March 15, 2015

Personal

Random finding (plus pi)

by Peter Attia

Read Time 6 minutes

The best part of parenting (so far)? Helping your kids overcome things you struggled with. It’s at least in the top 5.

Last Saturday my daughter came home from dance class—something she normally loves—and seemed upset. A bit of prodding led to the cause: a girl in her dance class told her she was “as fat as a hippopotamus.”  My first reaction (note to self: probably not the right one) was to laugh out loud, given that my daughter is probably in the 10th percentile of weight for her age. I’m worried she’s too skinny!

Of course I realized quickly the “facts” were irrelevant in this case. Her body habitus was moot. But her feelings were hurt, and as we all know this wouldn’t be last time someone said something to her—true or untrue—that would hurt her feelings.  I won’t go through the entire discussion we had, as I’m sure those of you with kids have already been through this, and those of you without kids probably aren’t worrying about this type of interaction.

I did, however, decide to tell her about all the people who dislike me and say mean things about me, usually things that aren’t true. She was shocked, “Like what, daddy?” I gave example after example. She was amazed—and relieved, I suspect—to know that she wasn’t alone and that I was able to shrug it off after temporarily being upset by it. I even told her about folks posting videos on YouTube specifically attacking me.

So, when our little talk was over she asked if she could see one of the videos I alluded to. I was a bit hesitant, if only for some of the language used when folks rant against my existence (if she’s going to learn choice 4-letter words in earnest, it should be from me after all), but I figured it was a good idea. She could actually see for herself that people say mean things about her dad and he’s still, more or less, ok.

Which brings me to the point of this quasi-post…

In searching for said YouTube videos, which I eventually found, I stumbled across two talks I gave last year which made their way online, unbeknownst to me.

In keeping with the current spirit of my co-op blog posts, below are links to the two talks.

Talk 1: Evidence for (and against) the dietary guidelines restricting saturated fat

This talk is an updated version of a talk I gave a few years ago and shared on the blog, in 2012 I think. Even if you watched the earlier version of the talk, if you find this question interesting—what is the case for restricting saturated fat (SFA) intake—it’s worth watching this version. I find this particular topic especially interesting because I think it highlights the challenge we all have, myself included, in setting aside bias when confronted with new information. (My friend Carol’s amazing book, Mistakes Were Made (But Not By Me) cannot be recommend highly enough for people who want to understand how cognitive dissonance wreaks havoc in even otherwise functioning societies.)

And contrary to what some (perhaps many) of you might think, I don’t believe this is a settled debate across the board. What do I mean by that (i.e., “across the board”)? Certainly in this presentation I try to make the case that the continually falling recommendations for SFA—from 12% to 10% to 8% to 5% of total calories—are not supported by convincing science. In fact, such recommendations likely do harm, courtesy of the “substitution effect,” i.e., people end up eating more of other things—namely, sugars and omega-6 polyunsaturated fats (n-6 PUFA)—that likely cause greater metabolic derangement.

However, some readers may interpret the data I present to mean it’s perfectly safe to consume, say, 25% (or more) of total calories from SFA. I realize I may have to turn in my keto-club card, but I am convinced that a subset of the population—I don’t know how large or small, because my “N” is too small—are not better served by mainlining SFA, even in the complete absence of carbohydrates (i.e., nutritional ketosis).  Let me repeat this point: I have seen enough patients whose biomarkers go to hell in a hand basket when they ingest very high amounts of SFA. This leads me to believe some people are not genetically equipped to thrive in prolonged nutritional ketosis.

In one particularly interesting case, a patient in self-prescribed nutritional ketosis presented to me with an LDL-P of more than 3500 nmol/L[note]i.e., more particles than could be measured by the NMR machine so the report simply said “>3,500 nmol/L”.[/note] despite feeling, performing, and looking great. Based on his through-the-roof desmosterol and cholanstanol levels, and a curb-side consult from the Godfather- I mean Dr. Tom Dayspring, I decided to try an experiment. You see, the logical thing to do in this setting would have been to start two drugs immediately (a potent statin to address the hypersynthesis and ezetimibe to address the hyperabsorption) or tell him to abandon ketosis altogether. But this patient was adamant about staying in ketosis given the other benefits, though obviously worried about the long-term coronary implications. So, we agreed that for a 3 month trial period he would reduce SFA to an average of 25 g/day (vs. about 75 to 100 g/day) and make up the difference with monounsaturated fat (MUFA).[note]We also reduced his omega-3 PUFA given very high RBC EPA and DHA levels.[/note]

So, on balance, he consumed about the same number of calories and even total quantity of fat, but his distribution of fat intake changed and he heavily swapped out SFA for MUFA.

The result?

His LDL-P fell from >3,500 nmol/L to about 1,300 nmol/L (about 55th percentile), and his CRP fell from 2.9 mg/L to <0.3 mg/L (and for the lipoprotein cognoscenti, both desmosterol and cholanstanol fell).

Pretty cool, huh? So, my point is this: while I believe the population-based guidelines for SFA are not supported by a standard of science I consider acceptable, it does not imply I believe SFA is uniformly safe at all levels for all individuals.

Some of you may be wondering about me. It turns out I’m in the group (recall: I have no idea how large or small this group is) that seems to do well—at least by the tools we have available to assess risk—with large amounts of SFA in my diet, if and when I elect to. Even when I was in ketosis, eating 4,000 kcal/day (literally getting 40 to 45% of my calories from SFA alone) my biomarkers—cardiovascular, insulin resistance, inflammation—were excellent. Better than they ever were or even are today. Though, my point still stands: there are some people who do not appear able to safely consume massive amounts of SFA.

One last point I’ll make on this highly charged topic. I realize there is a contingent within the LCHF community who argue that traditional biomarkers of coronary risk—such as LDL-C or its superior cousin LDL-P—“don’t matter” if one is on a low carb or ketogenic diet. Maybe they are right. I guess time will tell. But I am not convinced, at least not yet.  As a doctor I can’t look a patient in the eye and tell them a sky-high LDL-P is ok because they don’t eat carbohydrates. So if you’re following such a diet, and your LDL-P goes through the roof, I’d urge you to consider a variation of the diet.

(Note: If you post your NMR results, please understand I will not comment on them.)

Talk 2: It was the best of times, it was the worst of times—the tale of the U.S. healthcare system

This presentation has nothing to do with nutrition but is, nevertheless, a topic I’m pretty obsessed with: how do we achieve cost containment on healthcare in the United States? (Sorry non-U.S. readers, but we have a bigger problem right now, so I’m focusing on ours over yours!)

This is a pretty controversial topic, so before you jump down my throat, try to sit through the entire talk, especially the parts where I frame the question as one of optimization. Most problems that have been heavily politicized suffer a common problem: they fail to distinguish between what is desirable in a resource unconstrained world (e.g., free health care for everyone that provides perfect care) and what is plausible the real world (e.g., some combination of features, but not 5 starts across the board).

Hope you enjoy the departure from the usual topics.

Pi Day

The math geeks in the audience will appreciate that yesterday, March 14, 2015, represented a very special variant of pi day. Normally, March 14 represents pi to 3 significant digits, namely, 3, 1, and 4 (i.e., 3.14). Yesterday, however, being the pi day in 2015, was especially cute, because it advanced two more significant digits, 1 and 5, via the year (i.e., 3.1415). If you’re a watch geek, in addition to being a math geek–yes, I realize this is not a huge club–the beauty of a perpetual calendar (a type of watch that shows time, month, date, and year inclusive of leap years), made it a really fun day! Why? Because at 9:26 and 54 seconds you found yourself at the following place in time: the 3rd month, 14th day, 15th year (of this century), 9th hour, 26th minute, and 54th second, that is, 3.141592654–pi to 10 significant digits!

After capturing this wonderful moment in time, I sent the picture, below, to my watch mentor (also a math geek; yes I just wrote the words “watch” and “mentor” next to each other). He loved it, but his response was priceless: “Peter, don’t ever show this to any woman you have the slightest interest in….check that, don’t show it to any woman period. Pretty cool though. You are right. I dig it.”

Good thing my days of trying to impress the ladies are far in the rear view mirror.

Parting shot: I did a follow up podcast with Tim Ferriss a few weeks ago. It’s episode #65 which is available on iTunes. This was my first time doing the strange format of just talking by myself. Feedback appreciated if this should morph into something I do quasi-regularly on the blog.

 

Pi on abstract background with about 3500 decimal digits by Nicolo Canali De Rossi is licensed under CC by 2.0

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