Download - Vanity Metrics - Why your doctor learned to read your blood panel wrong and what to do about it
VANITY METRICS
Why your doctor learned to read your blood panel wrong and
what to do about it
What you will learn in the next 15 min
Vanity metrics
How we got into this mess
What do to about it:
Low Carb &
Blood Lipid Panels
Vanity Metrics “They might make you feel good, but they don’t offer clear guidance for what to do”
Eric Ries
Lean Startup –
Eric Ries Startup Bible of silicon
valley
Example
vanity metric actionable metric
website “Hits”
How many people have
visited my website?
What do I learn?
A/B split test
group A
group B: 20% more
revenue
Go with design B =>
more revenue
What has this got to
do with Doctors?
Surrogate Markers
In clinical trials, a surrogate endpoint (or
marker) is a measure of effect of a specific
treatment that may correlate with a real
clinical endpoint but does not necessarily
have a guaranteed relationship
Instead of monitoring heart disease risk, studies monitor
„surrogate markers‟
Startups/Business Medicine
vanity metric
actionable metric
surrogate marker
cholesterol
clinical endpoint
heart disease
all-cause mortality
What if the
surrogate markers
are Bull#*(&?
Raging Bull by Graeme Law
Example
Although observational studies might suggest a simplistic hypothesis for [HDL] […] cholesterol, that increasing the levels pharmacologically would […] reduce cardiovascular events […] substantial trials of these three agents do not support this concept.
We cannot judge health effects of pharmaceutical agents on their effect on so-called surrogate markers [e.g. HDL] such a cholesterol levels. The only important thing is their effect on overall health [e.g. mortality]
July 2014
http://www.bmj.com/content/349/bmj.g4379
How did we get in this cholesterol
mess?
Nikolai Nikolajewitsch Anitschkow
Test subjects
St Petersburg, 1913
On experimental cholesterol steatosis and
its significance in the origin of some
pathological processes by N. Anitschkow
and S. Chalatow photo: Tomi Tapio K
Cholesterol + Fat = Heart disease
Ancel Keys
1953 – “Six Country Study”
1961 – Time Magazine Cover
“Eat a low saturated fat diet”
September 24, 1955
President Dwight D.
Eisenhower
Heart attack with the low Total
Cholesterol of 165 ml/dL
Dwight D. Eisenhower
Eisenhower was ordered to eat dry toast [..] for breakfast and eat only 1 egg per week. His cholesterol continued to climb on a low fat, low cholesterol diet until it reached 259 the day he left office. Eisenhower had several more heart attacks and eventually died of heart disease.
Linking it together
A nation in shock
7 countries study
Eating cholesterol => high cholesterol
1984: The Lipid Research Clinics
Coronary Primary Prevention Trial
Results
The risk of death
from all causes
was only slightly
and not
significantly
reduced
Cholesterol
Essential structural
component of cell
membranes
Precursor for
biosynthesis of
Steroid hormones
Bile acid
Vitamin D
Cholesterol
Typical body production (Male, 68kg) =
1000mg
Typical dietary intake = 300mg (23%)
Cholesterol
Changing your diet (23% of cholesterol)
will not have a huge influence on your
Cholesterol
Eating Eggs is healthy
Rong Y, et al. Egg consumption and risk of coronary heart disease and stroke: dose-response meta-analysis of
prospective cohort studies. British Medical Journal, 2013.
Fernandez ML. Dietary cholesterol provided by eggs and plasma lipoproteins in healthy populations. Current
Opinion in Clinical Nutrition & Metabolic Care, 2006.
Blesso CN, et al. Whole egg consumption improves lipoprotein profiles and insulin sensitivity to a greater extent
than yolk-free egg substitute in individuals with metabolic syndrome. Metabolism, 2013.
LCHF Diet
More usage of fat as energy source
(ketones)
Body prefers saturated fats => uses them
as preferred fuel
LDL (“bad cholesterol”) is mostly „large
fluffy“ (good)
LDL Cholesterol
„Bad Cholesterol
(Transporter)“
LDL can be:
Large fluffy particles
Small dense particles
Boris Romac
Lindsay
Large fluffy
Small dense
My Values
TC 273 | HDL 69 | LDL 192 | TG 62
This is what my doctor sees
Total cholesterol 273
(goal < 200)
LDL cholesterol (calculated) 192
(goal < 160)
This is what my doctor sees
Total cholesterol 273
(goal < 200)
LDL cholesterol (calculated) 192
(goal < 160)
LDL calculated Friedewald (1972)
LDL = TC – HDL – (TG / 5)
Formula to calculate LDL
Cut-off for people with triglycerides > 400 mg/dl
SVA Vienna cut-off > 300 mg/dl
New Formulas (if your TG < 100 mg/dl)
Ahmadi (2008) http://www.ncbi.nlm.nih.gov/pubmed/18426324
LDL (mg/dl) = TC/1.19 + TG/1.9 – HDL/1.1 – 38
de Cordova (2013) http://www.ncbi.nlm.nih.gov/pubmed/23108766
LDL = 3/4 (TC - HDL)
Friedewald Formula
From 1972: Triglycerides (TG) must be <400
SVA (my insurance): TG <250
Low Carb (TG < ~100): Dr. William Davies “Friedewald equation relied on […] the assumption that the amount of triglycerides and cholesterol in ALL LDL particles was the same. In those of us following a wheat-free diet with limited exposure to junk carbohydrates, the triglyceride content of LDL particles is much lower, making the Friedewald equation invalid.”
http://www.wheatbellyblog.com/2012/12/cholesterol-belly/
My LDL Math (<160) TC 273 | HDL 69 | LDL 192 | TG 62
Friedewald
192 mg/dl
Ahmadi
161 mg/dl
Cordova
153 mg/dl
My LDL Math (<160) TC 273 | HDL 69 | LDL 157 | TG 62
Friedewald
192 mg/dl
Ahmadi
161 mg/dl
Cordova
153 mg/dl
Do I have other risk factors
European Cardiology Society Guidelines
SCORE Value => http://www.heartscore.org/
Newer Risk Assessment
TG/HDL ratio (<2,5 men, <3,5 women) http://www.ncbi.nlm.nih.gov/pubmed/24402298
Heartscore.org
Low Risk: TG / HDL < 2.5
TC 273 | HDL 69 | LDL 157 | TG 62
62 / 69 = 0,89
http://www.ncbi.nlm.nih.gov/pubmed/24402298
Conclusion (*IANAD + I do not play one on TV *)
If you are Low Carb (i.e. have low TG):
Calculate your own LDL with de Cordova
LDL = TC/1.19 + TG/1.9 – HDL/1.1 – 38
Check your heartscore.org
TG / HDL
< 2,5 for men
< 3,5 for women
Questions: @khbites [email protected]