LDL – Not Quite Ready to Change My Paradigm

StethoscopeReader Peter commented recently:

Ever consider changing your paradigm, as we long-term lob carbers are using markers levels for general populations who eat mostly SAD.
Instead of measuring and interpreting SAD bio-marker levels as proxies for probable risk, why not actually verify if you have the disease itself. For example, (hat tip to Dr. Rakesh Patel) carotid intima-media thickness (CIMT) measures occlusion or arterial plaque buildup in one’s carotid artery. According to a quick Google, a CIMT runs about $200.

An NMR runs about $100 and Lipid panel $60. These results are surrogates of health, not health itself. Aren’t we wasting our $$?

This is a question I’ve gotten a few times before and brings up many good points.  I planned to do a post on this but never got around to it because I hadn’t quite fleshed it all out in my mind.  Even now I still feel like there is a lot of it I haven’t quite figured out yet, but I’ll to write down some of the thoughts that I’m having.  Please excuse the haphazard, rambling format of my answer.

1. High LDL-C and LDL-P in SAD: 

  • We can all agree that in people who eat a standard american diet, elevated levels of these means something.  I don’t think the science is quite out on what the order is: something bad is happening which is causing a high LDL, OR if the high LDL itself is the culprit that is causing something bad.  Science is still working on this (and vice versa with HDL: whether its’ actually a good guy OR if it’s simply a marker signalling that something good is happening.

 2. High LDL-C and LDL-P in Low Carb-ers / Paleo:

  • I don’t think we know enough of what’s going on to change my paradigm.
  • Why do some people have picture perfect numbers and others have numbers that are extremely out of whack?  There are enough people out there with out of whack numbers that this is a thing that comes up frequently on message boards and forums.
  • Until we can explain what is happening, the best we can do is interpret these numbers through the lens of what we know, and what we know right now is that high LDLs are either bad or are signals of something bad happening.
  • My case is an example of why I’m not quite ready to change my paradigm.  In my case the high LDL-C’s reflected an underlying hypothyroidism or subclinical hypothyroidism that arose due to eating very low carb.  The moment I addressed the hypothyroidism by increasing my carb intake, my LDL-C began to normalize (I will get an NMR soon to see what my LDL-P’s did).
  • If I just accepted the fact that it is normal for some low carb-ers to have high LDL-C’s, and that this is the new paradigm, I wouldn’t have unmasked the underlying thyroid issues.
  • Again, just because this is the case for me doesn’t mean this will be the case for everyone else.
  • When I see convincing enough evidence to shift my paradigm, I’ll be more than happy to jump!

3. CIMT and other imaging exams:

  • I completely understand your point about measuring health markers themselves rather than surrogate markers.
  • Since I am 32 years old and relatively active without any significant medical history, I can pretty much guarantee that if I were to get a CIMT scan or even a Calcium Scoring Scan (CAT Scan to determine how many calcifications are in your coronary arteries), these tests will be negative.  The capacity I work in within the medical field has allowed me to see the results of these tests in others and gives me the confidence that someone in my age group, with my activity level, and history won’t really show much on these tests.
  • Paying for these tests at this moment would be a waste of money for me.  If I were in my 40s or older, or if I had a medical history of severe obesity, or some other condition such as diabetes, then I probably would have gotten these tests long ago… and blogged about them!
  • The other issue is that if you get these tests and they show a thickened carotid intima or calcifications in your coronary arteries, things are already too far along in the inflammatory cascade.  Damage has been done.  It takes a long time(years) of being exposed to inflammation and cellular insults for these things to appear.  By this point, the only thing you can do is to prevent more damage from being done.
  • Changes in surrogate markers such as cholesterol and thyroid levels can reflect changes in your lifestyle in mere days and weeks.
  • Also my goal is to make positive changes in my life BEFORE they become apparent on the imaging exams, and the surrogate markers are the best thing we have to do track this.

4. Other surrogate markers I’ve used in the past and will probably use in the future:

  • CRP – This is a marker of overall body inflammation.  I have measured them but haven’t reported it in my posts because each time I’ve measured it, it’s been normal.  Some people think that even though your LDL-C or LDL-P is high, if you don’t have inflammation, it’s nothing to worry about.  Having cholesterol in your system is ok… it’s the presence of inflamed cholesterol that causes the problem.  Like almost everything else I’ve discussed, the jury is still out on this, but CRP is still a valuable tool.
  • ESR – Another inflammatory marker to follow.
  • HBA1c – A marker I wrote about before (Part 1, Part 2) that reflects how much sugar you’ve been exposed to over the past 3 months.  A metabolism that uses sugar primarily for fuel is exposed to more inflammation.  More carbs in the diet = cells being exposed to more sugar = higher HBA1c.  Although as I’ve written previously, a higher HBA1c can also reflect a healthier metabolism while eating a very low carb diet.
  • Triglyceride:HDL RatioMore literature is coming out now about how this is actually more accurate in predicting cardiac disease than any other measure of cholesterol.  Since mine is well within the optimal range (under 2.0) I haven’t been too overly concerned with my LDL-C numbers.

Hope this helps to clarify where I stand on these issues.

Thanks for all the comments!  Keep them coming in.  I really enjoy answering them when I can and thinking about them when I can’t.

18 Responses to LDL – Not Quite Ready to Change My Paradigm

  1. Nadia Peters says:

    Great post, and great blog you have. I find it really interesting, and agree with you on the paradigm. I’ve been cutting down on dairy recently trying to improve LDL-C and apoB (I wrote about my lipid panel results in my blogpost My Lipid Panel) On the other hand I wonder if my dairy intake is the cause – since I seldom eat meat (don’t like it), the amounts of dairy I consume merely would equate sat fat intake in carnivores, I presume. Anyway, your subclinical hypothyroid markers are very interesting. Will have those checked too (last ones were ‘within norms’ I.e. right in the middle, and labelled euthyroid…. It’s still confusing and intriguing… Can’t quite sort it out. Also, am noticing discrepancies between results when having tests done in Belgium (country of origin) or Sweden (where I live)….
    Again, great blog, keep going!

    • BJJ Caveman says:

      Keep us updated on what your test results show! It always helps to have more examples for others to refer to.

  2. Chris says:

    Awesome posts. I have similar test results to you:
    TC: 398.07
    HDL: 80.69
    LDL: 304.63 (257 iranian)
    TG: 64.60

    I have also been doing ketosis for around 5 months before getting my test. I was shocked at my LDL as I never read anything about it going up on a LC diet. After massive amounts of research I came to same conclusions about what are possible solutions which you happened to test. What I WAS testing was increase in iodine, copper, selenium, eating 1 sweet potato a day which gives me +70-90g of carbs per day (~1 lb of them). I will be taking my lipid panel again in 3 months time so we will see how low I can get my LDL. I think my TG and HDL are good enough that if they vary it won’t make a big deal. I am also VERY thin now as I lost ~50 lbs going from ~190-140 so I need to use carbs to gain weight now while I work out.

    Wanted to thank you for your blog posts as they are making me feel better about my results and what i’m doing to take action. In my case my doctor says it is literally impossible for me to change my LDL through diet by more than 10% max. That really fuels my fire and I hope to reduce my LDL by 100 or more. I’ll post back on your blog my results when that time comes as well so maybe this coule be N=2.


  3. Peter says:

    Thank you for the extensive response to my paradigm shift comment. Each time I re-read your entry I learned more and countered my objections that popped in my head.

    Here’s my thinking: a high LDL-P count is used as a final arbiter to determine CVD risk for SAD-ers whose LDL-C is normal (discordant) or high (concordant).

    From what I have read, often in discordant instances (high LDL-P w/ normal) LDL-C) cases as cited by Dr. Dayspring, upon further analysis, these patients turn out to have triglyceride > 150 and low HDL <40 .

    I have not read of SAD-ers who have high LDL-P and yet all other NMR markers at low risk level and metabolic-syndrome free. In other words, using LDL-P marker is
    valid in SAD paradigm.

    On the other hand, I have read, and now myself included, where long-term non-SAD-ers, get high LDL-P count, yet have all other NMR markers at ideal low risk level and are metabolic-syndrome free. Therefore, I think that LDL-P in the LCHF, may indicate a unexplained metabolic function rather than a malady.

    Here's a podcast by Jimmy Moore interviewing Dayspring touching on LCHF ketoers getting scary high LDL-P number:


    In short, his take is that a high LDL-P in a ketoer who is healthy in other lipid markers and free of metabolic syndrome, may not indicate CVD risk, w/ the caveat that much is still unknown, since much of the clinical data is on SAD.

    Yes, one can do n=1 experimentation (iodine, copper, selenium, eating 1 sweet potato per day) to alter the LDL-P number to meet the SAD risk standard.

    But is the LDL-P a legit arbiter of CVD risk for keto-ers? Are we chasing an ideal proxy for SAD?

    I am leaning to toward using TG/HDL ratio from the standard lipid panel.

    BTW, for my recent annual exam, I got my internist to order NMR instead of the standard lipid panel. I got the results and interpreted the findings myself before the appointment, thinking I need to counter his analysis.

    During the appointment, he admitted that his practice ( one of the biggest group in Chicago), is still learning how to use NMR results. No wonder many doctors object to ordering NMR. They simply don't know it.

    Thanks again for your insightful blog.

    • BJJ Caveman says:

      Love all your comments Peter. You really bring up a great discussion.

      I actually listened to Jimmy’s Podcast with Dr. Dayspring… and my impression was that Dr. Dayspring was still hesitant about Jimmy’s high LDL-P numbers.

      I think in the end my feeling is that there isn’t ONE final lab test that we can use as the best arbiter of our cardiovascular and overall health. We have to use everything together

      If you feel and look great, your blood sugars are under control, your HBA1c is good, your weight/blood pressure/heart rate is good, you’re getting good sleep, triglycerides are low and HDL is high, your testosterone levels are in the normal range, your thyroid levels are good, and your stress hormone/cortisol levels are good, then having a sky high LDL-P probably won’t be much of an issue.

      But in my case if my sky high LDL-P is a reflection of an underlying thyroid dysfunction then it’s definitely something worthy of further investigation.

      The more questions you ask the more we can all learn and figure this stuff out together. This is all uncharted territory which makes it even more exciting!

  4. Peter says:

    Thank you for the feedback.
    Among the categories you listed ‘your blood sugars are under control, your HBA1c is good, your weight/blood pressure/heart rate is good, you’re getting good sleep, triglycerides are low and HDL is high, your testosterone levels are in the normal range, your thyroid levels are good,’, I am good, despite sleeping just 6-7 hours per day, instead of 9 back in SAD.

    Now here’s something unexpected: for decades I have taken Levothyroxine for hypothyroidism, lab-tested yearly and consistently stable at normal level. Back in 12/2011 when I went LCHF, I ceased taking Simvastatin for which I had taken for 12 months previously, ostensibly to lower LDL-C. And, btw, statin did lower my LDL-C by 50%.

    During my statin year, I also took bi-weekly testosterone (T) shots to boost my low T level. It did. After switching to LCHF, I noticed immediately I felt more rested from overnight sleep, experienced none of those dreadful tiredness after the typical SAD meal and my mood brightened, so I stopped the T shots. Perhaps a placebo effect and I would agree.

    This past June, besides getting NMR, I had T level checked: testosterone level returned to normal range. My doctor had no explanation. I think my consumption of egg yolks (I eat 4-5 a day) and daily magnesium supplement boosted my T. BTW, the T shots, injected by thick needles, are painful, lasting days.

    In my case, I don’t think my thyroid and testosterone hormones have a role in causing the high LDL-P. On the other hand, maybe LCHF has a positive effect in normalizing T level. Quite puzzling….

    I am still confounded over why long-term LCHF, healthy in all NMR markers and metabolically, get a frighteningly high LDL-P count. Maybe the 80/20 rule is applicable here, namely that 80% of the LCHF population gets a normal range of LDL-P count. The 10% at the two end spectrums of the population, due to phenotypic differences , get either an extremely high or low range of LDL-P count.

    The crux of the matter is this: does a high ldl-p by itself cause arterial plaque, as in too many cars in the road crashing into the arterial guardrail and causing injuries/plaque. I thought a function of cholesterol is to repair cellular damages. In SAD, cells are bombarded w/ high glucose, causing glycation/inflammation; cholesterol is transported to the injured sites, forming plaque. In the words, SAD provides the necessary conditions for LDL-P to form plaque. The SAD model would interpret the high LDL-P as the deciding indicator for signaling CVD risk. And often, upon further investigation, it’s validated by high TG and metabolic syndromes in SAD. What is the role of excessive LDL-Ps in a healthy LCHF? Do the excessive LDL-Ps in LCHF, after cruising around for glycation repair, get recycled or excreted. We need more clinical data from LCHF.

    Of course I wish I get a ‘normal’ LDL-P count, like the most LCHF eaters. Supposedly dietary fat/cholesterol has little impact or at most a 15% increase to one’s cholesterol level. Why not in our case? Is it the 80/20 rule again?

    Is there a downside to n=1 experiments (my current n=1 is tasty, one Brazil nut daily in the quest of lowering LDL-P) for magic bullet, besides the hassle, for those who have not settled into a LCHF routine, become frustrated, discouraged from n=1 results and veer back to SAD? Old habits die hard.

    • BJJ Caveman says:

      First of all, it seems like things are going very well for you. Are you now off the statin and testosterone injection? You mention a statin ‘year’ which makes it seem like it was just temporary. If you are able to wean yourself off of medications by diet and lifestyle, that is fantastic!

      The fact that all your other indicators are good is also a very positive sign!

      Your questions in the end echo mine… ‘what is the role of excessive LDL-Ps in a healthy LCHFer?’ I wish I knew the answer to this. But that’s why we’re here. Let’s all try to figure this out together.

      I don’t think there are any downsides to n=1 experiments, after-all it’s the only way to figure out if something does or doesn’t work from YOU. No one else on the planet has the same genetics, environment, and lifestyle as YOU… so what works for someone else won’t necessarily work for you, and the only way to figure this out is to try things out.

      In your case, it seems that everything is going well in your life with your LCHF lifestyle… with the exception of one loan biomarker… the LDL-P.

      I don’t see any reason for you to be discouraged at all. In fact you’re almost the poster child for all the benefits that LCHF can bring!

  5. Count me in as yet another paleo-ish eater with high LDL. My numbers last year were:

    Total: 324
    Trigs: 23
    HDL: 95
    LDL: 209

    I got my Apo-B checked a month later (I couldn’t talk my doc into an NMR) and it was 163 – QUITE high. My ratios are all superb, my thyroid checked out OK, and I’m slim and healthy, but these numbers definitely are a concern lurking in the back of my mind.

    I just wanted to make a clarification about the Hemoglobin A1c test. It’s not a measure of how much sugar or carbs you have been exposed to over the past three months, but rather an indication of your blood sugar over the past three months. Someone who is metabolically healthy and insulin-sensitive can eat a crap-ton of sugar, but their body will metabolize it properly and their A1c will be just fine.

    • BJJ Caveman says:

      Thanks for stopping by. Your Trigs are fantastic by the way.

      Did you check your thyroid levels with the most recent recommendations by the American Association for Clinical Chemistry (AACC)?

      When you checked your thyroid, did you also check your RT3 levels as well?

      I tried to write a brief explanation of these things here.

      You are correct about the A1c levels. I probably over simplified it in this post, but I tried to write a better explanation previously.

      Please keep us updated on how things turn out!

  6. […] this sounds familiar, it’s because I arrived at the same conclusion during my own n=1 […]

  7. […] doing a pretty good job of staying low carb.  Despite having a persistently high LDL, I’m not too concerned because my low CRP tells me that my body isn’t in an inflammatory state and my […]

  8. kelly says:

    context matter.. SAD vs Keto(ish) diets changes the context in ways we’re just beginning to understand.

    ” The moment I addressed the hypothyroidism by increasing my carb intake…” Dr. Ron Rosedale has a lot to say about this and it’s a good example of what I’m talking about. “subclinical” in the context of SAD? Yeah, maybe.. “subclinical” in the context of Keto??? Nope, he says to expect it and that it’s a sign of metabolic health.

    thanks for the blogs and website. Good thoughts here.

  9. BLappin says:

    I had an onsite check today which my company does each year.
    My total cholesterol has been a problem or high for quite some time. It was at 283 in Jan of this year.
    It goes up and down at times but generally although elevated until today my LDL and HDL have not been bad. Today my HDL was 41 which I think it pretty good – in the past it has been 55(in Jan).

    C. 254
    HDL 41
    LDL ? didn’t register?
    Triglycerides were off the charts at 464 (6.5 ratio)

    I have never had this before, well back in Jan they were 276 which is high but 464? This scared me. I did bake a couple of weekends ago with honey rather than sugar, had a DQ Malt, and baked for a church function which required taste testing of cookies. I used a light butter but generally I use the full fledged butter for baking which is supposed to be good for you. Wondering if it could be related to the baking? I am under some stress also bc I have a trip coming up soon etc.

    Feedback welcome….

    • BJJ Caveman says:

      The fact that your triglycerides are so high seem to indicate that you’re eating a fair amount of carbs. Is that correct?

      Do you know what your average daily carbohydrate intake is?

      • blappin says:

        I re – tested this am and my scores were different …. I had a tri score of 196 today
        266 cholesterol
        48 HDL (I exercised yesterday 1.5 hrs)
        LDL I don’t remember bc I don’t have the paper w me but can get that.
        Glucose was 114
        Elevated blood pressure both mornings also but to get to facility I climb about 70 steps so not sure if that’s related.

      • blappin says:

        LDL was 180 sorry…didn’t have that.
        Yes I do set at a desk and snack during the day.
        I do not know the intake per day and at times not sure something is a carb…feel silly saying that though. 🙁 Just downloaded myfitnesspal hoping this helps me track better.
        Feedback welcome.

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