My sharply rising CAC score - and why I'm staying the keto course 🖖

(Joey) #1


After embarking on a diligent keto eating style in July 2019, my CAC scores have risen steadily:

55 - Aug 2019
68 - Feb 2020
207 - May 2021

Virtually all of the calcification found (and increases thereof) is evident in the RCA (Right Coronary Artery).

After further research (and considerable angst), I can’t identify any heart-smart course of action besides staying the course and doing exactly what I’ve been doing since mid-2019 when I went keto.

If you’re either interested and/or have any science-based thoughts to share with me (and others in this situation), please enjoy the long version below and feel free to chime in.


July 2019: As a 62 yr old male who ate “low-fat” for decades (therefore high carb), I jogged daily, BMI=24, acceptable lipid panel and was generally healthy (i.e., no meds), yet I was feeling “old” … stiff morning joints, nighttime GERD attacks, trigger-finger in both hands, tired easily, soreness after yardwork, etc. I also worried about my wife’s well-being as she was not eating nearly as “healthy” as I was; I thought I could get us both aimed in a different direction.

So after much reading/research (including every episode of 2KDudes), I went full keto in 7/19, tracking every bite for almost a year (Carb Mgr app).

Within weeks I began to feel amazing. Every single “aging ailment” noted above disappeared. And my sense of feeling remarkably healthy again has remained with me for these past two years - now am 64 yrs old and loving life in this restored body.

BTW, I also lost 4" at the waist, 25 lbs on the scale, and my BMI is now 20. HIIT strength training 3x weekly, HIIT-Sprint cardio training. Now weigh 140lbs @ 5’ 9" My strength, concentration, digestion, stamina all now rival my “20 yr old” self. (My wife has followed along, but not as diligently - yet another story.)

Anyhow, my NMR lipid panel, being a LMHR (Lean Mass Hyper Responder) went bonkers at first, but has since settled down nicely. My most recent results:

TC: 264
LDL: 147
HDL: 108
Trig: 56
Trig/HDL = 0.5
Pattern A particle profile (LDL large/fluffy)
Highly insulin sensitive (LP/IR score <25 - off the chart in a good way)

Since there are a variety of “keto” eating styles, I’ll be more specific. During these past 2 years:

No breakfast other than 1 cup of coffee.
Two meals/day within 6/18 hr feeding window

DAILY MACRO AVERAGES (roughly 1800 kcal) per diligent Carb Mgr tracking:

25g of net carbs *(details below)
93g protein
116g fat **(details below)
Added sugar: 0g

*Note: Net carbs (after fiber) come only from extraneous sources: grilled meats, eggs, bacon, butter, cheese, lots of leafy green garden veggies, home ferments, limited nuts… but ZERO grains, rice, beans, potatoes, breads, corn, etc. and zero “cheating” (not that I’m a fan of that term).

**Note: Fat composition: 37g = 32% saturated; 35g mono, 11g poly, all sourced primarily from animal products; no seed oils; no frying (except eggs in real butter)

K2/MK4: 500 mcg
K2/MK7: 100 mcg
D3: 125 mcg (5000IU)
Fish oil: 1400 mg (330 mg Omega3)
Magnesium citrate (=500 mg of magnesium) mixed in my daily sea-salted water


Possible next steps:

  1. EAT CARBS AGAIN? Makes no sense … cutting out the carbs eliminated the inflammation that I hadn’t even appreciated from all those LFHC decades of eating prior to 2019.

  2. CUT BACK ON (SATURATED) FAT? All research I’ve read supports the view that dietary saturated fat is in no way correlated with adverse heart outcomes (or overall morbidity). On the contrary: higher carbs are correlated with bad heart/morbidity outcomes, not fat. Besides: my Trigs are a mere 56 and my HDL is 108 so it seems my dietary fat isn’t turning into serum fat in my blood (i.e., I’m a good example of what the scientific studies have revealed).

  3. SUPPLEMENT WITH K2/D3? I’m already on it. Perhaps I should increase my K2 intake further with higher dose (liquid K2 drops)? Well, if the calcium seen on my CAC CT scans represents “scabbing” of the soft plaque into hard protective plaque (with calcium), why would I want to try to leach those stable calcified areas away, perhaps exposing what’s beneath those “scabs” to then freely circulate around my arteries? Toward that end, how much K2 would be too much?

  4. TRY TO REDUCE INFLAMMATION FURTHER? Sure, but how does one do that beyond all of the things I’m currently doing? Besides, I have NONE of the symptoms that plagued me before cutting out the extraneous carbs - joints feel great, trigger fingers are cured, focus/concentration is tops, energy level high, hunger level low all day until dinner time. Haven’t even had a common cold in 2 yrs. And even my coronavirus Pfizer shots were non-events (arm didn’t even get sore). By all accounts - confirmed by high insulin sensitivity - I seem to have inflammation response well under control.

To be clear, I’m NOT happy to see my CAC scores rise like this. I was hoping I’d have a 0 score. And when my first result was non-zero, I hoped it would then fall from there. So far, no dice. Bummer. :roll_eyes:

But my current assessment is as follows:

Back in 2019, I probably had (decades’ worth) of non-calcified soft plaque in my arteries. Luckily, it never caused an issue (of which I was aware).

And since then, either as sheer coincidence or as a result of keto/K2/D3, my body has begun to “heal itself” by taking on those potentially dangerous soft plaques (which are likely to cause blood clots at some point upon rupture) and holding them in place through calcification, where - once stabilized - they are far less likely to do meaningful harm.

Of course, all of this could be wishful thinking on my part - i.e., assuming away a serious problem of rapidly rising CAC scores!

FWIW, our family internist just moved away so we’re in the process of establishing relationships with a new MD which takes months to get booked. If ultimately told to go on a statin, cut back on saturated fats, take aspirin, or other variations on outdated disproven guidance, I’m not inclined to follow any of those instructions.


(BTW, in addition to redoubling my research on related topics, I’ve watched a number of Dr Ford Brewer’s posts on rising CAC scores, K2 and such. Interesting perspectives offering some comfort that he’s seen many others go down this same kind of path with rising CAC scores.)

CAC Score - Calcium Density? :thinking:
(Old Baconian) #2

Interesting—because by all your lipid numbers, your arteries should be fine, and you should have no cardiovascular risk.

Something to consider would be your source of fats. Some researchers are pushing the idea that polyunsaturated fats are problematic, because they are so easily oxidised during cooking. Dr. Paul Mason, for example, recommends cooking solely with animal fats (fats solid at room temperature) rather than oils of any kind, not even olive oil.

Other than that, I’ve got nothing, sorry.

(Michael - When reality fails to meet expectations, the problem is not reality.) #3

There may be something in the following.

Unfortunately, the full article of this one is behind a paywall:

Full article here:


This may be of interest, maybe:

(Polly) #4

Do you also supplement with Mg along with vits D3 & K2?

I think Mg helps prevent Ca being deposited where we don’t want it. Past bedtime so too late to provide any authority for that thought tonight.

(Joey) #5

I like (and share) your Lipid-based encouragement :wink: I can’t imagine having a better Trig/HDL/insulin sensitivity profile, so something must be working well in those veins.

As for PUFAs, I’m rarely frying anything but eggs in butter. When I do soften up some veggies to go with the meat (for a cheese wrap or as part of a cauliflower rice bowl), I’m using Avocado oil which has a far higher burning point that anything I reach. Not quite animal fat… maybe I should load up on lard for the larder.


Do you track your dietary intake at all? Do you know how much fat you actually eat?

(Joey) #7

Many thanks for the links. Not sure how relevant hemodialysis issues might be in my situation, but will make time to read through and see what I can learn.

As for a new CAC Score paradigm (second link provided) I think there’s a lot to be said for refinement in the Agatston framework … inasmuch as it was constructed early on and no doubt there’s a lot of clinical data that could be the basis for a more sophisticated understanding of disease progression and associated risks arising from CT results.

Dr Ford Brewer’s content offered some comfort after my initial shock of seeing those rising scores having followed keto and supplementation so diligently. His perspective: since soft plaque does not show on a CT scan of arteries and it’s actually the dangerous stuff, it’s what you don’t see that ought to be somewhat greater concern. The calcified lesions are largely stable and of little concern (unless they’re so massive they cause a mechanical blockage - which is rather extreme). And since they’d be stable, they’d also be fixable with non-emergency surgical interventions.

But the more calcified plaque you have, the more it serves as evidence that you have had pre-calcified soft plaque presence at some point - again, the high risk plaque not visible through the CT scan. So while a zero CAC score is encouraging on the one hand, the lack of any calcified plaque might also be an indication that your body is simply not “healing” whatever soft plaque you might be accumulating … and that’s what you’ve got to worry about causing a sudden cardiac emergency down the road.

Kind of a weird paradox of comfort and concern? :man_shrugging:

(Joey) #8

Yes. I appreciate my “LONG VERSION” was TLDR material for most, but here’s a snippet from my original post up above:

DAILY MACRO AVERAGES (roughly 1800 kcal) per diligent Carb Mgr tracking:

25g of net carbs *( details below)
93g protein
116g fat ** (details below)
Added sugar: 0g

*Note: Net carbs (after fiber) come only from extraneous sources: grilled meats, eggs, bacon, butter, cheese, lots of leafy green garden veggies, home ferments, limited nuts… but ZERO grains, rice, beans, potatoes, breads, corn, etc. and zero “cheating” (not that I’m a fan of that term).

**Note: Fat composition: 37g = 32% saturated; 35g mono, 11g poly, all sourced primarily from animal products; no seed oils; no frying (except eggs in real butter)

This is based on a careful logging of everything that passed my lips for the better part of a year. The 25g/daily net carb figure varied not much from day to day … logging in at between 20g to 30g at most.

(Old Baconian) #9

So perhaps the CAC ought to be read in conjunction with a coronary intima media thickness evaluation? Hmmm . . . .

(Joey) #10

Good question. Buried up above in my “LONG VERSION” I noted that I consume 500mg daily in available magnesium (3300mg Magnesium Citrate powder) with my morning salt-water electrolyte jug. Hopefully I’ve met any need for Mg as a result.

(Joey) #11

Indeed, there’s discussion re: the benefits of combining insights from various views to discern what’s actually happening inside. Each has its pros & cons.

Notwithstanding modest radiation, CT scans are still better than most anything else at getting directly to the extent and location of any calcification.

The question then remains as to what that calcification means. And I’m not trying to kid myself (or others) that calcification doesn’t matter.

But it’s akin to having scabs. Scabs are proof positive of prior bleeding.

But a lack of scabs doesn’t prove a lack of bleeding … just means there’s no scabbing. :thinking:

I guess if I were really worried about my heart health, I’d be getting more tests. But I’m still at a loss as to what actions I’d take differently vs what I’m doing now … and medical tests that don’t lead to action or decision seem like rabbit holes to be avoided.

So much one might worry about, so little time :upside_down_face:

(Todd Allen) #12

Sounds like you are on a good path and I hope you are right with your speculation of the rising CAC being a positive conversion of soft plaque to safer hard plaques.

Are you seeing a cardiologist? I’d think a good one ought to be able to help you answer the questions of your degree of soft plaque burden and near term risk of a cardiac event. I got referred to one merely for having very high cholesterol and statin hesitancy. I passed the initial work up tests suggesting little to no heart disease and didn’t get a cardiac angiogram of which there are at least a couple varieties that I believe can measure soft plaques. I read a research paper on soft plaque where they used high resolution MRI to image plaques with great clarity without the invasive aspects of angiograms. Likely downsides are limited availability if available at all, higher cost and difficult to get covered by insurance and you would likely need to do it more than once to know where you are and to know where you are headed. And if you don’t like where you are going you would then likely need to repeat after any lifestyle adjustments to learn if they are helping or making things worse.

(Joey) #13

Thanks for your post.

Short answer: Nope, I’ve never seen a cardiologist. Frankly, I never thought about needing one. Perhaps I’m now wallowing in denial? :shushing_face:

But I cannot think of any lifestyle adjustments that would be warranted that I haven’t already made and adhered to beginning 2 years ago.

Other than taking a statin (with great lipids and no primary cardiac event?) or cutting down on dietary fat (to be replaced with carbs, or what?), I’m at a loss to imagine what would be better for heart health.

Hopefully this perspective helps explain why I’m so sanguine about things.

Meanwhile, in my mid-60s, I’ve never felt more healthy and alive in this (once-aging) body of mine. :vulcan_salute:

(Bob M) #14

You do NOT want to see a cardiologist. Or at least 99.9% of them. Almost none of them will like a low carb diet. Basically all of them will want to give you a statin. All of them consider LDL to be like killer BBs that cause heart disease. All of them consider zero LDL to be beneficial. Your LMHR values will be meaningless once they see the LDL.

Of course, there are a few exceptions. But you’re going to have to do some searching to find those.

I’ve personally not made up my mind about LPIR. I only got one test taken, and it showed very high LPIR. But that test was after the holidays, and my other values went awry too.

I personally have a hard time with an index based on a total of less than 5,000 people:

LPIR could be 100% correct, but I have to question if 5,000 people are representative of hundreds of millions.

More info on LPIR:

I also wonder about those of us, like me, who have been low carb for years. I have higher morning glucose, so my HOMA-IR is highest in the morning…which is when it’s measured. (Let’s ignore what happens to insulin for now, since I don’t know and can’t without a home insulin meter. I do know from blood tests at doctor’s office that my afternoon insulin can get low, if I fast during the day.)

What does that mean to the LPIR test? I don’t know.

(Old Baconian) #15

I’m wondering, @SomeGuy, if you are not seeing the results of a process that had begun before you began keto, and that is taking its time to get turned around.

(Joey) #16

@ctviggen Many thanks for the links.

Having just read them both, I’m not troubled by a N=5000 study size as the basis for the LP-IR algorithm. Statistical significance seems to have been achieved - and many studies upon which we rely are based on far smaller samples. If anything, I find the researchers’ commercial affiliations to be more worthy of scrutiny than their findings :wink:

As for your wise counsel re: cardiologists, I’m inclined to agree that seeing one makes little sense in my situation (i.e., given my other test results, diligent lifestyle, and lack of clinical concerns besides that darned finding of increased calcification in my CAC tests).

For your perusal, here’s a perspective I found to be compelling from a reliable Cleveland Clinic source (my highlighting) suggesting that “as many as half” of the stents/angioplasty procedures performed “may be inappropriate.”…

CoronaryDisease-CloggedPipeModel.pdf (234.5 KB)

(Joey) #17

@PaulL I appreciate that line of thinking :crossed_fingers:… it’s pretty much what I’m left with for the time being.

If I were abusing my body (refined carbs, smoking, sedentary lifestyle, high stress, poor sleep, …) there would be much to fix. And the rising calcification would be a siren call.

But on the contrary: I’m a diligently low-carb, TMAD, HIIT, low stress, happily-married, great sleeper, financially secure, early retiree who thoroughly enjoys his many nonprofit volunteer/mentoring efforts. Feeling truly blessed, I can’t grasp what aspect of my life I could possibly change for a better future health outcome.

Although I plan to stay the keto course, I thought I’d share my n=1 experience just in case (a) I’m really missing something under my nose and/or (b) my story is helpful to anyone else traveling this road behind me.

As an LMHR (as seen through my earlier NMR profile response), I appreciate that not all of us follow the same course as we change our WOE and make other lifestyle choices - so it’s great to have this community to connect.

(Old Baconian) #18

More and more I am reading about how important it is to look at the entire picture, and not go by just a few markers. Since the rest of your numbers look great, it is probably safe to trust that your body knows what it is doing. Also, a question I forgot to ask, what is the risk assessment associated with your CAC scores?

As an example of trusting foolishly in markers, I recently read up on PSA, and found that not only do they not really understand the role of PSA in the male body, they don’t really know what a PSA reading actually means, and it appears that most of the prostate interventions based on PSA number may, in fact, not only be useless, but can even be detrimental to the health of the patient. Sheesh!

But it’s a salutary lesson in not rushing blindly ahead based on some low-level clinical effect, no matter how statistically significant it might be. There is also the trap of concentrating on manipulating the marker, rather than addressing the underlying health condition.

(Michael - When reality fails to meet expectations, the problem is not reality.) #19

What struck me as interesting is the pH aspect of these studies. Changing pH can cause stuff that was otherwise in solution to precipitate out of solution.

(Joey) #20

Not entirely sure what you are asking. By “risk assessment” do you mean the verbiage associated with the score? If so, it went from “Mild calcification” (in previous <100 scores) to “Moderate calcification” (at 207 score, which now falls between 100-400). If you meant something else, please clarify?

I should also note that all three of my (rising) CT scans were conducted at the same hospital using the very same machine running on GE software - although each was performed by a different technician, if that matters (which is highly unlikely) then reviewed by the hospital’s assigned MD.

Yeah, I’ve been seeing much about the misapplication of PSA test results . In fact, a few years ago my internist stopped including an annual PSA test in my bloodwork, saying: my #s always looked fine, I experienced no symptoms of prostrate issues, and any results were more likely to invite angst than actionable guidance. Interesting, he was about my age and had fallen out of love with PSA tests over the years.