CAC is great for detecting calcified plaque in your coronary arteries. But before you have calcified plaque, the above risk factors tell you about the buildup of soft plaque. And 4 out of 5 of them are modifiable through lifestyle, exercise, and medication.
CAC is the right test for people who already have identified that they have major risk factors such as metabolic syndrome/T2D, high cholesterol, etc. It identifies whether heart disease has already advanced enough that the risk factor has become a risk.
Some of the tests you list (like A1C) are baseline things everyone should get checked every year. Agreed that the others could provide value for those who want to know more about their risk level; however, it’s uncommon for those tests to turn up positives without one of the baselines having already raised at least a yellow flag.
None of the tests you listed will tell you whether you have any soft plaque buildup. They just tell you more about your risk factors. However, there are ultrasound tests that can detect increased blood pressure in major arteries, which IIRC does reflect soft plaque buildup.
The test cost me $35.20 and I found out that I have sky high Lp(a), 218 nmol/L. I already take a statin and my cholesterol is well under control (LDL 83). But as has been pointed out, Lp(a) doesn't respond to statins. I'm getting a calcium score done (probably won't be covered but we'll see).
I'm prescribed a baby aspirin for the Lp(a). The AHA no longer recommends baby aspirin to the general population but 218 takes me out of the general population. The thinking is that Lp(a) clots and baby aspirin counteracts that.
I've had high-ish LDL for ages and diet alone couldn't knock it all the way down.
It's only the CAC score that provided me with peace of mind that I didn't need to reach for statins.
The way I view this is that, if you can get more information, why wouldn't you? Cost of course, and I understand why insurance might not cover the procedure, but anybody of a certain age with any risk factors who is in a position to afford it benefits from doing so.
I have a CAC score of zero (no calcified plaque) and I take both a statin and ezetimibe to lower my LDL and ApoB. I disagree with your assessment that your CAC score along means that I statin wouldn't lower your risk.
The problem we’ve found is that when you get more information, you are more likely to find things that look off somewhere, which may have no real bearing on your actual health but definitely can cause you to have a worse quality of life—whether because of stress or subsequent more invasive tests or just the time and energy it costs you.
This is why there are tests which previously were recommended to a wide range of people on a regular basis which are now only recommended in more limited settings. PSA is a good example of this.
The question to ask is, is doing this test likely to improve my life, or not? And while you probably can’t know the answer for a specific test in your specific case without trying, you can often know the probability that it will improve your life based on statistical analysis of other people who have gotten that test and how it went for them.
No, CAC only tests for end stage calcified plaque which is how your body tries to transform soft plaque. It's soft plaque that first lines your arteries and is capable of rupturing. You might be infested with soft plaque, but if none of it has calcified yet (which can take decades) then you'll have a CAC score of zero.
Using CAC store to gauge risk is like waiting until you have end stage symptoms of any disease before you consider yourself at risk. The ship has already sailed and you should have instead focused on prevention for decades.
The sibling comment is a great example of the misinformation here. They have high cholesterol but a CAC score of zero gave them the peace of mind to not use statins.
Saw your link, did your test and here's my feedback.
No "share" or "download" button in the app? Sure, "apps are cool" and all that - but what about folks who want to archive or share their health data? AFAIK literally no provision to share all those nifty biomarkers with my doctor (except many, many screenshots)?
Nowhere in the "how to get blood test" email instructions does it bother to mention a urine sample will also be needed. Kinda useful to know if you should not pee right before heading to the lab.
Fascinating how these tests are something that is an option in America with people getting them.
In the UK we have the NHS and, although private healthcare is available, the NHS are gatekeepers with long waiting lists to see the doctor.
In UK culture you are just not going to 'waste NHS time' by asking for the tests that could inform you on what lifestyle choices you might need to make in order to head off chronic non-communicable diseases. You have to get a chronic disease, then the doctor will interpret the test results and not let you know what the numbers are, just what medication to take, optionally with lifestyle changes.
As a consequence, nobody in the UK knows what their cholesterol levels and whatnot are, yet, in the USA, plenty of people know these numbers.
Do healthcare providers actively upsell testing in the USA?
>Do healthcare providers actively upsell testing in the USA?
In my experience, normal doctors do not, but there are a lot of private businesses that make their living selling testing.
Also, consider that despite a lot of people knowing their levels in the US through testing availability, health outcomes are not better. So, we know more, but don't do anything about it. I don't know what's worse.
I think, politely, this perspective misses the forest for the trees (or maybe the trees for the forest).
Out of the approx. 250 million adult americans, a large cross section do manage their health.
While average outcome might be better in the UK, it's useless to lump the 60% (150 million) of americans who are not obese in with the 40% (100 million) who are obese. And while this is easily the most major, it is just one measure of health.
As an anecdote, I saw just this morning plastic adirondack chairs for sale outside a grocery store, and they had a large sticker on them proclaiming in 4-inch lettering that they are rated for 350 pounds(!). That says something sad about the U.S.
As an aside, I am amazed that chairs can be sold without some redundancy, in case of breakage. 350 pounds is not exceptional these days, that is only 160Kg, which is only 90 Kg more than what I weigh with clothes, cup of tea and plate of food... 80Kg is reasonable for a healthy person and two people should be supportable by the chair.
However, chairs get left outside and they can rot. This can lead to collapse even if a 50Kg person gets on. This can be incredibly dangerous. Hence every chair should have a secondary support structure, in some cases this can be wire under tension, other times it might have to be steel tubing.
There are thousands of chair designs, none of them built for the ultimate eventuality of catastrophic failure.
No. There's a *big* difference between the load limit printed on something and it's true expected failure point. As somebody could be hurt by the chair failing I would expect the real strength to be in the ballpark of 3,000 pounds or even more. Figuring the permissible % of expected yield point is handled by the engineers, normally not by the end users.
Load ratings near the failure point are only done when the failure will not cause a problem, or when the failure is actually a desirable property (breakaway tethers of various types.)
They are better. Life expectancy at birth in the US is dragged down by myriad societal issues but if you survive to middle age, life expectancy begins climbing to the highest in the world.
In the UK, a cholesterol test is offered free of charge to everyone over the age of 40 by their GP, as well as younger people if they have a BMI over 25 or have a family history of high cholesterol levels or heart problems.
They're also available from most community pharmacies (again free of charge for at-risk patients, but for everyone else it should be about £10 for a simple finger-prick test or £30-50 for a full lipid profile).
That is interesting to know, clearly I never knew. It takes about two months to get an appointment where I live so I am not inclined to get a cholesterol test with no good reason. When I registered a blood pressure test, height and weight was all that was needed. With healthy blood pressure and a BMI of 19.5, I would like to see that full lipid profile. However, if I was in the overweight category, the last thing I would want to see is the lipid profile!
By community pharmacy, does that include a typical Boots the Chemist?
Yep, community pharmacy = anything outside of a hospital or similar setting. So Boots, Superdrug, or your nearest no-name chemist on your local high street.
I know my cholesterol numbers going back almost twenty years, over something like 15 tests. This is because that first test around 2007 showed my HDL was ridiculously low. So I took steps to modify it, and tested again (and again...) to see how it was progressing.
N=1, but: I read that carbs lower HDL, and I was eating a very carb-heavy diet.
So over about two months I switched to an informal low-carb diet. e.g. I stopped drinking milk, I ate Carl's Jr. six-dollar burgers as lettuce wraps for lunch, and sometimes just roast beef and mayo.
Over three months I lost something like 30 pounds, hitting a body fat percentage around 12% -- this wasn't the goal, but FWIW.
My HDL before was 17, after those three months, 25.
Then I added in various forms of exercise and got it up to about 55.
I've since engaged in various diets, and levels of exercise -- although I've never gone back to the original diet where whole meals consisted of a quart of ovaltine. My HDL has never dropped below 40, nor been higher than 65.
We don't even have the phrase 'bloodwork' in the UK. Also, in the UK, you can go to the doctor regularly for a checkup to never get this 'bloodwork' thing you Americans speak of. I have never had any done myself, all I get is my iron level when I donate blood, and I only ask about that after curiosity.
Healthcare is very different in America and I am not seeing the benefits of yearly 'bloodwork', it must be an upsell so they can get people onto statins and whatnot for life.
Multiple things are much better caught earlier. Off the top of my head:
Catch the elevated A1c before it does any damage, or get diagnosed from a hypoglycemic episode?? (By which point a lot of damage has been done.)
Catch the elevated TSH and supplement before there are any symptoms, or wait until the patient presents with hypothyroid? Note that the patient will have been through a fair amount of blah before the diagnosis is made. And thyroid hormones are very dose sensitive and it's a couple of months to stabilize on a new dose, so bringing the patient back to normal can take quite a while. US approach, my wife's TSH was high, they put her on some thyroid hormone, no symptoms of hypothyroid and no rush to dial in the dose because it's still within the body's ability to compensate and thus causes no problem.
And the subject of this thread, statins. Again, much, much better caught before it does damage.
Given the low side effect rate and limited overall impact, shouldn't the bar for deciding to take statins be near-zero? Like, the articles say if there's a 5% chance of a heart attack in the next 10 years there's no reason to take a statin, but if the statin changes that 5% to 4% (that's speculation on my part) then given the limited side effects it would likely be worth it, right?
Statins often have the side effect of raising blood sugar. So there’s a non-trivial tradeoff for a population that is usually on the edge of metabolic disease.
I know a number of people who report memory issues since starting statins. They also clearly exhibit memory issues but it's hard as an outsider to pinpoint when they started. Unfortunately, they really do need statins.
I used to work with a cardiologist who joked that "we should just add statins to the water," so you have a point.
The current guidelines for prescribing statins are based on your risk of a major cardiac event in the next 10 years (forecasted using a statistical model). But given that plaque builds up in your arteries over your lifetime, there's a strong argument for using a 30-year or lifelong time horizon.
My cardiologist did all of these except the eGFR. My calcium score was fairly high, but not high enough to be concerning since my cholesterol is controlled and my diet and exercise regime are good now. Until the CAC was done, I had no idea if I had any or not. It's better to deal with cholesterol earlier than I did.
> My cardiologist did all of these except the eGFR
eGFR is typically inferred from serum creatinine (not creatine!), which is part of both a comprehensive and basic metabolic panel (CMP/BMP), which your GP usually orders, along with a CBC, and perhaps an HbA1c.
Unfortunately there is no approved oral medicine to lower Lp(a) that I am aware of. (I mean given a normal LDL.) Statins don't lower it afaik. An oral medicine named muvalaplin is being tested for it.
There's a clinical trial for a new drug, lepodisiran, which lowered Lp(a) by 93.9%.
Outside of that, if your Lp(a) is high, then the first strategy would be to choose a lower ApoB target than you would otherwise. (Every Lp(a) particle is also an ApoB/cholesterol particle, but 6x more atherogenic. So by lowering ApoB, you are compensating for the effect of high Lp(a))
I was just noting the oddness of Lp(a) responding inversely to SFA intake (the reverse of LDL), which also contradicts the conventional wisdom that Lp(a) isn't amenable to lifestyle interventions.
You could theoretically increase SFA to target Lp(a) while still using lipid-altering drugs to target LDL.
That panel costs $190 (and includes 85 biomarkers).
FWIW, similar bundles I've seen online are priced at $400-$500.
All 85 biomarkers, if purchased separately, would cost a total of $1,490. ApoB, for example, usually costs $60 if done in isolation, Lp(a) is $45, hs-CRP is $65 at Quest, etc. The bundles end up having lower pricing due to volume discounts and being able to amortize some of the cost across biomarkers.
Thanks, that's good information. What is your relationship to the company, if any? I wouldn't ask, but it's common when the answer is "none" to provide that info before anyone asks.
I believe eGFR (via creatinine testing) and sometimes HbA1c (if diabetes screening is ordered) are the only things listed may be part of a routine health check from a common/inexpensive blood test.
Co-Founder of the company (it's on my profile). Yes, you're right--of the biomarkers listed, only eGFR and HbA1c are standard in a routine health check.
The first sign of trouble was chest pains while playing tennis. The pain subsided after a couple of minutes and I was fine. EKG showed no sign of heart attack or major blockage. Prior to that I had no symptoms whatsoever, exercised regularly, never smoked, 57yo male, 6 ft, 175lbs. A CAC scan revealed a calcium score of 411 and a stress test indicated a major lack blood flow to the front of the heart. A cardiac catheterization revealed 95% blockage of the Left Anterior Descending artery, the widowmaker. After placing two stents in the LAD I’m back to normal. It’s a small miracle I didn’t die that day on the tennis court. The CAC definitively diagnosed the life threatening blockage when I had absolutely no symptoms. I recommend everyone get this simple scan to find out if you have this killer inside of you.
63, no history of heart disease, all my numbers in the "normal" range, fit, don't smoke, not overweight, good diet, etc. I was building a greenhouse in the back yard and went from feeling kind of "shitty" to classic left chest and back of arm pain.
It's amazing how fast you get into the ER when you come in like that. I got an angiogram within 45 minutes and also had 2 stents in the LAD with 90-95% blockage.
Glad you’re ok. Stories like this are good to rebase myself and remember how important it is to enjoy life now while I can. No matter how healthy I try to keep myself, luck can change things in an instant.
I'm sure your doc already told you this but chest pain while playing tennis that goes away quickly sounds more like angina than a heart attack. IOW your episode was not a heart attack but rather a strong indicator that a future heart attack was likely and that further tests were warranted.
A real heart attack (MI) -- the kind that can kill you quickly -- is usually not exercise related and the pain continues for many tens of minutes without going away.
PSA: If you experience either type of symptom above, call 911. Don't wait around and don't drive yourself to the hospital. Take an aspirin if you have one handy and you're not allergic to it. Real aspirin, not ibuprofen or tylenol.
Chest pain during excretion is a symptom in my book.
>Recommend everyone to get it
A calcium scan is a ECG gated CT scan(a heart CT). It takes time from the CT machine schedule and it requires radiologists to describe it, meaning it's not infinitely accessible.
I wish cardiovascular monitoring was better. It's not uncommon for cardiologist to discharge you saying 'all fine, EKG ok' even though reality says otherwise.
EKGs should be extremely easy for AI to identify every disease with a range of probabilities and even some humans can’t identify from EKGs. Do we have the labelled dataset for this?
I had an EKG last week, the analysis comes back "borderline". Running down every abnormality listed (I know my cardiologist has seen it, didn't consider it notable) has a range of possible causes, including the changes that come with good endurance.
"It should be very easy for an AI to look at an x-ray, CT, ultrasound or MRI image and tell what disease a human got, even some that humans don't know of.
No the examples you give are extremely difficult compared to the 2D graphs of an EKG. The Apple Watch is clearly doing some fairly accurate inference with a single lead around arrhythmias, for example. I’m really sorry for being enthusiastic about machine learning, I just finished doing an intensive ML bootcamp and it was fun getting results. I also actually have some heart issues so I’d love to see if I could get a result. Thanks for your constructive comment though, I’ve never seen ones like this here before!
I'm not talking about me successfully building an AI that can do better than humans or identify all the worlds heart diseases I'm more looking to have fun and play around with some data (and yes learn more about the domain by doing!). I was maybe a bit too excited about seeing what would happen with a real dataset like this, but it's a hacker news comment not a PhD defence, no need to be so negative. Thanks.
Well I've been subjected to these tests and I fell between the lines, I was clearly below normal health (had trouble walking) but they said there was no issues. So I wondered if there's not more subtleties. Like lag between effort and signals showing up, or vascular issues like micro clotting impeding flow.
It’s only if heart muscle dies does that show up, you can have an important artery narrow without symptoms until suddenly a bit of plaque breaks off completely blocking a path causing bits of muscle to actually die.
What I was told in the ER is that troponin basically only shows up when there's been heart muscle damage so is a pretty clear sign. It doesn't show up immediately though - typically a rise within a few hours of the heart attack.
RE: EKGs. There are clear signs in the more detailed 12 lead EKG that can show irregularities in the electrical patterns and specifically help pinpoint the location of the active problem.
A cardiologist told me (after a calcium test showed 95th percentile for calcium) that what I was looking for was a rapid drop in ability. Not over a decade, but over a couple weeks or a month. Well, I play ultimate, and one day I realized "I didn't get this winded a month ago". So I got a stress test, and it showed "abnormal motion of the heart wall under stress" (that is, not enough oxygen getting to all the heart muscles). They did a catheterization, and I wound up with two stents.
I mean, look, if you get the chest pains, don't ignore that. But it doesn't have to be that way. If you lose athletic ability, or wind, or endurance, in a short amount of time, get a stress test.
Researchers have discovered that gut bacteria produce a molecule that not only induces but also causes atherosclerosis, the accumulation of fat and cholesterol in the arteries that can lead to heart attacks and strokes.
I'm not sure quip generalizations like that are useful. If it was as simple as cheese bad, we would see the dutch and the like as outliers in statistics, but that's not the case.
”we evaluated the full spectrum of nutrient intake and identified a significant positive correlation between ImP [imidazole propionate] and saturated fat intake (driven by high cheese intake)”
Perhaps this depends on the type of cheese consumed.
Of course, it’s a correlation; ImP could be modulating eating habits and making people prefer eating cheese.
This is much more likely related to gut microbia metabolism than it is to histidine. Unlike the dogma wants it to be believed, high protein and fat intake does not necessarily lead to cardiovascular issues. It does when combined with other lifestyle(sedentary, low intensity), metabolic(diabetes/prediabetes, inflammation), nutritional(highly refined carbohydrates, nitrated compounds, oxalate/other anti nutrients and refined seed oils) and dysbiosis issues.
There is an enormous scandal to come behind the vilification of cholesterol and the simplification of its level's interpretation to come, which led to the current epidemic of obesity and metabolic/inflammatory/autoimmune diseases. Cholesterol levels vary hugely based on the genetics, epigenetics and lifestyle of an individual, and there is a very large amount of individuals that are within normal range with much higher ldl levels. For example, the cholesterol levels of centennials are usually extremely high.
Things to look out for:
- high very small LDL(you need a proper analysis of your LDL levels with a histogram of the size distribution, which is very rarely done and more expensive)
- high Triglyceride/HDL ratio(in US units, anything above 2 is not a very good sign)
- high hbA1C (metabolic issues)
- high lp(a) and/or lp(b)
- high hs-CRP (general inflammation, but can be caused by infection if you are sick)
Usually those are all related and high when affecting a normally healthy individual).
”This is much more likely related to gut microbia metabolism than it is to histidine”
Yes and no: the study linked to in the El Pais article suggests that certain bacteria are converting histidine to imidazole proprionate.
More histidine -> more food for those bacteria -> bacterial overgrowth, dysbiosis and increased ImP levels -> eventually atherosclerosis.
There are probably some microbe(s) capable of outcompeting the ImP-producing ones even in the presence of increased histidine, which would serve as a mitigating factor.
My cardiologist pointed out that hard calcified plaques are unlikely to come loose, so unless there’s significant narrowing, they’re not a big problem. However, that situation correlates with a high calcium score. So the calcium score is not always correlated to risk.
A CT angiogram distinguishes soft vs. hard plaques (and shows narrowing), so that’s the ultimate way to clarify the situation. (Bearing in mind radiation exposure risk and cost, of course.)
Yeah. Dr. Ford Brewer(https://www.youtube.com/@PrevMedHealth) talks a lot about this. I find him to be pretty current and he translates things into an easily understood format.
Basically the calcium stabilizes the plaque. Unstabilized plaque is what can rupture, squirting out from the artery wall into the blood and forming a clot. High cholesterol can cause deposits in the artery wall simply due to chemical diffusion. Inflammation, often caused by metabolic syndrome/diabetes expands the plaques. Idk, I probably got that wrong, but anyway calcium scores aren't well correlated with risk.
Calcium score is mostly for trends over a period of time, to get a sense of progression of disease. A single reading is not very useful is what I was told
One thing I’ve wondered is why getting a diagnostic test done out of pocket in the US of your own volition (without a doc prescription) isn’t possible. Why does it need to be controlled by a doc and insurance?
In India this is common. They probably use the same expensive machines for x rays and MRIs but anyone can walk in, and pay for a diagnostic test and get numbers (well, not everyone can afford it, but generally middle class folks can). I’m not saying the healthcare system in India is great, but this distinction intrigues me. Maybe the volumes are much higher in India so the diagnostic center can recoup costs? Are there laws preventing this business model in the US?
Some of these imaging that are overdone in India involve radiation: the most problematic being (not low dose) CT. So there is a rationale for controlling these modalities.
A Doctors refferal for preventative tests are easy though. I've done this in the USA fwiw due to a family member having a heart attack at a very young age. Go to a doctor and state "I have risk factors for heart disease and would like a reference to https://stanfordhealthcare.org/medical-clinics/preventive-ca... ". Other hospitals (eg. Mayo clinic) have similar programs.
Any decent doctor should agree to this. Once you have a reference you'll be put through a battery of tests. Blood tests, ECG, ultrasound, etc. A lot of it was covered by insurance anyway but it was out of network for me. That didn't matter to getting the reference though. The tests they do are all non-invasive and not risky in the first phase so definitely worth doing.
I get a 6 monthly KUB ultrasound and xray for around 1k inr which is around us$10.
If I go to a government hospital and ask the emergency doctor for a test when there is a lean time for them, they prescribe the test and its done for a hundred bucks or $1.
My impression (might be wrong) is that one can get this for some subset of blood tests but not say an MRI or x ray, let alone more complex tests. Are these just insurance company rules? If I found a way to make it profitable can I open a diagnostic lab independent of insurance companies?
Diagnostic labs are just for-profit companies. They’re happy to do tests as long as they get paid by somebody. The only practical restrictions are if you want to convince insurance to pay for it. If you’re paying cash, you can get anything from a simple blood test up to a full-body MRI scan [0].
I got a CT angiogram from a cardiologist here who started her own business specifically to do them. (It’s just her, a nurse, and a CT machine, in a trailer in a parking lot!) Insurance doesn’t pay for imaging like this until things have already gone very wrong, and she feels it should be used much earlier for people who have risk factors.
CT is radiation. This is a case where too much testing is detrimental, not merely wasteful. You're sucking up 4 years worth of background for that CT angiogram.
I agree, it’s not recommended to get CTs on a whim. I have high risk factors, a high calcium score, and a bad family history, so getting the data to guide our mitigation approach was worth it.
The preventative heart health program i linked above at Stanford does an echocardiogram calcium score rather than a CT scan for the first phase. Saves you from radiation unless they see something that warrants it.
It is no issue at all to ask for and receive an echocardiogram referral since it has no risk, just ask for a referral.
The unwillingness to do anything involving radiation unless warranted seems reasonable. Just do the echocardiogram and go from there.
I recently requested this test from my doctor. The lab technician asked if I had requested it or my doctor, and gave a very judgmental "that's what I thought" type response. Ends up I was 95%-tile and put on an aggressive statin therapy, from a risk profile that otherwise didn't determine statin use. The test was easy and (relatively speaking) inexpensive. It helped me in risk stratification in a determinative way.
I got pitched (along with a bunch of other people at an investment conference) on an insanely expensive concierge medicine service and they trotted out some super impressive doctor who was fascinating. Anyway the thing that stuck was that he said it takes 10-20 years for meaningful advances in medicine to show up in general use, which was a little depressing
>he said it takes 10-20 years for meaningful advances in medicine to show up in general use
Could it be that it takes that long to determine whether those advances are actually worthwhile? I can’t count the number of HN posts I’ve seen touting breakthroughs in medical research that ultimately didn’t pan out.
No, this is the time it takes for the proven treatment advances to reach rank-and-file doctors (and insurance policies). I've read the numbers 17 to 22 years I think. There are studies on this, but I don't have references handy.
It cost <$200 to go pay cash and get a calcium score yourself. Its hard to talk a cardiologist into getting your insurance to pay for it if you're young. As a male who had a grandfather die in his 30's from heart disease it was even hard. If you're worried about this at all just pay for it yourself. I also reccomend getting Lp(a) testing (<$50) if this concerns you, DYOR, but it will give you a better grasp on how your body is handles bad cholesterol (everyone is different).
These tests expose one to a fairly high dose of radiation. From a quick googling, there does seem quite a range in exposures for this test. That being said, you probably don't want to get one of these scan every year.
This test is also being heavily misused and misinterpreted in some online communities. There are a lot of people posting CAC scan results after something like a year of keto dieting in their 20s or 30s and using that to conclude that the saturated fat connection to atherosclerosis is a myth or that high cholesterol is fine.
These tests don’t have perfect accuracy and resolution, so low or zero results don’t mean that a lifetime of high cholesterol won’t catch up with someone in their 60s and 70s, yet a lot of podcasters and social media influencers are making those claims.
Is this a keto diet that's mainly leafy greens with healthy protein like salmon? Or is this the "keto" diet of bacon and steak and as much fast as one can shove in the food-hole?
> keto diet that's mainly leafy greens with healthy protein like salmon?
A ketogenic diet is 70% fat.
It’s literally impossible to get into keto with a diet of leafy greens and salmon. You would have to augment with a lot of fat from some other source and also limit salmon intake to avoid consuming too much protein. Salmon has too much protein and not enough fat to even come close to keto ratios.
You must be thinking of a different diet. A lot of people think keto is another word for low carb, but a real keto diet is very low carb and low protein.
I don’t understand why some prople claim that diet does not impact cholesterol. I did ‘keto’ with bacon/steak/chicken/etc for 3 months, got bloodwork done before and after and my LDL went through the roof.
In contrast, I had a high LDL of 190, largely genetic, and panicked and switched to a vegan diet. I had my LDL tested again 10 days later and it was 120. I couldn't keep up with the strict diet, but learned some good habits and to avoid saturated fat. My doctor hasn't recommended statins... yet.
There’s an offshoot of the keto community that has become die-hard cholesterol deniers. They don’t necessarily argue that keto doesn’t raise cholesterol. They argue that it doesn’t matter to have high cholesterol. They believe doctors and science are wrong on the subject. They think statins are evil. They embrace a few fringe doctors who agree with them.
If you do try keto again, bacon and such are the worst way to do it. Getting your fat content from a monounsaturated source like avocado oil can be helpful. Taking statins is also a good idea.
Years ago I also experienced very high LDL after a few months of low carb. A doctor was convinced it was genetic (familial hypercholesterolemia) even though multiple earlier tests over the years had been in the normal range. He had never heard of low carb cholesterol hyper responders and dismissed that diet could have to do with it.
Nowadays I am convinced that what happened was completely explainable by the Lipid Energy Model [0]. Five days a week I was doing 60~90 minutes of cardio in the morning after skipping breakfast. Exercising in a fasted state while on a low carb diet meant that I had very low glycogen in my muscles and liver, which meant that the muscles had to mobilize fat as an alternative source of energy. Since fat is not water soluble, transporting fat through the blood stream requires packaging it inside a micelle wrapped in phospholipids -- a lipoprotein. Hence the elevated LDL & apoB.
The solution is simple: consume some carbs before and/or during exercise, and learn about the translocation of GLUT4 receptors if you are concerned about hyperinsulinemia.
no surprise that your reference is from Nicholas Norwitz. It's good he self-owned with the KETO-CTA trial and showed everyone that isn't already bought into the low card dogma that it's clearly a disaster for CVD risk
I agree the results after one year of a keto diet don't prove much, but getting that test seems like a good idea. I hope they'll keep testing and reporting the results for years, so we can learn more about the long term effects of a keto diet. And if it does cause problems, they'll want to know ASAP.
CAC tests come with a non-trivial radiation exposure if someone is getting them every few years.
The other problem is that they’re picking and choosing which tests to believe and which to ignore.
They disregard their cholesterol tests because they don’t like the results, but embrace one or two CAC tests because they do like the results (when they’re young).
However the CAC results are a lagging indicator of cumulative damage that has been done. Cholesterol tests are correlated with the rate of damage occurring.
So embracing CAC and using it to justify ignoring LDL and others is the problem.
I think the unknown factor here is whether other benefits of keto over a standard American diet--possibly including reduced inflammation, BP, blood glucose, and body weight--balance out the effect of cholesterol. CAC measures actual damage already done, while cholesterol is just one of many factors.
The downside, of course, is that once the damage is done, it's done, so it's a risk. (And as you said, they won't see the damage in their 20s.)
This is correct advice, thank you. I am reminded once again that correlation != causation and that doing tests 'just to be sure' is not a healthy or safe way to live. There is a lot of literature out this on what makes a good screening test.
can attest that this test is worth it. despite having no symptoms i decided to take at 32 yo it since I have a family history of cardio problems. altho no calcified plaque was found, it uncovered other serious issues I wouldn't have know about otherwise for probably a decade or two. if you call around different radiology labs you can get it for as low as $200 -- be warned tho many places (esp hospitals in my exp) will quote far higher numbers.
There are many different schools of thought regarding diet and nutrition. No topic is more controversial since everyone with a stomach has an opinion.
There is science but that has to be believed in. Depending on your favourite foods and your values, you have to dismiss one half of the science as paid for by big beef or the other half as vegan propaganda.
A change in my environment led me to re-evaluate my food choices and I was open minded to completely changing everything. However, I did not go down the butter and bacon route. I became strictly whole food, plant based. This means always cooking from scratch with no processed foods or animal products. It is just an ongoing experiment with a study size of just one.
I did my research and upped my kitchen game. I was surprised at how much I used to enjoy no longer interests me and how easy it has been to stick to a diet rich in vegetables, beans, pulses and much else that I previously never cared for.
So, why am I telling you this?
Well, some believe that a whole food, plant based diet is best for your arteries. Having given it a spin to have a body that I am happy with, I am hoping they are right.
Do your own research with scepticism. Remember that nutrition is highly controversial and, just out of intellectual curiosity, see how it goes on a whole food, plant based diet. Originally I was only going to try and go without processed food for a month, but, with that target met, I kept going and learned more about nutrition just in case there was anything I was missing out on. The only thing turned out to be vitamin B12, which I supplement, with that being the only supplement.
Plaque regression is possible through aggressive LDL lowering (statins+ezetimibe/PCSK9i), lifestyle changes, and has been documented in clinical trials like REVERSAL and ASTEROID showing 6-9% regression with intensive therapy.
AIUI per my doctor wife, plaque cannot currently be reversed with a medication. It's about minimising future risk rather than reversing damage. Remodelling the plaque with medications does happen to a limited extent as commented elsewhere in this thread.
So, the simple explanation is this: Cholesterol is a necessary and important chemical, specifically, it is a sterol, and a precursor for Vitamin D, cortisol, estrogen, testosterone, and the substance that makes up the myelin sheath is. Cholesterol is not, and never will be, "the bad guy". Your body produces almost a gram of it a day, but dietary amounts are only about a third of that.
It it also the backbone of apolipoprotein, which is the actual thing your Doctor is talking about when they say "good cholesterol" and "bad cholesterol". Apo combined with other things (triglycerides and phospholipids) make HDL, LDL, and other familiar "cholesterol particles".
Since they shuttle fatty acids around, these fatty acids can be oxidized. When there are too many lipoprotein particles than your cells can safely clear, macrophages end up being targeted by the particles. Macrophages that take on too many damaged particles (damaged by the fatty acid oxidizing) can ram into arterial walls, which summons platelets to try to fix it.
The platelets use a calcium-based substance to fix the damage. Its sorta like organic concrete. Over a lifetime, your arteries become clogged with the concrete.
So.
The western diet and lifestyle lacks many important things required for healthy living. One of these is sufficient sun. Although Vitamin D supplementation is absolutely required for many people (most science is indicating that 2000 IU isn't even enough but is a bare minimum), we also have extremely little K2 in our diet compared to our ancestors, since it comes from certain fermented foods, and we largely no longer eat the correct fermented in sufficient amounts foods, even though it has been a staple of our diet at least 20 or 30 thousand years; long enough that it has changed our gut bacteria to basically necessitate it for many reasons.
K2 is required for signaling of arterial plaque removal, among other things. That organic concrete? It's not meant to be permanent, its meant to merely to stop you from potentially hemorrhaging.
Also, fun fact, anticoagulants that act as K2 antagonists (Warfarin, etc) lead to vastly increased arterial calcification (since, as an antagonist, it blocks K2 signaling). Those anticoagulants also can lead to brittle bones, because K2 is also used for signaling in a few biological processes that want to deposit the calcium in the right place.
So, I could just say "eat healthily", but nobody knows what the fuck that means. Beef liver and hard cheeses are good sources of K2, so is Sauerkraut and Kimchi. Supplement companies also sell good Vitamin K-focused multivitamins, many of which are a oil-filled gelcap with K1, K2 MK4, K2 MK7, and a meaningful D dosage (so its a drop in replacement for your daily D gelcap) (ex: Jarrow K-Right, but all the major good ones have a product like that).
I have not seen it yet, however I have heard favorable responses about it. The responses have largely been that Dave's theory is basically a near-complete summary of science that doesn't include roughly the past 5ish years of scientific advancement, so it isn't entirely right, but a good deal of the way there. He's been shaping this theory for like a decade now. People who are more familiar with this (such as career research endocrinologists) have given favorable commentary about it, but it isn't perfect and has small gaps.
I have seen him speak about his theory on a few well known medical/science podcasts, so I am a little familiar with his work so far. I find it interesting that he isn't a career biologist in any way, but a software engineer. So, I imagine he'd fit in with the HN crowd quite well.
The major part of his theory I think that is interesting is people who have weird insulin responses (ie, have been or are insulin resistant; so, have, had, or will have Diabetes) have largely shaped what we consider normal cholesterol numbers. Also, people who are lean and eat low carb may just naturally have different ratios of cholesterol numbers; iirc part of his argument involves the LDL-P(articles) to LDL-C(holesterol in the particles) ratio or LDL-C to TG ratios, and how it may be that they have "bad" ratios that most doctors would try to treat with statins, but there is actually nothing wrong with them, as other biomarkers and CAC scans indicate there is no increase in arterial damage even though they have "bad" ratios.
So yeah, I'd consider it worth watching, but don't take it as gospel. If it shows up on a streaming service I have, I'll consider giving it a watch.
It is expected to be 0 if you're under 45 years old or so, I think. When I did a CAC test, the results came with charts showing where I was compared to the expected value for my age.
Also, taking a statin can increase the CAC score because statins cause fat build ups to calcify faster which makes them less likely to break free and cause big problems.
My experience is, your total cholesterol is over 200 (with some more specifics about LDL I can't recall, like 130 or something), all doctors everywhere will then hound you incessantly to get on Crestor, immediately. Diet and exercise don't matter (they cite research showing it doesn't make a difference). Whether you have plaque or not isn't considered, you need to be on Crestor right now to prevent it from starting anyway.
My cholesterol started really going up in my late 40s and I can concur an aggressive change to my diet where I significantly reduced my saturated fat intake and I lost about 20 pounds made absolutely no difference, and my total cholesterol started hitting 300, so I'm on the Crestor. My initial dose did cause me to have elevated liver enzymes and my total cholesterol went to about 170 in about a month, so I'm on an extremely low dose on alternating days.
I initially had an LDL of 152 and was prescribed Atorvastatin which gave me dizziness. So I switched to Pravachol with no side effects. But I needed to increase my dosage to get under 100 LDL and Pravachol is limited to 80mg. So I switched again to 10mg of Rosuvastatin which took me from 114 down to 83 also without side effects.
I got dizziness from lipitor (only in the hours after taking it) and I determined it seemed to be due to dehydration so now I just make sure to drink enough water and no more dizziness. Cut my LDL in half in 3 months and now I take every 2 days
i had the elevated liver enzymes on a higher dose (10 mg / day which is not considered a high dose) and jury is out on whether or not I perceive muscle weakness. unsure
It is surprising that no one has mentioned antioxidants and green tea yet.
Cholesterol is a substance the body naturally produces and requires for many functions. In the brain, cholesterol is essential for building and maintaining neuronal membranes, supporting synapse formation, and enabling myelin production. Statins interfere with cholesterol synthesis in the brain and have been associated in some cases with brain fog or short-term memory issues.
Cholesterol itself is not inherently harmful. It is oxidized cholesterol that causes atherosclerosis.
Antioxidants such as those found in green tea help prevent LDL oxidation.
I got a CAC scan for $75 just to catch anything crazy and I found out that I don't have a right coronary artery and also that I have 2 superior vena cava. My calcium score was 0 though so that's awesome.
One close friend died of a heart attack at 42 and another found a 95% blockage after his CAC scan came back north of 900 at age 40. I'd get it if it's available, the ability to catch certain catastrophic conditions is invaluable.
If you have all your numbers, you can run your own risk calculation. Definitely useful before deciding on this scan, or when talking to your doctor about statins (a lifetime drug).
“20% risk means we need to without a doubt medicate people for the rest of their life!”
This really says something to me about American medicine. Something is going to get you at some point. Is something that has a 80% risk of not happening really justify medication which comes with it own cost and risk?
Another article on this topic was posted a few weeks ago and prompted the same reaction in me.
Statins are a lot like climate change. Two sides, the establishment versus outsiders, each claiming their side is correct, arguing over mountains of data that you can never personally verify.
However, there is zero financial incentive for a physician to prescribe a statin. They are all generic medications. A month prescription is approximately $10.
We do not yet have final word on this topic, we will have a better understanding as time progresses, but until then I continue to recommend statins to my patients with appropriate risk factors, for the same reasons I find climate change credible. The data showing benefit is not just limited to the United States, it is international, and to essentially falsify something involving millions of individuals and thousands of researchers around the world just isn't feasible.
> There is zero financial incentive for a physician to prescribe a statin.
Well, doctors make money when they prescribe drugs: Patients will make more doctor visits when they are on prescription medications than if they are not.
> The data showing benefit...
The reason for the benefit is not fully understood. The argument is that the benefit comes not from lowering cholesterol but from reducing inflammation and stabilizing plaque. The medical community has no incentive to research this because they are raking in money, and any further research could only slow down the gravy train at best.
Setting aside the fact that the majority of people prescribed them tolerate statins with minimal side effects, there are other therapies besides statins available for treating dyslipidemia such as PCSK9 and ANGPTL3 inhibitors, to say nothing of non-pharmaceutical lifestyle interventions one can make.
Therapy for what, exactly? Cholesterol? A substance the human body naturally produces because it needs it (cholesterol is a key structural component of every cell membrane in the body)? A substance that has not been conclusively proved to be harmful?
Excess LDL and VLDL cholesterol have absolutely been shown to be harmful. We know from studies of familial hypercholesterolemia, a disorder caused by single mutation in the LDL receptor gene, that too much LDL cholesterol directly leads to artherosclerosis and early death from heart disease.
There's a pretty direct analogy to type 2 diabetes and metabolic disease generally. The human body naturally produces blood glucose and we would quite quickly die if our blood glucose levels went to zero. That doesn't mean that hyperglycemia is healthy and in fact, we know it directly causes all kinds of bad health outcomes. We absolutely need some LDL cholesterol, and in our evolutionary history when we faced famine there was probably some selection for people whose livers didn't aggressively metabolize LDL particles from the blood (an energetically costly process), but that doesn't mean that high LDL cholesterol today is safe if you're hoping to live a long life.
If LDL cholesterol is the villain it is made out to be then lowering it — by whatever means — should produce a proportionate reduction in heart disease. It does not (see ENHANCE trial [1]).
And yet lowering cholesterol using statins has proved beneficial for people who have already suffered heart attacks. How do you explain this? One explanation is that statins work for these people not because they lower cholesterol but because they reduce inflammation and stabilize plaque.
The science behind this is not fully understood. Big Pharma has no incentive to research this because they are raking in money, and any further research could only slow down the gravy train at best.
Cardiologists don't do their own research. Drug companies do the research, and cardiologists are limited to just trusting the drug companies. So then the question is how trustworthy are the drug companies? Pfizer’s Lipitor raked in $125 billion between 1996 to 2012, becoming the world’s best-selling drug of all time. You don't think drug companies are even a little bit motivated by profits?
You are right about one point: You should absolutely not trust a random medium article, anyone can write medium article. Instead you should follow the links, then decide whether the experts quoted in the NYT and Bloomberg articles have a point.
And you're offering nothing to back up your claim. Literally everything written in the article is backed up by sources such as New York Times, which in turn quotes experts in the field.
- Is it not true that the existence of a link between high cholesterol and heart disease is only a hypotheses that originated in the 1950s, not a scientifically proven fact?
- Is it not true that the FDA generally has not required drug companies to prove that cholesterol medicines (such as statins) actually reduce heart attacks before approval?
- Is it not true that lowering cholesterol by different means (i.e., other than statins) is not beneficial, and does that not mean cholesterol is not the villain it is made out to be?
- Is it not true that the only large clinical trial funded by the government (rather than drug companies) found no statistically significant benefit at all?
After I had a heart attack I was told that there’s no value in doing this test at that point. A couple years later at age 40 another doctor did order it for me and my score was 0, which apparently tells me I’m not on the verge of another heart attack, so that’s nice.
the score itself isn't the only relevant thing in the report. ask to see what the radiologist actually wrote and read it yourself. ai, aided by clarifications by a cardiologist, helped me understand the details immensely
CAC is pretty common, but I prefer Coronary CT Angiography, which is much more detailed CT of the heart and coronary arteries using IV contrast. It's a bit more radiation, but it shows soft plaque and arterial narrowing, which CAC does not.
It's better, but the contrast and much higher radiation dose compared to CAC carry their own risks. Individuals can evaluate their own risk but I wouldn't get this test under the age of 40 or 45 or so unless I had diabetes.
A CAC scan is a non-contrast CT scan and a coronary angiography is a contrast CT scan.
They are both ECG gated scans of the heart otherwise so they're pretty much the same scan area and same scan duration, if you're hooked for a Coronary CT angiography you can easily get the CAC at the same time by doing a scan sweep before contrast administration (at the cost of 2 minutes of time and an extra dose of radiation)
Though the logistics surrounding contrast administration makes it a bit more fiddly with a slightly higher risk profile.
I got one a couple of years ago when I was 41 due to a recurring palpitation and non-standard EKG reading. They are more commonly used to really get a good view of things before heart surgery, but it really depends upon your doctor. The cost usually ranges from $300 to $1,000.
Before getting a CAC scan, I'd probably do these tests first:
* ApoB - about 20% of people with normal cholesterol results will have abnormal ApoB, and be at risk of heart disease.
* Lp(a) - the strongest hereditary risk factor for heart disease.
* hs-CRP - inflammation roughly doubles your risk of heart disease
* HbA1c - insulin resistance is a risk factor for just about everything.
* eGFR - estimates the volume of liquid your kidneys can filter, and is an input to the latest heart disease risk models (PREVENT).
Easy to order online: https://www.empirical.health/product/comprehensive-health-pa...
CAC is great for detecting calcified plaque in your coronary arteries. But before you have calcified plaque, the above risk factors tell you about the buildup of soft plaque. And 4 out of 5 of them are modifiable through lifestyle, exercise, and medication.
CAC is the right test for people who already have identified that they have major risk factors such as metabolic syndrome/T2D, high cholesterol, etc. It identifies whether heart disease has already advanced enough that the risk factor has become a risk.
Some of the tests you list (like A1C) are baseline things everyone should get checked every year. Agreed that the others could provide value for those who want to know more about their risk level; however, it’s uncommon for those tests to turn up positives without one of the baselines having already raised at least a yellow flag.
None of the tests you listed will tell you whether you have any soft plaque buildup. They just tell you more about your risk factors. However, there are ultrasound tests that can detect increased blood pressure in major arteries, which IIRC does reflect soft plaque buildup.
Lp(a) is a once in your lifetime test and also not very expensive.
Sometimes free as well. Certain CROs offer free screening: https://cardiometabolicscreening.careaccess.com/en?_gl=1*1du...
The test cost me $35.20 and I found out that I have sky high Lp(a), 218 nmol/L. I already take a statin and my cholesterol is well under control (LDL 83). But as has been pointed out, Lp(a) doesn't respond to statins. I'm getting a calcium score done (probably won't be covered but we'll see).
I'm prescribed a baby aspirin for the Lp(a). The AHA no longer recommends baby aspirin to the general population but 218 takes me out of the general population. The thinking is that Lp(a) clots and baby aspirin counteracts that.
Yeah. I've got that evil gene. Presumably took out my uncle at 55. But I'm much more active and my heart still works properly.
I've had high-ish LDL for ages and diet alone couldn't knock it all the way down.
It's only the CAC score that provided me with peace of mind that I didn't need to reach for statins.
The way I view this is that, if you can get more information, why wouldn't you? Cost of course, and I understand why insurance might not cover the procedure, but anybody of a certain age with any risk factors who is in a position to afford it benefits from doing so.
I have a CAC score of zero (no calcified plaque) and I take both a statin and ezetimibe to lower my LDL and ApoB. I disagree with your assessment that your CAC score along means that I statin wouldn't lower your risk.
The problem we’ve found is that when you get more information, you are more likely to find things that look off somewhere, which may have no real bearing on your actual health but definitely can cause you to have a worse quality of life—whether because of stress or subsequent more invasive tests or just the time and energy it costs you.
This is why there are tests which previously were recommended to a wide range of people on a regular basis which are now only recommended in more limited settings. PSA is a good example of this.
The question to ask is, is doing this test likely to improve my life, or not? And while you probably can’t know the answer for a specific test in your specific case without trying, you can often know the probability that it will improve your life based on statistical analysis of other people who have gotten that test and how it went for them.
No, CAC only tests for end stage calcified plaque which is how your body tries to transform soft plaque. It's soft plaque that first lines your arteries and is capable of rupturing. You might be infested with soft plaque, but if none of it has calcified yet (which can take decades) then you'll have a CAC score of zero.
Using CAC store to gauge risk is like waiting until you have end stage symptoms of any disease before you consider yourself at risk. The ship has already sailed and you should have instead focused on prevention for decades.
The sibling comment is a great example of the misinformation here. They have high cholesterol but a CAC score of zero gave them the peace of mind to not use statins.
Saw your link, did your test and here's my feedback.
No "share" or "download" button in the app? Sure, "apps are cool" and all that - but what about folks who want to archive or share their health data? AFAIK literally no provision to share all those nifty biomarkers with my doctor (except many, many screenshots)?
Nowhere in the "how to get blood test" email instructions does it bother to mention a urine sample will also be needed. Kinda useful to know if you should not pee right before heading to the lab.
Fascinating how these tests are something that is an option in America with people getting them.
In the UK we have the NHS and, although private healthcare is available, the NHS are gatekeepers with long waiting lists to see the doctor.
In UK culture you are just not going to 'waste NHS time' by asking for the tests that could inform you on what lifestyle choices you might need to make in order to head off chronic non-communicable diseases. You have to get a chronic disease, then the doctor will interpret the test results and not let you know what the numbers are, just what medication to take, optionally with lifestyle changes.
As a consequence, nobody in the UK knows what their cholesterol levels and whatnot are, yet, in the USA, plenty of people know these numbers.
Do healthcare providers actively upsell testing in the USA?
>Do healthcare providers actively upsell testing in the USA?
In my experience, normal doctors do not, but there are a lot of private businesses that make their living selling testing.
Also, consider that despite a lot of people knowing their levels in the US through testing availability, health outcomes are not better. So, we know more, but don't do anything about it. I don't know what's worse.
I think, politely, this perspective misses the forest for the trees (or maybe the trees for the forest).
Out of the approx. 250 million adult americans, a large cross section do manage their health.
While average outcome might be better in the UK, it's useless to lump the 60% (150 million) of americans who are not obese in with the 40% (100 million) who are obese. And while this is easily the most major, it is just one measure of health.
As an anecdote, I saw just this morning plastic adirondack chairs for sale outside a grocery store, and they had a large sticker on them proclaiming in 4-inch lettering that they are rated for 350 pounds(!). That says something sad about the U.S.
As an aside, I am amazed that chairs can be sold without some redundancy, in case of breakage. 350 pounds is not exceptional these days, that is only 160Kg, which is only 90 Kg more than what I weigh with clothes, cup of tea and plate of food... 80Kg is reasonable for a healthy person and two people should be supportable by the chair.
However, chairs get left outside and they can rot. This can lead to collapse even if a 50Kg person gets on. This can be incredibly dangerous. Hence every chair should have a secondary support structure, in some cases this can be wire under tension, other times it might have to be steel tubing.
There are thousands of chair designs, none of them built for the ultimate eventuality of catastrophic failure.
No. There's a *big* difference between the load limit printed on something and it's true expected failure point. As somebody could be hurt by the chair failing I would expect the real strength to be in the ballpark of 3,000 pounds or even more. Figuring the permissible % of expected yield point is handled by the engineers, normally not by the end users.
Load ratings near the failure point are only done when the failure will not cause a problem, or when the failure is actually a desirable property (breakaway tethers of various types.)
And is that really so horrible? I would not own a chair flimsy enough that my wife couldn't sit on my lap when I was sitting in the chair.
> That says something sad about the U.S.
That a lot of couples like to share the same chair??
They are better. Life expectancy at birth in the US is dragged down by myriad societal issues but if you survive to middle age, life expectancy begins climbing to the highest in the world.
Really you just need to look at it by state to see the huge difference. There is almost a 10 year difference between the best and worst states.
In the UK, a cholesterol test is offered free of charge to everyone over the age of 40 by their GP, as well as younger people if they have a BMI over 25 or have a family history of high cholesterol levels or heart problems.
They're also available from most community pharmacies (again free of charge for at-risk patients, but for everyone else it should be about £10 for a simple finger-prick test or £30-50 for a full lipid profile).
That is interesting to know, clearly I never knew. It takes about two months to get an appointment where I live so I am not inclined to get a cholesterol test with no good reason. When I registered a blood pressure test, height and weight was all that was needed. With healthy blood pressure and a BMI of 19.5, I would like to see that full lipid profile. However, if I was in the overweight category, the last thing I would want to see is the lipid profile!
By community pharmacy, does that include a typical Boots the Chemist?
Yep, community pharmacy = anything outside of a hospital or similar setting. So Boots, Superdrug, or your nearest no-name chemist on your local high street.
I know my cholesterol numbers going back almost twenty years, over something like 15 tests. This is because that first test around 2007 showed my HDL was ridiculously low. So I took steps to modify it, and tested again (and again...) to see how it was progressing.
How can you increase your HDL?
N=1, but: I read that carbs lower HDL, and I was eating a very carb-heavy diet.
So over about two months I switched to an informal low-carb diet. e.g. I stopped drinking milk, I ate Carl's Jr. six-dollar burgers as lettuce wraps for lunch, and sometimes just roast beef and mayo.
Over three months I lost something like 30 pounds, hitting a body fat percentage around 12% -- this wasn't the goal, but FWIW.
My HDL before was 17, after those three months, 25.
Then I added in various forms of exercise and got it up to about 55.
I've since engaged in various diets, and levels of exercise -- although I've never gone back to the original diet where whole meals consisted of a quart of ovaltine. My HDL has never dropped below 40, nor been higher than 65.
Upsell? It's never been a matter of discussion. Doctors orders some standard bloodwork every year. HDL and LDL are part of it.
We don't even have the phrase 'bloodwork' in the UK. Also, in the UK, you can go to the doctor regularly for a checkup to never get this 'bloodwork' thing you Americans speak of. I have never had any done myself, all I get is my iron level when I donate blood, and I only ask about that after curiosity.
Healthcare is very different in America and I am not seeing the benefits of yearly 'bloodwork', it must be an upsell so they can get people onto statins and whatnot for life.
Multiple things are much better caught earlier. Off the top of my head:
Catch the elevated A1c before it does any damage, or get diagnosed from a hypoglycemic episode?? (By which point a lot of damage has been done.)
Catch the elevated TSH and supplement before there are any symptoms, or wait until the patient presents with hypothyroid? Note that the patient will have been through a fair amount of blah before the diagnosis is made. And thyroid hormones are very dose sensitive and it's a couple of months to stabilize on a new dose, so bringing the patient back to normal can take quite a while. US approach, my wife's TSH was high, they put her on some thyroid hormone, no symptoms of hypothyroid and no rush to dial in the dose because it's still within the body's ability to compensate and thus causes no problem.
And the subject of this thread, statins. Again, much, much better caught before it does damage.
I'd add in the LDL subcomponent assay as well -- LDL pattern, particle number, peak size, etc. you can get those and all the ones you mentioned for relatively cheap https://www.walkinlab.com/products/view/cardio-iq-advanced-l...
The latest evidence is that if you have ApoB and Lp(a), then particle sizes don't add any more information. This is the most recent research (published July 2025): https://academic.oup.com/eurheartj/article-abstract/46/27/27...
Given the low side effect rate and limited overall impact, shouldn't the bar for deciding to take statins be near-zero? Like, the articles say if there's a 5% chance of a heart attack in the next 10 years there's no reason to take a statin, but if the statin changes that 5% to 4% (that's speculation on my part) then given the limited side effects it would likely be worth it, right?
Statins often have the side effect of raising blood sugar. So there’s a non-trivial tradeoff for a population that is usually on the edge of metabolic disease.
I know a number of people who report memory issues since starting statins. They also clearly exhibit memory issues but it's hard as an outsider to pinpoint when they started. Unfortunately, they really do need statins.
I used to work with a cardiologist who joked that "we should just add statins to the water," so you have a point.
The current guidelines for prescribing statins are based on your risk of a major cardiac event in the next 10 years (forecasted using a statistical model). But given that plaque builds up in your arteries over your lifetime, there's a strong argument for using a 30-year or lifelong time horizon.
> the low side effect rate
The rate of serious side effects is quite low (e.g. brain fog), but the reported rate for muscle weakness is non-trivial.
It caused a lot of muscle weakness in the legs for two members of my family. The weakness went away for one of them when they stopped taking it.
Anyone know of an equivalent in Europe? Dutch doctors always ignore me and say to come back after I’m dead. (But will happily tell me to take Tylenol)
Switch doctors? Ask on dutch social networks I think? Some stuff will also not be approved/covered.
My cardiologist did all of these except the eGFR. My calcium score was fairly high, but not high enough to be concerning since my cholesterol is controlled and my diet and exercise regime are good now. Until the CAC was done, I had no idea if I had any or not. It's better to deal with cholesterol earlier than I did.
> My cardiologist did all of these except the eGFR
eGFR is typically inferred from serum creatinine (not creatine!), which is part of both a comprehensive and basic metabolic panel (CMP/BMP), which your GP usually orders, along with a CBC, and perhaps an HbA1c.
Unfortunately there is no approved oral medicine to lower Lp(a) that I am aware of. (I mean given a normal LDL.) Statins don't lower it afaik. An oral medicine named muvalaplin is being tested for it.
There's a clinical trial for a new drug, lepodisiran, which lowered Lp(a) by 93.9%.
Outside of that, if your Lp(a) is high, then the first strategy would be to choose a lower ApoB target than you would otherwise. (Every Lp(a) particle is also an ApoB/cholesterol particle, but 6x more atherogenic. So by lowering ApoB, you are compensating for the effect of high Lp(a))
Summary of the current research/evidence is here: https://www.empirical.health/blog/lipoprotein-a-blood-test/#...
There are some in trials. I'm part of one by Eli Lily. Lp(a) sucks, is genetic and so far there was no medication.
The best way to get tested may be in conjunction with a trial. This was can potentially enroll.
This guy talks about lowering his own with collagen and vitamin C
https://x.com/gregmushen/status/1917780163242385586
And another guy lowering his with Amla, lysine and vitamin C
https://x.com/gregmushen/status/1924660722786828584
It is nonsense because I have truly taken all four in good daily doses for years, and my value is still high.
I’ve read that (injection currently, not oral) ‘PCSK9 inhibitors’ may help lower Lp(a) where few other things do today.
https://my.clevelandclinic.org/health/drugs/22550-pcsk9-inhi...
Oddly enough, there's evidence that saturated fat intake inversely affects Lp(a) levels: https://pmc.ncbi.nlm.nih.gov/articles/PMC10447465/
It doesn't help if LDL gets raised due to the SFAs, as LDL is an independent risk factor.
I was just noting the oddness of Lp(a) responding inversely to SFA intake (the reverse of LDL), which also contradicts the conventional wisdom that Lp(a) isn't amenable to lifestyle interventions.
You could theoretically increase SFA to target Lp(a) while still using lipid-altering drugs to target LDL.
Since typical blood tests start at under $10, can you codify the value that the company at that link provides that makes their list price $1,490?
That panel costs $190 (and includes 85 biomarkers).
FWIW, similar bundles I've seen online are priced at $400-$500.
All 85 biomarkers, if purchased separately, would cost a total of $1,490. ApoB, for example, usually costs $60 if done in isolation, Lp(a) is $45, hs-CRP is $65 at Quest, etc. The bundles end up having lower pricing due to volume discounts and being able to amortize some of the cost across biomarkers.
Thanks, that's good information. What is your relationship to the company, if any? I wouldn't ask, but it's common when the answer is "none" to provide that info before anyone asks.
I believe eGFR (via creatinine testing) and sometimes HbA1c (if diabetes screening is ordered) are the only things listed may be part of a routine health check from a common/inexpensive blood test.
Co-Founder of the company (it's on my profile). Yes, you're right--of the biomarkers listed, only eGFR and HbA1c are standard in a routine health check.
Tape on the posters name:
about: Data for good. Co-Founder at Empirical Health (https://empirical.health).
Before: Risk Engineering at Brex
I imagine nothing like this is available in Canada?
The first sign of trouble was chest pains while playing tennis. The pain subsided after a couple of minutes and I was fine. EKG showed no sign of heart attack or major blockage. Prior to that I had no symptoms whatsoever, exercised regularly, never smoked, 57yo male, 6 ft, 175lbs. A CAC scan revealed a calcium score of 411 and a stress test indicated a major lack blood flow to the front of the heart. A cardiac catheterization revealed 95% blockage of the Left Anterior Descending artery, the widowmaker. After placing two stents in the LAD I’m back to normal. It’s a small miracle I didn’t die that day on the tennis court. The CAC definitively diagnosed the life threatening blockage when I had absolutely no symptoms. I recommend everyone get this simple scan to find out if you have this killer inside of you.
63, no history of heart disease, all my numbers in the "normal" range, fit, don't smoke, not overweight, good diet, etc. I was building a greenhouse in the back yard and went from feeling kind of "shitty" to classic left chest and back of arm pain.
It's amazing how fast you get into the ER when you come in like that. I got an angiogram within 45 minutes and also had 2 stents in the LAD with 90-95% blockage.
Glad you’re ok. Stories like this are good to rebase myself and remember how important it is to enjoy life now while I can. No matter how healthy I try to keep myself, luck can change things in an instant.
I'm sure your doc already told you this but chest pain while playing tennis that goes away quickly sounds more like angina than a heart attack. IOW your episode was not a heart attack but rather a strong indicator that a future heart attack was likely and that further tests were warranted.
A real heart attack (MI) -- the kind that can kill you quickly -- is usually not exercise related and the pain continues for many tens of minutes without going away.
PSA: If you experience either type of symptom above, call 911. Don't wait around and don't drive yourself to the hospital. Take an aspirin if you have one handy and you're not allergic to it. Real aspirin, not ibuprofen or tylenol.
Since you mentioned take asprin, just curious , how does that help ?
It prevents platelets from clotting further[1].
[1]: https://www.fda.gov/drugs/safe-use-aspirin/aspirin-questions...
Blood thining characteristics
Aspirin is not a blood thinner per se. It interferes with platelet action so it reduces the likelihood of clots forming.
>when I had absolutely no symptoms
Chest pain during excretion is a symptom in my book.
>Recommend everyone to get it
A calcium scan is a ECG gated CT scan(a heart CT). It takes time from the CT machine schedule and it requires radiologists to describe it, meaning it's not infinitely accessible.
> excretion
Heh, I think you mean exertion
I wish cardiovascular monitoring was better. It's not uncommon for cardiologist to discharge you saying 'all fine, EKG ok' even though reality says otherwise.
Happy you got stents at the right time.
EKGs should be extremely easy for AI to identify every disease with a range of probabilities and even some humans can’t identify from EKGs. Do we have the labelled dataset for this?
Eric Topol has a cool post on "machine eyes" -- using deep learning to identify subtle signals in ECGs and medical images that would be invisible to the naked eye: https://erictopol.substack.com/p/the-amazing-power-of-machin...
There are still regulatory/deployment/reimbursement barriers to cross, but this is happening.
You're assuming EKG is definitive.
I had an EKG last week, the analysis comes back "borderline". Running down every abnormality listed (I know my cardiologist has seen it, didn't consider it notable) has a range of possible causes, including the changes that come with good endurance.
There is a decent looking dataset available here, let's see my model can generate random numbers from this for each of the diseases: https://www.nature.com/articles/s41597-022-01403-5
"It should be very easy for an AI to look at an x-ray, CT, ultrasound or MRI image and tell what disease a human got, even some that humans don't know of.
Are there any labeled datasets "
-Some Software dude, every month since 1971
No the examples you give are extremely difficult compared to the 2D graphs of an EKG. The Apple Watch is clearly doing some fairly accurate inference with a single lead around arrhythmias, for example. I’m really sorry for being enthusiastic about machine learning, I just finished doing an intensive ML bootcamp and it was fun getting results. I also actually have some heart issues so I’d love to see if I could get a result. Thanks for your constructive comment though, I’ve never seen ones like this here before!
>I just finished doing an intensive ML bootcamp
Then maybe learn a bit more about the domain before posting silly things.
I'm not talking about me successfully building an AI that can do better than humans or identify all the worlds heart diseases I'm more looking to have fun and play around with some data (and yes learn more about the domain by doing!). I was maybe a bit too excited about seeing what would happen with a real dataset like this, but it's a hacker news comment not a PhD defence, no need to be so negative. Thanks.
I wonder if all symptoms would show on an EKG though. Would reduced coronary blood flow alter electrical signals ?
That’s a stress test.
Attach an EKG, have the patient ride a bike with significant exertion.
If there is a lack of blood flow, it will show up in the EKG as alteration of the electrical signals through the heart.
Well I've been subjected to these tests and I fell between the lines, I was clearly below normal health (had trouble walking) but they said there was no issues. So I wondered if there's not more subtleties. Like lag between effort and signals showing up, or vascular issues like micro clotting impeding flow.
That’s what’s fascinating about AI it might find patterns with enough data that we don’t see.
EKG changes are a late sign. You need structural imaging like CAC or CCTA or echo.
What were your lipids? Was a stress test not conducted?
When did you previously have a stress test before this? Would you also mind sharing what your blood pressure levels were at?
> EKG showed no sign of heart attack
What about troponin? I was told by a Dr that it's more accurate than an EKG.
Edit: I had the word tryptophan before.
Did you mean Troponin? Troponin shows up in the blood when there's been damage to heart muscle.
Yes I meant that! I spelled it wrong on Google, then copy/pasted the wrong word from the suggested replacement.
It’s only if heart muscle dies does that show up, you can have an important artery narrow without symptoms until suddenly a bit of plaque breaks off completely blocking a path causing bits of muscle to actually die.
What I was told in the ER is that troponin basically only shows up when there's been heart muscle damage so is a pretty clear sign. It doesn't show up immediately though - typically a rise within a few hours of the heart attack.
RE: EKGs. There are clear signs in the more detailed 12 lead EKG that can show irregularities in the electrical patterns and specifically help pinpoint the location of the active problem.
For me, it was different.
A cardiologist told me (after a calcium test showed 95th percentile for calcium) that what I was looking for was a rapid drop in ability. Not over a decade, but over a couple weeks or a month. Well, I play ultimate, and one day I realized "I didn't get this winded a month ago". So I got a stress test, and it showed "abnormal motion of the heart wall under stress" (that is, not enough oxygen getting to all the heart muscles). They did a catheterization, and I wound up with two stents.
I mean, look, if you get the chest pains, don't ignore that. But it doesn't have to be that way. If you lose athletic ability, or wind, or endurance, in a short amount of time, get a stress test.
Researchers have discovered that gut bacteria produce a molecule that not only induces but also causes atherosclerosis, the accumulation of fat and cholesterol in the arteries that can lead to heart attacks and strokes.
https://english.elpais.com/health/2025-07-17/revolution-in-m...
Apparently eating too much cheese is a large risk factor.
I'm not sure quip generalizations like that are useful. If it was as simple as cheese bad, we would see the dutch and the like as outliers in statistics, but that's not the case.
https://www.nature.com/articles/s41467-020-19589-w
”we evaluated the full spectrum of nutrient intake and identified a significant positive correlation between ImP [imidazole propionate] and saturated fat intake (driven by high cheese intake)”
Perhaps this depends on the type of cheese consumed.
Of course, it’s a correlation; ImP could be modulating eating habits and making people prefer eating cheese.
This is much more likely related to gut microbia metabolism than it is to histidine. Unlike the dogma wants it to be believed, high protein and fat intake does not necessarily lead to cardiovascular issues. It does when combined with other lifestyle(sedentary, low intensity), metabolic(diabetes/prediabetes, inflammation), nutritional(highly refined carbohydrates, nitrated compounds, oxalate/other anti nutrients and refined seed oils) and dysbiosis issues.
There is an enormous scandal to come behind the vilification of cholesterol and the simplification of its level's interpretation to come, which led to the current epidemic of obesity and metabolic/inflammatory/autoimmune diseases. Cholesterol levels vary hugely based on the genetics, epigenetics and lifestyle of an individual, and there is a very large amount of individuals that are within normal range with much higher ldl levels. For example, the cholesterol levels of centennials are usually extremely high.
Things to look out for: - high very small LDL(you need a proper analysis of your LDL levels with a histogram of the size distribution, which is very rarely done and more expensive) - high Triglyceride/HDL ratio(in US units, anything above 2 is not a very good sign) - high hbA1C (metabolic issues) - high lp(a) and/or lp(b) - high hs-CRP (general inflammation, but can be caused by infection if you are sick)
Usually those are all related and high when affecting a normally healthy individual).
”This is much more likely related to gut microbia metabolism than it is to histidine”
Yes and no: the study linked to in the El Pais article suggests that certain bacteria are converting histidine to imidazole proprionate.
More histidine -> more food for those bacteria -> bacterial overgrowth, dysbiosis and increased ImP levels -> eventually atherosclerosis.
There are probably some microbe(s) capable of outcompeting the ImP-producing ones even in the presence of increased histidine, which would serve as a mitigating factor.
My cardiologist pointed out that hard calcified plaques are unlikely to come loose, so unless there’s significant narrowing, they’re not a big problem. However, that situation correlates with a high calcium score. So the calcium score is not always correlated to risk.
A CT angiogram distinguishes soft vs. hard plaques (and shows narrowing), so that’s the ultimate way to clarify the situation. (Bearing in mind radiation exposure risk and cost, of course.)
Yeah. Dr. Ford Brewer(https://www.youtube.com/@PrevMedHealth) talks a lot about this. I find him to be pretty current and he translates things into an easily understood format.
Basically the calcium stabilizes the plaque. Unstabilized plaque is what can rupture, squirting out from the artery wall into the blood and forming a clot. High cholesterol can cause deposits in the artery wall simply due to chemical diffusion. Inflammation, often caused by metabolic syndrome/diabetes expands the plaques. Idk, I probably got that wrong, but anyway calcium scores aren't well correlated with risk.
Calcium score is mostly for trends over a period of time, to get a sense of progression of disease. A single reading is not very useful is what I was told
Don't statins calcify plaques? So presumably being on statins would raise the score?
Exactly, the score would be going up, but for a good reason. Best to have no plaques, second best to have calcified ones.
It is free where I am but the radiation is a problem: maybe every 5 years is OK?
yeah generally CT scan has crazy amount of radiation. want to probably switch to another test (like an echocardiogram) for long term monitoring
Better characterisation on CAC is key. This is a software problem - AI will help.
One thing I’ve wondered is why getting a diagnostic test done out of pocket in the US of your own volition (without a doc prescription) isn’t possible. Why does it need to be controlled by a doc and insurance?
In India this is common. They probably use the same expensive machines for x rays and MRIs but anyone can walk in, and pay for a diagnostic test and get numbers (well, not everyone can afford it, but generally middle class folks can). I’m not saying the healthcare system in India is great, but this distinction intrigues me. Maybe the volumes are much higher in India so the diagnostic center can recoup costs? Are there laws preventing this business model in the US?
Some of these imaging that are overdone in India involve radiation: the most problematic being (not low dose) CT. So there is a rationale for controlling these modalities.
A Doctors refferal for preventative tests are easy though. I've done this in the USA fwiw due to a family member having a heart attack at a very young age. Go to a doctor and state "I have risk factors for heart disease and would like a reference to https://stanfordhealthcare.org/medical-clinics/preventive-ca... ". Other hospitals (eg. Mayo clinic) have similar programs.
Any decent doctor should agree to this. Once you have a reference you'll be put through a battery of tests. Blood tests, ECG, ultrasound, etc. A lot of it was covered by insurance anyway but it was out of network for me. That didn't matter to getting the reference though. The tests they do are all non-invasive and not risky in the first phase so definitely worth doing.
Its not impossible to get diagnostic tests done outside the scope of a GP. It's generally very expensive.
I get a 6 monthly KUB ultrasound and xray for around 1k inr which is around us$10. If I go to a government hospital and ask the emergency doctor for a test when there is a lean time for them, they prescribe the test and its done for a hundred bucks or $1.
My impression (might be wrong) is that one can get this for some subset of blood tests but not say an MRI or x ray, let alone more complex tests. Are these just insurance company rules? If I found a way to make it profitable can I open a diagnostic lab independent of insurance companies?
Diagnostic labs are just for-profit companies. They’re happy to do tests as long as they get paid by somebody. The only practical restrictions are if you want to convince insurance to pay for it. If you’re paying cash, you can get anything from a simple blood test up to a full-body MRI scan [0].
I got a CT angiogram from a cardiologist here who started her own business specifically to do them. (It’s just her, a nurse, and a CT machine, in a trailer in a parking lot!) Insurance doesn’t pay for imaging like this until things have already gone very wrong, and she feels it should be used much earlier for people who have risk factors.
[0] https://prenuvo.com/
CT is radiation. This is a case where too much testing is detrimental, not merely wasteful. You're sucking up 4 years worth of background for that CT angiogram.
I agree, it’s not recommended to get CTs on a whim. I have high risk factors, a high calcium score, and a bad family history, so getting the data to guide our mitigation approach was worth it.
The preventative heart health program i linked above at Stanford does an echocardiogram calcium score rather than a CT scan for the first phase. Saves you from radiation unless they see something that warrants it.
It is no issue at all to ask for and receive an echocardiogram referral since it has no risk, just ask for a referral.
The unwillingness to do anything involving radiation unless warranted seems reasonable. Just do the echocardiogram and go from there.
You can have those tests done, it's just timing and cost.
For example: https://radiologyassist.com/MRI.html
I recently requested this test from my doctor. The lab technician asked if I had requested it or my doctor, and gave a very judgmental "that's what I thought" type response. Ends up I was 95%-tile and put on an aggressive statin therapy, from a risk profile that otherwise didn't determine statin use. The test was easy and (relatively speaking) inexpensive. It helped me in risk stratification in a determinative way.
I got pitched (along with a bunch of other people at an investment conference) on an insanely expensive concierge medicine service and they trotted out some super impressive doctor who was fascinating. Anyway the thing that stuck was that he said it takes 10-20 years for meaningful advances in medicine to show up in general use, which was a little depressing
>he said it takes 10-20 years for meaningful advances in medicine to show up in general use
Could it be that it takes that long to determine whether those advances are actually worthwhile? I can’t count the number of HN posts I’ve seen touting breakthroughs in medical research that ultimately didn’t pan out.
No, this is the time it takes for the proven treatment advances to reach rank-and-file doctors (and insurance policies). I've read the numbers 17 to 22 years I think. There are studies on this, but I don't have references handy.
That’s not true in my experience.
Look at the adoption of CAR-T therapies. It took 3-4 years before they were regularly used in the US.
https://archive.ph/uqvkl
It cost <$200 to go pay cash and get a calcium score yourself. Its hard to talk a cardiologist into getting your insurance to pay for it if you're young. As a male who had a grandfather die in his 30's from heart disease it was even hard. If you're worried about this at all just pay for it yourself. I also reccomend getting Lp(a) testing (<$50) if this concerns you, DYOR, but it will give you a better grasp on how your body is handles bad cholesterol (everyone is different).
These tests expose one to a fairly high dose of radiation. From a quick googling, there does seem quite a range in exposures for this test. That being said, you probably don't want to get one of these scan every year.
my doc recommended doing alternative tests to monitor instead (eg echocardiogram)
https://archive.today/ckFV7
(coronary artery calcium testing)
https://web.archive.org/web/20250726182350/https://www.nytim...
This test is also being heavily misused and misinterpreted in some online communities. There are a lot of people posting CAC scan results after something like a year of keto dieting in their 20s or 30s and using that to conclude that the saturated fat connection to atherosclerosis is a myth or that high cholesterol is fine.
These tests don’t have perfect accuracy and resolution, so low or zero results don’t mean that a lifetime of high cholesterol won’t catch up with someone in their 60s and 70s, yet a lot of podcasters and social media influencers are making those claims.
Also age is huge so people shouldn't be reading much into a reading of 0 unless you're over 65. https://dirjournal.org/articles/coronary-artery-calcium-scor... (see table 2)
Imagine claiming "my diet is great, i got 0% on my calcium score" when that just means you have the same score as 95%+ of people at age 40.
By 55, 25% of people start showing some % of calcium and at 65, 75% of people have a reading on calcium score.
So anyone under 45 being proud of a zero score is just silly.
Is this a keto diet that's mainly leafy greens with healthy protein like salmon? Or is this the "keto" diet of bacon and steak and as much fast as one can shove in the food-hole?
> keto diet that's mainly leafy greens with healthy protein like salmon?
A ketogenic diet is 70% fat.
It’s literally impossible to get into keto with a diet of leafy greens and salmon. You would have to augment with a lot of fat from some other source and also limit salmon intake to avoid consuming too much protein. Salmon has too much protein and not enough fat to even come close to keto ratios.
You must be thinking of a different diet. A lot of people think keto is another word for low carb, but a real keto diet is very low carb and low protein.
I don’t understand why some prople claim that diet does not impact cholesterol. I did ‘keto’ with bacon/steak/chicken/etc for 3 months, got bloodwork done before and after and my LDL went through the roof.
In contrast, I had a high LDL of 190, largely genetic, and panicked and switched to a vegan diet. I had my LDL tested again 10 days later and it was 120. I couldn't keep up with the strict diet, but learned some good habits and to avoid saturated fat. My doctor hasn't recommended statins... yet.
There’s an offshoot of the keto community that has become die-hard cholesterol deniers. They don’t necessarily argue that keto doesn’t raise cholesterol. They argue that it doesn’t matter to have high cholesterol. They believe doctors and science are wrong on the subject. They think statins are evil. They embrace a few fringe doctors who agree with them.
If you do try keto again, bacon and such are the worst way to do it. Getting your fat content from a monounsaturated source like avocado oil can be helpful. Taking statins is also a good idea.
Years ago I also experienced very high LDL after a few months of low carb. A doctor was convinced it was genetic (familial hypercholesterolemia) even though multiple earlier tests over the years had been in the normal range. He had never heard of low carb cholesterol hyper responders and dismissed that diet could have to do with it.
Nowadays I am convinced that what happened was completely explainable by the Lipid Energy Model [0]. Five days a week I was doing 60~90 minutes of cardio in the morning after skipping breakfast. Exercising in a fasted state while on a low carb diet meant that I had very low glycogen in my muscles and liver, which meant that the muscles had to mobilize fat as an alternative source of energy. Since fat is not water soluble, transporting fat through the blood stream requires packaging it inside a micelle wrapped in phospholipids -- a lipoprotein. Hence the elevated LDL & apoB.
The solution is simple: consume some carbs before and/or during exercise, and learn about the translocation of GLUT4 receptors if you are concerned about hyperinsulinemia.
[0] https://pmc.ncbi.nlm.nih.gov/articles/PMC9147253/
no surprise that your reference is from Nicholas Norwitz. It's good he self-owned with the KETO-CTA trial and showed everyone that isn't already bought into the low card dogma that it's clearly a disaster for CVD risk
Have you seen/read cholesterol code? It doesn't deny cholesterol but rather has interesting, and unusual findings.
https://cholesterolcode.com/
There’s a good talk as well that presents this information in a very accessible way:
https://youtu.be/jZu52duIqno?si=NCEf4UGtgHG9sBOP
I agree the results after one year of a keto diet don't prove much, but getting that test seems like a good idea. I hope they'll keep testing and reporting the results for years, so we can learn more about the long term effects of a keto diet. And if it does cause problems, they'll want to know ASAP.
CAC tests come with a non-trivial radiation exposure if someone is getting them every few years.
The other problem is that they’re picking and choosing which tests to believe and which to ignore.
They disregard their cholesterol tests because they don’t like the results, but embrace one or two CAC tests because they do like the results (when they’re young).
However the CAC results are a lagging indicator of cumulative damage that has been done. Cholesterol tests are correlated with the rate of damage occurring.
So embracing CAC and using it to justify ignoring LDL and others is the problem.
I think the unknown factor here is whether other benefits of keto over a standard American diet--possibly including reduced inflammation, BP, blood glucose, and body weight--balance out the effect of cholesterol. CAC measures actual damage already done, while cholesterol is just one of many factors.
The downside, of course, is that once the damage is done, it's done, so it's a risk. (And as you said, they won't see the damage in their 20s.)
This is correct advice, thank you. I am reminded once again that correlation != causation and that doing tests 'just to be sure' is not a healthy or safe way to live. There is a lot of literature out this on what makes a good screening test.
can attest that this test is worth it. despite having no symptoms i decided to take at 32 yo it since I have a family history of cardio problems. altho no calcified plaque was found, it uncovered other serious issues I wouldn't have know about otherwise for probably a decade or two. if you call around different radiology labs you can get it for as low as $200 -- be warned tho many places (esp hospitals in my exp) will quote far higher numbers.
Places around me do it even cheaper. $50.
What I always wondered is if I get this test done, what would I even do with the results? If my arteries are already clogged, etc.
Can this plaque be reversed?
I hope so!
There are many different schools of thought regarding diet and nutrition. No topic is more controversial since everyone with a stomach has an opinion.
There is science but that has to be believed in. Depending on your favourite foods and your values, you have to dismiss one half of the science as paid for by big beef or the other half as vegan propaganda.
A change in my environment led me to re-evaluate my food choices and I was open minded to completely changing everything. However, I did not go down the butter and bacon route. I became strictly whole food, plant based. This means always cooking from scratch with no processed foods or animal products. It is just an ongoing experiment with a study size of just one.
I did my research and upped my kitchen game. I was surprised at how much I used to enjoy no longer interests me and how easy it has been to stick to a diet rich in vegetables, beans, pulses and much else that I previously never cared for.
So, why am I telling you this?
Well, some believe that a whole food, plant based diet is best for your arteries. Having given it a spin to have a body that I am happy with, I am hoping they are right.
Do your own research with scepticism. Remember that nutrition is highly controversial and, just out of intellectual curiosity, see how it goes on a whole food, plant based diet. Originally I was only going to try and go without processed food for a month, but, with that target met, I kept going and learned more about nutrition just in case there was anything I was missing out on. The only thing turned out to be vitamin B12, which I supplement, with that being the only supplement.
Plaque regression is possible through aggressive LDL lowering (statins+ezetimibe/PCSK9i), lifestyle changes, and has been documented in clinical trials like REVERSAL and ASTEROID showing 6-9% regression with intensive therapy.
At least one clinical trial is underway for a drug that can remove the plaques: https://www.lifespan.io/news/cyclarity-launches-human-trial-... But yeah, we badly need more companies doing more research in this space.
Normally yes, through some combination of diet, exercise, statins, and the new kid on the block, PCSK9 inhibitors.
Manganese has been show to reverse plaques.
https://medicalxpress.com/news/2023-11-manganese-bullet-card...
AIUI per my doctor wife, plaque cannot currently be reversed with a medication. It's about minimising future risk rather than reversing damage. Remodelling the plaque with medications does happen to a limited extent as commented elsewhere in this thread.
Yes.
... more info please..
So, the simple explanation is this: Cholesterol is a necessary and important chemical, specifically, it is a sterol, and a precursor for Vitamin D, cortisol, estrogen, testosterone, and the substance that makes up the myelin sheath is. Cholesterol is not, and never will be, "the bad guy". Your body produces almost a gram of it a day, but dietary amounts are only about a third of that.
It it also the backbone of apolipoprotein, which is the actual thing your Doctor is talking about when they say "good cholesterol" and "bad cholesterol". Apo combined with other things (triglycerides and phospholipids) make HDL, LDL, and other familiar "cholesterol particles".
Since they shuttle fatty acids around, these fatty acids can be oxidized. When there are too many lipoprotein particles than your cells can safely clear, macrophages end up being targeted by the particles. Macrophages that take on too many damaged particles (damaged by the fatty acid oxidizing) can ram into arterial walls, which summons platelets to try to fix it.
The platelets use a calcium-based substance to fix the damage. Its sorta like organic concrete. Over a lifetime, your arteries become clogged with the concrete.
So.
The western diet and lifestyle lacks many important things required for healthy living. One of these is sufficient sun. Although Vitamin D supplementation is absolutely required for many people (most science is indicating that 2000 IU isn't even enough but is a bare minimum), we also have extremely little K2 in our diet compared to our ancestors, since it comes from certain fermented foods, and we largely no longer eat the correct fermented in sufficient amounts foods, even though it has been a staple of our diet at least 20 or 30 thousand years; long enough that it has changed our gut bacteria to basically necessitate it for many reasons.
K2 is required for signaling of arterial plaque removal, among other things. That organic concrete? It's not meant to be permanent, its meant to merely to stop you from potentially hemorrhaging.
Also, fun fact, anticoagulants that act as K2 antagonists (Warfarin, etc) lead to vastly increased arterial calcification (since, as an antagonist, it blocks K2 signaling). Those anticoagulants also can lead to brittle bones, because K2 is also used for signaling in a few biological processes that want to deposit the calcium in the right place.
So, I could just say "eat healthily", but nobody knows what the fuck that means. Beef liver and hard cheeses are good sources of K2, so is Sauerkraut and Kimchi. Supplement companies also sell good Vitamin K-focused multivitamins, many of which are a oil-filled gelcap with K1, K2 MK4, K2 MK7, and a meaningful D dosage (so its a drop in replacement for your daily D gelcap) (ex: Jarrow K-Right, but all the major good ones have a product like that).
Since you appear to be quite knowledgeable on the matter, I wonder what’s your opinion on Cholesterol Code and Dave Feldman? Thank you.
I have not seen it yet, however I have heard favorable responses about it. The responses have largely been that Dave's theory is basically a near-complete summary of science that doesn't include roughly the past 5ish years of scientific advancement, so it isn't entirely right, but a good deal of the way there. He's been shaping this theory for like a decade now. People who are more familiar with this (such as career research endocrinologists) have given favorable commentary about it, but it isn't perfect and has small gaps.
I have seen him speak about his theory on a few well known medical/science podcasts, so I am a little familiar with his work so far. I find it interesting that he isn't a career biologist in any way, but a software engineer. So, I imagine he'd fit in with the HN crowd quite well.
The major part of his theory I think that is interesting is people who have weird insulin responses (ie, have been or are insulin resistant; so, have, had, or will have Diabetes) have largely shaped what we consider normal cholesterol numbers. Also, people who are lean and eat low carb may just naturally have different ratios of cholesterol numbers; iirc part of his argument involves the LDL-P(articles) to LDL-C(holesterol in the particles) ratio or LDL-C to TG ratios, and how it may be that they have "bad" ratios that most doctors would try to treat with statins, but there is actually nothing wrong with them, as other biomarkers and CAC scans indicate there is no increase in arterial damage even though they have "bad" ratios.
So yeah, I'd consider it worth watching, but don't take it as gospel. If it shows up on a streaming service I have, I'll consider giving it a watch.
Thank you for the thoughtful and thorough response!
For those who supplement with vitamin d and calcium, do you know the benefits of vitamin k2 to prevent calcium deposit in arteries?
I had a calcium score of zero, is that good? Hereditary high-cholesterol.
It is expected to be 0 if you're under 45 years old or so, I think. When I did a CAC test, the results came with charts showing where I was compared to the expected value for my age.
Also, taking a statin can increase the CAC score because statins cause fat build ups to calcify faster which makes them less likely to break free and cause big problems.
If you’re young: Good but doesn’t guarantee anything.
If you’re old: Great! Keep an eye on cholesterol.
CAC is a lagging indicator. Its usefulness is more about assessing damage done, not rate of change or future risk.
hard to say. the score itself is just a small part of what is included in the report. ask to see the full one to see what all the radiologist found.
This article is so anathema to me.
My experience is, your total cholesterol is over 200 (with some more specifics about LDL I can't recall, like 130 or something), all doctors everywhere will then hound you incessantly to get on Crestor, immediately. Diet and exercise don't matter (they cite research showing it doesn't make a difference). Whether you have plaque or not isn't considered, you need to be on Crestor right now to prevent it from starting anyway.
My cholesterol started really going up in my late 40s and I can concur an aggressive change to my diet where I significantly reduced my saturated fat intake and I lost about 20 pounds made absolutely no difference, and my total cholesterol started hitting 300, so I'm on the Crestor. My initial dose did cause me to have elevated liver enzymes and my total cholesterol went to about 170 in about a month, so I'm on an extremely low dose on alternating days.
Do you have side effects from the statin?
I initially had an LDL of 152 and was prescribed Atorvastatin which gave me dizziness. So I switched to Pravachol with no side effects. But I needed to increase my dosage to get under 100 LDL and Pravachol is limited to 80mg. So I switched again to 10mg of Rosuvastatin which took me from 114 down to 83 also without side effects.
I got dizziness from lipitor (only in the hours after taking it) and I determined it seemed to be due to dehydration so now I just make sure to drink enough water and no more dizziness. Cut my LDL in half in 3 months and now I take every 2 days
i had the elevated liver enzymes on a higher dose (10 mg / day which is not considered a high dose) and jury is out on whether or not I perceive muscle weakness. unsure
It is surprising that no one has mentioned antioxidants and green tea yet.
Cholesterol is a substance the body naturally produces and requires for many functions. In the brain, cholesterol is essential for building and maintaining neuronal membranes, supporting synapse formation, and enabling myelin production. Statins interfere with cholesterol synthesis in the brain and have been associated in some cases with brain fog or short-term memory issues.
Cholesterol itself is not inherently harmful. It is oxidized cholesterol that causes atherosclerosis.
Antioxidants such as those found in green tea help prevent LDL oxidation.
Yes, trying to fight cardiovascular disease by getting rid of cholesterol is like trying to fight rust in your car by getting rid of the metal parts.
I got a CAC scan for $75 just to catch anything crazy and I found out that I don't have a right coronary artery and also that I have 2 superior vena cava. My calcium score was 0 though so that's awesome.
One close friend died of a heart attack at 42 and another found a 95% blockage after his CAC scan came back north of 900 at age 40. I'd get it if it's available, the ability to catch certain catastrophic conditions is invaluable.
If you have all your numbers, you can run your own risk calculation. Definitely useful before deciding on this scan, or when talking to your doctor about statins (a lifetime drug).
https://tools.acc.org/ascvd-risk-estimator-plus/#!/calculate...
“20% risk means we need to without a doubt medicate people for the rest of their life!”
This really says something to me about American medicine. Something is going to get you at some point. Is something that has a 80% risk of not happening really justify medication which comes with it own cost and risk?
Another article on this topic was posted a few weeks ago and prompted the same reaction in me.
This is a recommendation done globally though. 20% risk = statins. This is true in Japan, Europe, China, Oceania, etc.
Why does that fact make it not worth questioning?
Yep, doctors in the US routinely prescribe statins for people with less than 5% risk. Very common.
Why does common equal not worth questioning?
The point of this test is to decide whether to take statins. But statins are a problematic drug, see here: https://medium.com/@petilon/cholesterol-and-statins-e7d9d8ee...
Statins are a lot like climate change. Two sides, the establishment versus outsiders, each claiming their side is correct, arguing over mountains of data that you can never personally verify.
However, there is zero financial incentive for a physician to prescribe a statin. They are all generic medications. A month prescription is approximately $10.
We do not yet have final word on this topic, we will have a better understanding as time progresses, but until then I continue to recommend statins to my patients with appropriate risk factors, for the same reasons I find climate change credible. The data showing benefit is not just limited to the United States, it is international, and to essentially falsify something involving millions of individuals and thousands of researchers around the world just isn't feasible.
> There is zero financial incentive for a physician to prescribe a statin.
Well, doctors make money when they prescribe drugs: Patients will make more doctor visits when they are on prescription medications than if they are not.
> The data showing benefit...
The reason for the benefit is not fully understood. The argument is that the benefit comes not from lowering cholesterol but from reducing inflammation and stabilizing plaque. The medical community has no incentive to research this because they are raking in money, and any further research could only slow down the gravy train at best.
Setting aside the fact that the majority of people prescribed them tolerate statins with minimal side effects, there are other therapies besides statins available for treating dyslipidemia such as PCSK9 and ANGPTL3 inhibitors, to say nothing of non-pharmaceutical lifestyle interventions one can make.
Therapy for what, exactly? Cholesterol? A substance the human body naturally produces because it needs it (cholesterol is a key structural component of every cell membrane in the body)? A substance that has not been conclusively proved to be harmful?
Excess LDL and VLDL cholesterol have absolutely been shown to be harmful. We know from studies of familial hypercholesterolemia, a disorder caused by single mutation in the LDL receptor gene, that too much LDL cholesterol directly leads to artherosclerosis and early death from heart disease.
There's a pretty direct analogy to type 2 diabetes and metabolic disease generally. The human body naturally produces blood glucose and we would quite quickly die if our blood glucose levels went to zero. That doesn't mean that hyperglycemia is healthy and in fact, we know it directly causes all kinds of bad health outcomes. We absolutely need some LDL cholesterol, and in our evolutionary history when we faced famine there was probably some selection for people whose livers didn't aggressively metabolize LDL particles from the blood (an energetically costly process), but that doesn't mean that high LDL cholesterol today is safe if you're hoping to live a long life.
If LDL cholesterol is the villain it is made out to be then lowering it — by whatever means — should produce a proportionate reduction in heart disease. It does not (see ENHANCE trial [1]).
And yet lowering cholesterol using statins has proved beneficial for people who have already suffered heart attacks. How do you explain this? One explanation is that statins work for these people not because they lower cholesterol but because they reduce inflammation and stabilize plaque.
The science behind this is not fully understood. Big Pharma has no incentive to research this because they are raking in money, and any further research could only slow down the gravy train at best.
[1] https://www.nejm.org/doi/full/10.1056/NEJMoa0800742
not sure I'm gonna trust a medium article that lists NYT and Bloomberg as references over what basically every single cardiologist recommends
Cardiologists don't do their own research. Drug companies do the research, and cardiologists are limited to just trusting the drug companies. So then the question is how trustworthy are the drug companies? Pfizer’s Lipitor raked in $125 billion between 1996 to 2012, becoming the world’s best-selling drug of all time. You don't think drug companies are even a little bit motivated by profits?
You are right about one point: You should absolutely not trust a random medium article, anyone can write medium article. Instead you should follow the links, then decide whether the experts quoted in the NYT and Bloomberg articles have a point.
That’s a horrible article to share as a source. Literally almost everything written there is wrong. What you’re doing is dangerous.
And you're offering nothing to back up your claim. Literally everything written in the article is backed up by sources such as New York Times, which in turn quotes experts in the field.
- Is it not true that the existence of a link between high cholesterol and heart disease is only a hypotheses that originated in the 1950s, not a scientifically proven fact?
- Is it not true that the FDA generally has not required drug companies to prove that cholesterol medicines (such as statins) actually reduce heart attacks before approval?
- Is it not true that lowering cholesterol by different means (i.e., other than statins) is not beneficial, and does that not mean cholesterol is not the villain it is made out to be?
- Is it not true that the only large clinical trial funded by the government (rather than drug companies) found no statistically significant benefit at all?
What exactly are you saying is wrong?
After I had a heart attack I was told that there’s no value in doing this test at that point. A couple years later at age 40 another doctor did order it for me and my score was 0, which apparently tells me I’m not on the verge of another heart attack, so that’s nice.
the score itself isn't the only relevant thing in the report. ask to see what the radiologist actually wrote and read it yourself. ai, aided by clarifications by a cardiologist, helped me understand the details immensely
CAC is pretty common, but I prefer Coronary CT Angiography, which is much more detailed CT of the heart and coronary arteries using IV contrast. It's a bit more radiation, but it shows soft plaque and arterial narrowing, which CAC does not.
It's better, but the contrast and much higher radiation dose compared to CAC carry their own risks. Individuals can evaluate their own risk but I wouldn't get this test under the age of 40 or 45 or so unless I had diabetes.
How do you get one and what is the cost?
A CAC scan is a non-contrast CT scan and a coronary angiography is a contrast CT scan.
They are both ECG gated scans of the heart otherwise so they're pretty much the same scan area and same scan duration, if you're hooked for a Coronary CT angiography you can easily get the CAC at the same time by doing a scan sweep before contrast administration (at the cost of 2 minutes of time and an extra dose of radiation)
Though the logistics surrounding contrast administration makes it a bit more fiddly with a slightly higher risk profile.
I got one a couple of years ago when I was 41 due to a recurring palpitation and non-standard EKG reading. They are more commonly used to really get a good view of things before heart surgery, but it really depends upon your doctor. The cost usually ranges from $300 to $1,000.
seeing soft plaque is critical, as is the structure of vessels such as the aorta. highly recommend getting the more expensive test.
https://archive.md/n9viB