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 leonard.tulipan@outlook.com