Low Carb and Cholesterol – A Case History

Three months ago I had a visit from a 53 year old gentleman who was worried about his health. His name is Peter. He had been gaining weight for some time, his knees were aching and he was having trouble playing his weekly tennis with his old classmates. He told me he had probably put on approximately 55 lb (25 kg) in the past five years. “It all started when I quit smoking,” he said.

Low Carb and Cholesterol - A Case HistoryPeter was working as an accountant. There was a lot a stress at work, long working days and sometimes he had to go in on the weekends as well. Apart from his weekly badminton, he wasn’t really exercising at all. Although he had quit smoking, he had never really bothered about his lifestyle and was totally uninterested in diet and nutrition.

His wife took care of the cooking at home and was trying to limit his intake of calories. She was very conscious about cholesterol and tried to use low-fat varieties. At work however, Peter relied mainly on fast food, sandwiches, sodas, chocolate bars, chips, and an occasional fruit in between. Usually a few beers and some red wine on the weekends, bot otherwise not much alcohol.

Peter had suddenly become worried about his weight gain and felt his general condition was slowly becoming worse. He was feeling out of breath.

For the first time in his life he was really thinking about his health. He appeared to have suddenly realized that, he himself might have to take action.

Peter told me he wanted to try a low carb diet. A friend of his had been getting good results with such an approach, was feeling well and had lost a lot of weight. Peter thought this might be the way for him to go.

However, his wife was reluctant. She didn’t like the idea of eating so much fat. She had a history of elevated cholesterol herself, and had been trying to avoid animal and dairy fats for years. Her brother who was a physician recently started taking a cholesterol lowering drug. She wanted Peter to see a cardiologist before starting on a low carbohydrate high fat diet.

When I saw Peter he didn’t have any obvious signs or symptoms of heart disease. He was 5 ft 11 (181 cm) long and weighed 260 lb (118 kg). His body mass index (BMI) was 36. He had many of the classical features of the metabolic syndrome, his waist circumference was 47 inches (120 cm), and his blood pressure was 156/102 mm Hg.

His blood work showed the following results:

  • Total cholesterol: 251 mg/dl (6.5 mmol/L)
  • Calculated LDL-cholesterol (LDL-C): 169 mg/dl (4.4 mmol/L)
  • HDL cholesterol (HDL-C): 31 mg/dl (0.8 mmol/L)
  • Triglycerides (TG): 257 mg/dl ( 2.9 mmol/L)
  • Glycated hemoglobin (HgbA1C): 7.1 %
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A Low Carb Hig Fat Diet – A Bad Idea?

Peter’s main problems were obesity, metabolic syndrome and type-2 diabetes. Glycated hemoglobin is a measure of long term blood sugar. A value higher than 6.5% indicates diabetes. His TG/HDL ratio was 8.3. A ratio higher than 3.5 is associated with insulin resistance. His LDL-C was certainly not ideal, but possibly not the biggest of his worries.

I told Peter and his wife about the risks associated with the combination of obesity, metabolic syndrome and type 2 diabetes. I tried to educate them about the problems associated with insulin resistance. His wife was mostly interested in his cholesterol numbers. I certainly don’t blame her because that’s been our main target for decades when it comes to the prevention of cardiovascular disease.

“Doctor, I would like to see him cut down on the fast food, eat less calories and exercise more” she said. “I don’t see how starches and whole grains will hurt him. It’s just the sugars and the beer he has to get rid of”.

“Okay Peter” I said. “What do you say?  We all agree that weight loss is essential to improve your health. If you don’t change your lifestyle and lose weight there is a risk that your health will get worse. In order to cut your risk we may have to put you on medication for high blood pressure, another one for your diabetes and a drug to lower cholesterol. There are many ways to go when it comes to losing weight. There are no simple tricks. The most important thing is to keep focus and understand what it is that you have to do”.

He seemed to have made up his mind. “I don’t like the idea of just eating less and exercising more”. I’ve tried that before. It sounds very sensible, but it hasn’t worked for me. It works for two weeks and then I’m back to the same old shit.  I need to try something else. I’ve read a few articles on the low-carb high fat approach and it appeals to me. Do you think that’s a bad choice doctor?”

“No” I said. “I certainly don’t think so. Indeed there is a lot of scientific data showing that such an approach may help you lose weight, reduce insulin resistance, improve your blood sugar and lower blood pressure.”

Three Months Later

I saw Peter and his wife again last week. He seemed quite happy. He had avoided refined sugars entirely, throwing candy and beverages out of the window. He had cut down on other types of carbohydrates, avoided potatoes, bread, pasta and rice. Basically, the only carbohydrates he had eaten came from vegetables and fruit. He had eaten a lot of eggs, cheese, meat and fish.

He was feeling better and less out of breath. He had lost almost 18 lb (8 kg)  in three months. His body mass index was 33.6. His blood pressure was 142/88 mm Hg. His tennis was going better and his knees were aching less

This was his blood work:

  • Total cholesterol: 290 mg/dl (7.5 mmol/L)Three months before: 251 mg/dl (6.5 mmol/L)
  • Calculated LDL-cholesterol (LDL-C) 210 mg/dl (5.4 mg/L)Three months before: 169 mg/dl (4.4 mmol/L)
  • HDL cholesterol (HDL-C): 54 mg/dl (1.4 mmol/L)Three months before: 31 mg/dl (0.8 mmol/L)
  • Triglycerides (TG): 132 mg/dl (1.5 mmol/L)Three months before: 257 mg/dl ( 2.9 mmol/L)
  • Glycated hemoglobin (HgbA1C) : 6.2 %Three months before: 7.1%

Peter was quite happy but his wife was worried. Her brother doctor had seen the blood work and pointed out that LDL-C was way too high, and would likely increase risk of having a heart attack or a stroke. He should start treatment with a cholesterol lowering drug as soon as possible.

I went over the positives and the negatives with Peter and his wife. He had certainly lost weight and his blood pressure had improved. His glycated hemoglobin had improved as well and the value was below the cut-off for diabetes. His TG/HDL ratio was 2.4 indicating less insulin resistance. I also told them that the fact that TG were so much lower could mean that the size of his LDL particles had improved, with less small LDL-particles and more large LDL-particles. A number of studies indicate that this may be a positive thing and associated with less risk of cardiovascular disease, despite the higher LDL-C.

What Does All This Mean?

Peter’s response to a low carb  high fat diet is quite typical. Weight loss usually occurs. Total cholesterol and LDL-C often increase and so does HDL-C. TG usually go down. Blood pressure often improves and typically blood sugar and glycated hemoglobin improve. Of course the big question is: “Is his situation better or worse than before”? Does the high LDL-C mean that his risk of heart disease is higher than before, despite all the other positive findings?

Peter’s wife wanted to change direction, cut out the fat, cut down the calories and believed he was better of with a cholesterol lowering drug. She is a sensible woman and she definitively wants the best for her husband.

 What Should Be the Next Step?

Because his wife was the one taking care of the groceries and cooking, Peter felt a bit like a misbehaving child not taking her advice. He was feeling better and definitively didn’t miss the weight he had lost. He felt a bit insecure because he had never before had an opinion about diet, and about what to eat or not to eat.

I’m quite curious to know my readers opinion so I’ve put up this poll for you. This is the firs time I do this on my blog. Please give me your vote and don’t hesitate to explain your choice in a comment. Last day for voting will be Wednesday, July 31, 2013.

Vote Results

What dietary approach would you recommend?

    • Continue with the low carb high fat approach and don’t worry about the LDL- cholesterol, partly because it is likely that LDL-particle size has improved 76% (176 votes)
    • Continue with a low carb high fat approach, but eat less saturated fat and cholesterol (less animal and dairy fat and eggs), and consume more poly-and monounsaturated fats 12% (27 votes)
      Adopt a Mediterranean type diet. Such a diet has been shown to improve type 2 diabetes and reduce the risk of heart disease 5% (12 votes)
    • Adopt a plant based diet. Skip all animal products, eggs and dairy products. Basically go vegetarian 3% (7 votes)
    • None of the above 3% (6 votes)
    • Drop the low carb high fat approach. Eat less fats and more carbs, focusing on good carbs, whole grains and starches, and try to reduce total calories 1% (3 votes)
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