Dieting is as old as the hills. In fact, the history of dieting can be traced to 4000 BC. The first recorded diet was an Egyptian medical treatise written by Imhotep and it was recommended for people suffering from diabetes, high blood pressure or malaria.

Cholesterol is a type of fat that is produced in the body to produce hormones, but too much cholesterol can result in plaque build-up in the blood vessels and form dangerous clots that can cause heart attacks and strokes. To help control cholesterol levels, some people choose to follow a low-carb diet.

From , medical opinion from – Updated 29. June 2021

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What is your main health goal?

Cholesterol is an important component of our body and although there is clear evidence of an association between high blood cholesterol levels and increased cardiovascular risk, it is not clear that cholesterol is always and for everyone associated with increased cardiovascular risk.

Read on to find out what cholesterol is, how your body uses it, why low-carb and keto diets can cause changes in blood cholesterol levels, and whether you should be concerned if your cholesterol levels rise with a low-carb or keto lifestyle.

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What is your main health goal?

Basic : What is cholesterol?

Cholesterol is a waxy substance that is essential for all animals, including humans. Cholesterol is found in almost every cell in your body and is needed for many bodily functions, including

  • Cellular integrity : As an integral part of every cell membrane in the body, cholesterol is essential for maintaining cell structure and fluidity.
  • Hormone Synthesis : Cholesterol is necessary for the production of steroid hormones such as estrogen, testosterone, cortisol and other related hormones such as vitamin D3.
  • Formation of bile acids : The liver converts cholesterol into bile acids, which help digest fats and the essential fat-soluble vitamins A, D, E and K.
  • Myelin formation: The myelin sheath that surrounds and protects the nerve cells contains a lot of cholesterol.

Your body produces most of the cholesterol in your blood. It is mainly produced in the liver.

Dietary cholesterol, found in animal products such as eggs, shellfish, cheese and organ meats, makes up a smaller proportion of cholesterol in the blood.

Unlike fat, which contains nine calories per gram, cholesterol contains no calories. Because it is present in very small amounts in foods, it is measured in milligrams, not grams. Most fatty meats and whole dairy products are very low in cholesterol, while some shellfish and organ meats are high in cholesterol but low in fat.

After years of being advised to skip the egg yolk and eat only protein, we have learned that eating foods high in cholesterol does not have much effect on blood cholesterol levels. When people take in more cholesterol from food, the liver usually produces less, keeping blood cholesterol levels stable.

 

How is cholesterol transported in the body?

Cholesterol is absorbed by the digestive tract or produced by the liver and circulates in the bloodstream where it is used by cells according to their needs. The remaining cholesterol returns to the liver, where it is converted to bile acids or used for other purposes.

It is important to know that cholesterol does not move through the circulatory system on its own. Because it is a hydrophobic (water-repellent) substance, it must be packed into lipoproteins to get into the bloodstream.

Think of lipoproteins as the boats needed to transport cholesterol safely through the bloodstream. When we talk about cholesterol levels in the blood, we are talking about the amount of cholesterol in the individual lipoprotein particles (like the number of passengers on a ship).

Besides cholesterol, these lipoprotein particles also contain special proteins called apolipoproteins, triglycerides and other components.

  • Cholesterol packed into lipoproteins containing apolipoprotein B100 (commonly known as apo B) is called low-density lipoprotein (LDL) cholesterol (later in this guide, the more common term LDL is used).
  • Cholesterol packed into lipoproteins containing apolipoprotein A is called high-density lipoprotein cholesterol (HDL) or HDL-C (in this guide it will be called HDL).

Contrary to what we have all heard, there really is no such thing as good or bad cholesterol; there is only one kind of cholesterol. The LDL and HDL values indicate the amount of cholesterol contained in the LDL and LDL lipoprotein particles. In fact, the same cholesterol is constantly transferred between these and other types of lipoproteins as they move through the bloodstream.

LDL is often called the bad cholesterol because its high levels are associated with an increased risk of heart disease. HDL, on the other hand, is often called good cholesterol because low HDL levels are associated with increased heart risk. In addition, one of the main functions of HDL is to transport cholesterol to the liver for use when needed or to be excreted through the bile.

However, this is an overly simplistic view of LDL and HDL that does not take into account the fact that LDL likely has important beneficial functions. For example, research shows that LDL plays a role in immune function and response to injury, among other things.

Furthermore, this simplistic reasoning assumes that all LDLs are equal, which we believe is not the case. This is especially true when considering metabolic diseases and their effects on LDL, as well as the role of oxidized LDL.

So LDL is not necessarily bad, just as HDL is not necessarily good. But they can play both a positive and a negative role in our bodies, depending on the specific situation.

 

What is a normal cholesterol level?

Recommended cholesterol levels vary somewhat from country to country and from health care facility to health care facility. The U.S. National Institute of Health website lists the following optimal cholesterol and triglyceride levels for people at low risk of heart disease, measured after 9 to 12 hours of fasting:

  • Total cholesterol: < 200 mg/dL (5.2 mmol/L)
  • LDL cholesterol: < 100 mg/dL (2.6 mmol/L)
  • HDL cholesterol: > 40 mg/dL (1.0 mmol/L) for men, > 50 mg/dL (1.3 mmol/L) for women
  • Triglycerides: < 150 mg/dL (1.7 mmol/L)

LDL levels >160 mg/dL (4.1 mmol/L) are considered high, and levels of 190 mg/dL (4.9 mmol/L) or higher are considered very high.

Many factors can affect blood cholesterol levels, including genetics, hormonal changes, injuries, and certain health problems. For example, people with untreated hypothyroidism often have high cholesterol.

A person’s diet can also affect cholesterol levels, sometimes to a significant degree.

Some argue that these limits are based on epidemiological studies and are therefore unlikely to apply equally to all individuals, regardless of their metabolism and general state of health. For example, there is evidence that people with low LDL levels can have heart attacks, while those with high LDL levels can live long lives.

The point is that LDL levels should be considered as one variable among others in assessing cardiovascular risk, using a person’s metabolic status and other risk factors to adjust the risk estimate up or down.

 

How does a ketogenic or low-carbohydrate diet affect cholesterol levels?

Some people who follow a keto diet or a low-carb diet have little or no increase in total blood cholesterol. Some even show a decrease in LDL cholesterol levels after following a low-carb diet. Others, however, have high levels of LDL and HDL cholesterol. There may also be an increase in HDL cholesterol alone, resulting in an improvement in the LDL/HDL ratio.

A meta-analysis of randomized trials found that on average, people who followed a low-carbohydrate diet had a decrease in total LDL particles and small LDL particles and an increase in maximum LDL size.

Elevated cholesterol levels during a keto or low-carb diet may be associated with weight loss. Although cholesterol levels often drop in the first two to three months after significant weight loss, there may be an increase in cholesterol levels thereafter that persists until weight stabilizes. Once weight loss is stopped, cholesterol levels usually drop.

Therefore, it may be wise to wait to determine cholesterol levels until a person’s weight has been stable for several months.

About 5-25% of people – with or without weight loss – have significantly elevated LDL cholesterol, sometimes by 200% or more, in response to a diet with very few carbohydrates. Many of these people belong to a group that Dave Feldman of Cholesterol Code calls the Hyperponder Lean Body Masses (LMHR). These often healthy people are sometimes shocked to discover that their LDL cholesterol has increased by more than 200 mg/dL (5.2 mmol/L) since switching to the keto diet.

We understand that quoting data from a blog is not up to the highest scientific standards. Unfortunately, there is a lack of medical literature in this area, so we decided to present the available data. We acknowledge that Dave’s work has not been subjected to the same critical review by the scientific community as work published in medical journals.

Feldman’s theory of hypersensitivity to dry weight is based on experiments he performed on himself, and on data from hundreds of other hypocaloric people who performed similar experiments on themselves.

He says that higher energy demands, lower body fat reserves and lower glycogen stores in these LMHRs cause the liver to increase production of lipoprotein particles so that triglycerides (fat) can be delivered to the cells for use as fuel. When cholesterol travels with triglycerides, blood cholesterol levels can rise because the liver makes more lipoproteins to meet the body’s energy needs.

To date, the lipidological community has not endorsed Dave’s theory or any other theory of hyperresponders. However, there are other possible explanations.

Another theory is that increased consumption of saturated fat increases cholesterol absorption, while low insulin levels reduce LDL receptor activity. Thus, a reduction in receptor activity reduces the amount of LDL that is removed from the circulation and excreted in the bile. In combination, these factors can significantly increase circulating LDL levels.

The synthesis and absorption of cholesterol are complex mechanisms that are influenced by diet, genes and other factors. Not surprisingly, significant changes in blood LDL cholesterol levels occur in a minority of people following a low-carb diet, and perhaps this is why the exact mechanism remains unclear.

In general, no major changes in serum lipids occur with a ketogenic diet. Stable LDL cholesterol levels, lowered triglycerides and increased HDL cholesterol are typical results.

 

Should you be concerned if your cholesterol rises on a low-carb diet?

This is an emerging area of research that is currently the subject of much debate and uncertainty.

Traditional lipid and cardiovascular specialists treat elevated LDL cholesterol levels with concern because they generally indicate high concentrations of LDL particles (LDL-P) circulating in the blood.

Excessive levels of LDL particles have been shown to be associated with the development of atherosclerosis, the leading cause of heart disease. In atherosclerosis, LDL particles are known to be found in damaged artery walls and are associated with an inflammatory response. Over time, cholesterol, calcium, white blood cells and other substances accumulate in this area and form plaque. Most, if not all, heart attacks and strokes occur when a plaque breaks down and forms a blood clot that blocks blood flow through the arteries.

It is believed that the duration of exposure of the arteries to high concentrations of LDL particles plays an important role in the development of atherosclerosis. Small LDL particles typically spend more time in the bloodstream than large ones, making them an easier target for oxidation and sequestration in plaques. In addition, people with lots of small LDL particles often have low HDL cholesterol and high triglycerides – all markers of insulin resistance and expressions of increased risk of cardiovascular disease.

Although small LDL particles can be particularly problematic, some large studies have also found an association between high levels of large LDL particles and heart disease (although this did not control for metabolic health or insulin resistance).

Despite these associations between high levels of LDL particles and heart disease, studies consistently show that the keto diet reduces many heart disease risk factors in people with diabetes and other insulin-resistant conditions. Of course, these are not studies that show an actual reduction in heart attacks, but such studies do not yet exist. But the demonstrated improvement in risk factors suggests that we will see these favorable results one day.

A 2009 randomized trial comparing a low-fat diet to a very low-carbohydrate diet in people with metabolic syndrome found that the very low-carbohydrate diet was more effective in improving many cardiovascular health outcomes, including the following:

  • Reduction of body and abdominal fat
  • Reduction of triglyceride levels
  • Increased HDL cholesterol level
  • Reduction of small LDL particles
  • Lowering of blood sugar levels
  • Decreased insulin levels
  • Increased insulin sensitivity

Similarly, a non-randomized study showed that a ketogenic diet reduced the proportion of small LDL and increased that of large LDL. Also in this study, no significant increase in atherosclerosis or fat accumulation in the carotid artery was observed after two years, even in the hyperresponders.

The fact that so many risk factors remain unchanged or improve with carbohydrate restriction – even though LDL cholesterol levels rise – shows that it is important not to consider each value in isolation. Instead, it might be better to think of the body as a holistic system.

However, the well-known lipidologist and lipid educator Dr. Thomas Dayspring urges caution. In his book The Case of 291 Lipidogolics Anonymous: Can weight loss worsen lipids? he notes:

Proponents of low-carbohydrate diets claim that there are no studies showing the harm of elevated LDL-P and HDL-C levels in patients who have eliminated or significantly reduced insulin resistance and inflammatory markers by a low-carbohydrate diet. True, but they want to ignore the fact that there is no evidence anywhere that they are the exception.

However, many proponents of low-carb diets dispute that none of the studies showing a link between high LDL and heart disease have been done in people following a keto or low-carb diet.

Dave Feldman aims to collect as much data as possible from people with similar experiences, which over time can provide very valuable information. If you are a hypercorrespondent and would like to participate in his ongoing data collection, please contact him by responding to one of his posts at www.cholesterolcode.com.

Since there are currently no formal studies examining this response, we cannot predict what will happen in the long term in people with very high LDL cholesterol who follow a low-carb diet.

 

Five ways to lower LDL with a ketogenic or low-carb lifestyle

Did the low-carb diet increase cholesterol levels? Are you afraid to give up this type of diet and its potential benefits?

Here are five ways to lower your total and LDL cholesterol while following a keto or low-carb lifestyle. Try them in this order.

1. Avoid bulletproof coffee

With Bulletproof Coffee, butter, coconut fat or MCT oil is added to the coffee. Avoid eating large amounts of fat when you are not hungry. This alone can sometimes normalize high cholesterol.

2. Only eat when you are hungry

Eat only when you are hungry and consider intermittent fasting. It can lower your cholesterol. Although most studies on intermittent fasting and LDL lowering have come from poor-quality observational studies conducted during Ramadan, a recent pilot study on time-restricted feeding showed a significant reduction in LDL levels. Although we need more data, this intervention remains promising.

3. Eat foods rich in unsaturated fats rather than saturated fats

Foods rich in unsaturated fats are fats such as olive oil, fatty fish and avocados. Replacing saturated fat sources with these foods may be enough to lower LDL cholesterol.

However, keep in mind that many unsaturated oils are highly processed. As with food, we recommend choosing the least processed oils, such as olive oil, macadamia oil and avocado oil.

4. Eat foods that lower LDL and are suitable for the keto diet

These low-carbohydrate plant-based foods can help lower cholesterol a bit:

  • Counselor: An analysis of 10 studies showed that regular consumption of avocados significantly lowered LDL cholesterol levels.
  • Greens: Dark leafy vegetables and cruciferous vegetables bind bile acids, which are excreted as waste products instead of being absorbed into the intestines, ultimately leading to a slight reduction in blood cholesterol levels. To maximize this effect, it is better to steam the vegetables rather than eat them raw.
  • Cocoa and dark chocolate: Cocoa and dark chocolate not only lower LDL cholesterol levels, but may also help protect LDL from oxidation or damage. To avoid consuming too much sugar, chocolate with at least 85% cocoa is preferred.
  • Nuts and seeds : Nuts and seeds are rich in fiber and monounsaturated fats, which help lower cholesterol. An analysis of 25 studies showed that eating two portions of nuts per day reduced LDL cholesterol levels by an average of 7%.

5. Eat more carbohydrates

Finally, if steps 1 to 4 are not sufficient: Ask yourself if you really need to follow a strict keto diet for health reasons.

If a moderate to liberal low-carb diet (e.g., 50 to 100 grams of carbs per day) works for you, it may also lower your cholesterol. Remember to choose unprocessed carbohydrate sources (so no wheat flour or refined sugar).

Bonus: Q2

This is still speculation, and there is no quality evidence yet. But eating enough foods containing vitamin K2 can help reduce the risk of developing atherosclerosis.

Vitamin K exists in two forms: K1 and K2. Vitamin K1 is found in plants and is involved in blood clotting. Vitamin K2, on the other hand, is mainly found in animal products.

There is no definitive evidence yet, but taking enough vitamin K2 may help protect heart health by keeping calcium in the bones and arteries. The best sources of vitamin K2 are liver, eggs, grass-fed dairy products and chicken.

 

Advanced Test

As mentioned earlier, the rise in LDL cholesterol is sometimes temporary, especially if you lose weight. However, if your values remain very high, and especially if you have additional risk factors (family history of heart disease, certain genetic markers, diabetes, or if you smoke), you should be tested further. This can give a clearer picture of your risk profile and health compared to your normal blood cholesterol levels:

  • NMR (nuclear magnetic resonance) spectroscopy: provides detailed information on the size and number of LDL and HDL particles, as well as an index of insulin resistance that reflects the risk of developing diabetes.
  • Coronary arterial calcium scan (CAC): measures calcium accumulation in the coronary arteries using CT scans to detect early signs of heart disease.
  • CIMT test (carotid intima-media thickness) : Measure the thickness of the inner layer of the carotid artery to detect atherosclerosis and fatty deposits.

 

Video

Dave Feldman: Cholesterol Network System

Dr Andrew Mente : Dietary fats and cardiovascular disease

Sarah Hallberg: LDL at LCHF

Dr Peter Attia: Direct information about cholesterol

Article

Dr. Peter Attia: Talking frankly about cholesterol (part 1 of 9)

Dr. Thomas Dayspring: Insight into the total lipid profile

Cholesterol code : Are you a dry matter hyperresponder?

Frequently Asked Questions

Can I do a low carb diet if I have high cholesterol?

Yes, you can do a low carb diet if you have high cholesterol.

How can I lower my cholesterol on a low carb diet?

There are many ways to lower your cholesterol on a low carb diet. Some of the most effective include: Eating more vegetables and fruits, especially berries. Eating more omega-3 fatty acids from fish, nuts, and seeds. Eating more saturated fat from animal products. Eating less sugar and refined carbohydrates. Eating more fiber. Eating less processed foods. Eating less salt. Eating more protein. Eating more healthy fats. Eating less alcohol.

Can I do Keto if I have high cholesterol?

Yes, you can do Keto if you have high cholesterol.

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