Needed: advice for imminent cardiologist visit

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(Gabe “No Dogma, Only Science Please!” ) #1

Hi guys, I’m new on the forums but been on LCHF since July last year. Came across @richard and @carl 's podcast a few weeks ago when I ran a search for “keto” in my podcasts app. Really enjoying it – very entertaining and informative; where Jimmy Moore’s podcast has more lectures from LCHF conferences which is great, 2KD includes a great mix of anecdotes, recipes, science, and experts. Great stuff, guys!

So I’ll try keep it brief and I’ll include a TL;DR at the end. I’m Aussie born and raised (hi, Richard!) but living in NY/the US for about 5-6 years now (hi, Carl!)

I’m 37 and never had major metabolic issues according to traditional biomarkers – that is, apart from elevated liver enzymes (ALT) and a doctor a couple of years ago who was doing an ultrasound on my abdomen and happened to notice a fatty liver. Last July I clocked in at 93.5kg (206lb) and, after starting on LCHF, I rapidly dropped 10kg so that by late September 2016 I was 83.5kg (184lb). Stayed stable till about 6 weeks ago, when I started Atkins induction (aka ketogenic) and I’m now roughly 79-80kg and shooting for 73-74kg.

OK so about 2 weeks ago, whilst on keto, I got my blood tested in a routine physical. HBA1C = 4.8, fasting blood glucose of 87. Lipids as follows:

CHOLESTEROL, TOTAL 218 mg/dL 100 - 199 mg/dL
TRIGLYCERIDES 53 mg/dL 0 - 149 mg/dL
HDL CHOLESTEROL 48 mg/dL >39 mg/dL
VLDL CHOLESTEROL, CALCULATED 11 mg/dL 5 - 40 mg/dL
LDL CHOLESTEROL 159 mg/dL 0 - 99 mg/dL
CHOLESTEROL/HDL RATIO 4.5 ratio units 0.0 - 5.0 ratio units

Note that my TG/HDL = 1.1.

So at this point my GP/PCP was slightly concerned about the LDL and suggested that “now you’ve achieved your goals you might consider upping your whole grains” etc etc. He wasn’t too worried though – I think I was more concerned because when I had my lipids done in Australia in October after losing 10kg on LCHF, my LDL was 3.0 (and by my calculation it’s now 8.8 on the Australian measure, meaning it’s tripled.)

So I asked the PCP for an advanced lipid profile so I could see LDL-P and the subfraction analysis. Impressed with my knowledge, he referred me to a cardiologist, who I’m seeing this Thursday. I thought this was overkill a couple of weeks ago, but now I’m glad I’m seeing him, because I have the following concerns:

  1. What tests should I be asking for at this point? From the 2KD podcast, I know that a Coronary Artery Calcium scan is probably the best measure of vascular health. But from Dr Joseph Kraft, the glucose-insulin tolerance test (insulin assay) is highly effective – @richard has noted that it can show you if you’re diabetic years before fasting glucose/insulin/A1c will ever do. I also want an advanced lipid profile done. Will a cardiologist agree to any/all of these tests given that all my biomarkers are good except for the borderline high LDL-C result?
  2. How worrying is LDL anyway? Again, worth doing LDL-P and subfraction analysis?
  3. More generally, I have been concerned recently with whether an ongoing ketogenic diet could lead to a kind of insulin resistance. Very interested in all y’all’s opinion on this. I’ve read a little about this and this has been flagged as an issue on some of the LCHF blogs and forums.
  4. What do I do if the cardiologist is very resistant to LCHF/keto?
  5. Fats: is the amount of saturated fat I’m eating OK? What about PUFAs? What should I be avoiding? What oils should I be using more of for high heat, and for low heat/cold?
  6. How can I find a LCHF-friendly doctor on my insurance network (Cigna) here in Manhattan?

For making it this far through the post, I have some helpful tips for you too:
a. If you don’t own the Four Hour Chef, buy it immediately. It’s completely compatible with our diet and will pay back its cost in spades.
b. Get Montezuma’s 100% chocolate from Trader Joe’s for $2.50. A couple of drops of TJ’s stevia will make it delicious.
c. Speaking of chocolate, get this – Michel Cluizel 99% dark. It’s ZERO CARB and requires no sweetener at all. Delicious. And I have a sweet tooth! (Less so on keto!)

Thanks!
Gabe

TL;DR: I’m seeing the cardiologist on Thursday this week and all my biomarkers are good after 1 year LCHF/6 weeks keto, except for a tripling of LDL-C (dropped 15kg/30lb). What further testing should I be asking for? Fasting insulin? Insulin assay? CAC? LDL-P and particle subfraction analysis? What are the chances the doc will order it based on my good biomarkers apart from borderline high LDL? Also, should I be worried about keto CAUSING insulin resistance?

(Brad) #2

Ask for a CAC test, your trig/hdl ratio is great…don’t get to worried, also read www.cholesterolcode.com

(Gabe “No Dogma, Only Science Please!” ) #3

Thanks! I’m not especially worried, but after watching the Dr Joseph Kraft video, I wonder if I was on the diabetic spectrum prior to going LCHF last year!

What are the chances my doc will be prepared to order a CAC? Or that insurance will cover it?

I’m also REALLY curious to see my LDL-P and subfraction analysis… you think it’s overkill? I want to prove to myself/family/doctors that the LDL increase is nothing to worry about, and this seems to be the way to do it.

(KCKO, KCFO 🥥) #4

A calcium scan of the heart is a good baseline for tracking your progress. You will want to retest in 3-5 yrs. to see if the % has gone up or down. A lot of folks on LCHF see downward movements with this WOE.

A cardiologist is probably not going to order the Kraft protocol as it is for diabetes, not cardio health. Insurance probably won’t cover it either. The calcium scans you can get yourself a number of companies around the country do them with special deals being common. My husband got his last one for $100 from a local hospital. No referral needed.

The NMR (Nuclear Magnetic Resonance) Lipoprofile is a cholesterol test which provides more information than a standard Lipid Panel. This test includes measurements for Total Cholesterol, LDL, HDL, Triglycerides, Insulin Markers, Lipoprotein Particle Number and Size, and Lipoprotein Subfractions. This would be an excellent test to get down.

Good luck with the visit and I hope you get an up to date educated cardiologist.

(Gabe “No Dogma, Only Science Please!” ) #5

Thank you for this thoughtful reply.

Great to know I can get the CAC on the cheap if need be. Is there a way to get the Kraft insulin assay either on or off insurance?

Re NMR: easy to get it covered by insurance if the cardiologist orders it? Surely it can be argued to be necessary given the tripling of my LDL?

Also: what do you think about getting fasting insulin tested? Is it just pointless, or is there value in it?

(Brad) #6

CAC runs about $100-150 , as @DaveKeto protocol shows you can manipulate you cholesterol by what you eat prior to the test.
Hopefully your Cardio doc is a free thinker…my cardio guy was ok with keto, and my numbers were t that good.

(Dave) #7

  • I ALWAYS recommend getting a CAC score ASAP when starting Keto. You want to have a dividing line between when you started and before it. Unfortunately, the later one starts, the harder it is to know how much was due to the way of life before. While anecdotal, I know many who started with a high CAC and went keto to observe their progression of calc slowed. But again, this was anecdotal (not a lot of studies in this area).

  • Your LDL doesn’t even register on my radar as even concern-debatable at 159 mg/dl. But alas, I know this is the same with most GPs and cardiologists. The entrenchment in the lipid hypothesis is very strong.

  • I believe a ketogenic diet does often produce insulin resistance. But this a short to medium term effect for effeciency with glucose sparing. If you ramped up your carb intake it would likewise re-adapt this same degree of IR to compensate. Imagine a small town that used to have lots and lots of crime, but now after years of not having it, they paired down their police force given it was wasted money. Then suddenly you hit them with a big crime wave, of course they’d need some time to hire back the staff, etc. In short, I haven’t seen any evidence of permanent insulin resistance brought on my a keto diet.

  • If your cardiologist is resistant to a LCHF/keto diet in spite of lower inflammation, hyperinsulinemia, weight, etc because they believe LDL is the only thing that matters – it should say more about how they see your health as a whole.

  • It’s hard to avoid PUFAs, but I certainly try where I can. Coconut oil is great for higher smoke points.

  • I’ve heard there are actually a lot of low carb doctors in NY, but I don’t know the best means of finding them.

#8

This is the only list I know and it is limited

With regard to the temporary Keto IR,

how long does it last? When does it appear

how would you know you have it while still on keto or is this only if you return to high carb?

I thought for people who are already IR, that being on Keto is supposed to help them deal with glucose BETTER. I know the 2Ketos will mention a cheat meal and how their BG did not incease as much as expected which seems to imply increased insulin sensitivity

(Gabe “No Dogma, Only Science Please!” ) #9

Really appreciate this reply. Look, the PCP wasn’t super concerned about the LDL-C; in fact, maybe I was more concerned than him, largely because of it tripling in just 9 months. The studies I’ve read suggest that over time LCHF shouldn’t cause such large increases in LDL, so I was, and remain, confused.

I plan to ask for a CAC because even though I’ve been on LCHF for a year, it’ll provide a good baseline for the years to come. I intend also to ask for:

  • fasting insulin
  • CRP
  • NMR to see if my particle size distribution is looking good, which I hope and imagine it is.
  • I’m going to wait till I’m in Australia in October because a DEXA scan costs US$65 there, whereas it’s more like $650 here in NY out of pocket.

What you’ve said about insulin resistance is interesting and makes me think I should, at some point, do an insulin assay (Kraft protocol). But it sounds like it’s hard to get such a test ordered for a patient with good biomarkers – even though it’s exactly the sort of test you should be ordering for everyone in the population every 10 years. I don’t think concern is unwarranted in my case, because my sister is pre-diabetic.

(Gabe “No Dogma, Only Science Please!” ) #10

By the way, I have an errata about the chocolate I recommended – the Michel Cluizel 99% dark. I was reading the ingredients yesterday and the second ingredient listed is sugar. This is very weird, because the macros listed say 0g carbs and 0g sugars. Anyone know what’s going on? Could it just be a really small amount of sugar?

Either way, I kind of regret ordering 8 blocks of it now!

(Dave) #11

Again, I’m thinking of this more from a systems standpoint rather than a scorecard. I’m completely fine if my body is somewhat more insulin resistant in order to keep more glucose mobile – after all, I’m providing less of it from the diet, and perhaps my body has a higher preference for it on some core activities (such as cofactors or maybe brain fuel % relative to ketones). What I do care about is insulin, as I’m confident my body does not intend to have high levels of insulin in my blood (hyperinsulinemia).

Thus, I haven’t been concerned that my fasting glucose has increased slightly since I went keto, yet my fasting insulin has gone way down (typically <2 to 4). I don’t have any good reason to assume this is dysregulation given the context of my regularly eating a low carb diet. (Per the example above, why staff up the extra police?)

(Anderson Herzogenrath Da Costa) #12

I googled it and it says 0g carbs but 7g fiber, which means 0 is already net carbs - total carbs is 7g.

(Dave) #13

This is a central focus of my research and one I’m very keen on getting to the root cause of. The key thing to keep in mind is that when being fueled by fat, you absolutely are trafficking more LDL particles whatever your cholesterol test score says. (See my Simple Guide here) The catch is that many will have longer residence time following fuel up for the cells and this seems to be more predominant with what I call Lean Mass Hyper-responders, which actually makes mechanistic sense given the needs they provide for.

Good tests, all of them! As a short list goes, this will help you see if there’s anything to follow up on. (CRP is my favorite something-might-be-wrong needle. But note it will also get triggered by intense exercise and muscle repair – as I’ve seen in my marathon experiments)

To further drive home my point above – I believe if I were to take a OGTT right now with insulin (Kraft-style), I’d have a higher glucose and insulin spike than I would’ve pre-keto. Why? Because I’ve conditioned my body to anticipate a lower glucose load environment and thus it likely has some medium term “insulin resistance” for proper efficiency. But it isn’t actual, permanent insulin resistance, it’s a kind of re-regulation that makes systemic sense.

(Gabe “No Dogma, Only Science Please!” ) #14

Yep I listened to your interview with 2KD, very interesting stuff and as a result of your work and others, I am not overly worried right now. I’m more concerned about the insulin resistance, but it sounds like you’re quite comfortable with what’s happening to our bodies getting used to a lower carb intake. My big question on that subject would be: what happens if we have a cheat meal? I notice when I cheat my weight goes up by a couple of kilos over the next few days and takes a week or more to come back down to where it was – this contrasts markedly with what @carl and @richard have said about their experience with being able to tolerate cheating occasionally.

I’ll bear in mind your advice – I’m planning to front up to the cardiologist after 14-15 hours of fasting and no massive exercise beforehand, so we should be good to go on all these tests, including CRP.

Also very interesting to hear you imply (if I’m understanding you correctly) that an insulin assay whilst only a year into LCHF might not be especially helpful.

(Richard Morris) #15

So my body can go up or down several kilograms based just on my hydration level. If I cycle for 2 hours, even if I think I am staying adequately hydrated from my water bottle I usually lose over 2 kgs. That’s just 2l of water, so even if I am drinking as much as I urinate … I am probably losing as much through my breath and sweat.

The last time I jumped off the wagon was April 2016 at a friends wedding where I ate half a pavlova (an Australian meringue dessert). I recall that I gained weight the next day probably from the change in hydration that occurred as I refilled my liver and Muscle’s glycogen reserves. I also recall that the pain of my knee cartilage injury returning was so intense that I could not sleep and I have not willingly “cheated”, per se, since.

What I have done was eaten portions of a meal that I thought had very little sugar or starch and found out later that I’d been inadvertently knocked off the wagon. I don’t think that rises to the standard of a “cheat”.

(Gabe “No Dogma, Only Science Please!” ) #16

Fair enough mate! Actually I cheated last night for the second or third time in 2 months – I have no metabolic issues apart from a few pounds left to lose, so the occasional deliberate cheat isn’t a total disaster – and interestingly the scales were unchanged this morning. Who knows what it’ll look like tomorrow, but despite overeating loads of keto for dinner (admittedly after a 20 hour fast) and then smashing cheese and crackers and wine and a bit of 99% dark choc even though my stomach was bursting more than it’s been in years, unchanged scales? Weird, and even weirder: my cheat didn’t include any sugar (except for what I’ve since discovered seems to be trace amounts of sugar in the 99% chocolate!)

TL;DR: After a year on LCHF, I no longer crave sugar (or starches) nearly as much as I used to – and I haven’t yet cooked fathead pizza or low carb cheesecake, so I still have those up my sleeve!

(Richard Morris) #17

Unfortunately starch (crackers) is just a polymer of lots of glucose molecules joined together and we’re really good at cracking them out. Table Sugar is only half glucose, so gram for gram a cracker is likely twice as much glucose as the same amount of table sugar.

(Gabe “No Dogma, Only Science Please!” ) #18

My view on this is that IF I’m going to cheat, I’d rather cheat with a starchy carb (rice/crackers/potato) than with sugar. I’m of the Robert Lustig/Lewis Cantley school: there’s something uniquely ominous about sugar.

Another thing to note is that I’ve never had high A1C or fasting glucose or really terrible lipids, so I’m lucky, and I don’t feel the occasional cheat (even if it did include sugar!) would wreak havoc. Though I’m beginning to think that if you’re on an LCHF diet, your body may be far less prepared to deal with glucose spikes than it was when you were glucose-powered…

(Doug) #19

Gabe, whether we call it “cheating” or not, as long as it’s pretty rare, over time, i.e. a small minority of days, then I think it doesn’t matter that much whether it’s sugar or starches. We’ve still drastically lowered the burden on our insulin-producing and using cells, viewing the whole deal as quite cumulative.

When I was 37, I had similar readings to you - no problems showing up with blood sugar or lipids, just an elevated ALT enzyme number. Had one doctor advise to entirely eliminate alcohol for two months, and get another blood test. Heh, yeah, right - had a good laugh about that.

Gained about 5 lbs. per year steadily, and this year, at age 58, is where it really caught up with me, a big jump in A1C and fasting blood sugar, and a notable wrong turn in the lipid numbers. The human organism is one tough bugger, but there is a limit. Sure wish I could go back 20 or more years, knowing what I know now.

(Gabe “No Dogma, Only Science Please!” ) #20

I hear you. I just saw the cardiologist, who ordered a calcium score and lipid subfraction analysis, as well as C-reactive protein. I think the calcium score will be the most telling number, although I am interested in my LDL subfractions given my current diet. The calcium score will give a great overall picture of my health, but the lipid profile will tell me in a more granular way how my diet is affecting my body.

I’m already considering switching some meat for more fish (on the advice of the cardiologist and another well-known cancer specialist) but the advanced lipid profile, if it comes back the wrong pattern, will put the nail in the coffin of this amount of red meat and dairy. Crossing my fingers it comes back fine and then I can keep eating like a happy camper!

The important thing for you is that you figured it out and you’re doing something about it now!