There are certain things you don’t want to hear from your doctor. “Wow, that’s weird.” “I think I read about this once, but I’ve never actually seen it.” “Technically, you shouldn’t be able to do that.”
What about this one? “We’ve never been asked to do that before.”
This is one of those stories that will appeal to the bio-hacker. If you’re a triathlete or a paleo fan, or the phrase N=1 means something to you, this story is for you. Or if you just find yourself frustrated with the status quo of Americans’ passive relationship with healthcare and information, this story is for you too. We’ll turn you into a self-experimenter.
Yesterday was my annual medical exam. I have usually scheduled them on my birthday, which is next Thursday (well, sort of, as I am a leap year baby) but there won’t be an MD in the office next week. I don’t mind seeing a PA normally, I think they are well-trained enough for the basics. But I knew I would run the risk of throwing a monkey in the wrench of the whole system on this visit, so I figured I may as well save us all the trouble and see the MD outright. This might save a follow up visit if the PA wasn’t authorized to entertain my request.
It started normally enough. I live right next door to the doctor’s office, so I have a good bit of casual observation based on the parking lot activity. The number of cigarette butts that make their way into our driveway astounds me. The sheer volume of drug reps coming in and out is mind-boggling. Even going into the waiting room is an eye rolling experience, as a kid no older than 4-5 is brought in with an older family member who has an appointment, and the little kid is snacking away on his own bag of sour cream and onion potato chips at 8:15am.
Just another day in Snyder County. Just for Vinnie Tortorich listeners: it’s basically Donaldsonville North.
I need to say, none of these details should be taken to reflect a negative association with the staff at all. And I am not just saying this because there is a .5% chance one of them may read this somehow, and this is a small town where everyone knows everyone. I really do appreciate their demeanor, professionalism, and willingness to entertain troublemakers, I mean TRENDSETTERS, like myself. My impression, again based on my very limited and unscientific observational study, is that they don’t get a lot of patients who come in intending NOT to get a prescription. I would imagine that being a doctor in Snyder County would be as frustrating as having a hot dog cart at a PETA event.
So I get in the room after vitals and weight check, and like any medical office, my identity is reduced to my chart. Years ago I admitted that I smoked occasionally in college, so there is apparently some huge sticker that exclaims EX-SMOKER. And of course, no matter that last year’s blood tests were really good, the medical protocol is to brand a patient with the Scarlet D of DIABETES for life, no exceptions. Test high once, and you are in a category for which the establishment recognizes no cure, only “management.”
OK, so after I get over my personal affront at the usual way of doing things, and try to stop thinking of myself as somehow special, I get down to business.
I describe to the doctor, in broad strokes, my change in diet. I tell him to expect ketones in my urine, that I am not in keto acidosis, but dietary ketosis. I try to do this in such a way as I do not come off as someone who read three articles on webMD, but a guy who has done thorough research on the matter for myself. I know the doctor has limited time, so I try to keep it brief, yet thorough. This is actually the first time we have met. I let him know my recent mail in A1C was 5.0% (For the uninitiated, this is awesome. You can test yours with a mail in kit from Wal-Mart that costs less than $10.)
The only pushback I get from the doctor, and reasonably so, is that ketosis is not something he recommends long term. I assure him that this is for a year to start, then I will re-assess, but I add that I know of a few people going several years like this in good health. He is also skeptical of this as a lifestyle, but I don’t pick an argument about the absurdity of modern food as a lifestyle. I do drop a strong statement that I am not a conspiracy nut, but I don’t believe in pharmaceuticals. I should have added the caveat “for chronic conditions.” I don’t think I did, so I know I probably have a label of nutcase floating around somewhere forever. Like Elaine Benis, I may end up at a veterinarian to try and escape my permanent record as a problem patient.
So then I ask: when you do the lipid panel, can I get a breakdown of LDL A and B?
And now, I’ve done it. I’ve gummed up the works.
Again, I must be clear: from the doctor to the desk staff, no one gave me a problem about this, and worked to get it done. They were awesome. I would even go so far as to say extra mile. Usually patients are not used to being given much credibility in asking for their own tests. Two years ago on one of the earliest blog posts here, I recounted how calling to ask for an A1C was treated like I was practicing medicine without a license. (I was a bit more edgy with my mood back then, and my tone reflects that.)
But I knew that if I went about this properly and got the doctor to order it, it should go smoother. Whether or not a patient is educated on their health, the system only works with the MD as a gate keeper. Instead of treating this as an adversarial relationship, I will work within the system as it is.
As it turns out, there was no code in the computer system for this test. And, it took some digging to find a code at all. I didn’t help matters by having half my information. I should have asked for more than just an A/B breakdown. There are no lab tests that they could find for just that. What they did find is a lipoprotein fractionated panel. The problem was, if it’s not in the office system, it can’t be done. So they put it in the system. Again, I want to say the staff was great. I know they had a busy schedule this week, but as I sat in the waiting area for bloodwork, I could hear through the thin walls. They were really on this thing, doctor included.
I asked a question to confirm my suspicion: “So, if this wasn’t an available code in your computer, does that mean it wasn’t appearing in the whole system?” My local office is part of a multi-office group in Central PA with 26 locations.
I am deducing that this means I am the first patient at any of these locations to have this test ordered. I am a trendsetter.
I told the nurse who did my draw, two things. First, if I need a needle stuck in me, she’s my first choice. Smooth like butter. Second, I predict that in 5-10 years, this is going to be a standard test.
Why do you want to ask for this test?
I will link to some resources on this test, but here’s my layman’s understanding.
First, get off the cholesterol myth altogether. I’ve already linked references for that.
But the things in our blood that drive athlerosclerosis, or hardening of the arteries, are of concern. They fall under the category of LDL, low density lipoproteins. BUT, and this is the huge BUT that comes with the major caveat: there is more than one kind of LDL. The breakdown of A and B types shows that one is comparable to a light and fluffy particle. It is considered harmless. It doesn’t drive itself into your blood vessels. Whether it is high or low, it is benign. The other kind, however, is formed like a dense BB. It gets into the arteries and causes problems.
Lead Vs Feathers
There’s an old trick question: which weighs more, a pound of feathers or a pound of lead? Obviously the answer is neither. A pound is a pound. But ask this, would you rather have someone drop 10 pounds of feathers on you from 10 feet up, or 10 pounds of lead?
The current state of lipid testing conflates feathers and lead and says “you have X number of feathers and lead.” Then if the number is high, your assessment is made as if it’s all lead.
Does this remind anyone of a similar shortcut metric?
If you said BMI, ding ding ding! You read my mind.
The thing is, both of those short tests can work for many, if not most people. But for anyone lifting weights, the BMI quickly becomes not only irrelevant, but inaccurate to the point of silliness. I’ll never forget the story from SteveL I knew 10 years ago. He was a 60 year old weight lifter who sat in his doctor’s office as the doctor stared at his clipboard with numbers on it and announced Steve was obese. At under 10% bodyfat, this was ridiculous. He said “um, doc? Take a look.” The doctor got his eyes off the clipboard and on a shirtless Steve. The potbellied doctor paused and said “huh. Well this number is useless….”
But BMI is easy. So is the basic lipid panel.
What many in the research community are showing, is that the basic lipid panel profiles may be doing the same thing: assuming a problem where there isn’t one. And in my case, as a high fat, low carb eater, I could very well show a high LDL on a basic panel, but not have the whole story.
If my fractionated panel comes back with alarming results on my BB style particles, I will make dietary adjustments. My first two months of change have probably included too much cornfed meat for one thing.
But let’s say I was a typical American overweight 40 year old guy, going to a routine physical. I get a high LDL panel. I’m told to cut down on fat and include more whole grains. Then next year I come in and my triglycerides are way high from that. At some point, someone just puts me on a statin because it’s easiest.
The frustrating thing is, we don’t all have to be biohackers and super fine tuned with our charts and research, bugging our doctors. We can avoid the diseases of civilization by eating like our ancestors. It really is that simple. We have the benefit of modern science to show why. But we don’t need it. It simply shows us under a microscope what they knew without the terminology years ago.
So for more detailed information on a fuller lipid panel, here are some resources.
As mentioned, it’s not standard yet. I’ve already written about the AHA’s resistance to new research. Here’s their take on this test. If I put my tinfoil hat on, I would say there is a bias here against anything that doesn’t parrot the all-fat-is-bad message they’ve pushed.
To really geek out on these details, Dr. Peter Attia is the man to go to. He has a massive article about cholesterol online that is a great resource. Here is Part Five on measuring. Actually, I find this quite readable when you get down to the A vs B discussion.
And I never miss an opportunity to recommend Dr Lustig’s amazing lecture Sugar: The Bitter Truth. He discusses A vs B in there as well.
So What Did the Test Show?
Well, this is going to have to be a post with a sequel. My basic labs were back by the end of the day. The LFP was sent further away, so it will be a bit of time.
Long Term Principles
They call medicine a practice for a reason. Our system would do well with more pro-active patients. I don’t think we can podcast/internet article our way to a degree, but we can learn how to ask the right questions. Your family doctor likely had very little nutrition coursework. They mostly go by the default conventional wisdom. They are also trained in a paradigm of prescribe to treat. This is not all their fault. We’ve trained them to be this way as a culture. Still, my next big topic will be on this very problem:
The Soft Bigotry of Low Expectations