ApoE4.Info

40 yr old Indian male, BMI 25 (too high for Indian descent) HbA1C 43 ie pre diabetes. Both parents diabetic.
Has a couple units alcohol a night. Drinking sugar containing sodas. Jam on toast.Eating mucho refined carbs.
Lipid profile: TC 8.4mmol/l (324mg/dl).
HDL 0.8 (30)
LDL unable to be measured because....drum roll....
Triglycerides 12.8 mmol/l (1133mg/dl)
Yip its not a typo.
Well I intend to read him the riot act tomorrow morning, and I'll be referring him to the hospital lipid clinic cos he's at high risk of acute pancreatitis right now let alone cvd risk for the future: it'll take about 2 months or more for him to be seen. In the meantime I can talk to the lipidologist re statin vs fibrate.
But here's the rub....
Id dearly like to start him on HFLC in the interim, but can't cos at TG levels above 1000 the chylomicron clearance pathways are saturated and fat in the diet just accumulates in an accelerated fashion and then he will get pancreatitis and can die.
I'm going to have to start him on VeryLFHC. According to uptodate (the world's best, constantly updated online textbook that costs me a huge amount every year but worth every cent) 25grams a day max. Shudder.

Interesting huh? its always about context.
And for him Im hoping his 2 week old baby is context enough.

Stavia, can you do APOE genotyping on him? He may carry the rare E2 allele and need a very low carbohydrate diet. They have hypertriglyceridemia in response to carbohydrates. It's on my radar because my husband is a 2/3.

Yah, I can. I saw that on uptodate last night.
Its one of the things Im going to ask the lipidologist today.
Really interesting.
And I'm again impressed by your knowledge in the field

He's very lucky to have you for his physician, Stavia. I agree with your assessment; this guy is in bad shape. My husband's Grandmother (very dear to us) had similar lipids- VERY elevated TGs- consistently over 1,000. Once we learned of his E2, we suspected she may have had the very rare 2/2. (APOE genotyping wasn't done back then.) She began having MIs in her early 50s and ultimately died of CVD. I hope this guy can turn things around in time. His brand new baby may be the perfect incentive

Hi Stavia,

How about low carb, low fat, sufficient protein for a period of time. Carbs - only non-starchy veggies & leaves. Protein - very lean and sufficient for his mass, on the low end of the scale like 0.7g/kg. His system has plenty of TG's circulating & stored. Carbs are not essential. The only thing necessary is protein. Then add in some electrolytes - Mg++, K+ & Na+, so when insulin drops, he doesn't have electrolyte issues.

This might drop his TG's fairly quickly, then he could be transitioned to LCHF.

George, exactly!! I discussed him with the top lipidologist this morning. He thinks its most likely multifactorial but primarily insulin resistance and excess dietary sugars/fructose driven. He doesn't think checking apoe2 will add any value: even if he is apoe2 it won't change the following:
2 weeks zero sugar, I've even banned fruit for 2 weeks (lol the start of a lifetime of zero added sugar), zero starchy carbs, moderate lean protein, predominantly non starchy veggies. Zero alcohol.
Then we'll see what he can go down to. Sadly he may need metformin for his insulin resistance and possibly a statin cos this is nasty nasty. But I'll be cautious and see what he can do with lifestyle.
Thanks for the electrolyte tip. I'll call him now, he's gonna have some massive shifts.

Btw Julie our practice's record for TGs is 85. Thats about 80 thousand in your units. Insulin resistance, obese, sedentary 40yr old woman on an atypical anti psychotic.

ok team, update on this patient.
He's done stunningly: only two weeks remember:

TC 178 (4.6)
TG's 88 (1.0) !!!!!!!
HDL 49 (1.27)
LDL 112 (2.9)

wow
WOW
<happy dance>
I've showed all the other docs here. They are blown away. Good learning for them huh! That the answer is not always a pill. And how much excess carbs can drive dyslipidaemia in the context of even mild insulin resistance.

Wow. Good job figuring it out.

I think we tend to go with pills because there is little faith in compliance. But that is patronizing to some of us - others might want a quick answer and pill, anything more is beyond their mental/emotional capability. On a side note, I've been reading about open mindset which sort of delves into some of the fundamental assumptions that create the 2 ways of dealing with things. Although the open mindset discussion is about changing psychological attributes (such as intelligence), I think it is similar dynamics in that people feel they have no control on their health (it's genetic and you can't change it).

At least people should be given a choice.

In this case you armed the patient with the information he needed to make the best choice. And he did.

Again, good job.

Stavia,

That is awesome!!

Textbook case of getting rid of the excess carbs!

Hopefully the guy appreciates what you've done for him (and without meds).

George

Helping people improve their health and lives all around the world is the team goal. Great job team members!