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Javier DAR, Manubolu VS, Norwitz NG, Kinninger A, Aldana-Bitar J, Ghanem A, Ahmad K, Vicuna WD, Hamidi H, Bagheri M, Elsayed T, Villanueva B, Ichikawa K, Flores F, Hamal S, Feldman D, Budoff MJ. The impact of carbohydrate restriction-induced elevations in low-density lipoprotein cholesterol on progression of coronary atherosclerosis: the ketogenic diet trial study design. Coron Artery Dis 2024:00019501-990000000-00244. [PMID: 38861193 DOI: 10.1097/mca.0000000000001395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/12/2024]
Abstract
BACKGROUND Despite innovations in pharmacotherapy to lower lipoprotein cholesterol and apolipoprotein B, risk factors for atherosclerotic cardiovascular disease (ASCVD), ASCVD persists as the leading global cause of mortality. Elevations in low-density lipoprotein cholesterol (LDL-C) are a well-known risk factor and have been a main target in the treatment of ASCVD. The latest research suggests that ketogenic diets are effective at improving most non-LDL-C/apolipoprotein B cardiometabolic risk factors. However, ketogenic diets can induce large increases in LDL-C to >190 mg/dl in some individuals. Interestingly, these individuals are often otherwise lean and healthy. The influence of increased levels of LDL-C resulting from a carbohydrate-restricted ketogenic diet on the progression of atherosclerosis in otherwise metabolically healthy individuals is poorly understood. This observational study aims to assess and describe the progression of coronary atherosclerosis in this population within 12 months. METHODS Hundred relatively lean individuals who adopted ketogenic diets and subsequently exhibited hypercholesterolemia with LDL-C to >190 mg/dl, in association with otherwise good metabolic health markers, were enrolled and observed over a period of 12 months. Participants underwent serial coronary computed tomography angiography scans to assess the progression of coronary atherosclerosis in a year. RESULTS Data analysis shall begin following the conclusion of the trial with results to follow. CONCLUSION Ketogenic diets have generated debate and raised concerns within the medical community, especially in the subset exhibiting immense elevations in LDL-C, who interestingly are lean and healthy. The relationship between elevated LDL-C and ASCVD progression in this population will provide better insight into the effects of diet-induced hypercholesterolemia.
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Affiliation(s)
- Denise Alison R Javier
- Division of Cardiology, The Lundquist Institute at Harbor-UCLA Medical Center, Los Angeles, California
| | - Venkat S Manubolu
- Division of Cardiology, The Lundquist Institute at Harbor-UCLA Medical Center, Los Angeles, California
| | | | - April Kinninger
- Division of Cardiology, The Lundquist Institute at Harbor-UCLA Medical Center, Los Angeles, California
| | - Jairo Aldana-Bitar
- Division of Cardiology, The Lundquist Institute at Harbor-UCLA Medical Center, Los Angeles, California
| | - Ahmed Ghanem
- Division of Cardiology, The Lundquist Institute at Harbor-UCLA Medical Center, Los Angeles, California
| | - Khadije Ahmad
- Division of Cardiology, The Lundquist Institute at Harbor-UCLA Medical Center, Los Angeles, California
| | - Will D Vicuna
- Division of Cardiology, The Lundquist Institute at Harbor-UCLA Medical Center, Los Angeles, California
| | - Hossein Hamidi
- Division of Cardiology, The Lundquist Institute at Harbor-UCLA Medical Center, Los Angeles, California
| | - Marziyeh Bagheri
- Division of Cardiology, The Lundquist Institute at Harbor-UCLA Medical Center, Los Angeles, California
| | - Tasneem Elsayed
- Division of Cardiology, The Lundquist Institute at Harbor-UCLA Medical Center, Los Angeles, California
| | - Bea Villanueva
- Division of Cardiology, The Lundquist Institute at Harbor-UCLA Medical Center, Los Angeles, California
| | - Keishi Ichikawa
- Division of Cardiology, The Lundquist Institute at Harbor-UCLA Medical Center, Los Angeles, California
| | - Ferdinand Flores
- Division of Cardiology, The Lundquist Institute at Harbor-UCLA Medical Center, Los Angeles, California
| | - Sajad Hamal
- Division of Cardiology, The Lundquist Institute at Harbor-UCLA Medical Center, Los Angeles, California
| | | | - Matthew J Budoff
- Division of Cardiology, The Lundquist Institute at Harbor-UCLA Medical Center, Los Angeles, California
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Takemura Y, Inoue T, Matsunaga K, Tani R, Fu HY, Minamino T. The impact of dietary fat type on lipid profiles in lean mass hyper-responder phenotype. Clin Case Rep 2024; 12:e8485. [PMID: 38323135 PMCID: PMC10844582 DOI: 10.1002/ccr3.8485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/15/2024] [Accepted: 01/28/2024] [Indexed: 02/08/2024] Open
Abstract
Key Clinical Message Although the lean mass hyper-responder (LMHR) phenotype is well known, its diagnosis is impeded by the influence of fat type and intake on the lipid profile. Accordingly, a detailed assessment is warranted if LMHR is suspected. Abstract A 47-year-old man with suspected familial hypercholesterolemia presented with elevated triglyceride and low-density lipoprotein cholesterol levels. He had adhered to a ketogenic diet and was suspected of a lean mass hyper-responder phenotype; however, his lipid profile did not meet the definition. His lipid profile improved through dietary management without medication.
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Affiliation(s)
- Yuma Takemura
- Department of Cardiorenal and Cerebrovascular Medicine, Faculty of MedicineKagawa UniversityKagawaJapan
| | - Tomoko Inoue
- Department of Cardiorenal and Cerebrovascular Medicine, Faculty of MedicineKagawa UniversityKagawaJapan
| | - Keiji Matsunaga
- Department of Cardiorenal and Cerebrovascular Medicine, Faculty of MedicineKagawa UniversityKagawaJapan
| | - Ryosuke Tani
- Department of Cardiorenal and Cerebrovascular Medicine, Faculty of MedicineKagawa UniversityKagawaJapan
| | - Hai Ying Fu
- Department of Cardiorenal and Cerebrovascular Medicine, Faculty of MedicineKagawa UniversityKagawaJapan
| | - Tetsuo Minamino
- Department of Cardiorenal and Cerebrovascular Medicine, Faculty of MedicineKagawa UniversityKagawaJapan
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Bubeck AM, Urbain P, Horn C, Jung AS, Ferrari L, Ruple HK, Podlesny D, Zorn S, Laupsa-Borge J, Jensen C, Lindseth I, Lied GA, Dierkes J, Mellgren G, Bertz H, Matysik S, Krautbauer S, Liebisch G, Schoett HF, Dankel SN, Fricke WF. High-fat diet impact on intestinal cholesterol conversion by the microbiota and serum cholesterol levels. iScience 2023; 26:107697. [PMID: 37694136 PMCID: PMC10485154 DOI: 10.1016/j.isci.2023.107697] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 06/02/2023] [Accepted: 08/18/2023] [Indexed: 09/12/2023] Open
Abstract
Cholesterol-to-coprostanol conversion by the intestinal microbiota has been suggested to reduce intestinal and serum cholesterol availability, but the relationship between intestinal cholesterol conversion and the gut microbiota, dietary habits, and serum lipids has not been characterized in detail. We measured conserved proportions of cholesterol high and low-converter types in individuals with and without obesity from two distinct, independent low-carbohydrate high-fat (LCHF) dietary intervention studies. Across both cohorts, cholesterol conversion increased in previous low-converters after LCHF diet and was positively correlated with the fecal relative abundance of Eubacterium coprostanoligenes. Lean cholesterol high-converters had increased serum triacylglycerides and decreased HDL-C levels before LCHF diet and responded to the intervention with increased LDL-C, independently of fat, cholesterol, and saturated fatty acid intake. Our findings identify the cholesterol high-converter type as a microbiome marker, which in metabolically healthy lean individuals is associated with increased LDL-C in response to LCHF.
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Affiliation(s)
- Alena M. Bubeck
- Department of Microbiome Research and Applied Bioinformatics, Institute of Nutritional Sciences, University of Hohenheim, Stuttgart, Germany
| | - Paul Urbain
- Department of Medicine I, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Cathrine Horn
- Mohn Nutrition Research Laboratory, Centre for Nutrition, Department of Clinical Science, University of Bergen, Bergen, Norway
- Mohn Nutrition Research Laboratory, Centre for Nutrition, Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Anna S. Jung
- Department of Microbiome Research and Applied Bioinformatics, Institute of Nutritional Sciences, University of Hohenheim, Stuttgart, Germany
| | - Lisa Ferrari
- Department of Microbiome Research and Applied Bioinformatics, Institute of Nutritional Sciences, University of Hohenheim, Stuttgart, Germany
| | - Hannah K. Ruple
- Department of Microbiome Research and Applied Bioinformatics, Institute of Nutritional Sciences, University of Hohenheim, Stuttgart, Germany
| | - Daniel Podlesny
- Department of Microbiome Research and Applied Bioinformatics, Institute of Nutritional Sciences, University of Hohenheim, Stuttgart, Germany
| | - Stefanie Zorn
- Department of Medicine I, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Johnny Laupsa-Borge
- Mohn Nutrition Research Laboratory, Centre for Nutrition, Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Caroline Jensen
- Mohn Nutrition Research Laboratory, Centre for Nutrition, Department of Clinical Science, University of Bergen, Bergen, Norway
- Mohn Nutrition Research Laboratory, Centre for Nutrition, Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | | | - Gülen Arslan Lied
- Mohn Nutrition Research Laboratory, Centre for Nutrition, Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Jutta Dierkes
- Mohn Nutrition Research Laboratory, Centre for Nutrition, Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Gunnar Mellgren
- Mohn Nutrition Research Laboratory, Centre for Nutrition, Department of Clinical Science, University of Bergen, Bergen, Norway
- Mohn Nutrition Research Laboratory, Centre for Nutrition, Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Hartmut Bertz
- Department of Medicine I, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Hematology, Oncology and Stem Cell Transplantation, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Silke Matysik
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Sabrina Krautbauer
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Gerhard Liebisch
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Hans-Frieder Schoett
- Singapore Lipidomics Incubator (SLING), Life Sciences Institute, National University of Singapore, Singapore, Singapore
| | - Simon N. Dankel
- Mohn Nutrition Research Laboratory, Centre for Nutrition, Department of Clinical Science, University of Bergen, Bergen, Norway
- Mohn Nutrition Research Laboratory, Centre for Nutrition, Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - W. Florian Fricke
- Department of Microbiome Research and Applied Bioinformatics, Institute of Nutritional Sciences, University of Hohenheim, Stuttgart, Germany
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
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Severe Dyslipidemia Mimicking Familial Hypercholesterolemia Induced by High-Fat, Low-Carbohydrate Diets: A Critical Review. Nutrients 2023; 15:nu15040962. [PMID: 36839320 PMCID: PMC9964047 DOI: 10.3390/nu15040962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 02/04/2023] [Accepted: 02/07/2023] [Indexed: 02/17/2023] Open
Abstract
Emerging studies in the literature describe an association between high-fat, low-carbohydrate diets and severe hypercholesterolemia consistent with the levels observed in patients with (homozygous) familial hypercholesterolemia (FH). High levels of low-density lipoprotein cholesterol (LDL-C) may result from the reduced clearance of LDL particles from the circulation, the increased production of their precursor, or a combination of both. The increased intake of (saturated) fat and cholesterol, combined with limited to no intake of carbohydrates and fiber, are the main features of diets linked to hypercholesterolemia. However, several observations in previous studies, together with our observations from our lipid clinic, do not provide a definitive pathophysiological explanation for severe hypercholesterolemia. Therefore, we review these findings and possible pathophysiological explanations as well as opportunities for future research. Altogether, clinicians should rule out high-fat, low-carbohydrate diets as a possible cause for hypercholesterolemia in patients presenting with clinical FH in whom no mutation is found and discuss dietary modifications to durably reduce LDL-C levels and cardiovascular disease risk.
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Norwitz NG, Soto-Mota A, Kaplan B, Ludwig DS, Budoff M, Kontush A, Feldman D. The Lipid Energy Model: Reimagining Lipoprotein Function in the Context of Carbohydrate-Restricted Diets. Metabolites 2022; 12:metabo12050460. [PMID: 35629964 PMCID: PMC9147253 DOI: 10.3390/metabo12050460] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 05/02/2022] [Accepted: 05/04/2022] [Indexed: 12/11/2022] Open
Abstract
When lean people adopt carbohydrate-restricted diets (CRDs), they may develop a lipid profile consisting of elevated LDL-cholesterol (LDL-C) and HDL-cholesterol (HDL-C) with low triglycerides (TGs). The magnitude of this lipid profile correlates with BMI such that those with lower BMI exhibit larger increases in both LDL-C and HDL-C. The inverse association between BMI and LDL-C and HDL-C change on CRD contributed to the discovery of a subset of individuals—termed Lean Mass Hyper-Responders (LMHR)—who, despite normal pre-diet LDL-C, as compared to non-LMHR (mean levels of 148 and 145 mg/dL, respectively), exhibited a pronounced hyperlipidemic response to a CRD, with mean LDL-C and HDL-C levels increasing to 320 and 99 mg/dL, respectively, in the context of mean TG of 47 mg/dL. In some LMHR, LDL-C levels may be in excess of 500 mg/dL, again, with relatively normal pre-diet LDL-C and absent of genetic findings indicative of familial hypercholesterolemia in those who have been tested. The Lipid Energy Model (LEM) attempts to explain this metabolic phenomenon by positing that, with carbohydrate restriction in lean persons, the increased dependence on fat as a metabolic substrate drives increased hepatic secretion and peripheral uptake of TG contained within very low-density lipoproteins (VLDL) by lipoprotein lipase, resulting in marked elevations of LDL-C and HDL-C, and low TG. Herein, we review the core features of the LEM. We review several existing lines of evidence supporting the model and suggest ways to test the model’s predictions.
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Affiliation(s)
- Nicholas G. Norwitz
- Harvard Medical School, Boston, MA 02115, USA;
- Correspondence: (N.G.N.); (D.F.)
| | - Adrian Soto-Mota
- Metabolic Diseases Research Unit, National Institute for Medical Sciences and Nutrition Salvador Zubiran, Tlalpan, CDMX 14080, Mexico;
| | - Bob Kaplan
- Citizen Science Foundation, Las Vegas, NV 89139, USA;
| | - David S. Ludwig
- Harvard Medical School, Boston, MA 02115, USA;
- New Balance Foundation Obesity Prevention Center, Boston Children’s Hospital, Boston, MA 02115, USA
| | - Matthew Budoff
- Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA 90502, USA;
| | - Anatol Kontush
- National Institute for Health and Medical Research (INSERM), UMRS 1166 ICAN, Faculty of Medicine Pitié-Salpêtrière, Sorbonne University, 75013 Paris, France;
| | - David Feldman
- Citizen Science Foundation, Las Vegas, NV 89139, USA;
- Correspondence: (N.G.N.); (D.F.)
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