carb community.

Many LMHRs are concerned about their cholesterol and are taking steps to change it. However, many others are completely fine with it and have no interest in living any other way. (For the record, we try to help everyone meet their goals and urge community respect for their decision, whatever it may be).

Collision Course

So clearly, the ideal group of individuals to test the Lipid Hypothesis are those who are:

  1. Free of all major CVD risks, such as hypertension, hyperinsulinemia, high waist circumference, high triglycerides, and low HDL (to name a few).
  2. Have extremely high LDL-C and LDL-P

And here we are. If the Lipid Hypothesis is indeed an independent risk factor, then LMHRs should be showing signs of progressive atherosclerosis and higher mortality from heart disease — and rapidly, for that matter. There’s nowhere left to move the goalposts.

I think once we get a decent sample size of LMHRs and a solid follow up period of time, we’ll have a strong answer to that question.

You can probably guess what I’m predicting.

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John Pavao
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John Pavao

I found this most encouraging: “In other words, if you grab everyone who had a moderately low TG (less than 100), a moderately high HDL (more than 40 for men, 50 for women) — then even if their LDL was above 130, their risk was nearly identical to someone with LDL of below 100 (0.7 and 0.6, respectively).”

After being keto for a year, my HDL is an all time high of 51 (never before been higher than 44), and my TG was 99 (even though I wasn’t quite 12 hours fasted). Without your work I would have no idea how to back up my hunch that my “high cholesterol” isn’t the problem the doctors make it out to be. Thanks Dave!

Juls
Guest

Hi Dave: I am still getting caught up on the discussion here after listening to you talks on the Keto Dudes podcast. I am a 52yo 121 lb. 5’2″ female. I sit in a chair all day but am active when not at work. I started eating keto at the end of March and am still in the fat loss stage of my ketogenic journey. Prior to going keto, I noticed a poor trend in my cholesterol panel although they remained within normal limits when last checked in 2017. Since I did not get a baseline lipid panel prior to starting Keto, I thought it was best to wait some time before having my numbers checked. I now wish I had requested the labs before as she just ordered labs (glucose and cholesterol panel). While I do want to see where things are now, I am a bit worried. I don’t necessarily want to biohack, I would like to time my blood draw to show the best possible outcome limiting as many confounding factors as possible. I normally IF 6 days/wk and do a 24h fast 1 day/wk. Would it be best to have the draw done after a day of (~16h) IF or following a longer (~24h) fast? Other than coffee and MCT oil, are there any other food/drink that I should avoid?

hayley
Guest
hayley

Hi Juls! I am someone who did the Intensive Dietary Management program with Jason Fung and Megan Ramos. I went through some of what you are going through and Megan’s advice was to not fast for a week before I got my blood work done. She said most people she says three days. I got 11.88 I think on my total cholesterol which freaked out everyone but I truly believe that fasting messed with the numbers. Doing a hack on my next test I brought down to about 6.45. However, they still wanted to give me statins! I have no other risk factors for cardiovascular disease. So I forced them to give me a CT Scan and the test came back with NO evidence of coronary artery disease. I am in Canada so your experiences may be different but I am here to say don’t let a high LDL or total cholesterol fill you with fear!!

Juls
Guest

Hi Hayley! I just got back from my blood draw and am now reading your response. Thanks for your advice. It reassures me that I did the right thing in holding off on my weekly 24h fast (although I have fasted within the 7 day prior, it has been 5 days). I had to look up the conversion for Canada. I have family history of cardiovascular disease but have been really healthy without risk factors. If the value turns up high, I believe my doctor will be open to monitoring it before jumping to suggest medication. However, if she does suggest it, I plan to push back. Thanks again. I’ll post my results when available.

Siobhan Huggins
Admin

Hi Juls,
along with avoiding coffee, MCT and coconut oil, just try to eat as you normally would, and track if you can (just taking pictures of what you eat would be fine). If possible try to time your IF window the day before the blood test so you hit about 12-14 hours fasted when you get the blood draw, and make sure that 12-14 hour fasted is water only (no tea, coffee, etc). Definitely avoid fasting longer than that as it can mess with the results as demonstrated in Dave’s Fasting Disaster post.

Considering your height and weight I wouldn’t be surprised if you fall into the camp of a Lean Mass Hyper-responder, so just be aware beforehand.

Juls
Guest

Hello Siobhan. Thank you for your response. I did my test earlier today and am still awaiting results. My fast prior to the blood draw was just shy of 14 hours. I have not had coffee and/or MCT oil for the 2 days prior. I don’t know if it matters but other than yoga, I have not done much exercise in the past 2 days due to a sore ankle. I did practice prior to my test today.

Thanks for the warning on the probably lean mass hyper-responder. I’m going to have to look that up. I am guessing that something is up with my tests as my doctor has generally released results by this time and still hasn’t.

Juls
Guest

P.S. I just watched the presentation on LMHR. I love the simplified explanation. It definitely helps. BTW, results still not made available to me.

Juls
Guest

Here are my results:
Total Chol: 302 mg/dL
TG: 102
HDL: 88
LDL: 194

Siobhan Huggins
Admin

Nice! That’s pretty much what I would have expected as far as results go, as I mentioned before 🙂

Juls
Guest

Siobhan: In looking at your posts on LMHRs, I was expecting my TGs to be much lower. Prior to keto, they were generally below 50. I only stopped coffee and MCT oil for the 2 days prior. I wonder if that could be a confounding factor still. Also, my morning glucose (fingerstick) that morning was 91. Yet, 3 hours later after a moderate ashtanga yoga practice the serum glucose was higher at 99. Would this be the result of the body ramping up in anticipation of more intense exercise, as I generally do on the weekends and after work?

Siobhan Huggins
Admin

Yes, I suspect the coffee was a confounder. There may be a bit of a withdrawal period for coffee, so it’s suggested you quit for at least 2 *weeks* prior to the blood test. Same for coconut/MCT oil (cut these for at least a week).
It is pretty typical for blood glucose to up after exercise, or before if you have a routine, but even without that blood sugar fluctuates throughout the day, or it could have just been variation in the reading from the monitor.

Roger
Guest
Roger

I find the finger sticks surprizingly can vary 10 to 15 mg between 2 sticks close together. Not expected.

Karen
Guest
Karen

Roger FYI: “Meter Accuracy Reality. … In order to be considered “accurate” and thus approved for use in at-home testing scenarios, the FDA requires that blood glucose meters provide: 99% of blood glucose measurements within 20% of lab results. 95% of blood glucose measurements within 15% of lab results.Feb 5, 2018”

Paul
Guest
Paul

Is there such a thing as a lean mass familial hyper cholesterol anyway responder ? Being apoe3/4 I looked in terror at my doctor who told me I might as well eat lard as my risk of heart disease was highly based on my ldl, yet my triglycerides are the lowest they’ve been and how is highest , I’m fit with no inflammation markers and skinny. But my cholesterol goes down (slightly) on keto, not up
Ldl 5
Hdl 1
Trig 1

Jennifer Ozuna
Guest

Two days ago. Fasted 12 hours, black coffee only.
Tennis 4-8 hours a week. 39, 5’4, 136 lbs.
keto for 1 year. Lazy Keto, but I am high fat and I don’t cheat bc I get nausea if I taste sugar.

LDL: 202
HDL: 95
TG: 59

AARON P
Guest
AARON P

Hey Dave and Siobhan,

I am an Apoe4 carrier and a lean mass hyper responder.

As an Apoe4 carrier, with high LDL (Low trigs, high HDL), I have been trying to research what kind of diet would be most protective for my cardiovascular and neurological health.

Dr. Gundry and Dr. Bredesen, who specialize in Alzheimer research and Apoe4 suggest that a ketogenic diet is preferable, but the fat source should be monosaturated as opposed to saturated (animal) fat.

Do you have any insight into the benefits of mono vs saturated fats? Does the science support their recommendations? In your opinion, are Apoe4 carriers better off avoiding butter in favor of olive oil?

Siobhan Huggins
Admin

I’ve yet to see any real justification for it, honestly. From what I’ve seen mentioned in passing it partially comes from slightly higher LDL with satfat and apoe4, but as for what that does for CVD risk… I have my doubts that it worsens it, although I can’t say for sure. A lot of it also seems to come from research involving high saturated fat, *and high sugar/carb* – which is obviously not a wise combo, regardless of what genes you have. Yet more from epidemiology which is far too confounded by other variables (processed food? trans fats? high fat high carb?) to be worth much (as far as conclusions go).

From what I *have* seen apoe4 carriers are more predisposed/vulnerable to modern disease but – as Ivor Cummins points out – this would put emphasis on avoiding insulin resistance in general. FWIW Dave is an apoe4 carrier, from what I remember, and he eats plenty of saturated fat.

So, in my opinion, I haven’t found much of anything convincing as far as reasons to avoid animal/saturated fats for apoe4 carriers. That could always change in the future, but my stance is “unconvinced” as of now.

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[…] a look this Framingham Offspring study.  As Dave Feldman points out in a recent post, the study found if your triglycerides are less than 100 and your HDL is more than 40 (more than 50 […]

Sheelagh Littlewood
Guest
Sheelagh Littlewood

Hi.
I am uk based but think I fall into LMHR.
Been low carb 3 years, work out 5-6 days a week and am 5ft 10 and 62kg. Waist to height ratio 4.4. Had an insurance medical(wish I hadn’t) and shocked to find cholesterol 360 but T/G 71 and HDLP 104. Worrying level of LDL 239.
Reassured to find your site but now awaiting an appointment at a specialist lipid clinic and think I know what they will say. Stop diet and taken a statin- even though I’m female, 65 and this would be primary prevention!. Would like to be brave enough not to go but have a medical background and years of the old way of thinking difficult to shake off. Will take the Farmington study you highlight with me but would you suggest anything else that might sway them
Sheelagh

Siobhan Huggins
Admin

Hi Sheelagh,
Apologies for the very late reply on this, we ran into some issues with accidentally comments and were luckily able to recover them albeit a bit late…
It certainly does look like you fall into the camp of a lean mass hyper-responder 🙂
We have a few highlighted studies you might feel will be useful to bring (or just read for yourself), right here:

Top Ten Lipid Related Studies


Especially #10, #3, and #1.

As two of them point out that, in women, the higher the cholesterol the lower the death from all causes. With no real cut off point… which is interesting to note, and raises some interesting questions.
Additionally, another one mentions that in those with genetic causes of high LDL it isn’t the LDL level that determines their risk of heart disease, but rather their level of insulin resistance and fasting insulin.

But the other thing is whether or not you take the medication they prescribe is entirely your personal decision. So, I would really just recommend in general that people do their own studying and decide for yourself if you want to take it or not.

mike
Guest
mike

maybe the game starts now ….
http://www.mdpi.com/2308-3425/5/3/36

Linda Cooper
Guest
Linda Cooper

Hi Dave, Can you explain to me why in the last decade my TG’s hover between 0.7 & 0.9 and my HDL between 1.4 & 1.65. And, I have a CAC score of 230…LDL by the way in the same time has been between 3.0 & 3.9

Dolores Yanez Noonan
Guest
Dolores Yanez Noonan

Listened to your podcast recently on Ketogeek. My quick story – I am a 52-year-old female runner and started keto in Feb 2018. I was religiously keto for 4 months and as I slowly dropped the baby weight from 4 pregnancies, I allowed a few extra carbs into my diet but have kept it low carb. It is now October and I am down to 137 lbs at 5′ 6.5″ which is almost 20 pounds less than where I started! My goal is to get a little closer to my pre-kid weight but I am very close. I feel great and hope it will help my ultra running goals. But enter the dreaded blood test! I have not had a blood test in a few years so I can only compare to 5 years ago and my numbers are crazy high.

2/12/13 9/28/18
Cholesterol/HDL Ratio <5.0
2.9 3.2
Cholesterol
50 mg/dL
54 81
LDL Cholesterol
<130 mg/dL
89 168 H
Triglycerides
<150 mg/dL
61 68

The second set is the new numbers. My HDL & triglycerides still look good. Also, my fasting glucose was 84 down from about 90 a few years ago.

The QUESTION – how do I deal with my dr if she wants to put me on meds? I would like to avoid this if possible. I am taking a heaping tablespoon of MCT oil in my coffee each morning so I can stop this. Any other discussion points with my doctor? I see her tomorrow. THANKS!

Siobhan Huggins
Admin

Something to keep in mind is that your doctor is working for you as a health consultant. She can suggest what she thinks is best, but it is ultimately up to you whether to follow that recommendation.
What I did when I was in your position was I did my own research – not just from one source, but from many different sources – and came to my own conclusion about whether medication was right for me. Just recently I also brought some of the studies mentioned in this article, as well as this one, to my doctor as a conversation starter.

MARK WOFFORD
Guest
MARK WOFFORD

These are the 2 studies you mentioned in the podcast with PA, but you didn’t get to go into detail on them. They present the data and conclusion exactly as you described it. Frustrating that you couldn’t get there.

Has Peter helped you (since the podcast) to get access to other data that can be analyzed.

Keep up the good work,

Mark

Roger Johnson
Guest
Roger Johnson

If LFH were to serially test there CAS say yearly and it is not increasong @ oh maybe non, it would be the fastest way to get support fir your theory. Invidence og CV events will not prove it till i die of old age. (74 years of age)

DENI ROCHE
Guest
DENI ROCHE

Hi, my name is Deni. I’m a 57 year old woman. I’ve been on the Keto diet since August 2018. I had my blood drawn on 10/12/18. I had been doing intermittant fasting (16:8) for at least a week before my test, though I would have a tbls of butter & MCT oil in my coffee every morning, so not a true fast. I fully expected great results especially because I was feeling amazing, had dropped 13 pounds, and was more active and energetic than I’d been in a long while. My results: LDL 185, HDL 79, Tri 58.
Also, my TSH is 5.19 (My voice definitely has changed)
I meet with my doctor this week and I know she is going to want to put me on drugs but after researching online and reading and listening to your studies as well as so many others, I have a real peace of mind and will not take drugs. I want to continue this course I’m on and give my body more time to adjust to all these changes. I feel too good to go back. I feel better than I did at 30!

Jackie
Guest
Jackie

Curious to know if your doctor recommended any medications?
I’m going through the same thing. Elevated total cholesterol but HDL is high.

Anne
Guest
Anne

I am so glad to have found this site. I have been following LCHF way of eating for the past 7 years & have been watching my cholesterol gradually rise until last month where I found it had skyrocketed. Total cholesterol 11.5 mmol HDL 2.34 mmol Triglycerides .06 LDL 8.9. Needless to say my doctor was horrified however was a little placated by the HDL & TG levels. Of course, because it has been hammered into us over the years that cholesterol is so “bad” I am a little concerned myself. Should I be trying to do something about this?

Siobhan Huggins
Admin

Hi Anne! It looks as though you’re a Lean Mass Hyper-responder, AKA someone who is lean and/or active and powered by fat! Unfortunately the science is still ongoing regarding the question of whether someone with high cholesterol (but great markers otherwise) should worry, although there are some hints that this may not be a high risk profile in-and-of-itself. But that’s obviously not a guarantee. There’s also this bit regarding women and cholesterol which is something I’ve found fascinating (seemingly less over all death in women with higher cholesterol).

I think the best bet is to look into the research and see what conclusions you draw (not just research from this site, but from multiple viewpoints). There’s a lot of great discussion going on at our Lean Mass Hyper-responder facebook group on all sides of the issue, that you might find helpful, as well.

Anne
Guest
Anne

Thanks Siobhan – I have been doing a lot of research & whilst a lot of it is very technical & involved I have gleaned a little helpful information. I am 64 & have always tended to have a “higher” TC (usually around the 7 mmol/l mark but not sure what HDL was as no-one ever worried about anything but the TC back then!). I have always managed to regulate it with diet so when I went low carb 7 years ago I noticed a continual increase but it wasn’t until this last test a month ago that it went so high. I had been eating a lot more double cream & I suspect that may have caused the spike along with a small weight gain. I have given up the cream & have actually lost weight again so maybe that may have some influence on my LDL. I will continue my experiment & re-test in the New Year. Thank you again for your response & links.

Siobhan Huggins
Admin

Dairy and liquid fats can be such a bother! I experienced the same when I dropped dairy (lost weight, then regained when I reintroduced).
Generally though as people get leaner their baseline LDL goes up if they’re on a high fat low carb diet, and then on top of that the results are heavily influenced by what you’ve eaten in the past 3-5 days before the blood draw (that’s why I try to picture log my food before blood tests!)
The next test should provide a bit more information though 🙂

denise stecconi
Guest
denise stecconi

I am seriously worried as my cholesterol is off the charts, more so than what I hear from others:
HDL: 72
LDL: 277!!
Tryglicerides: 113
Cho total: 372!!
At least inflammation is 0.3, phew. But does this mean I need to quit keto?
I am a couch potato so I might not fit this “lean mass” profile. I am 44 years old, female, 5’5 and 134 lbs.
What to do next?
Many thanks I’m advance

Siobhan Huggins
Admin

Hi Denise!
Were you 12-14 hours fasted when you got this blood draw done? I ask because the only thing that stands out is the slightly higher triglycerides than I’d expect for that profile in a low carber.
For what it’s worth LMHRs are generally “lean and/OR active” so you don’t have to be an athlete or stick thin to qualify. I’ve seen plenty of Lean Mass Hyper-responders with bodyfat at around <23% if female. There are definitely sedentary/less active Lean Mass Hyper-responders around, as well.

If your triglycerides are normally <70 mg/dL or so when 12-14 hours water-fasted I would say you qualify.

denise stecconi
Guest
denise stecconi

Hi Siobhan,
I should provide more details:
I was fasted and had given up coffee for the 10 days prior to the test. Calories were normal for that week (I eat about 1300-1500 depending on the day). I am still losing some weight: I started keto about 4 and a half months ago, lost aprox 18 lbs. Right now, at this calorie intake, I am losing about a 1/2 lbs a week.
My last physical (roughly 8 months before starting keto) looked a lot better:

10/25/17
-==== CholesterolCode.com/Report v0.9.3 ====–
…40 years on Standard American ::: 10 hours water fasted…

Total Cholesterol: 222 mg/dL 5.74 mmol/L
LDL Cholesterol: 140 mg/dL 3.62 mmol/L
HDL Cholesterol: 73 mg/dL 1.89 mmol/L
Triglycerides: 46 mg/dL 0.52 mmol/L

–CHOLESTEROL REMNANTS–
Remnant Cholesterol: 9 mg/dL 0.23 mmol/L >>> Lowest Risk Quintile
Remnant Chol to HDL: 0.12 >>> Lowest Risk Quintile
Go to https://tinyurl.com/y84u92wm for more on Cholesterol Remnants
–ATHEROGENIC INDEX OF PLASMA (AIP)–
AIP: -0.56 >>> Lowest Risk Third
Go to https://tinyurl.com/ycccmmnx for more on Atherogenic Index of Plasma
–CONVENTIONAL MARKERS AND RATIOS–
Friedewald LDL-C: 140 | Iranian LDL-C: 106
Total/HDL Ratio: 3.04
TG/HDL Ratio in mg/dL: 0.63 | in mmol/L: 0.28

Then I started keto about the end of August, do about 25g net carbs a day, dont count fiber. I went in for my physical on 11/15/18:
(I think i fainted when I read these)

–==== CholesterolCode.com/Report v0.9.3 ====–
…4 months on LCHF (20g to 25g carbs) ::: 12 hours water fasted…
Total Cholesterol: 391 mg/dL 10.11 mmol/L
LDL Cholesterol: 291 mg/dL 7.53 mmol/L
HDL Cholesterol: 77 mg/dL 1.99 mmol/L
Triglycerides: 113 mg/dL 1.28 mmol/L

–CHOLESTEROL REMNANTS–
Remnant Cholesterol: 23 mg/dL 0.59 mmol/L >>> Medium-Low Risk Quintile
Remnant Chol to HDL: 0.3 >>> Medium-Low Risk Quintile
Go to https://tinyurl.com/y84u92wm for more on Cholesterol Remnants

–ATHEROGENIC INDEX OF PLASMA (AIP)–
AIP: -0.192 >>> Lowest Risk Third
Go to https://tinyurl.com/ycccmmnx for more on Atherogenic Index of Plasma

–CONVENTIONAL MARKERS AND RATIOS–
Friedewald LDL-C: 291 | Iranian LDL-C: 280
Total/HDL Ratio: 5.08
TG/HDL Ratio in mg/dL: 1.47 | in mmol/L: 0.64

My doctor and I were in shock, we re did the test, this time, I quit coffee for 10 days prior just in case. I got almost exactly the same, this was done on 12/8.

-==== CholesterolCode.com/Report v0.9.3 ====–
…4 months on LCHF (20g to 120g carbs) ::: 12 hours water fasted…
Total Cholesterol: 372 mg/dL 9.62 mmol/L
LDL Cholesterol: 277 mg/dL 7.16 mmol/L
HDL Cholesterol: 72 mg/dL 1.86 mmol/L
Triglycerides: 113 mg/dL 1.28 mmol/L

–CHOLESTEROL REMNANTS–
Remnant Cholesterol: 23 mg/dL 0.59 mmol/L >>> Medium-Low Risk Quintile
Remnant Chol to HDL: 0.32 >>> Medium Risk Quintile
Go to https://tinyurl.com/y84u92wm for more on Cholesterol Remnants

–ATHEROGENIC INDEX OF PLASMA (AIP)–
AIP: -0.162 >>> Lowest Risk Third
Go to https://tinyurl.com/ycccmmnx for more on Atherogenic Index of Plasma

–CONVENTIONAL MARKERS AND RATIOS–
Friedewald LDL-C: 277 | Iranian LDL-C: 269
Total/HDL Ratio: 5.17
TG/HDL Ratio in mg/dL: 1.57 | in mmol/L: 0.69

——–
The big question is what to do next:
I have started exercising (hiking 3 times a day, walking 7-10k steps daily).
I added an omega 3 supplement
I am taking probiotics
My fats: I get at least half my fats from olive oil, avocado, macadamias. The rest is from meats and dairy. Rarely do bacon and pork rinds. Never coconut or MCT oil.
Ordered 23 and me test, I wanna find out if I am Apo2 or worse, Apo4.
That is all I can think of. I feel better than ever, except for those numbers. What to do next? (any other test you recommend for cardiac risk?). I am concerned. Is this normal or am I somehow defective and should not do keto? 🙁
My doctor is giving me 3 months do get those lower somehow or else…statins :-0

denise stecconi
Guest
denise stecconi

BTW oh my gosh, thanks SO MUCH for listening 🙂 and I should mention most times my ketones are about 0.8-1 when lowish, 1.5 to 2 when highish.

denise stecconi
Guest
denise stecconi

Hi Siobhan! Have you had a chance to look into this? Any advice greatly appreciated. Many many thanks and happy holidays

Siobhan Huggins
Admin

Apologies! As Dave stated I was on holiday – I’d pretty much go with what Dave said. Considering your trigs were lower before and assuming you haven’t changed much, it could very well be just a one-off number. Triglycerides can be a bit noisy, so with a followup test I’d guess it’ll go back to normal if none of the other possibilities (improper fasting, etc) were likely. This has happened to me as well.

Second, I’ll reiterate what Dave said – I was asking out of curiosity, as they are *slightly* higher than I would have expected considering the profile, but not something I’d be concerned by if I saw it on my own panel. But, I always try to doublecheck that it isn’t potentially being caused by something else before assuming it’s nothing.

What I’d likely do in your shoes is just re-test, making sure confounders aren’t involved e.g. making sure to properly fast, no coffee on the morning of the test, etc, and confirm it doesn’t go higher, and/or returns back to your normal. Track your food for the week before the test so if it doesn’t go back down you can troubleshoot if needed/desired.

Tam
Guest

Hi Dave, So happy I stumbled on your work. I am 58, 128lbs. I do regular HIIT training and meditation. I eat a whole foods, low carb, high fat (MCTs) diet. I have high LDL-C, high HDL and low TGs and low C-RP. No signs of CVS. I’ve had a full cardiac workup, no signs of CVD. I refused statins. I can’t find a study that shows I’m in danger of a CV event. And no study that shows statins will lower my risk of a cv event. I saw what statins did to my Dad. Convinced his CVD,leg and back pain were caused by statins and eating a low-fat high, sugar diet. And guess what? He died of a heart attack. Thank you for pursuing this LDL-C issue. For now, I’m going to keep doing what I’m doing.

Chris Cottreau
Guest
Chris Cottreau

Hi i’m Chris at 43 i had open heart surgery i underwent a type A Aortic Dissection ( dacron aortic arch with a mechanical heart valve installed). I was persistant with recovery and two years later i had my first ever exercise stress test the Bruce Protocol stress test It was a breeze i did 20 mets on the Bruce Mets Scale that’s as high as it goes. Around the same time i was prescribed 20 mg lipitor i’m considered to be in a high risk category therefore LDL cholesterol is to be maintained under 2 mmols I was 5’8″ 155 lbs. Four years later i had a severe case of Infectious Endocarditis it ruined my Mechanical Heart Valve and popped a stitch so now there’s a 5.5cm Psydo Anurism on top my heart . Infected heart tissue flaked off and settled in a artery in my foot blowing out that artery which had to be surigically removed . Luckly it settled in my foot and not gone to my brain or i wouldn’t be here right now. At this moment i am awaiting open heart surgery to try and redo my Type A aortic dissection . There no lifting an no strenuous activities .
Around my 52 birth day in July 2018 a friend told me about the keto diet . I read everything i could find and still do fine tuning it . November 8 of 2018 i trashed my Lipitor 20mg cold turkey i feel great lots of energy mental clarity great blood work results other than total cholesterol and LDL which my Dr is freaking out about . Since my LCHF lifestyle I’ve dropped 5 prescription meds . Still taking amolidipine 10mg and coversyl 6mg both for blood pressure BP kept around 110/60 and also 14mg warfarin daily due to the mechanical heart valve . I want to be in shape for the next open heart surgery.
I kept most of my bloodwork ever done over the last 9 years . Its now been 7 months on a LCHF diet and loving it

7 months LCHF
Latest bloodwork was on Feb 8 2019
Hba1c 4.6
lipid profile
Cholesterol 302
LDL 224
TRIG 61
HDL 71

Remnant cholesterol 7 MG/DL lowest risk quintile
Remnant cholesterol to HDL 0.1 lowest risk quintile
Atherogenic index of plasma -0.426 lowest risk third
Conventional Markers Frieldwald LDLC 219
Iranian LDLC 183
Total/HDL ratio 4.25
TG/HDL ratio mg/dl 0.86

Siobhan Huggins
Admin

Wow – that sounds like quite a stressful ordeal – I am glad you are still with us, today!
I am glad you’re feeling better, and have more energy, that must feel great. 🙂
As for your panel, it looks like you are, or are a borderline, Lean Mass Hyper-responder. You might want to check out the Lean Mass Hyper-responder facebook group as there’s a lot of great studies, and discussion there.

Chris Cottreau
Guest
Chris Cottreau

As of March 5 2019 i had a Cardiac Calcification Score finally putting to rest my fears of any high cholesterol and high LDL numbers . There was no sign of plaque in my arteries . I’d lie to now have a cholesterol particle size test done but it seem as if no one in Yarmouth Nova Scotia is familiar with the lab test.
Regards Chris

Siobhan Huggins
Admin

You should be able to order it through a lab ordering service. There are a couple listed at the bottom of this post, as well as in the comments.

pam
Guest
pam

thank you for all the great information and studies you have posted. 🙂 Just got my labs back and my DR was seriously wondering why i wasn’t as disturbed as he was , by my Cholesterol results.. Well, I did actually expect a change but this was big. Mind you, I am 54 yo – 118 pounds – 16% BF, i spend 2 hours in the gym, lifting, 4 days a week, own and operate a plant nursery, so clearly active – I don’t smoke, drink alcohol, or eat anything other than animal kingdom. Here are my numbers:
HDL=110
TG = 40
LDL = 227

I have been in ketosis for over 3 years and carnivore for 7 mos….. If i have understood all that you wrote, my take away is that the reason for the large number of LDLs is more than likely due to carrying the higher volume of FAs around. Did i get that somewhat correct?

Siobhan Huggins
Admin

Yes, that’s the current leading hypothesis for the rise we see in Lean Mass Hyper-responders (as you are – or standard hyper-responders) is that more VLDL are sent out to shuttle around more triglycerides, due to their being a higher demand for global transport of fat-based energy, and so there is higher turnover and resulting higher LDL. 🙂

Dr Afshari
Guest
Dr Afshari

Thanks for great info
I’m definitely a hyper responder, and at the same time a cardiologist, so you can guess that maintaining my low carb diet is such a challenge!
I have a question about my fasting glucose. It is always around 100. Do you have any explanation why it is so high?

Pedram Ataee
Guest
Pedram Ataee

So interesting!
I follow a carb cycling diet so that I eat about 100 grams of carbs on non-training days and 300 gr on training days. I do weight lifting 4 days a week.
Is it possible for somebody like me to be a hyper responder? Because I don’t really follow a strict low carb diet.
Here are my numbers:
Chol: 318
TG: 82
HDL: 71
LDL: 229

Pedram Ataee
Guest
Pedram Ataee

Thanks for reply

Nathan
Guest
Nathan

OK- I’ve just successfully completed the Feldman Protocol.

Background, I’ve been prediabetic until just this past January, when my HbA1c went to 5.7 from 6.1 after starting a LCHF lifestyle. In January, I got my annual lipid panel, and I came back approaching hyperresponder territory, and I got “The Talk” about my high LDL numbers. My 2017 test unfortunately only measured total cholesterol and HDL, which were 226 and 55 mg/dl respectively. Then January of 2019 (after 6 months of LCHF), 272 total, 56 HDL, 187 LDL (calculated), and 147 TG. Then “The Talk,” and a promise to re-test in 3 months. So here it is, and 3 months ago I cut out coffee completely, and started drinking black tea with 1/2-and-1/2. Three days ago (Wednesday, today is Saturday), I started the Feldman Protocol, eating 4000+ calories/day of at least 75% of calories from fat. Saturated fat varied, but averaged around 20% of calories.

Today’s results, why I’m happy to share- 230 total, 58 HDL, 134 LDL, but 190 TG. So it worked, I’ll get the follow-up to “The Talk” at my next appointment (Friday).

Looking at remnant cholesterol, I was healthier 3 months ago, but still in a riskier territory. And looking at TG, I’m not sure why it went up. I was expecting it to go down. I was 12 hours fasted for this latest test.

And for the record, I’m mid-40’s, BMI of 21, and I exercise regularly.

Just wanted to add another data point, please feel free to send any questions my way, I’ll check this comment thread for any responses.

Dan
Guest
Dan

I am a 45 year old male and have been on a LCHF diet for the last year. I decided to go on LCHF diet once I reached a weight of 208lbs. I am 5’10”tall. I have lost 30 lbs and have been able to keep it off. I feel better now than I have felt in a long time. I recently had my blood work done. My HgA1c is 5.3 and fasting insulin is 4.7. I recently had my first lipid panel done since going LCHF. My TG are 64 and my HDL is 64. However, my total cholesterol is 302, VLDL calculated is 13, and LDL calc is 225. My results prior to starting LCHF were total cholesterol 181, TG 95, HDL 46, LDL-direct 120. I am a relatively actively person (I run/walk 3-4 days per week and work outside doing yard work on the weekends). Needless to say I a bit surprised by those numbers. I am wondering if I am a hyper-responder? I am getting ready to go to my primary care doctor and am guessing they will want to put me on a statin which I am not excited about. I am wondering if I should have advanced lipid testing to determine particle size or a cardiac ct scan. Any suggestions? Thank you

Siobhan Huggins
Admin

Certainly sounds like a hyper-responder profile! If in your position, I’d also want to get a baseline CAC (cardiac CT scan), plus check into other markers of risk like hs-CRP, and insulin just to keep an eye on things, as you have been doing. And of course it’s always worth noting that it is your doctor’s job to suggest what they think will help you reach your health goals, but it is yours to decide if you think it will help or not.