I met a new patient recently who was quite concerned about his cholesterol after his last doctor suggested he go on a statin. After discussing this patient’s medical history and reviewing his labs, it became obvious that he does NOT have a cholesterol problem, and certainly not one that warrants medication. This is a common scenario I run into in clinical practice, so I thought it would be useful to take a few minutes to run through some of the thought processes that a doctor should take when evaluating a patient’s cholesterol.
Without further ado, let’s delve in. Here are a few key points that are important to understand when thinking about cholesterol. Read through them, and then I’ll come back to the patient.
In my last post, I reviewed some of the background on how and why cholesterol came to be viewed as a risk factor for heart disease, and how this creates a clinical conundrum for those who go on a low-carb diet and see a big rise in their LDL (the “bad”) cholesterol but see every other aspect of their health improve. I discussed how there is a paucity of research on this particular population of patients and, hence, a lot of controversy about this topic. Then I introduced the work of Dave Feldman, a software engineer and internet personality who has been leading a grass roots research effort into this very topic. And I reviewed how Dave has proposed that maybe – just possibly – the metabolism of people on low-carb/keto diets is so different from that of a person following a more typical diet that cholesterol simply doesn’t behave the same way in their bodies, and hence the research we have until now suggesting that high cholesterol is a risk factor for heart disease might not apply to them.
I’m going to spend the rest of this post discussing a fascinating study that Dave and his colleagues just published which attempts to shed some light on this question. But first, let me stress that all of this remains theoretical, and – spoiler alert – we still do not know if having severely high levels of cholesterol due to a low-carb/keto type of diet is safe. One study does not a fact make, and most doctors would advise continued caution in this area. And while I do feel that the obsession on cholesterol and its treatment has had some real downsides (by emphasizing a laser focus on this one risk factor, while far more important risk factors such as metabolic syndrome/insulin resistance get ignored), it’s only fair to admit that there are still many, many, papers out there showing that – on a population level – there is a strong link between elevated cholesterol and cardiovascular disease risk. Please keep that in mind as you read the rest of this.
I’ve spent my last few posts focusing on some very bad studies that have been prominently featured in the media lately. Now I’d like to discuss a recent study that has gotten less attention, but that I think is far more interesting and useful. However, before I get to the study itself (in the next post), I need to go into some background.
A patient recently brought this study to my attention: as reported in the journal Nature Metabolism, high protein diets apparently lead to heart disease. Or, as the New York Post put it in their headline:
At the risk of sounding like a broken record, this is another example of the “Academic-Media Complex” that I often warn about, in which a terribly designed study that tells us nothing about human health is reported on in sensational terms by our “if it bleeds, it leads” media.
