What A Doctor Asks His Lipidologist

Lipidologist Part 1

Despite 3 years of struggling with a markedly elevated LDL cholesterol particle count I’ve finally managed to make substantial progress in bringing it down over the past 4 weeks, but before I go into the results and the exact methods I used, I want to give you a detailed description of everything leading up to it.

After experimenting with different macronutrient ratios and various supplements without much success, I finally decided that I took things as far as I could take them on my own and needed help, so I arranged to meet with a lipidologist.

I contacted Dr. Dayspring via Twitter and was disappointed to discover that he wasn’t taking any patients at the moment, so he referred me to a colleague located about 90 miles away from me.  I reached out to her and scheduled an appointment.

These next few posts will be about my experience with the lipidologist.

This post itself is meant to be a sort of prologue.

Before meeting with the doctor I organized a list of questions I wanted to address to ensure that I didn’t forget anything and to make the most of the visit.

A lot of the research that I used for preparation came from Dr. Dayspring’s lecture series on Sterol Testing which I took notes on here.

I thought it might be helpful to give you a window into how I approached this by showing you my list of questions.

Here they are:

Cholesterol Questions for Lipidologist

What is my cardiovascular risk?  Is it high or low?

Why did my body all of a sudden develop/acquire hypercholesterolemia?  

  • Change in gut bacteria?
    • L reuteri can deconjugate bile acids which can lead to decreased FXR stimulation, and subsequent increased bile acid formation (cholesterol excretion)
    • Less of the gut bacteria that metabolize cholesterol into coprostanol/cholestanol
  • Increased conversion of ketones into LDL?
    • This should regress with increased carb consumption and not being in ketosis correct?
  • Weight loss?
    • Increased mobilization of endogenous fatty acids
    • Recent change in body composition
  • Changes in CETP activity?
    • Seen more with binge and purging anorexics
    • Is there any way to measure this?
  • Change in LDL receptor expression or activity?
    • Can this be measured?
    • Thyroid related – but my numbers are normal now
    • Insulin related -?
      • Insulin effect on PCSK9 (PCSK9 destroys LDL receptors)?
    • Fasting -> decreased IGF-1 -> high cholesterol?
    • Late expression of familial hypercholesterolemia
      • Is this possible?
    • Acquired change in genetic expression of NPC1L1 and ABCG5/8?
      • Is this possible?

High ApoB and LDL-P Numbers – What does this mean?

  • When these are elevated does it automatically mean overproduction?
  • What about in the absence of elevated TGs?

LDL hypersynthesis vs decreased clearance – How can we differentiate these?

Can we review my NMR results in detail?

Am I insulin resistant?

  • We have many LP-IR scores to go on.
  • HbA1C – Steadily at 5.7% which is high
  • Recent fasting blood sugars in 100s despite weight loss.
  • Consistently low fasting Insulin.

What tests should we order?

  • Apo E Genotype
    • E4s have cholesterol hyperabsorption
  • Sterol synthesis/absorption markers
    • Desmosterol, Lathosterol
    • Cholestanol, Campesterol, Sitosterol
    • Absolute values are necessary instead of ratios correct?
      • When investigating synthesis and absorption differences among two groups, one would like to be certain that these effects are independent of the cholesterol concentration and therefore values should be expressed relative to cholesterol (as a ratio).
      • However, investigating the relationship between absorption markers, synthesis markers, and cholesterol levels, the absolute sterol concentrations should be used due to the fact that normalizing or adjusting for total cholesterol would mean that you are masking the outcome variable you are interested in assessing.
    • Omega 3
    • MTHFR
    • Galectin??
    • PCSK9 – is this worth measuring?

Am I inflamed?

  • Lp-PLA2 – Why is it elevated?
    • Periodontal disease?
      • I recently obtained a Myperiopath test
    • What else can cause this to be high?
  • CRP – Normal
  • Ferritin – Why is it elevated?

What benefit is there in reducing dietary saturated fat?

  • “Neither dietary cholesterol nor dietary fat significantly altered % absorption of cholesterol. Regardless of diet type, the individuals within the group differed markedly in the percentage dietary cholesterol absorption.”
  • Dayspring said that this will reduce substrate for formation of LDL, but if I’m mobilizing endogenous fat, isn’t that providing the needed substrate?

Will these be my main treatment options?

Hypersynthesis

  • Statin
    • Decrease cholesterol production
    • Increase LDL receptor expression
    • Why do patients with high level of synthesis AND LOW level of absorption respond poorly to statin monotherapy?

Hyperabsorption

  • Ezetimibe (inhibits NPC1L1)
    • Decrease cholesterol absorption
    • Increase LDL receptor expression
  • Bile Acid Sequestrant – Colesevelam, Cholestipol, Cholestyramine
    • Excrete more bile -> increased LDL receptor activity
  • Fibrates – Clofibrate, Fenofibrate, Gemfibrozil
    • PPAR alpha agonist, decrease NPC1L1 expression
  • Sterol and Stanol Therapy – Benecol
    • Saturate NPC1L1
  • Probiotics
    • reuteri deconjugates bile acid, leading to decreased absorption.

Next up… the lipidologist’s answers to these questions.

*Image found here

11 Responses to What A Doctor Asks His Lipidologist

  1. Fung Yen says:

    Too technical for non-medical major to comprehend.

    • BJJ Caveman says:

      Yeah, the next few posts will get pretty deep into this topic. After I finish this series, it’ll probably be a good idea for me to sum things up in a more understandable format.

  2. charles grashow says:

    Would you be wiling to share the name of the doctor you saw?

    • BJJ Caveman says:

      Sure, I’ll send it to you via email.

      I need to check with her first before publishing it online directly on my website.

  3. Dale says:

    The answer to your first question might make the rest of the questions unimportant. Since she was recommended by Dr Dayspring, I can’t imagine she’d be one of those “statins are for everybody” doctors. My PCP had me do a carotid calcium score and carotid intima-media thickness test. Both showed zero reason for concern, and no inflamation markers, so the level of LDL is irrelevant.

    • Wonderer says:

      Dale:
      FYI – Last year I had CIMT showing “NO” deposits and report concluded “Artery age is 15 years younger than chronological age”..& my LDL-C in the 120 range…(LCHF-er of 2 years)

      But, ….had a heart-attack with 90% block in LAD. (No other blocks in the heart was found during the stenting procedure).
      Almost died. Lucky to be alive and more so without any heart-damage/brain damage (thanks to timely medical help and a 25 years exercise lifestyle…).

      I still not sure what tests are reliable to find a block early enough – if there is any.

      • BJJ Caveman says:

        Holy cow, it’s hard to believe you had a 90% blockage despite having a clean CIMT. Did you happen to have a coronary calcium scan done? I’d imagine that having that done could have caught the blockage…

  4. charles grashow says:

    Jimmy Moore’s latest blood work

    OMG!!

    https://t.co/RCCBKkzjdT

    LDL-P 2889
    Small LDL-P 1446
    Lp(a) 441
    hsCRP 1.6
    Testosterone 435
    TC 295
    HDL 61
    TG 90
    LDL 216
    Fasting Glucose 100

    • BJJ Caveman says:

      Oh man… scary. He’s not looking too good on his Periscopes either, like he’s gained weight.

      Once I finish my series of posts on cholesterol, I’ll send it to him. Regarding his cholesterol at the very least, I think he would benefit from some of the things I’ve tried.

      • charles grashow says:

        The Lp(a) is very scary. If it’s genetic in nature he may be told he needs a statin. He will of course refuse.

        • BJJ Caveman says:

          Yes… I agree with you. Learning what I have from the lipidologist so far, it really doesn’t look like Jimmy is in a good place.

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