Friday, August 16, 2019

Retrospective #183: My New “Lipidologist” and Me

I had an appointment recently with a “new” doctor – new to me, that is. He’s an established physician in a large group that is part of a larger consortium of groups. He practices “Family Medicine,” which means he’s a generalist.
I met my new doctor in a bar. He was having broiled salmon, and I was having a drink (while my wife shopped). Anyway, he told me he was a physician, and he mentioned the group. I told ­­­­­­­him I had just been “fired” (for being rude) by an endo in that group. His suggested I call his office the next day to make an appointment, so I did.
The appointment didn’t go well. In the clinic I told him I had been off my Very Low Carb eating plan off almost 2 months and had gained more than a few pounds. I expected my A1C would probably go up from 5.7% to +/- 6.0%. “My goal is to get it back to 5.6% or below,” I said. He replied, “That would be ‘non-diabetic.’” He added that if I lost 40 pounds, “You would be non-diabetic.” I replied that a few years ago I was 50 pounds lighter than I was now, and I added, with emphasis, “believe me, I was still diabetic,” because I would still be Insulin Resistant.
I then mentioned that when I am “on” my program, I eat between 10 and 15 grams of carbohydrates a day. He responded with a tone and air of certitude, “Twenty grams of carbohydrate a meal is what you should eat.” This really set me off. My new doctor knew everything there was to know about me without even taking a history. I had been a Type 2 diabetic for 28 years, the last 12 of which I have managed to get off virtually all my oral meds and keep (for the most part) good glucose control by diet alone, and now he was telling me how to manage my diabetes his way. I know. I know. He was just following clinical guidelines, as set down by the ADA, the AHA, etc., etc.
He then brought up the subject of statins, declaring he was a lipidologist. I told him I would refuse a statin if he ordered it, and I told him why. I mentioned my latest lipid panel (at the time): TC: 217; LDL: 122: HDL: 85; TG: 49; TC/HDL ratio: 2.6). I said I considered that stellar. He replied that the National Cholesterol Education Program (NCEP-4) Guidelines recommend a TC < 200 and an LDL < 100 (which was true; those were the old guidelines). The new ACC/AHA guidelines (see Retrospective #181) no longer set LDL targets in absolute numbers. I called the NCEP guidelines pure BS and said the gurus and guidelines that I follow are very happy with my lipid (cholesterol) panel.
Actually, I later recalled that one of my favorite books, Paul and Shou-Ching Jaminet’s “Perfect Health Diet” says, “The ideal serum lipid profile – the one that produces the best health and minimum mortality – looks like this:
·         Total Cholesterol level between 200 and 260 milligrams per deciliter
·         LDL Cholesterol level above 100 milligrams per deciliter
·         HDL Cholesterol level above 60 milligrams per deciliter
·         Triglyceride level around 50 to 60 milligrams per deciliter
I then repeated my exceptional HDL (85) and TG (49) numbers and added that my LDL (122) was Pattern “A.” His response was: “Define ‘Pattern A.’” I replied, “large, buoyant, fluffy, rather than small dense, to avoid having oxidized, small dense LDL particles get stuck in the eroded endothelial layer of my arteries. I added that my very low hs C-Reactive Protein scores suggest that my arteries were not inflamed. I showed him my history of CRPs, and he did admit it was “impressive.” They had gone from 6.4 when I started very low carbing to a recent low of 0.1.
But then he said something that shook my faith that my new doctor and I were going to work out. He said, “The latest science is that all LDL are alike. They all get stuck. I asked him for a citation for that. I said I read a lot of medical journals and scientific papers – probably more than he did. He didn’t like that, and replied I did not. How can he know? Anyway, when I asked him later for the “LDL are all alike” citation, he replied, “Give it up!”
What I gleaned from this appointment is that Family Medicine MDs are trained to diagnose “incipient” Type 2 diabetes and treat it with pharmacotherapy. They’ve learned by rote the clinical definition of “diabetic” and “non-diabetic.” They know what Insulin Resistance (IR) is and believe it can be reversed, and “non-diabetic” status achieved, by weight loss alone. But this one doesn’t understand that THAT DOES NOT REVERSE Insulin Resistance

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