Help:
I’m 33, Male, 155lbs. Been on keto for a year and have lost 65lbs. Just had a lipid panel done, and of course the gave me the whole chat about statins… I did a little research (divide triglycerides by HDL), and I’m within the healthy bracket… my results are:
HDL: 73
LDL:325
TRY:165
Do these numbers look ok? Any feedback?
These might help to put things into perspective:
I assume “TRY” are triglycerides? They could be lower. Do you exercise? You could be a so-called Lean Mass Hyper-Responder, LMHR:
If you drink coffee, that will raise trigs for some (not for me).
See if you can get a coronary arterial calcification (CAC) scan done. It’s a CT scan telling you the calcification of your arteries.
I’m assuming you got the standard basic lipid panel? If so, I would suggest getting an NMR Lipid test which can provide more meaningful info about the various size ranges of your LDL and HDL, and typically will also provide an insulin sensitivity figure.
While your triglycerides do seem a bit higher than preferred (despite having a nice high “protective” HDL figure), this additional information might calm your concerns or provide areas where additional attention might be warranted.
In general LDL-C by itself tends to be a pretty ambiguous (if not useless) metric - especially without any context, so for me at least, the LDL=325 would be the least of any concerns.
FYI, the NMR is fairly cheap to get done even if your doc isn’t interested in requesting it (runs about $100 or less through RequestATest.com and other such portals).
Thank you! … btw, I do drink a lot of coffee… I am very lean too… I do go running 2 to 3 times a week, and usually run about 5 miles… I’m going to do my research on this LMHR.
Ok cool. Thank you. Yeah, I was thinking that my triglycerides were a little too high too. Maybe I should cut on saturated fat? I eat way too much bacon
Oh goodness, no! Especially now that you’re (presumably) following a low-carb keto diet and fully fat-adapted.
On the contrary, those saturated fats are the way you keep your body metabolizing fat. (Okay, admittedly bacon may not be the cleanest animal fat source given the way much of it is produced and preserved, but hey, I don’t want to start a flaming war around here over bacon 
You’ve had wonderful success with keto eating for a year, so it’s hard to knock your track record and results. But if I were in your shoes with the triglyceride figure, I’d want to make doubly sure that after a year I hadn’t let my carb count creep back up, either by cutting some corners or perhaps eating hidden carbs in menu items I thought were not spiking my insulin. If so, I wonder if that might render some of that fat (pun intended) into higher triglyceride levels?
Others with greater expertise can certainly weigh in here if I’m barking up the wrong tree.
I would look at coffee first. (And I hate to say this.) But saturated fat usually causes trigs to go down, in the short term at least (and fasting causes them to go up):
Not good. Nobody has yet provided a good answer to those of us who respond to a low carb diet with poor lipid numbers, but one suggestion I’ve heard from my cardiologist (no less) is to switch out your saturated fats like butter for monounsaturates like olive and avocado oil. You might try that for 3 months and then get retested. I note that Peter Attia (who is an ex-ketoer) used to pull those of his patients who turned up with terrible lipid numbers off the keto diet completely, and this was when Attia was avidly pro-keto.
I got my NMR 2-3 times and it showed nothing of interest. If anything, my numbers are fine on the regular lipid profile but horrific on the advanced lipoprofile. The advanced lipid profile (NMR) will tell you very little; I suppose theoretically it might assuage your concerns because the LDL particles will turn out to be “large and fluffy” (though mine decidedly did not show this), but with trig numbers like you’ve got, I don’t think you’re going to get better news from the NMR, and it might in fact be worse. And anyway there’s no diagnostic relevance to the NMR, so it’s interesting but almost completely useless on a practical level.
After 3 years eating low carb, I remain unconvinced that hardcore keto is right for everyone. It may even be best for me to reduce my fat intake and increase my slow carb intake. I suspect I’d do quite well with less butter and chicken skins, and some more lentils and okra. Shocking I know, but after 3 years I still have a big gut, so I’d be willing to play around with my diet a bit.
All of those are irrelevant. The ONLY test that shows you heart disease progression is a CAC scan. That’s it. Let me repeat: That’s it.
Here are my results after almost 6 years low carb/keto with fasting 4.5 years:
My personal opinion of Peter Attia is low. Very low. He’s a lipidophile to the Nth degree.
All the NMR does is tell you whether you have Pattern A or B (I have Pattern A). Pattern A is good, but does not tell you the progression you have had until now.
I’ll give you another example, Lp(a). An “ideal” value is 75 nmol/L. A “high” value, where you better write your will due to imminent death, is 125 nmol/L. I had a test the day after I got that CAC score. The value? 367 nmol/L. High enough to make Peter Attia crap his pants. Yet, at least by the metric of calcification of my arteries, Lp(a) is not doing much.
The lipidologists like Peter would have me on statins and PSCK9 inhibitors and whatever the freak else they could throw at me, and maybe have me mainlining PUFAs. That’s why I no longer follow Peter and the like.
@gabe I’ll certainly agree that when it comes to a particular diet, any one approach cannot possibly be best for everyone. Nor will it likely be best for any one particular individual over time.
But as for your take on NMR lipid panels: It’s hard to see how they can be “completely useless on a practical level” but also “interesting.” Since your NMR report showed horrific numbers that weren’t reported on the regular lipid panel, I’d think that would be something to pay close attention to, no?
I’ll acknowledge that nutritional science is an ever-moving target, but I wonder why you believe that NMR results provide “no diagnostic relevance” as to what’s going on with one’s lipids?
At this point, there’s literally nothing the NMR will tell you that will change what most doctors will advise. So my last NMR was in late 2017 (and I’m probably getting another one this week, believe it or not) and my LDL particle count was through the roof. This wasn’t reflected in my standard lipid results, which were basically normal. The particle sizes and distribution were not good, either. Lots of small dense LDL particles, and I was at the “high” end of the statistical distribution.
Doctors will look at that, and at my 0 CAC score as @ctviggen noted, and they’ll say, well that’s quite interesting that you have an insanely high LDL-P number, but there’s no standard of care for NMR data, so we’re going to go off the standard LDL panel and advise that you keep doing what you’re doing (and then probably advise you to eat to the food pyramid and reduce your meat intake and increase your cardio – all very bad advice.)
The point being, what do I do with a sky-high LDL-P number and bad particle size distribution? I probably should take my own advice, cut saturated fats and increase monounsaturates. Will that change anything? We don’t have research, AFAIK, to show this, so it’ll just be n=1. We don’t even have research to tell us just how dangerous a high LDL-P is in the absence of a super high LDL-C and high trigs. Like, who even knows what “normal” NMR results are for low carb people? There isn’t any science on it.
Which is why it’ll be quite interesting to see what’s happened with my NMR, but it won’t really tell me what I should be doing.
This makes sense to me. I drink a lot of coffee… I’m also going to try these tests and see … thanks for your help
That’s why one marker (LDL, LDL-P, Lp(a)) is useless. For me, while I’ve had both high LDL and LDL-P, mainly only Lp(a) is high. EVERYTHING else, HS-CRP, ferritin, GGT, ALT, AST, ApoA1/ApoB ratio, Trigs/HDL, etc. are low. I find it hard to believe that even if I were to have high LDL and/or LDL-p yet every other marker is low and I’ve lost 60+ pounds, that my body is trying to kill me. Logically, it simply doesn’t make sense.
The sole reason LDL became a marker was because the statin manufacturers could test for it and lower it. And they had “evidence” suggesting this “lowered” heart disease. And they could make billions doing so.
But what about drugs that raised HDL while lowering LDL? They caused many more deaths than patients taking placebo. Doesn’t that mean raising HDL and lowering LDL is bad? Not according to the statin manufacturers: those drugs cause effects other than raising HDL and lowering LDL that caused death. But what about statins: couldn’t they have effects that cause their “benefits”, unrelated to lowering of LDL? And the answer is, of course, “yes”, but they don’t have a test for that and do have a test for LDL.
As Gabe noted, there are no RCTs or other information, particularly for those of us on low carb/keto diets for years. We’re an anomaly. No one knows what happens in that case.
But I, for one, am hesitant to start saying that saturated fat is bad and I should be gobbling oils. What would the effect be there? I think we can see the effect: obesity might be caused by high PUFA intake.
And don’t these people also realize that meat is primarily monounsaturated fat anyway? Hell, lard is over 50% oleic acid, that miraculous monounsaturated fat in “heavenly” olive oil (at about 70%).
Now, there may be genetic conditions where eating saturated fat (which, by the way is in everything having fat) is “bad”, but unless you have that, it’s difficult for me to believe that the difference in eating a steak with a bit more saturated fat than drinking olive oil is going to kill anyone.
@gabe Thank you for your fulsome reply. You’ve raised several points to unpack…
1 - Whether one’s doctor is a helpful source of medical insight and guidance varies widely. Perhaps yours is not. But just because your physician is stumped - and is willing to leaves things like that - doesn’t mean the test itself is irrelevant.
2 - Then again, if indeed it is a worthless exercise, I’d suggest you cancel your next one slated for this week and refuse any in the future. Why waste your time, treasure, and blood?
3 - My understanding is that high LDL-P counts (in isolation) are not especially meaningful. But since your LDL particle size is concentrated in the small/dense variety - following Pattern B - then, yes, I understand this is fairly important to know. The current position among lipidologists who closely research such things is that, no, this is not a good lipid profile for heart health. So, back to your point, then what?
4 - Okay, here’s what: An individual with Pattern B (small/dense LDL particles) would be wise to pay special attention to their eating and exercise habits … and Gabe, it sounds like this is precisely what you are doing. That’s excellent. You’re a wise man.
5 - Happily, based on your CAC results, you apparently have no discernible calcium damage appearing in the arteries that support your heart. Double excellent. As @ctviggen rightly notes, the CAC is the only test that shows you actual heart disease progression caught in the act. But I disagree with his conclusion that, therefore, the other sources of information about what’s going on inside your veins is irrelevant in monitoring heart health. (Besides, you can’t safely get a CAC x-ray every other month if you were so inclined, so many other biomarkers are useful as practical tools to keep abreast of what’s going on - especially as you make significant changes in lifestyle.)
6 - Regardless, I’d guess that your NMR results - as disappointing as they must be for you - do in fact provide an invaluable “shot across the bow” in the sense that they suggest your body is more prone to heart trouble than the average guy. If it were me, I’d be motivated to take especially good care of myself. Perhaps others have more tolerance to eat like crap than you do. And, for your 3 years of low-carb eating, it’s likely you’ve dodged some of the damage that would have otherwise been accumulating over time. Triple excellent!
7 - Whether going on/off saturated vs monosat fats (or whatever other n=1 trials you care to try) might be helpful or not is a personal choice. But if I were in your situation, I would test regularly before/during/after such self-experiments (as it sounds you’re inclined to do) to see what I might learn about how my body reacts. Yeah, the tests might provide additional relevant information along the way.
Gabe, if your reaction to the NMR as being a waste of time is rooted in your disappointment over what the results are telling you, I certainly understand and empathize. After 3 years on keto, I’d certainly feel the same way with similar lab reports. But knowing what you know seems extremely worthwhile.
On the other hand, if you truly feel it’s irrelevant, this would be a good time to stop wasting your time and money on getting yet another one to toss into the file drawer.
Regardless, I do wish you the very best.
First things first: When you prepared for the blood draw, how long, exactly did you fast? (Tell the truth, now, we won’t bite, lol!) And secondly, did you drink any coffee before the draw?
Dave Feldman wants the people who supply him with data to fast between 12 and 14 hours only, and to have only water before the blood is drawn. (I heard several people at Ketofest this year say that there was no way they were going to wait that long before their first cup of coffee!)
These numbers are not great. Your trig/HDL ratio is over 2.0, so you are at risk of heart disease. Your LDL is over 3 times the level above which they now want to prescribe statins (but watch those videos of David Diamond to find out why you probably don’t need to worry, regardless). The real measure of heart disease is a CAC (coronary arterial calcification) scan, which actually measures the calcified plaque and provides an estimate of your cardiovascular risk. An alternative would be a CIMT (coronary intima media thickness) scan.
What you want to do about these numbers depends on how strongly you care about the lipid hypothesis of coronary heart disease risk. David Diamond has participated in research on this topic, and he and other researchers are sceptical about the idea that cholesterol in any form has any kind of causal role in heart disease. (It appears to be part of the body’s repair mechanism, instead.)
Cholesterol forms part of the wall of every cell in our body. It is the precursor to certain sex hormones (one of the reasons impotence is a side effect of taking a statin) and to Vitamin D, and a host of other chemicals important to the healthy functioning of the human body. It forms a large part of every brain cell and is an important part of the process of neuronal signaling (one of the reasons people experience cognitive problems when taking a statin). It even has functions as part of the immune system. I strongly doubt that a chemical so necessary to the proper functioning of the human body could also cause it harm.
Ravnskov and Diamond, after analyzing data about people with familial hypercholesterolaemia, find that only half of such people ever develop cardiovascular disease, much less die from it, and what they all have in common is genetic variations, primarily affecting fibrinogen and clotting factor VIII, that make their blood much likelier to clot. People with FH who do not have these clotting abnormalities do not develop heart disease or have heart attacks, and they die at a normal old age of other causes.
Ravnskov and DIamond have therefore proposed clotting abnormalities as the real root cause of cardiovascular disease. (It is a plausible hypothesis, and dietary carbohydrate can increase the likelihood of clots, especially by glycating our haemoglobin.)
I had been fasting for about 10 hours when I took the test, that could be the culprit. I was also given a tetanus vaccine right before the blood was drawn, I dont know if it matters… I think I’m going to retake the test in a more fasted state and also do the CAC, and NMR… I’m a little worried about the triglycerides, but I think it could be the crazy amounts of coffee I drink (about 3 large americanos) a day.
Yes, every doctor I have consulted says coffee confounds a fast.
Thanks for your reply, @SomeGuy. The trouble is that it doesn’t really matter who the doctor is. Nobody has, AFAIK, looked at people on low carb diets with fairly normal lipid readings but sky high LDL-P and a poor mix of particle sizes. So nobody can tell you what to do with the data apart, as you say, from “paying attention” to your lifestyle, but nothing more specific than that.
For instance, as you say, the mix of fats I consume is a personal choice. We have no data on whether changing that mix will make any difference, so I’m stuck with laboriously going through a year or two of personal experimentation just to change one or two numbers on the NMR if I want to see if it makes a difference, and even then it’s totally unreliable because any number of other intervening factors could bring down those numbers.
I’m getting blood drawn this week anyway, and there’s no additional cost to do the NMR, so why not, and it’d be interesting to see if there’s been a change in the last 1.5 years. Would be nice to see that the numbers have dropped, one less thing to worry about.
Well I know I was insulin resistant to begin with, so I’ve likely dodged inevitable diabetes. I’m not sure if I was genetically predisposed to heart trouble, but my eating habits in the past may have done that damage.
@PaulL I know you were addressing OP but I want to also clarify that my NMR was, both times, done fasted properly on nothing but water. Then again my lipid results have been fine, both before and after low carb. NMR hasn’t been.
Frankly, however, I’m more interested in why my body is stuck around 83kg and doesn’t want to drop any more fat after 3 years eating this way! But that’s for another thread…
That’s a fair point. Folks on keto are rare birds compared to the population at large and so randomized controlled trials that are relevant to our situation(s) are few and far between compared to the rest of the available (and often conflicting) research.
Frankly, I wouldn’t be concerned about the size of the LDL-P population. As @PaulL rightly notes, cholesterol writ large is a natural, healthy component of our metabolisms (most of which is self-manufactured, not from diet) and plays an essential role in keeping us alive and healthy. I’ve come across several reliable sources (can’t recall at the moment) that maintain that LDL-P is prone to rise on a keto diet - and this is a good thing.
It’s really only the “Pattern B” that would give me pause. But as you rightly ask, okay then what? And again, I suggest that what you are doing in terms of your eating (and monitoring) is precisely the best approach.
Given your CAC score = 0, whether you really have all that much to worry about given the current lifestyle course you’re on remains debatable. But one thing’s for sure, worrying solves nothing anyhow, so to the extent possible, while keeping tabs on things and perhaps doing a little self-experimentation if you’re so inclined, enjoying all the other benefits of low-carb eating along the way should remain your top focus.
Insulin resistance. Ah, this piques a question (sorry if you’d already answered this elsewhere): Have you been doing any intermittent fasting, .e.g., eliminating breakfast for an 18/6 hour window, or perhaps other more extended fasting periods? As you probably know, taming the insulin cycle/resistance beast can be fairly important - as one’s daily hormonal cycle drives a great deal of everything else downstream. Many report that fasting practices of various types have also helped to break through weight “plateaus” - which you’ve described above as being stuck at a certain weight. Worth exploring further, for both reasons.
