G'day, Dr. Ulrich Bishop here, and welcome to my podcast and videocastation. I really hope you're well. Look, thanks heaps for tuning in. If you enjoy this podcast, I would love you to subscribe. If you think of someone who might find the content beneficial or interesting, please share it with them. And if you can think of any topics I should cover, let me know. And if you can think of anyone I should interview so that I can allow them to share their wealth of knowledge, please put them in touch or let me know. Today, I've got a couple of things to cover. Little bits around the edges. And I'd like to talk about keto diets. I'd like to talk about unusual circumstances for cholesterol management. such as what do we do with chronic renal failure? How do we handle some of the specific issues for women? What do we do with transplants? What do we do with older patients? So let's leap into keto diets to start with. Now, what do I mean by a keto diet? Well, I'm going to talk about very low carbohydrate diets. Same thing, keto. very low carbohydrate ketone diet simply means that you have such a low amount of carbohydrate in your diet that you are burning ketones means you're burning fat these sort of diets really um you'll often see people eating cream butter meat a lot of meat and not touching the carbohydrates at all. Remember, carbohydrates can sneak in in all sorts of places and surprise us. But bread, pasta, rice, potatoes, cereal, fruit and beer are probably the big carbohydrates that we're all aware of. Well, what's the story with a reduced carbohydrate or keto diet? Historically, I've always been in favour of reducing carbohydrates. And I've been a supporter of a reduced carbohydrate eating regime for many of my patients for at least a decade or two. And the very patients I'm supportive of in this situation are those who seem to put on weight around the middle of their tummy. We call that central adiposity. Or those who are from a family where there's a risk of diabetes or pre-diabetes. And those whose triglyceride levels seem to be on the higher side in their HDL cholesterol, their high-density lipoprotein levels tend to be on the lower side. These individuals are a little bit metabolic in such a way that they're almost a little bit pre-diabetic. And I think removing or minimizing sugar in their diet or exposure to carbohydrate, which of course breaks down to sugar, is a really sensible thing. plenty of success inviting people to do that. Keto is almost going a little bit further along that spectrum of carbohydrate reduction and really adding in even more fats. And what tends to happen is people add in saturated fats. Well, why have I been supportive of a reduced carbohydrate eating guideline? Well, basically it flattens the sugars out. If you flatten the sugars out, people don't have the same... hunger. It flattens our appetite a bit, which is really nice. It also helps people lose weight. And if you lose weight and you're flattening out sugars, as you're losing weight, you'll drop your blood pressure. You might mobilize a bit more. That flattening out of the sugar also means that the insulin's not running up and down. And I think insulin has a role in the sort of inflammatory processes within the body. So reducing that carbohydrate tends to lead to better insulin control, better sugar control, better blood pressure control and reduced weight. Well, it sounds like an absolute winner, doesn't it? And many people, because their sugar levels and insulin levels are not fluctuating, they actually feel better as well. So they have a bit less volatility in their mood during the day. They don't get as... hangry and for that reason feel good following these sort of diets. Well, as we push that reduced carbohydrate recommendation down to the line of ketone, we can find that people are replacing their carbohydrates with saturated fats. Well, what's the implication of that? We know that cholesterol consumption itself doesn't have a huge impact on raising cholesterol levels in the body. But we do know that consumption of saturated fats really does, really pushes cholesterol levels up. And for some people who are hyper responders, this saturated fat diet can really, really push the cholesterol levels up through the roof. Now, I end up caught in a conversation with many of these patients who want to remain on a keto diet or a saturated fat enriched diet saying, look, I've lost weight. My sugars are better. My insulin levels are better. My blood pressure is better. I'm feeling great. Why would I change anything, particularly when all those other factors would suggest that I also have large, fluffy, low-density lipoprotein particles? Well, all of that is true. The problem is... high levels of low-density lipoprotein particles, or which would also mean that that person has high levels of LDL cholesterol, even though it's the large fluffy, can still be linked to cholesterol buildup within the arteries. We know that because we see young, young people with familial hypercholesterolemia with nothing but large fluffies still end up with plaque in their arteries. Now, there are, without question, good reasons for a reduced carbohydrate eating regime to bring positive outcomes to cardiovascular risk, but that consequence of raised LDL particle numbers and total LDL-C has still not been resolved clinically. It turns out that there is some research being done at the moment. Professor Matt Budoff in the United States is running a trial at the moment, looking at ketogenic diets and imaging the arteries, trying to understand if ketogenic diets lead to regression or progression of plaque within the arteries. This will really inform this space. And I'm super duper looking forward to the information that comes from that because at the moment, I can understand that there is a clash of logic and a clash of positive and negative in that space. My suspicion because of what we see in young individuals with familial hypercholesterolemia is that the number of particles present, even though some of the other risk factors are going to be less. is still going to have a consequence of ending up in the arteries. Time will tell, but in the meantime, I'm cautious. And if those individuals with the keto diet are either defined as high risk from imaging, so on that continuum, that primary prevention continuum, but high risk. or if they're secondary prevention, I tend to err on the side of caution and where our data sits at the moment, which is lower those cholesterol levels as much as possible, I still support keeping the carbohydrates down and we steer away from as much saturated fat and we try and get those LDL-C targets as low as we can for those people. What are some of the other situations that give us some moments, pause, require us to think about them in a little bit more detail. Well, there has been, up until relatively recently, some uncertainty as to whether women actually benefit from having their cholesterol lowered with statins. Well, there's been substantial research into this and the Cochrane Review Library has pulled together enough data to confirm for us that there is no question that women do benefit from statin. lowering their cholesterol with all-cause mortality and cardiovascular-related mortality. Really importantly, we also know that women will benefit from the non-statin cholesterol-lowering medications as well. And this has now been shown in studies. And we're seeing more and more of our studies bring women into those study populations so we're being better informed in that space. We don't believe hormone replacement therapy drives up risk of cardiovascular disease, and it's probably beneficial for mood and bones. So from a cardiologist perspective, we're pretty happy to see perimenopausal women exploring hormone replacement therapy if it's appropriate for them as guided by their local doctor or their OBGYN. What do we do for pregnant women? Well, there is no clear evidence that we've got any drugs that are safe in pregnancy, so we tend to avoid them altogether. This means we need to be extremely careful when we're planning pregnancy for young individuals, young women, and what might be that we've, for example, commenced cholesterol-lowering therapy for a young woman because of familial hypercholesterolemia. When she wishes to explore getting pregnant, then that is a planned intervention to her therapeutic strategy. And she would do that with the guidance of her, probably her cardiologist or lipidologist to make sure that's done with the appropriate supervision and the right care. During breastfeeding, we don't give women... medications except possibly for the bile acid sequestration agents that can be taken by sachet but again not used very regularly these sort of preparations they're just not easy to take but the bile acid sequestration we might use depending on the clinical situation for the individual. What other situations have been if you like, out of the spotlight when it comes to lipid management. Well, for a long time, we've wondered about should we treat older people? And part of the reason we've wondered about treating older people is because most of the studies have been around individuals whose cutoff age is up around 65, 70, thereabouts. And we don't have data beyond that. We have very limited data. And so there's no... or has not been any clear evidence base. But as we think about it, we realise that the older population are probably those at highest risk. And I guess we could make a case that depending on that individual's desire to be taking another tablet or open to therapy, that we could evaluate those individuals, at least in a primary prevention setting. with an open conversation about what their risk may or may not be. In the secondary prevention setting, I would think that there's no reason for us to stop therapy when people get to a certain age. That just wouldn't be cool. Chronic renal disease. Now, we know renal disease is a very high risk indicator for cardiovascular disease. And interestingly, there's no question we should be trying to lower risk. for people with renal disease. We also should be aware that because people with chronic renal disease on dialysis carry such a high risk of other comorbidities that there's not clear data to support the use of statins for individuals with renal failure on dialysis. However, Some of those patients with renal failure on dialysis may be suitable candidates for a transplant. And if they are, we need to protect their vasculature so that should they get their transplant, get off dialysis, that they're probably still at high risk from the preceding time of chronic kidney disease. and therefore would be carrying that risk forward because they're getting a new kidney, but not a new vasculature. So those particular individuals, I think we really need to be aware that cardiovascular disease is one of their highest risk factors, and that we can modify that with cholesterol lowering. And if they get through to getting a transplant, then they certainly would need to be considered. Now, one also needs to be aware that some of the transplant medications are metabolized through similar pathways to the statins, and that will require specialist input to decide what's what and whether adjustments need to be made. But it also raises the question, should transplant patients in general, whether it's heart, lung, kidney, receive cholesterol-lowering therapy? Well, these will be specialist decisions in that space. But often is the case these individuals will need LDL cholesterol lowering for their safest journey forward. Well, I've covered a fair bit there. I've talked about keto diets. I've talked about specific issues surrounding women. I've talked about older populations. I've talked about renal failure and renal impairment and transplants. We've covered a fair bit, haven't I? Well, I hope you found that interesting. I really want to share that because they are a little bit out of our normal group of patients that we see on a daily basis. But nonetheless, we do have to think about how to deal with them because they do come up from time to time. Thank you so much for listening. I am going to say goodbye. I do hope you live as well as possible for as long as possible. Until next time, take care and bye for now.
