I'll be sharing some occasional cases from my clinic to help you learn about some of my approaches to helping my patients. I'll make some minor changes to the history and possibly tweak the labs a bit to protect the patient's identity. My goal for doing these case files is so my readers, many of whom consist of patients and health care providers, can learn how incredibly powerful lifestyle changes are in reversing health conditions.
LDL cholesterol has become a controversial topic in the health space. Traditionally regarded as the “smoking gun” in your cholesterol panel which when elevated raises your risk of heart disease, now LDL is being questioned as being a consistent and reliable heart disease risk marker.
As I detail in my book, the LDL on a standard cholesterol test ordered by most doctors (aka “LDL-C”) can be highly misleading because there are multiple aspects of LDL that are not captured.
What is the size of the particle? How many LDL particles are there? Does the particle reside in a highly inflammatory/oxidative environment? Does the individual have insulin resistance and if so, the more insulin resistant he/she is, the less relevant an LDL-C value becomes.
Unfortunately, there is a growing camp of anti-LDL activists who believe LDL has no relevance at all as long as you are lean and insulin sensitive. I have patients like these in my clinic. They are a picture of optimal health, but are walking around with LDLs above 200. Some of these individuals have a marked surge in LDL after adopting a low carb, high fat diet and are referred to as “Lean Mass Hyper-Responders (LMHR). What's my stance on these cases after years of treating individuals with high LDLs and also following heart scans?
First of all, to date there are no good studies that have followed healthy individuals with high LDL over time to see whether they develop premature atherosclerotic heart disease. By “healthy,” I set a high bar and am referring to individuals who exhibit no detectable signs of insulin resistance, inflammation or other traditional cardiovascular risk factors, and who maintain an optimal lifestyle with adequate physical activity, stress management and sleep.
Keep in mind that even isolated chronic stress in the presence of a high LDL worries me.
Over the years I have come to appreciate the highly inflammatory nature of chronic stress and if that is combined with an elevated LDL level, it can potentially trigger an event like a heart attack. Again, this is my anecdotal experience and there might be multiple other confounding factors in the presence of that chronic stress like disrupted sleep (another important risk) that are playing a role. I wrote about a case study of chronic stress triggering a heart attack in an otherwise young and healthy appearing Silicon Valley executive in a prior post here. Unfortunately I have lost track of how many similar cases I've come across since then.
I do have a fair number of these “healthy high LDL” patients in my practice because they diligently follow my lifestyle advice and despite the standard recommendation to start a statin, they choose not to.
In my own anecdotal experience of doing this for over a decade, I have not had a single case that I'm aware of where a healthy individual (by my definition) with an isolated elevation in LDL develop an atherosclerotic heart event (heart attack, etc.). I hope in the future we can have studies to confirm whether this observation is valid.
Until we do have such a study, I am still not completely comfortable with isolated elevations of LDL-C that are typically north of 180-190 mg/dL. I typically do additional risk stratification with an advanced lipid profile test, maybe check an hsCRP, and in many cases get a heart scan which you can read about here.
I will still have a detailed discussion about the risks and benefits of statin medications and inform patients that the standard recommendation would be to start a statin. If you are a health care provider, you must document this as a standard recommendation in case your patient chooses not to go on a statin. If a patient agrees and is comfortable starting statins after repeated lifestyle interventions that have not reduced the LDL to a level I'm comfortable with, then I will prescribe it.
There are individuals in the blogosphere who feel statins are poison and should not be prescribed to anyone, and some of these individuals are physicians. In the absence of sound clinical data I just cannot wholeheartedly endorse such recommendations, since I do feel based on the weight of evidence that statins used in the right patients can potentially lower heart disease risk. I would love to be proven wrong in the future, since I hardly consider statins to be harmless drugs.
Now with my background perspective out of the way, let's talk about this particular individual who is a 44-year-old male who had elevated LDLs dating back almost 20 years ago. He had been put on statins, but stopped them on his own.
A couple of years ago he implemented a lower carbohydrate diet after reading my book. See his lipid profile below which shows that in 10/2018, his lipid profile showed a very good ratio of triglycerides-to-HDL (I prefer <3.0 and the lower the better), which is a central lipid marker for insulin resistance, but an “elevated” LDL by our laboratory cutoff of 100. If you want to learn more about interpreting your lipid results, read chapter 2 of my book or download my free Cholesterol Decoded e-book here.
Given his triglycerides and HDL looked good and his glucose numbers (A1C and fasting glucose) have been in excellent range, we could have said “don't worry about the LDL and just continue onward,” but instead we used this elevated LDL as an opportunity to further fine-tune his lifestyle.
To this patient's credit, he used a 1 week wellness retreat in India to really kickstart comprehensive lifestyle changes, such as eating a much cleaner mostly plant-based diet, cutting back on gluten and other inflammatory foods, and doing daily yoga, pranayama breathing exercises and meditation. Fortunately when he came back to the US, he didn't just return to his prior lifestyle habits. He continued the same practices and also incorporated 16/8 intermittent fasting twice a week.
Also of note is that he has a history of hypothyroidism which not surprising also improved with these changes and optimizing thyroid function can also help lower LDL. To learn more about reversing hypothyroidism (aka Hashimoto's thyroiditis) naturally, read my post here.
Often making significant lifestyle shifts like these not only reverse lab abnormalities, but also give patients more energy, focus and purpose. He left his job at a major high-tech company and is now working in a startup job that he loves, while still maintaining all of his healthy practices. This is what I preach to my patients. It is absolutely possible to incorporate many of our traditional practices in the midst of our busy working lives and in fact, it will help you to thrive both personally and professionally.