Thread by @nicknorwitz

1/ It's been quite a week on Twitter regarding #lowcarb and LDL

I have been on the fence about weighing in, not wanting to add to the dog pile, but decided 2drop my thoughts in this thread

If u don't have time to READ THE WHOLE THING IN CONEXT, ignore& consider me🪰 on the wall

2/ I'll first address @deirdre_tobias analysis of LDL and all cause mortality. With the caveats that I'm not an epidemiologist &hope to have more insightful questions when time passes and the dust settles, I am not in disagreement w/ the main results: high LDL associated with ACM

3/ That's actually old news, isn't it?Not so say that the analysis doesn't bring something to the table, but on a population level v high LDL levels (will get to low LDL in a minute) are generally undesirable. Thus, all things being =, a conservative gambler would pick low-is LDL

4/ But what are some of the nuances & what are the implications? A few notes:

(i)Dose-response to LDL is absent in "metabolically healthy" group. As you go from Q1 up in LDL to Q3, risk goes down - not up.

This doesn't mean the highest quintile doesn't have an elevated risk...

5/ But it also means "the lower the LDL, the better ❤️" interpretation of these data are 'unproductive' to put it politely.

(again, because I know someone is going to RT this, I encourage ppl to read the whole thread in context)

6/ Thus, point (ii) would be very low LDL is also associated with increased risk of ACM. Again, nothing new.

But point (iii) is where things get interesting (at least for me). Given the source of these data I'd suspect the high LDL in the Q5 group had a large genetic component

7/ The reason I think this is important is because the low-carb lipid triad and #LMHR phenotype is - we think - a metabolic response and high LDL due to genetics, e.g. FH, is likely mechanistically distinct from high LDL due to high LDL due to genetics. But wait, there's more

8/ While I think there is something interesting going on with the #LEM and #LMHR that can't be captured in epidemiology, that is NOT to say I am flippant or unconcerned about the astronomically high LDL observed in LMHR subjects. Mechanism and risk are two diff questions.

9/ It also saddens and frightens me to see so many laypeople led stray by extreme claims about lipid lowering medications. News flash: they are not rat poison and have a place. I myself know several LMHR who have chosen to start statins and I applaud them. That said, it's true

10/ that I myself am an unmedicated LMHR. My personal reasons for that choice are outside the scope of this thread, but suffice it 2say I have tried several means of LDL lowering, take the options of my MDs seriously, and continue to get testing and reassessing my decision...

11/ The fact of the matter is that individual patient care is not as simple as "low LDL is better" or "statins are rat poison"

It's a matter of thoughtful discussion and estimations of the pros and cons in each case. Now, I realize that's easy for me to say because

12/ I'm in the privileged position of being set in academia and being able to have an educated and civil discussion with my healthcare team about my personal decision and am able to digest the data they supply to me. By contrast, I know a lot of MDs are worried for their patients

13/ patients who aren't scientists and who just get the Twitter soundbite of "statins are bad and LDL is a lie" and then forgo therapy or lifestyle change that, in their case, may be sorely needed. In fact, I spoke with someone earlier this week who I felt was in that camp and

14/ I clearly stated that, were I in his/her shoes I'd start pravastatin and a PCSK9i. (NB: this persons had far lower LDL than myself). I'm grateful to have a distinct patient circumstance and present concerns. And, again, my personal decisions are continually being reassessed.

15/ So, Cliff notes version of the first 14 points in this thread: there is no Cliff notes version. If you're getting the Cliff notes, you're missing important context.

Now, moving on to a different topic: I have been following the journey of @TheCarnivoreKid...

16/ First off, I'm grateful he's still with us and celebrate his sharing. I think anecdotes do have value in so fat as they are often most influential in shaping public opinion (like it or not). Thus, his story shines a spotlight on what I'm trying to say in so many parts:context

17/ With that said, I'm disappointed by members of both diet camps for trying to trying to capitalize on this moment to make points for their camp.
...

18/ E.g. On the carni side, I've seen people saying it's "just" the seed oils & that Michael's handle is disingenuous. That he should cut the oils and change his handle and do clean carnivore. Okay, in all seriousness, this is untrue and uncool.

19/ Then, on the other side, I've seen people using this moment to lambaste the carnivore lifestyle and the 'idiocy' of people's 'choice' to be #LMHR. This too is unfair for many reasons, perhaps most important of which is that...

20/ This particular case was one in which (i) LDL appears high from baseline (with possibly a moderate decrease on low-carb) (ii) + a strong family history (iii) + advanced disease at baseline (hence, lifestyle change).

Points on the minutiae of his diet, any1 who takes time

21/ To consider this particular circumstance and who has the expertise to analyze the situation at even a basic level would know this isn't an #LMHR, very likely a genetic phenomenon, and that IMHO (IMHO!) medication is a good idea, as supported by @deirdre_tobias analysis

22/ Now, I know I keep 'ping-ponging' here (kinda' the point) but I'm sure a devil's advocate would say "it wouldn't matter if he were LMHR and this were a metabolic response. High ApoB is risky and should be treated." This is a fair statement and to that I would say...

23/ All things being equal, I agree (I agree!). Given the present state of the data the conservative approach is to treat high ApoB with lifestyle and/or medications.

But that doesn't mean there aren't more questions to ask and more to learn, esp re bona fide #LMHR and the #LEM

24/ Okay, I'm done. Now let's see just how many people take bits of this thread out of context and just how much trouble I've generated for myself. Sigh.