Apo E4 Heterozygous (Male) and Keto


Quite frankly I don’t think there is one publication that I return to time and time again but rather, I look up studies and their authors and then start researching. My wife is also a doctor. I have read a number of papers written by Dr. Allan Sniderman. He is a professor of cardiology and medicine at McGill and one of the foremost experts in cardiovascular disease. He makes the case for ApoB as a superior metric that is currently being underutilized.

One reason is confirmation bias. People will naturally only read the information that confirms their choice. I attempt to be objective as best I can and will regularly read viewpoints or studies that confirm the opposite of what I believe. Most will only read the science or their expert that supports their choices and will dismiss the other viewpoints because it does not “Fit” with their choice or agenda. Conflicts of interest are not always listed or the experts will cherry-pick their studies that “prove” their points of view. This happens in all fields, including our Keto world as well.

(Michael) #29

I will look up Allan Sniderman’s publications and add his more recent to my list - thank you.

(Danny) #30

I find this all so confusing… Before doing keto, in April 2022, I had a routine blood panel for my annual physical. At the time, I was probably 173lbs and not “out of shape” per se, but much less in shape than I am now at 160lbs. And I was eating more of a standard American diet and had mildly severe GERD and gastro issues (constant bloating, gas etc.)

These were my numbers at which nobody blinked an eye

LDL 130
HDL 56
TRIG 134
(2.35 ratio)
ApoB ?? Never did a test back then.
Glucose 93

Then, when doing “pseudo keto” with cheat meals a couple days a week and a decent amount of microbrews on the regular, I was down to about 165lbs but still had some subcutaneous love to lose and my numbers from 1/11/23 were

LDL 172
HDL 70
TRIG 102
(1.42 ratio)
ApoB 117
Glucose ~75 (from 11/3/22 but eating similarly)

Again, these above numbers were the result of a 5 day per week keto-ish diet with a few cheat meals (burgers, sometimes even some pizza) and drinking probably around 12 microbrews per week…

Now that I’ve been doing true keto, eliminated beer and cut way back on any drinking for a couple months, I have practically alleviated my GERD/gastro issues but some of my numbers have gone up. Namely my LDL of 210 and, especially , my ApoB of 144… I would’ve thought eliminating cheat meals and beer along with reducing my alcohol consumption overall would’ve helped these numbers. But now my cardiologist is telling me we should possibly be considering medication

So, I know in my heart of hearts, this isn’t true but this result makes me feel like I was slightly better off eating a couple of cheat meals and drinking beer! I mean an ApoB of 117 wasn’t excessively high, more borderline, but now at 144 it seems I’m in a bad spot…

Also, on the topic of ApoB, why the hell is it that my test result sheet shows the acceptable range to be 50-155 if 144 is considered so high…? The damn result isn’t even marked as high on this sheet! See attachment below.

I find this all so confusing and frankly frustrating… Apologies, that will end my rant/vent.

3-1-2023 Blood Panel.pdf (342.8 KB)

(Bacon is a many-splendoured thing) #31

I don’t see what your doctor is worried about. Given that your ApoB is in the normal range, and your ratio of triglycerides to HDL is as good as it is, I can’t imagine what the problem is. LDL of 210 is concerning to doctors who haven’t kept up with the literature, but seeing LDL go up like that when you cut out carbohydrate is a sign that you are one of Dave Feldman’s lean-mass hyper-responders. Dave doesn’t really encourage lying to our doctors, but if you really need to get a good lipid panel, there is a pattern of eating you can follow a few days before the blood is drawn that will make your lipids look good to the doctor. Go to this site, and check things out:

Alternatively, you can ask your doctor to do an NMR analysis of your LDL, which will show the healthy Pattern A, and ask also for a CAC (coronary arterial calcium) scan and a CIMT (coronary intima media thickness) scan, and see what they say. I’m betting that everything will indicate that you are just fine.

(Danny) #32

Thank you - I may try that little cheat just to prove a point… I did do a CAC and it was 0.

I just find it so strange that this doctor claims to be keto/low carb friendly YET says my cholesterol should not increase from eating that way. Though it seems most people experience an increase in cholesterol levels… And since mine did increase, I have some kind of metabolic issue that requires medication… Almost feels to me like a trap to purvey prescription meds.

Don’t mean to sound like a conspiracy theorist but it’s quite the contradictory stance.

(Bacon is a many-splendoured thing) #33

Well, normally, people’s cholesterol does normalise on a keto diet. But the percentage of lean-mass hyper-responders is apparently quite high. The figure 30% comes to mind, but don’t quote me, because I may be making it up.

Dave Feldman is recruiting for a study to see if high LDL in the context of someone who is lean and fit is actually any kind of problem.

We do know that, in the case of people with familial hypercholesteroaemia, the high LDL itself does not cause cardiovascular disease. About half the people with FH do develop cardiovascular disease, but they are the ones with genetic variants that make their blood more likely to clot. At a certain point in their lives, the people with FH who don’t have these clotting abnormalities actually have a higher life expectancy than people in the general population with normal or low cholesterol. Go figure!

(Joey) #34

I would suggest asking your doctor to explain why he believes medication is the best course. The pros and cons, the potential side effects, and ask if he can point you to any relevant research about whichever medication he has in mind, so you can get up the learning curve.

If he is open to this exchange, you’ve found a good doctor. And you can then make an informed decision - either with his support or not.

But keep an open mind. There are many poor applications of Pharma products. But some are worthwhile depending on the context and situation.

You deserve to benefit from understanding all the options available. (Personally, I wouldn’t be taking a statin, if that’s what he has in mind. But that’d be my decision based on extensive reading of the reliable research.)

Yeah, people are funny that way :wink:


The so-called normal range (50-150) is just plain crazy for ApoB. The rough percentile numbers are:
5th % = 62
95th % = 140
Newer cardiologists or those who are current with more recent research are treating early and are treating high ApoB aggressively even if the calcium score is zero. The research of Dr. Allen Sniderman is starting to gain some traction. Many other published papers in the last few years also point to reducing ApoB asap to reduce ASCVD risk. Statins with a PCSK9 inhibitor and you can basically eradicate ASCVD or the odds that you’re going to suffer ASCVD are incredibly low. An ApoB number below 50. (IMHO) I am not a medical doctor.

(Danny) #36

Well, the range is actually 50-150 not 50-144. And odds are, if your LDL is elevated from, say, doing keto, your ApoB is going to be elevated as well… My wife, for example, had an LDL of 77 and an ApoB below 100 two months ago before starting keto. After doing a lipid panel and ApoB a week ago, two months into keto, her LDL was 186 and ApoB was 149…

So, all of this is to say that an otherwise extremely healthy person who has lost weight, become more physically capable and improved many other critical numbers (increased HDL, reduced TRIGs, improved blood glucose and fasting insulin, etc.) should not be on a keto diet?

And, for someone like me, who’s had chronic gastro issues on all fathomable diets until finding keto and was able to reduce his TRIG/HDL ratio from 2.35 to 1.33 is now less healthy? I don’t buy it…

To just punctuate my point here… All I’ve done since my last ApoB test in January (which was a “much better” 117) was cut out microbrews, reduce my drinking significantly and stop having weekly cheat meals which consisted of things like cheeseburgers with french fries, pizza, etc.

Are you saying I was technically healthier when I was doing all of those things because my ApoB was 117 instead of the current 144 without them?

(Bacon is a many-splendoured thing) #37

Just let me say that you shouldn’t take this as permanent. Lipid numbers often do weird things in the beginning, as the body sorts itself out. We recommend having another lipid panel done at six months into this diet, and the numbers will likely be more reasonable and more stable.


DannyG, as I have stated before, I am not a medical doctor. Rather, I have an interest in health and longevity. I have also done an inordinate amount of research on the number one cause of death in the western world. ASCVD if addressed, there are actionable steps that you can do to significantly reduce the risk, unlike the other 3 main causes of death.
Why not do your own research on ASCVD and CAD risk factors and ApoB?

(Danny) #39

Well, for me, after about 4 months, my ApoB is at 144. But, I suppose, that’s only really about 7 weeks into cutting out the beer and cheat meals… I don’t plan to add either of these things back into my diet the way they used to be (may have a beer once in a blue moon and a cheat meal once a month) so will be interested to see how things look in a few months.


Your life expectancy with FH depends on the type of FH you have and whether or not you get treatment. Without treatment, life expectancy with FH is reduced.

I would like to see the research on that?

(Danny) #41

Wonder how much Dr. Allen Sniderman is getting paid for prescribing statins… Or possibly for publishing studies like this that promote the use of them.

(Danny) #43

Also, not to hammer this home too hard but if the whole reason I’m doing keto is to fix my gastro problems, why the HELL would my doctor (who knows this) try to prescribe me statins when these are the side effects…? I’ve highlighted the one that’s most relevant for you…

This, in lieu of telling me to go back to a standard diet, when my cholesterol/ApoB numbers were normal on such a diet. Could that possibly have anything to do with wanting to prescribe medication…?

Also, can we just acknowledge the laundry list of nasty common and potential side effects of this drug??? It’s because of crap like this that my poor 73 year old mother, whose on numerous medications, many of which are meant to counteract the other, has countless issues and fairly poor quality of life. All because doctors would rather throw a pill at a problem than try routes of treatment that may work but wouldn’t pay for their mansions.

Common side effects

Side effects can vary between different statins, but common side effects include:

Uncommon side effects

Uncommon side effects of statins include:

Rare side effects

Rare side effects of statins include:

  • muscle weakness (myopathy)
  • loss of sensation or tingling in the nerve endings of the hands and feet (peripheral neuropathy)
  • tendon problems (tendons are tough cords of tissue that connect muscles to bones)

(Bacon is a many-splendoured thing) #45

Try this study: “Familial hypercholesterolemia: A genetic and metabolic study,” Wm. R Harlan, John B. Graham, and E. Harvey Estes (Medicine, 1966; vol. 45, no. 2).

Also Ravnskov and Diamond have written a couple of review papers summarising the data, which have provocative, not to say polemical, titles. They are advocates of the hypercoagulability hypothesis of cardiovascular disease.

If you are looking for an alternative to the standard narrative of the lipid hypothesis, I believe the Web site of the International Network of Cholesterol Sceptics (THINCS) is still active. The membership comprises such internationally-known researchers as Ravnskov, Feinman, Ludwig, McKendrick, de Lorgeril, and the like.

(Bacon is a many-splendoured thing) #46

Interestingly, while Professor Sir Rory Collins, the head of the Oxford University team that keeps all the proprietary research data on statins and does all the industry-funded research (for which Oxford receives very generous funding), claims that statins have very few side effects, the company he set up to market his patented genetic test to detect vulnerability to statin side effects claims that at least 25% of the population is vulnerable. When asked about this, Professor Sir Rory brushed it off as a marketing ploy.

However, Prof. David Diamond has analysed the manufacturer-funded studies of the efficacy of statins, and it appears that, despite the researchers’ attempts to minimise the number of study participants likely to develop side effects, the 25% figure is more likely to be accurate.

(Danny) #47

Great to know. If it was deemed absolutely necessary that I lower my ApoB, I would much rather go back to the way I was eating prior to keto, and enjoy microbrews as an added bonus, than medicate and risk having the same issues that way of life caused.

The fact that my doctor would attempt to prescribe something to me that may cause the same problems is infuriating, reckless and seems almost malicious. If he’s really just concerned about my cholesterol, all he’d have to say is “keto may not be right for you, you should go back to the way you were eating because your bloodwork looked better then.”

(Bacon is a many-splendoured thing) #48

Unfortunately, that is the standard of care, and he would be legally liable for a malpractice suit if he failed to prescribe. You, however, are under no legal obligation to take a medication, simply because it was prescribed. (That is, until some bright young think at a company that makes statins thinks of talking to the legislature. They are already trying to get statins added to the public water supply.)

(Danny) #49

Now THAT is utter insanity…