The Proof with Simon Hill
Is high cholesterol on a keto diet always a problem? | Dave Feldman and William Cromwell, Md
Episode guests
Podcast summary created with Snipd AI
Quick takeaways
- High LDL cholesterol levels on a keto diet may not always pose a cardiovascular risk.
- Understanding APOB lipoproteins is crucial in assessing cardiovascular health.
- Genetic predispositions like familial hypercholesterolemia impact LDL levels and atherosclerosis risk.
- A comprehensive understanding of lipid metabolism is essential for cardiovascular prevention strategies.
- Long-term exposure to high LDL levels may contribute to atherosclerosis progression and disease risk.
- Balancing short-term and long-term health impacts of high LDL levels requires tailored interventions and risk assessments.
Deep dives
Understanding Blood Lipids and Cardiovascular Risk
Blood lipids, especially APOB-containing lipoproteins, impact cardiovascular disease risk. A discussion with Dr. Cromwell and Dave Feldman delves into how factors like LDL levels affect cardiovascular health. Dr. Cromwell, a lipidologist, emphasizes the importance of looking at lipoproteins carrying cholesterol rather than focusing solely on cholesterol itself. The interaction between these particles and their impact on plaque formation and artery health is a key aspect.
Insights into LDL Cholesterol and Metabolic Health
Dave Feldman discusses his experience with a ketogenic diet and the significant rise in his LDL cholesterol levels despite improvements in metabolic health. This raised questions about the correlation between high LDL levels and optimal metabolic health. The conversation touches on genetic predispositions like familial hypercholesterolemia and the role of LDL levels in atherosclerosis risk.
Dietary Impact on APOB Levels and Cardiovascular Health
The discussion explores the impact of diet on APOB levels and cardiovascular health. Differences in views on the diet-heart hypothesis emerge, with insights into how saturated fats affect APOB-containing lipoproteins. The complexity of factors influencing atherosclerosis risk beyond just APOB levels is highlighted, emphasizing a comprehensive understanding of lipid metabolism.
Considerations in Cardiovascular Prevention and Treatment
The conversation delves into the nuances of cardiovascular prevention and treatment strategies. Discussions include the importance of early intervention to lower APOB levels for long-term benefits. Considerations for secondary prevention and the role of factors like inflammation, metabolic vulnerability, and lipid profiles in optimizing cardiovascular health outcomes are emphasized.
Understanding the Impact of High LDL Levels on Lifespan and Disease Risk
High LDL levels may have an impact on longevity and disease risk, with a focus on cholesterol exposure over time and its association with plaque progression and events. The podcast delves into the notion of cumulatively high LDL levels leading to atherosclerosis and the potential consequences over time.
Analyzing Plaque Progression in Lean Mass Hyperresponders
Delving into the progression of plaque in lean mass hyperresponders with high LDL cholesterol levels. The discussion centers on the implications of rapid plaque progression and the possible lower risk of other diseases in these individuals.
Potential Trade-Offs in Managing High LDL Levels
Exploring the trade-offs and considerations when managing high LDL levels, particularly in lean mass hyperresponders. The dialogue revolves around the complexities of addressing high LDL levels in individuals with varying metabolic health statuses and the potential need for lifestyle or pharmacological interventions.
Balancing Short-Term and Long-Term Health Impacts of High LDL
Addressing the balance between short-term and long-term health impacts of high LDL cholesterol levels, especially in individuals following a ketogenic diet. The conversation emphasizes the importance of understanding the implications of sustained high LDL levels and considering potential interventions to mitigate risks.
Frequency and Understanding Frequency of Statin-Associated Effects
The challenge lies in understanding the frequency of adverse effects of statins, especially amidst amplified negative anecdotes. Large data sets show low occurrence rates of severe reactions, emphasizing the importance of context in assessing risks and benefits of statins.
Intensities of Statin Therapy and Adverse Effects
Moderate intensity statins used initially showed minimal adverse effects due to their dosage levels. High-intensity statin therapy, driven by studies like Miracle Trial, led to more adverse events, emphasizing the importance of tailored dosing based on individual risk factors.
Selective Approach to Statin Therapy
Guidelines post-2013 advocate selective statin therapy based on specific criteria like ASCVD, high LDL cholesterol, diabetes, and validated risk calculators. This targeted approach helps mitigate the risks and benefits by analyzing individual risk factors.
Balancing Risk and Benefit in Statin Therapy
The consideration of risk and benefit is crucial when discussing statin therapy with patients. Understanding the percentage of side effects attributed to negative biases while focusing on mitigating individual risk factors plays a key role in informed decision-making for statin use.
Some people follow a ketogenic diet seeking to lose weight, feel more energised, or gain control over their eating habits. Others may turn to this diet in an effort to treat conditions such as epilepsy, bipolar disorder, diabetes and inflammatory diseases. Regardless of their reasoning for adopting this eating pattern, a key question remains: is there ever an instance where having high LDL cholesterol levels on a ketogenic diet can be safe? In Episode #311, I’m joined by Dr William Cromwell, MD and Dave Feldman to explore this question.
In this discussion, Dr William Cromwell and Dave Feldman share their professional opinions on whether high cholesterol on a keto diet is a problem. We investigate where their opinions align and where they differ, where Dave’s hypotheses diverge from the norm, and what we do and don’t know with the available evidence. We also explore the significance of ApoB, lifespan and healthspan considerations, research Dave is currently conducting, and much more.
Specifically, we discuss:
- Intro (00:00)
- Dr. William Cromwell: Background as a Lipidologist and LDL Research (01:54)
- Dave Feldman's Ketogenic Diet and Elevated LDL Experience (05:34)
- Unpacking the Lipid Hypothesis and Cardiovascular Risk (12:30)
- The history and evolution of the lipid hypothesis (20:40)
- The role of apoB lipoproteins in atherosclerosis (23:39)
- Factors beyond apoB involved in atherosclerosis and mortality risk (31:59)
- The complexity of interpreting mortality data in the context of apoB (41:40)
- Macrophages and the process of atherosclerosis (44:00)
- Beyond ApoB: Metabolic Vulnerability, Inflammation and Mortality Risk (52:57)
- Transcytosis: A New Perspective on LDL Movement and Atherosclerosis (1:10:36)
- Exploring Low Cholesterol Impacts and Genetic Disorders (1:17:30)
- Macrophage function and phenotype in the context of different drivers of high apoB (1:22:30)
- Defining Lean Mass Hyper-responders in the Context of a Ketogenic Diet (1:31:40)
- Investigating PCSK9 and Its Effects on Healthspan (1:38:00)
- Assessing cardiovascular risk in lean mass hyper-responders (1:43:50)
- Statin safety, adverse effects, and patient reluctance (2:01:54)
- Ketogenic Diets and Elevated LDL: Balancing Individual Risks and Benefits in the Absence of Long-term Data (2:10:40)
- Insulin Resistance, ApoB, and Cardiovascular Risk: Navigating the Challenges in Assessment and Imaging (2:18:12)
- Lean Mass Hyper-responder Study: Design, Recruitment, and Eligibility Criteria (2:32:45)
- Closing Perspectives on Research and Dietary Options (3:04:47)
- Outro (3:06:42)
Connect with Dr William Cromwell: Twitter/X, LinkedIn, and https://www.mylipid.com/. Discover more of his work with Precision Health Reports: Twitter/X, LinkedIn, Facebook, Instagram, and at https://precisionhealthreports.com/.
Connect with Dave Feldman: Twitter/X, YouTube, and Instagram, and discover more of his work at https://citizensciencefoundation.org/, https://ownyourlabs.com/, and https://cholesterolcode.com/.
This episode is brought to you by:
InsideTracker
If you want to improve your health, you need to measure where you’re currently at. InsideTracker analyses up to 48 blood biomarkers including ApoB, LDL, HDL, A1C, and more before giving you advice to optimise your health. Get a 20% discount on your first order at insidetracker.com/simon.
Shopify
Shopify, the world's leading e-commerce platform, helps you turn browsers into buyers with the internet’s best-converting check out–up to 36% better compared to other leading e-commerce platforms. To boost your conversion rate, and grow your business, sign up for a one-dollar-per-month trial period at shopify.com/proof.
Sun Home Saunas
Invest in your body and mind with Sun Home Saunas, pioneers in crafting premium saunas and cold plunges. Safe, effective, research-backed wellness tools to improve cardiovascular health, offer psychological benefits, and reduce muscle soreness. Head to sunhomesaunas.com/theproof for $300 off your purchase.
Remember Everything You Learn from Podcasts
