Thread by @DoctorTro

🚨 Thread on LDL & low carb🚨

How I approached high LDL in my patients, and how we observed a decrease in LDL of 480mg/dl

About the case-series of 5 patients…

(1/20)

As data supporting low carb diets has proliferated for weight loss, diabetes, seizures and other conditions, patients are now presenting with various issues related to the diet

2/20

For example, while it’s true that consistently a1c, triglycerides, HDL and lpa seem to improve, some patients report some adverse events.

3/20

While some adverse events are complete BS like “keto krotch” others like keto rash or elevations in LDL are commonly seen by doctors who implement this modality.

In my case series, we highlight patients who presented to my office with lipid abnormalities.

4/20

Patients came to my practice w/ extremely high LDLs after self starting a ketogenic diet

My approach is to regularly check lipids on our patients when initiating LC to screen for this phenomenon & address it before LDL rises too high, usually without any medications

5/20

In our patients, we routinely screen for this and adjust to prevent this, but these particular patients from the case series had started keto on their own or with other doctors and the patients/doctors didn’t know what to do & wanted to learn more & address it

🤯

6/20

So I went to the literature so that I could provide the best insight possible

A thorough review showed some interesting findings

In Ramadan fasting, low BMI & weight loss was associated w/ increased LDL!

NOT EATING SATURATED FAT, INCREASED LDL during Ramadan fasting
🤔

7/20

A look into the FASTING literature confirmed that not eating saturated fat during fasting INCREASES cholesterol TOO 😂 (this is true)

@ethanjweiss

8/20

Furthermore medications like SGLT2i that promote increased fat oxidation, ketosis and improved gylcemia (by increasing the urination of them) INCREASES LDL, despite improving CV mortality

Very similar LIPID patterns to Ramadan fasting & fasting!

🤔

9/20

And if you look into the literature, marked transient increases in LDL ALSO occur in anorexia, the prototypic example, albeit pathological & devastating, of high compliance with carb restriction and fasting

10/20

What I found was, consistent in the anorexia literature, the observation of massive increases in LDL occurred FREQUENTLY and that this phenomenon was reversible with refeeding and weight gain

11/20

So fasting data, anorexia data, pharmacologic data and massive online community worth of data all seemed to show a similar pattern of lipid behavior in response to dietary change that was otherwise unrecognized in the medical literature

12/20

Now armed with this data, I turned to my patients.

These patients often had teams of cardiologists and came to me saying “I won’t take a medication, I know this is related to diet”
(They weren’t wrong)

13/20

I educated them about the ACC/AHA recommendations and the devastation of those with FH

And the benefits and adverse events of statins, and other meds in high risk patients

Often I worked with teams of cardiologists and ordered genetic tests, stress tests etc

14/20

Now, some patients wanted medications but these patients aren’t included in this case series. Some patients refused, as it wasn’t consistent with their values.

So I asked them to consider adding back carbs

15/20

Now given that some data has shown that fructose increases LDL, I told them to add back starch preferably, separated from fats so as to not over consume. I also suggested low carb fruit particularly around exercise.

We aggressively monitored all of these patients

16/20

I told them if they accepted the higher risk of CVD of high LDL, then at the least we needed to surveil with CAC, CIMT, and in some most cases stress tests

17/20

And what we found was actually quite amazing

A drop in LDL in SO LARGE that it’s the greatest EVER DOCUMENTED IN THE LITERATURE to my knowledge.

~500mg/dl

18/20

Now please understand that these type of patients in my practice are HIGHLY monitored and others not included in this series have gone on to adopt medications & alternate strategies

But nonetheless, THIS data, from this series of patients is interesting & worth publishing

19/20

You do not have to accept an extremely high LDL, if you want to make modest changes in carbohydrates this can make huge impacts on this important CV risk factor

In some cases, it may spare the need of medications per ACC/AHA guidelines

20/20

So, yes, the @LCMDPodcast host has published an observation of INCREASING carbs which shows how to LOWER LDL (something I’ve been erroneously criticized for not supporting)

21/20

Bottom line, it’s been @DaveKeto important work that highlighted this phenomenon. And now clinicians have an observation of it and it’s reversal.

I hope this helps clinicians worldwide dealing with patients on keto

22/20

If you have made it this far, here’s the paper:

Read it, Share it, discuss it!

This represents YEARS of data and collaboration.

academic.oup.com/cdn/advance-ar…

/end thread