July 30, 2018


#07 – Deep Dive: Lp(a) — what every doctor, and the 10-20% of the population at risk, needs to know

"Elevated Lp(a) may have conferred a survival advantage for most of human history: a better ability to deal with acute trauma, but possibly at the expense of poor handling of chronic damage. In today's environment, for many people, that's not an advantage." —Peter Attia

Read Time 11 minutes

This is our first “deep dive” episode that goes into detail on one topic. Pronounced, el-pee-little-a, this lipoprotein is simply described as a low-density lipoprotein (LDL) that has an apoprotein “a” attached to it…but Lp(a) goes far beyond its description in terms of its structure, function, and the role that it plays in cardiovascular health and disease. Affecting about 1-in-5 people, and not on the radar of many doctors, this is a deep dive into a very important subject for people to understand.


* If you would like us to do a deep dive on a particular topic, please submit your request to the comments section of this post. Please look at the existing comments before posting, and “upvote” the topic (or topics) you want us to cover. *

Note: this podcast gets technical at times. The figures in the show notes are your friends. They truly speak more than a 1,000 words apiece. I can’t emphasize enough how helpful it is to look at the figures before, during, and/or after I try verbally walk you through things like kringle repeats, molecular weight isoforms, lysine-binding domains, and plasminogen homology, as a few examples. If you stick with it, I think you will be rewarded.

We discuss:

  • A quick primer on lipoproteins [7:30];
  • Intro to Lp(a) [11:00];
  • Lab tests for Lp(a) and reference ranges [20:00];
  • The physiologic functions of Lp(a) [31:00];
  • The problems associated with high Lp(a) [34:15];
  • Lipid-lowering therapies of Lp(a) [44:45];
  • Lp(a) modification through lifestyle intervention [1:00:45];
  • High LDL-P on a ketogenic/low-carb-high-fat diet [1:05:30]; and
  • More



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  1. In the show notes you mention the 2 Lp(a) SNPs but in the podcast, I didn’t hear mention of those. Can you please feature these SNPs?

  2. Please deep dive dietary ketosis especially talking about risks/benefits of short term, intermittent, and life-long adherence.

  3. I’m one of those 1 in 10 who is homozygous for at least one LPA mutation and have elevated LP(a). Big light went off when I learned this…as despite low cholesterol and not many risk factors, all four of my grandparents died of stroke or MI (although in 70s or 80s). I have known about this for about 7 years now and experimented with all sorts of interventions. I can say hands down, I am also one those people who does not do well on keto..I rarely enter ketosis despite getting 90% of fat (mostly monounsaturated as I follow a mediterranean ketogenic diet: olives, avocado, etc.) and I feel horrible. My LDL-P and fasting blood glucose go up. I think one explanation may be falling into one of the categories for Keto diet contraindications:
    Carnitine deficiency (primary)
    • Carnitine palmitoyltransferase (CPT) I or II deficiency and Carnitine translocase deficiency, CAT
    • Fatty Acid Desaturase Deficiency FADS
    • b-oxidation defects
    • Medium-chain acyl dehydrogenase deficiency (MCAD)
    • Long-chain acyl dehydrogenase deficiency (LCAD)
    • Short-chain acyl dehydrogenase deficiency (SCAD)
    • Long-chain 3-hydroxyacyl-CoA deficiency
    • Medium-chain 3-hydroxyacyl-CoA deficiency
    • Pyruvate carboxylase deficiency
    • Porphyria
    While, the autosomal recessive “xCAD” loss of function metabolic diseases are rare, being heterozygous for some of the responsible alleles is not, and I carry several of those. I suspect my ability to switch from carb to fat burning is compromised/less efficient as compared to someone without those alleles.
    Long story short: Over time what I feel best on (and is supported my significantly improved HbA1C, LDL-P, TG, total Chol, c-peptide, hsCRP) is following a whole foods, plant based diet, switching back to oral estradiol (I’m postmenopausal) and plenty of exercise.

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