[00:00] I know you're sick of hearing about LDL cholesterol, but a new analysis finds that high LDL cholesterol is not associated with the degree of coronary artery calcification. This is a really interesting analysis by Dave Feldman, Nick Norwitz, and Nati Budoff.
[00:15] I'll put all the images on the screen here. I really want to go slow with this and break this down. I'm sure Dave and Nick and other people have talked about this study at length, but this is a really interesting analysis because we have a cohort of 80 individuals,
[00:29] One from the Keto, I think it's called the Keto Trial. There's 80 individuals who have been doing a low-carb diet for a minimum or median length of 4.7 years who have an LDL cholesterol level greater than 190 milligrams per deciliter,
[00:43] which is on the higher side. Most doctors would pretty much freak out, you know, and make sure that you leave their office with a statin. And this analysis looked at using coronary CCTI.
[00:55] This is a CT scan of the coronary arteries to look at the coronary artery calcification, which approximate the degree or severity of atherosclerosis or the plaque buildup in the coronary artery.
[01:07] And they looked at coronary artery CT scans from individuals in the Miami Heart cohort. And I'll share with you the baseline characteristics shortly. But essentially, what they wanted to see is if there was an independent association with high LDL cholesterol
[01:21] and the degree to coronary artery atherosclerosis and coronary artery calcification. And newsflash, there was no significant association. There was no independent associational correlation with the degree of the LDL cholesterol
[01:35] and the degree of coronary artery calcification in metabolically healthy people. I want to just emphasize that right out of the gate because in some people who are insulin resistant and type 2 diabetic, You know, we know that the metabolic milieu would exacerbate or worsen the propensity of that LDL
[01:52] to initiate the process of coronary artery atherosclerosis and lead to plaque buildup and possibly a major adverse cardiovascular event over time. But in this cohort or subset of metabolically healthy people, because their triglycerides were low,
[02:06] their ATL cholesterol was over 60 milligrams per deciliter, these individuals, and again the cut point for the sort of lean mass hyper responder phenotype is an LDL cholesterol greater than
[02:18] 190 mg per deciliter an HDL greater than 60 mg per deciliter and triglycerides less than 80 mg per deciliter and so we're comparing head to head here
[02:30] in the study if I haven't yet mentioned it is titled Carbohydrate Restriction Induced Elevations in LDL Cholesterol and Atherosclerosis this was published in the Journal Cardiometabolic. There's a screenshot there. Here is the graphical abstract, and we're
[02:46] going to dive into the weeds on this There a few images that you have to see but here the graphical abstract As you can see here we are matching 80 individuals from the Miami Heart Study that you can see here And we going to dive into the weeds on this There a few images that you have to see but here the graphical abstract As you can see here we are matching 80 individuals from the Miami Heart Study that generally don have high LDL cholesterol
[02:59] I think the median LDL was somewhere around 120 or 130 milligrams per deciliter, not considered on the high side. But in the keto group, 80 individuals, and we're comparing apples to apples, right?
[03:13] Because I think there was one former smoker in each group. They were age-matched, you know, hypertension, no previous diagnosis. That was matched, and diabetes status was matched. And so we're really comparing apples to apples, which I like.
[03:27] And so this study was really, I think this analysis was well done. And you can see that there are significantly higher levels. The LDL cholesterol, that is, is significantly higher in the keto cohort compared to the Miami heart cohort.
[03:40] But the plaque score was not significantly different. In fact, the Miami Heart Cohort had higher levels of plaque. So we're going to dive into that. But first, friends, thank you for being here. Hopefully you enjoyed this video.
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[05:00] And you can save with the code PODCAST at checkout. Okay, so let's dive into the baseline characteristics. I just want you to recognize this. And anytime you see a study, this is really important. And just for continuing education for many of you, you know that when, you know,
[05:15] epidemiological research comes out from Harvard and Stanford and they say, oh, the plant-based diet is linked with lower prevalence of diabetes and all that, we always look at the baseline characteristics of the study participants, you know, because then we can see if there's a healthy user bias or there's any other confounding factors
[05:30] that might influence whether or not one cohort that is supposedly similar or different from another one. we can see there elements of their lifestyle that confound the study results And in this case there the confounding variables like blood pressure like age hypertension status past smoking status are equivalent right
[05:52] So there's two past smokers in each group, hemoglobin A1C and blood glucose and seroforce. No significant differences between groups. But what is significant here is the lipid markers, right? We have, and this is what I want to focus on.
[06:05] What makes this group different, these two groups different, is the lipid markers. You look here at LDL cholesterol in the keto group, and again, there's 80 people in each one, each cohort.
[06:17] The LDL cholesterol in the keto group is 272 milligrams per deciliter. The LDL cholesterol in the Miami Heart is just 123 milligrams per deciliter. The HDL in contract is almost 50% higher in the keto group.
[06:31] It's 90 milligrams per deciliter versus just 63 milligrams per deciliter in the Miami Heart cohort. and the triglycerides are, you know, the same. They're about 45% lower in the keto group.
[06:43] The average triglyceride level here, the median, was 64 milligrams per deciliter, and it's 96 in the Miami Heart cohort. Okay? So, I think that's really important. It is interesting to note that the body mass index is quite lower in the keto group,
[06:58] 22.5 the BMI is versus 25.8 in the Miami Heart. Age and so forth, no differences here. Okay, so let's look at the coronary artery calcium score from the CT scan.
[07:13] You can see here looking at, there's no correlation, right? LDL is all over the place, and it doesn't strongly correlate with the degree of coronary artery calcification. So I think that's important. So the median coronary artery calcium score was zero for the keto subjects and was one for the Miami heart subjects.
[07:30] Not that big of a deal, but it was actually higher in the Miami Heart subjects. And remember, their LDL cholesterol was about 50% lower. So why is that?
[07:42] They say in the subset of the keto subjects, meaning all three stricter lean mass hyper-responder criteria, the median coronary artery calcium score was zero for keto subjects and zero for MAPS Miami Heart subjects.
[07:54] So I think that's very interesting. Now, when we look at figure one here, this is the plaque scores stratified for LDL cholesterol levels. In the keto, you see LDL cholesterol, you know, as we mentioned,
[08:08] about the median was like 190 milligrams per deciliter. But some people had LDL cholesterol in the keto group going up to 600. That's insane. But again, you didn't see major outliers in the coronary artery housing score.
[08:21] And when they look at the, what's called a stenosis score. So stenosis is the way the it a medical jargon term for the degree of narrowing or occlusion in the coronary arteries There was no significant difference in the stenosis score when you compare the different groups and there were no significant differences in the coronary
[08:42] artery calcium scores when you compare the different groups. So what does this mean? I mean, I think it's quite interesting. You know, there's a lot of competing theories, and I'm going to share with you the conclusions momentarily. A lot of competing theories, though, when it comes to LDL cholesterol, and, you know,
[08:56] the nation medical community has this idea known as the continuous exposure hypothesis. And that is, it goes like this. The longer that you're exposed to high levels of LDL cholesterol,
[09:08] the more likely that you will develop coronary artery plaque, and that will lead to stenosis and occlusion and increase your risk of having a major adverse cholesterol event. So that's one theory.
[09:20] It's not necessarily proven. It's talked about in a lot of the narrative reviews. The other theory from the so-called lean mass hyper-responder camp, Nick Norwood, Dave Feldman, and others, is that, hey, in metabolically healthy people,
[09:35] if the LDL is high, but it's matched by a high HCL and a low triglycerides, i.e., there's reason to believe there's high ketone utilization and fatty acid mobilization in the body, a
[09:48] greater reliance on fat oxidation, therefore probably lower levels of oxidative stress and so on, that the LDL is not being modified or oxidized and contributing to the coronary artery calcification process.
[10:01] And so they say, in conclusion, coronary plaque in metabolically healthy individuals with carbohydrate restriction-induced LDL cholesterol levels greater than 190 milligrams per deciliter on a keto diet for a mean of 4.7 years is not greater than a matched cohort with 149
[10:15] milligrams per deciliter lower average LDL cholesterol. There is no association between LDL cholesterol and plaque burden in either cohort. That's the conclusion. So what do we make of this?
[10:27] What do we do? And this may take another decade or maybe two decades for the medical community to actually adopt this. If your LDL is high, but your HDL is also high, greater than at least 60 milligrams per deciliter in your shrug,
[10:42] your shrugs are low, and you don't have signs, overt signs of insulin resistance or metabolic dysfunction, you should really be worrying about the high LDL cholesterol. It seems that the answer is probably not. So I can't give you medical advice.
[10:55] I just think that you should work with a doctor who's a little bit more open-minded and does some advanced lipoprotein particle testing, metabolic health testing, so you can more confidently continue to eat in such a way that helps you stay lean, energetic,
[11:11] metabolically fit, and feeling good mentally, you know. And if in doing so your LDL creeps up a little bit, you know, is it that big of a deal? Should we really worry about it? In my opinion, probably not.
[11:23] Let me know what you think in the comment section below, my friends. I appreciate you watching all the way through. We'll catch you on a future video down the road.