Peter Attia· MD
The same reason that if we were to say I want to confirm ambulances aren't the cause of death for people who are dying inside of ambulances yeah I mean we have to be a little careful with that analogy so let's be clear can you get three sclerosis without having an oxidized sterile taken up by a macrophage no okay so if I could take all the LDL particles out of your body right now I can feel totally confident that you will not die of atherosclerosis okay so does that not imply that LDL is necessary but not sufficient for atherosclerosis I don't disagree with that without question LDL particles are it's important it's important for some people to understand that because I do think put it this way I've certainly heard people in this community argue the following that the burden of proof should be on the lipid ology community to demonstrate that LDL is causal rather than the reverse and I find that comical if it weren't for tragic let's go back to the analogy for a second are ambulances causal for ambulance related deaths absolutely they're a part of the project if I took life say the same thing because what you're basically saying is I'm emphasizing an association over causation we both realize that right so okay it could be in this town you actually are in worse shape if an ambulance picks you up there's very incompetent EMTs and their life-saving measures are poorly done and therefore if you could ban all ambulances in this town you'd find that actually all your Delian randomization of ambulances would ferret that out I would agree if there wasn't anything associated in the ambulance in the Mendelian randomization with response by ambulances in the first place only way I think you can discount the Mendelian randomization is if you believe that the mutations that you are measuring because so you're looking at a series of mutations that are affecting a phenotype in this case cholesterol level you'd have to convince yourself that each and every one of those is also affecting something else that's driving the underlying cardiovascular process yes yes but we've already went through this right it can't be the LDL receptor because that's not even ubiquitous and there aren't LDL receptors I want to I want this tested on a healthy vascular system however that's a crude I want every cell and I why does a person with FH not have a healthy vascular system when they're born when they're born yeah meaning they inherit a clean slate right someone who's born with FH has a normal beautiful vascular system sure that over time and most of them becomes destroyed just answer this question is there any cell in somebody who has FH that would function like a normal cell and somebody who doesn't have FH in order to be able to acquire the lipids or lipoproteins it wants to take yes plenty of patients with FH who do not have defective completely defective LDL receptors and therefore are not impeded but it this way there is a tab ilysm is not impeded is what you're saying not all of them again we have to be very careful when we talk about FH because there are at least 2,000 known versions of that disease it's very cumbersome so that's why I think it gets FH gets talked about like it's one disease it's a phenotype that has all of these things that can cause it so the broader question is is everyone with FH struggling to make steroid hormones I don't know the answer that no in fact FH maybe slightly protective in the case of an infection and in the case of diabetes and one argument for that via diabetes one's a little hard to explain the infection one FH has stuck around for a long time so there may have been a time when having the ability to mount an incredible immune response would have proved to have a survival advantage right and if you have four times the cholesterol of somebody else that's one moment in when that could come at a huge advantage right which gets back to the immunological response sugar but to get back to the the larger point I wouldn't blame somebody who has a poor digestive system for being malnourished as long as we can count on everybody's tissues to be properly nourished and but it's not believing by blaming them like help me understand what you mean by that what I mean by that is if there was a problem with