Low Carb and Cholesterol – A Case History

Estimated reading time: 8 minutes

Three months ago I had a visit from a 53 year old gentleman who was worried about his health. His name is Peter. He had been gaining weight for some time, his knees were aching and he was having trouble playing his weekly tennis with his old classmates. He told me he had probably put on approximately 55 lb (25 kg) in the past five years. “It all started when I quit smoking,” he said.

Low Carb and Cholesterol - A Case History

Peter was working as an accountant. There was a lot a stress at work, long working days and sometimes he had to go in on the weekends as well. Apart from his weekly badminton, he wasn’t really exercising at all. Although he had quit smoking, he had never really bothered about his lifestyle and was totally uninterested in diet and nutrition.

His wife took care of the cooking at home and was trying to limit his intake of calories. She was very conscious about cholesterol and tried to use low-fat varieties. At work however, Peter relied mainly on fast food, sandwiches, sodas, chocolate bars, chips, and an occasional fruit in between. Usually a few beers and some red wine on the weekends, bot otherwise not much alcohol.

Peter had suddenly become worried about his weight gain and felt his general condition was slowly becoming worse. He was feeling out of breath.

For the first time in his life he was really thinking about his health. He appeared to have suddenly realized that, he himself might have to take action.

Peter told me he wanted to try a low carb diet. A friend of his had been getting good results with such an approach, was feeling well and had lost a lot of weight. Peter thought this might be the way for him to go.

However, his wife was reluctant. She didn’t like the idea of eating so much fat. She had a history of elevated cholesterol herself, and had been trying to avoid animal and dairy fats for years. Her brother who was a physician recently started taking a cholesterol lowering drug. She wanted Peter to see a cardiologist before starting on a low carbohydrate high fat diet.

When I saw Peter he didn’t have any obvious signs or symptoms of heart disease. He was 5 ft 11 (181 cm) long and weighed 260 lb (118 kg). His body mass index (BMI) was 36. He had many of the classical features of the metabolic syndrome, his waist circumference was 47 inches (120 cm), and his blood pressure was 156/102 mm Hg.

His blood work showed the following results:

  • Total cholesterol: 251 mg/dl (6.5 mmol/L)
  • Calculated LDL-cholesterol (LDL-C): 169 mg/dl (4.4 mmol/L)
  • HDL cholesterol (HDL-C): 31 mg/dl (0.8 mmol/L)
  • Triglycerides (TG): 257 mg/dl ( 2.9 mmol/L)
  • Glycated hemoglobin (HgbA1C): 7.1 %

A Low Carb Hig Fat Diet – A Bad Idea?

Peter’s main problems were obesity, metabolic syndrome and type-2 diabetes. Glycated hemoglobin is a measure of long term blood sugar. A value higher than 6.5% indicates diabetes. His TG/HDL ratio was 8.3. A ratio higher than 3.5 is associated with insulin resistance. His LDL-C was certainly not ideal, but possibly not the biggest of his worries.

I told Peter and his wife about the risks associated with the combination of obesity, metabolic syndrome and type 2 diabetes. I tried to educate them about the problems associated with insulin resistance. His wife was mostly interested in his cholesterol numbers. I certainly don’t blame her because that’s been our main target for decades when it comes to the prevention of cardiovascular disease.

“Doctor, I would like to see him cut down on the fast food, eat less calories and exercise more” she said. “I don’t see how starches and whole grains will hurt him. It’s just the sugars and the beer he has to get rid of”.

“Okay Peter” I said. “What do you say?  We all agree that weight loss is essential to improve your health. If you don’t change your lifestyle and lose weight there is a risk that your health will get worse. In order to cut your risk we may have to put you on medication for high blood pressure, another one for your diabetes and a drug to lower cholesterol. There are many ways to go when it comes to losing weight. There are no simple tricks. The most important thing is to keep focus and understand what it is that you have to do”.

He seemed to have made up his mind. “I don’t like the idea of just eating less and exercising more”. I’ve tried that before. It sounds very sensible, but it hasn’t worked for me. It works for two weeks and then I’m back to the same old shit.  I need to try something else. I’ve read a few articles on the low-carb high fat approach and it appeals to me. Do you think that’s a bad choice doctor?”

“No” I said. “I certainly don’t think so. Indeed there is a lot of scientific data showing that such an approach may help you lose weight, reduce insulin resistance, improve your blood sugar and lower blood pressure.”

Three Months Later

I saw Peter and his wife again last week. He seemed quite happy. He had avoided refined sugars entirely, throwing candy and beverages out of the window. He had cut down on other types of carbohydrates, avoided potatoes, bread, pasta and rice. Basically, the only carbohydrates he had eaten came from vegetables and fruit. He had eaten a lot of eggs, cheese, meat and fish.

He was feeling better and less out of breath. He had lost almost 18 lb (8 kg)  in three months. His body mass index was 33.6. His blood pressure was 142/88 mm Hg. His tennis was going better and his knees were aching less

This was his blood work:

  • Total cholesterol: 290 mg/dl (7.5 mmol/L)Three months before: 251 mg/dl (6.5 mmol/L)
  • Calculated LDL-cholesterol (LDL-C) 210 mg/dl (5.4 mg/L)Three months before: 169 mg/dl (4.4 mmol/L)
  • HDL cholesterol (HDL-C): 54 mg/dl (1.4 mmol/L)Three months before: 31 mg/dl (0.8 mmol/L)
  • Triglycerides (TG): 132 mg/dl (1.5 mmol/L)Three months before: 257 mg/dl ( 2.9 mmol/L)
  • Glycated hemoglobin (HgbA1C) : 6.2 %Three months before: 7.1%

Peter was quite happy but his wife was worried. Her brother doctor had seen the blood work and pointed out that LDL-C was way too high, and would likely increase risk of having a heart attack or a stroke. He should start treatment with a cholesterol lowering drug as soon as possible.

I went over the positives and the negatives with Peter and his wife. He had certainly lost weight and his blood pressure had improved. His glycated hemoglobin had improved as well and the value was below the cut-off for diabetes. His TG/HDL ratio was 2.4 indicating less insulin resistance. I also told them that the fact that TG were so much lower could mean that the size of his LDL particles had improved, with less small LDL-particles and more large LDL-particles. A number of studies indicate that this may be a positive thing and associated with less risk of cardiovascular disease, despite the higher LDL-C.

What Does All This Mean?

Peter’s response to a low carb  high fat diet is quite typical. Weight loss usually occurs. Total cholesterol and LDL-C often increase and so does HDL-C. TG usually go down. Blood pressure often improves and typically blood sugar and glycated hemoglobin improve. Of course the big question is: “Is his situation better or worse than before”? Does the high LDL-C mean that his risk of heart disease is higher than before, despite all the other positive findings?

Peter’s wife wanted to change direction, cut out the fat, cut down the calories and believed he was better of with a cholesterol lowering drug. She is a sensible woman and she definitively wants the best for her husband.

 What Should Be the Next Step?

Because his wife was the one taking care of the groceries and cooking, Peter felt a bit like a misbehaving child not taking her advice. He was feeling better and definitively didn’t miss the weight he had lost. He felt a bit insecure because he had never before had an opinion about diet, and about what to eat or not to eat.

I’m quite curious to know my readers opinion so I’ve put up this poll for you. This is the firs time I do this on my blog. Please give me your vote and don’t hesitate to explain your choice in a comment. Last day for voting will be Wednesday, July 31, 2013.

Vote Results

What dietary approach would you recommend?

    • Continue with the low carb high fat approach and don’t worry about the LDL- cholesterol, partly because it is likely that LDL-particle size has improved 76% (176 votes)
    • Continue with a low carb high fat approach, but eat less saturated fat and cholesterol (less animal and dairy fat and eggs), and consume more poly-and monounsaturated fats 12% (27 votes)
      Adopt a Mediterranean type diet. Such a diet has been shown to improve type 2 diabetes and reduce the risk of heart disease 5% (12 votes)
    • Adopt a plant based diet. Skip all animal products, eggs and dairy products. Basically go vegetarian 3% (7 votes)
    • None of the above 3% (6 votes)
    • Drop the low carb high fat approach. Eat less fats and more carbs, focusing on good carbs, whole grains and starches, and try to reduce total calories 1% (3 votes)

56 thoughts on “Low Carb and Cholesterol – A Case History”

  1. On the LCHF program Peter is headed in the correct direction and the wife and her brother physician are going to die before Peter does. Coconut oil or MCT oil and butter and fish, oysters should be Peter’s main fuel along with leafy green veggies. There are no essential starchy carbs. Live like a polar bear and eat like a Great White Shark gets people well.

    Why not run an NMR profile to get the LDL particle number and the percent LDL large bouyant of his total?

    Did you rule out thyroid disorders? Did you do an Iodine Loading test and a bromine loading test. Most people are iodine deficient and have poor thyroid function because of the Iodine is suboptimal because of flourine, chlorine and bromine. Poor thyroid function generally means LDL is not being used…thus a somewhat higher than optimal LDL particle number.

    If I were a doc, I would get him on 25mg Iodoral or the liquid form Lugol’s 5% solution. He will feel even better.
    He would need to be on the cofactors also for a while…… Vit C, Selenium, Niacin, Borax, Apple Cider Vinegar and non fluoridated water. Basically the Dr David Brownstein protocol.

    Nice to know Iceland has knowledgeable paleo type doc. We have a few in the US but most are like the wife’s brother. Statinize anyone with a TC of over 200.

    You might give a look to this massive blog http://www.jackkruse.com He is a neurosurgeon out to change the way people approach their food and environment. This is the index: https://www.jackkruse.com/blog-index/

    Good luck with Peter

    • Dexter. Thanks for the comment. An NMR profile, LDL-P in particular would certainly be interesting and probably helpful. However, we don´t have access to it here in Iceland. The only thyroid test done was TSH which was normal.

    • Recent studies have shown that coconut oil is NOT good for you. It’s a saturated fat, and it’s bad for your arteries. All of the hype about it amounts to nothing more than a fad.

  2. I have followed a LCHF diet and had the same cholesterol result. Further test revealed my raised LDL-C was due almost entirely to large particles. My doctor wants me to go to ezetimibe but that is shown to lower LDL-C particle size. Sometimes you have to read and study and make your own decisions.

    Given Peter’s improvement in 3 months, he could continue for another 6-9 months and reassess then, perhaps having further analysis of his cholesterol fractions.

  3. I voted “none of the above”

    I suggest he opt for modified DASH diet…consume 150 mg of cholesterol daily and supplement with vegetables, fruit, and healthy oils, as well as low fat dairy.

    He will get adequate protein. Stay away from the heavy carbs in whole grains and stick to plenty of vegetables, 1/2 cup legumes, 1/2 cup sweet potato.

    From what I read, this will work for weight loss….and should also lower cholesterol and blood pressure.

    • Thanks for the comment Bill. There certainly is a lot of scientific data on the usefulness of the DASH diet. It has been recommended for individuals with high blood pressure for years. And you are right, such a diet would probably lower Peters LDL-cholesterol.

  4. Although my overall weight, fitness, lipid profile and blood pressure characteristics in combination were better than “Peter’s,” I decided to pursue a low carb/high fat diet because all metrics and health profile were moving in the wrong direction over the previous two years.

    My GP and the cardiologist wanted me to take a statin, with the potential looming of a high blood pressure medication.

    Subsequent investigations into their recommendations forced my hand. I knew I had to change to get healthier because their recommendations meant I lost control of my body, my independence and my own health-sanity that comes with zero pill popping (I really don’t want to worry about forgetting to take a pill one day with the result being a day of guilt, angst and fear for doing so).

    So after 3 months of LCHF, I lost the desired 15 pounds; reduced the waist size by 4″ and the hips by 3.5″; and never felt hungry. My blood pressure dropped to an average of 120/70 and my resting pulse rate dropped to the high 60’s. And, all my inflammation markers remained low. My HDLs made a marked improvement and my triglycerides fell below 100.

    With that said, my TC jumped to a new record high, as did my LDLs. Yikes!

    I kept to the LCHF diet though, and 3 months later the TC and LDL had both dropped significantly. Plus my LDL particle size finally increased to the ‘A’ size – larger and fluffier. All my inflammation markers and other blood/insulin/glucose profiles either remained rock solid healthy or improved. (First time in 20 years my fasting glucose came in below 98…92 this last time.)

    These improvements took place with a diet that I changed from about 25% fat calories per day to about 65% fat calories (eating a lot of avocados, macadamia nuts and walnuts and dark chocolate – my actual GFbeef/bison/fish consumption on a daily basis is about 7-8oz, often less, never more). In addition, my total cholesterol consumption tripled on a daily basis (mostly from omega3 enriched eggs).

    Btw, after the first 3 months of the LCHF diet, I added more strenuous cardio workouts versus the daily walks I took. And then later I added strength exercises, at least twice a week.

    Per my experience, I would recommend Peter continue with his LCHF diet with the thought that a few more months of doing so may result in the desired drops in TC and LDLs. I would recommend improving his cardio/strength routines knowing that one’s overall health/attitude improves when done.

    To counter the concerns and advice of a well-meaning wife and brother-in-law, I would recommend two tests to better identify/assess Peter’s risks:

    1. A genetic test to determine if the Apoe trait is a factor for Peter since this can play havoc on a person’s blood lipids (I finally discovered why my blood lipids were so wacky when I got my http://www.23andme.com results – I am Apoe3/4.)

    Knowing the existence of this trait helps one understand why the TC and LDLs are high. Also, it forces one to come to grip with the idea that maybe his/her body is telling them something important – it needs more cholesterol than the normal person (the non-Apoe 3/4 or 4/4). In addition, if one has this trait the use of statins may be the absolute worst treatment choice – think Alzheimers.

    2. A heart scan – if Peter’s current arterial calcification is non-major then there is not much reason why an extended LCHF diet experiment can’t proceed sans the needless hand-wringing.

    Finally, just because one has lousy blood lipid metrics does not mean one’s arteries are a clogged and calcified mess. In fact, the heart scan could prove that Peter has ‘clean pipes’ and thus his main focus should be on lowering his BMI, bettering his blood pressure and improving his metabolic metrics, which LCHF has a better chance of doing than a higher carb diet.


    • That´s an interesting story Jim and certainly something we could learn from. It also tells us that there are a lot of options in choosing the types of fats to eat on an LCHF diet. That choice may certainly affect the level of LDL-cholesterol.

      I agree that a coronary calcium score is helpful to assess cardiovascular risk. However, due to costs we don´t use it often in the risk assessment of asymptomatic individuals.

  5. Peter needs to continue the low carb diet but I would try and get him to add more low glycemic vegetables, especially green vegetables, and cut down on the meat and grains while increasing fish intake, especially fatty fish like salmon. Salads every day may work wonders for him. A moderate amount of fruit could be used if it didn’t cause weight gain. If he can handle Walnuts and other nuts, he mat feel bette and feel full besides.

  6. I think that the LCHF terminology is misleading ,especially for somebody defined as obese. Its only high fat in the sense that as the percentage of carbohydrate intake falls and protein intake remains about the same then the percent fat is higher. This means that to get out of the obese group definition you should reduce carbohydrates , eat vegetables and protein and maybe some modest amount of fruits.No need to eat fats because you have them on your body, ready and waiting to be metabolised. At least until you reach your target weight.

    In any event this is the approach I took over the last five months and it has resulted in my shedding 27 Kgs so far.I exercised daily, recorded everything I ate and measured blood glucose and blood pressure every day.

    Since I have heart problems, I now need to go to my cardiologist for an extensive check up to see that I have not introduced any new problems.

  7. I was a vegetarian for almost a decade with my health going down hill. When I saw the sunday night sweet poison video my sugar addiction stopped immediatly. I then started doing a lot of research into nutrition. What I have noticed in my recent blood tests is that the HDL and LDL has gone up but the triglycerides have gone down. I queried it and learnt that the drop in your triglycerides (which is very common on a LCHF diet) can put your numbers out and give you an inaccurate result. Next time you see your doctor ask for a direct LDL test and you are much more likely to give you a better more accurate result. I eat as much saturated fat as I can get my hands on. I am losing the weight effortlessly. Dont be worried about your cholesterol. I advise you see the DVD Statin Nation-the great cholesterol cover up. Im not worried about my results.

    • Thank you for writing that piece and providing the link. Amongst all the diet controversy there is only one thing of which I am certain and that is that the medical community is confused.

      • I think this also comes from the fact that there isn’t one diet that fits all…period. Our genetic makeup ensures that. If you take Dougs story above, Ive seen a blogger also comment about how she after 3 years being Paleo, saw her TC and LDL climb through that period and ended up suffering a mild MI and has now re-evaluated her diet.

        Certain people, myself included probably just cannot handle these types of diet…maybe…. or is there just one small variation one needs to make..who knows?. I saw a statement from a lipidoligist state that almost a third of his low carb eater patients see substantial increases in their TC and LDL profiles as well as apoB and LDL-P…that’s a LOT! Is this dangerous for the person on a LC diet….seems like we don’t really know.

      • Rory. Thanks for the comment. You make a very interesting point. I couldn´t agree with you more. There is very much individual variation. I´ve seen cholesterol and LDL-cholesterol go through the roof on low carb high fat diets. I´ve also seen cholesterol levels go down on such diets. So, we all act differently which is very important to keep in mind.

      • Does that really make sense? Do we know that from the animal kingdom? Are farmers trying to figure out what’s best to give each individual cow? Are our bodies really that different that we can’t know which food are good for us and which are bad? Don’t get me wrong, of course people react differently to different food but my point is, aren’t there certain foods which we all thrive on?

      • Yes it does make sense Halldor. Farmers know exactly what to give their cows to get what they (the farmers) want. Of course there are certain foods we all thrive on, certain nutrients, vitamins and minerals we all need. Apart from that, what we eat contributes significantly to our health. It affects our well being, our body weight, our blood pressure, our blood sugar, the insulin levels in our blood, the levels of different fats in the blood, the inflammatory response of our immune system, and it determines what substances our cells use for energy production.

      • It sounds like you don’t agree with me but then go on to say exactly just what I said 🙂 or at least was trying to say.

        Let’s say the farmer just wanted the cows to be healty, would he then give them all different things to eat?

        Cows out in the wild all pretty much eat the same thing and the same applies to apes and just most animals.
        If we know what foods we thrive on, isn’t it then just our taste buds that are getting in the way and making this complicated?

        Like, eat lots of fruits and vegetables and drink lots of clean water and do some exercise. Is it really any more complicated than that?

  8. I always look to what is traditional in each person’s ethnic background since I’m a big believer in my theory of what we have genetically adapted to. I believe Icelandic food is great for Icelanders, especially those who are as active as our ancestors physically, as they had to struggle in the harsh environments. However, I think our modern day life doesn’t demand quite as much nutrition as back then. I also believe that the French handle bread better than we do, as that tradition is stronger for them. My measures for myself is to look at the health buffs in my family and mirror what works for them, and having recently followed my PT youngest brother in the low-carb direction, I’ve seen it work magic. I’m only 27, so age wise me and Peter differ, however, at 23, I weighed approx 265lbs (120kgs), turned my life around to approx 175 (77kgs) in one year, and having kept athletic excellence since, I have learned a lot from that journey.

    I feel like I do to some degree agree that if he needs to lower the LDL-C, he might wanna seek different fat sources, but there’s a debate now whether the high cholesterol levels detected in heart patients truly are the cause or even the body’s way to try and fix the problem by lubricating the veins to release clots, so I’m excited to see the follow-ups on that speculation.

    Bottom line, however; listening to the body is great, and what feels right is possibly very right, and losing weight is a good sign. I feel like he should at least be monitored every 3-6 months, and looking up the current cholesterol researches might give a clearer idea. I hope all the best for you and Peter, and hopefully his case, as the story progresses, might teach us something.

    I hope you keep us posted so we can all learn, and cheer for you guys.

    • Thanks for the comment Halldor. I think you are absolutely right that we are all different. Therefore I don´t believe in a “one size fits all” formula when it comes to dietary recommendations. I´ve learned from my practice that LDL-cholesterol and other lipid parameters respond very differently to low carb high fat diets. Peter´s response is the most common with lowering of TG and elevation of LDL-C and HDL-C as well as total cholesterol.

      There is still much we don´t know about cholesterol and it´s causative role in heart disease. Although LDL-C correlates strongly with cardiovascular risk it may sometimes be misleading and is definitively not the only thing that matters. We know for example that many people with coronary artery disease don´t hav a particularly high LDL-C. In these individuals measurements of LDL particle number or apoB may be helpful.

  9. 22 months ago I weighed 123kg (188cm tall), BMI-35, 42-43% body fat, was taking Rosuvastatin (Crestor), ‘Coolmetec’ (Olmesartan + Hydrochlorothiazide), Allopurinol and Fluindione (Previscan=warfarin, replacing Amiodarone which had been fingered as the cause of peripheral neuropathy) and about to start a course of ADT (Triptorelin – standard side effect weight gain).

    Bloods at the time: TC-171, LDL-63, HDL-66, TG-208, TG/HDL-3.2. (not good at all, although some doctors would be happy with them)

    I was worried, did a lot of research (multi-pronged: cholesterol, cancer, biochemistry, nutrition, …), decided to cut down heavily on starches, sugar and vegetable oil, ‘persuaded’ my doctor that a ‘holiday’ from all the medication (apart from the Fluindione and then upcoming ADT) would be fine…

    After 2.5 months, I had lost 10kg and was feeling better generally
    Bloods at the time: TC-201, LDL-123, HDL-49, TG-145, TG/HDL-3. (some improvement, but far from great)
    The ‘holiday’ from medication was prolonged (it’s been permanent) and I gradually switched to a ‘more normal’ LCHF intake (approx. 15%C, 20%P, 65%F) by eliminating wheat & PUFA ‘vegetable’ oils, greatly reducing sugar (to about 2kg/year, also eliminating fruit juice and reducing fruit consumption, which had been very high) and adding eggs, butter, cream, coconut oil, duck fat, goose fat, sardines, mackerel, chocolate (85%+), liver, yoghurt (full fat of course), plus extra meat and fish.

    After 14 months from the start, my weight stabilized at about 85-86kg, where it has remained (37-38kg less than at the beginning), with a ‘foot’ (12 inches=30cm) gone from my waist.
    Latest bloods: TC-237, LDL-133, HDL-91, TG-64, TG/HDL-0.7 (I’m happy with those, although my doctor considers TC & LDL to be high).

    My general health has been better than I can recall and ADT weight gain has been completely side-stepped (18 months of ADT – IADT commenced 3 months ago).

    All LDL figures are calculated, but it is likely that my blood lipids are now massively superior (the LDL particle size has probably greatly improved and the elimination of PUFA ‘vegetable’ oils reduces the danger of oxidised LDL**) and the sole medication I currently take is the fluindione as a blood thinner (mediating risk of ischemic stroke from AF), in respect of which I am very happy with my TC number, since the range 200-240 seems to be something of a sweet spot (risk of haemorrhagic stroke increasing greatly below 160; risk of ischemic stroke increasing greatly above 300, or maybe 280).

    **Dr Sigurdsson, what is your take on the idea that it is *oxidised* LDL that is the real culprit in the development of atherosclerosis?

    • Kevin. Congrats on your results, I think they are fantastic. I believe you have substantially improved your health although you are seeing higher LDL-C numbers than before.

      Circulating cholesterol is not a problem in itself. It is not until cholesterol is trapped within the vessel wall that it becomes a part of the atherosclerotic process. Oxidation of cholesterol within the arterial wall certainly plays a role among many other factors, inflammation being one of them.

  10. I voted for staying with the LCHF diet as is for the reasons pointed out by some of your readers. Many people experience a transient increase in LDL-C initially when eating LCHF, particularly if they are losing weight. However, eventually it usually goes back down. Some people will always have higher LDL cholesterol than others,and whether elevated levels contribute to heart disease risk is a controversial topic. At any rate, the benefits of lower TG, higher HDL, and well controlled blood sugar are universally agreed upon, and I feel Peter should stick with LCHF, which will likely result in further improvement of these values.

  11. I voted to stay on the low-carb, high-fat diet, but I think it’s very useful to point out that you don’t have to “assume” or “guess” that the LDL cholesterol is switching over to the large, fluffy type that seems to not be a concern as it comes to heart disease. You can do a test and see for sure.

    I’d have him continue on for several more months and with the next bloodwork do the more detailed test that will tell him what type of LDL he is producing. Then, depending on the results, you and he can decide what the best approach is.

  12. Try to get most of his calories from fruits like bananas and dates and those kinds of things. Make fruits be the number one snack and what ever possible. Endless benefits and nothing negative, the people who just eat fruit, even crazy amounts of fruit are extremely skinny. Add to that vegetables, nuts, bread, rice and things like that. I totally agree with his wife, avoid animal fat and animal protein. A billion skinny Asians eating rice proves that rice does not make you fat so nothing to worry about when it comes to rice and potatoes even though they are not the best food for you.

    • Halldor. The emphasis on low fat and plant based foods usually works very well. You just have to adhere to it.

  13. Stick with Low carb , but tweak the types of fats.

    We need a variety ,, saturated , Mono , Poly ,, They each are needed and need each other.
    As is found in the fatty acid profiles of wild game meats ( both hot and cold blooded ( often overlooked ) ) and plants.

    Important information here I feel . make sure to open the graphs ( Figures )

    I myself am doing plenty of tweaking .. fatty acids are not just energy , but important factors that trigger gene expression too.


  14. Please everyone remember Vitamin K2 along with the LCHF diet (4 years now for us). Vit K2 is essential for laying calcium into the bones not the arteries and kidneys. Since I have taken K2 not only is there a reduction of arterial plaque in my husbands arteries there is also hardly any tartar on my teeth. My husbands osteoporosis is improving with his bone density showing a much better Dexa scan result this year.
    Natural sources of K2 is grass fed meats not grain finished. We take a supplement also.

  15. Ive had a similar situation that Im seeing more and more of as I research.
    Been Paleo for 1 year now. Prior to Paleo I had a low fat/high carb diet. TC was always under 200 and the only elevation were trigs (150)
    6 months into Paleo this was my lipid panel:

    1 year later and my TC and LDL had jumped.
    TG-100 (did not fast)

    So I went and got an NMR 3 weeks later and another big jump in just that short time frame:
    LDL-P-1979 (more type A)

    So not good. Im now 2 weeks into a diet of cutting down on saturated fat and incorporating more starch such as rice and potatoes and more fruit. I wasnt really a big saturated fat eater anyway and Im leaning towards more of a low carb issue for me. My Vit D was on the low end and for some reason I had high Total Testosterone but vey low Free Testosterone?

    I am also supllementing with Vit D, C, Magnesium, K2 and small amounts of Iodine.

    But it is interesting in seeing that this is a not so uncommon problem amongst low carb eaters and Im not convinced that all is well just because you are pattern A. My TSH, T3,T4 were all normal.

    If my lipids changed that much in 3 weeks Im wondering if this diet can have an effect in 3 weeks as well, to get retested to see if the trend is changing on the new diet?

  16. My before and after numbers resemble those of your patient, although I went from “heart healthy” food pyramid on whole grains only to low carb. I haven’t lost any weight, already being at a healthy weight and BMI, with consistently good life style habits. I’m a good “control” , therefore, for some of the confounding factors in diet studies. I can’t say about others, but for myself low carb is a great improvement. My doctor promotes DASH and drugs, but I disagree.

    • Thanks Carol. That´s interesting because often low carb is recommended primarily for those who are overweight/obese or suffer from the metabolic syndrome. But I presume the best diet for you is the one that makes you feel best.

      • Actually I don’t feel any different, except that on lchf I am not hungry all the time. The transition to a ketogenic state was effortless. I miss the whole grains, but now I can eat cheese without guilt.

    • If you go on youtube and search for “Durianrider : Low carb diets vs High carb diets” you’ll find an interesting video. The guy is not very politically correct or nice..or polite but what he does there is quite interesting. He compares how the authors of diet books are doing, the one’s who recommend plant based diets, low fat high carb diets to the one’s who recommend animal based diets and high fat, low carb diets.

  17. So I got another cholesterol test done…this was another 3 weeks after the NMR above. This was just a regular lipid panel so no LDL-P count which I WISH I had now done based on the latest numbers. You can see what I changed above. This also wasnt done by the same labs as above so sure there are variances.

    LDL-120 (Calculated)
    Tri’s-90 (I knew this would be higher as the day prior I has consumed almost 300g of carbs)

    Im pretty stunned as I was not expecting this dramatic of a drop in such a short space of time. So right now I dont really know if it was iodine/vitamin supplementation or the additional carbs. I guess I was to impatient to want to eleminate one thing at a time.

    Im not jumping for joy too much as its that LDL-P that Im very curious about. I will get that tested in another 2 months as I really just wanted to see if I could reverse the trend that was emerging and potentially rule out familial hypercholesterolemia.

    • Your experience is interesting Rory. Your lipid response is quite typical for a low carb high fat diet. You have certainly managed to lower TC and LDL-C by cutting down on saturated fat and introducing healthy carbs. It will be interesting to see your LDL-P. Keep us informed.
      Thanks for sharing.

  18. Hi Dr. Sigurdsson, thought I’d add myself as an additional case study on the top of low-carb diets and cholesterol.

    I’ve been on a low-carb, high-fat diet for over 4 months now and have gained a six-pack but also a 56% INCREASE in my total cholesterol. The fat burning benefits of a low-carb diet are undeniable but my lipid biomarkers have gotten worse in pretty much every respect. I’ve listed my detailed figures here:

    I would greatly appreciate any advice/suggestions you might have as I continue to experiment with my diet. Thanks!

  19. Hi Dr. Sigurdsson, I’m glad to have found this site…great info!. My story: About a year and a half ago my Naturopathic Doctor (ND) diagnosed me with a number of “things,” including adrenal fatigue, depression, MTHFR Gene Mutation (can’t process folate), low thyroid function, insulin resistance / pre diabetes and high cholesterol…geez, I read this and want to pull the covers back over my head.

    Anyway, back in January of this year (2014) my weight was 202 (I’m a 51 y/o male, 5’11”) and my lipid panel was “bad.” My ND told me to lose weight, and cut back on carbs else she would have to recommend a statin,which for ND is almost unthinkable. So, I went on a HFLC diet (essentially less than 20 grams of carbs per day) for 4 months and got re-tested two weeks ago.

    Aside from the labs (see below), my weight dropped from 202 to 176!!! Yeah, that is pretty cool, and I feel better. Interesting note: I got stuck 185 lbs for several weeks….until I cut out all dairy…then the remaining pounds melted away. So, like many of you, my HDL, VLDL, Insulin, Trigly, A1C and CRP got better on the HFLC diet. However, my TC and LDL got a lot worse. My ND is very concerned and again threatened me with statins. She suggested getting off the HFLC diet and switch to a Paleo diet (which if I add more greens I’m almost there).

    She also suggested that my low thyroid function could be the cause of these bad numbers and wrote me a script for Naturethroid (thyroid booster). I have those lab #s, too. So, now I’m confused and would appreciate any help. Regarding the lipid panel, should I be concerned with higher TC and LDL? Not sure why they are higher, will they go down, is this dangerous, etc. Any advice is appreciate. Thanks, Matt

    Marker JAN 2014 MAY 2014

    Glucose, Serum 102 108
    Insulin 12.7 10.2
    TC 265 321
    Triglyc 340 140
    HDL 35 48
    VLDL 68 28
    LDL 162 245
    A1C 5.9 5.7
    CRP 6.91 5.6

  20. Great stuff! Im 41 and fit. Always have been. Ive ate a low fat diet my whole life. 5 months ago I switched to high fat vey low carb.
    Exercise a lot.
    as a carb eater
    TC 211
    LDL 125
    hdl 54
    Tri 117
    low carb
    TC 325
    LDL 210
    HDL 100
    Tri 46.
    My doctor is going nuts as well as a cardiologist. I plan on doing the NMR test. Im not sure what to do next. I think I will increase good carbs to 100g a day and see what happens.

    • Your tg/hdl ratio is very good. From what I’ve been reading is that this is predictive of large,fluffy ldl. Please update when you have NMR results

  21. Hello…while researching whether I should
    go on a lchf diet I found this discussion…my TC is about 425 and always has been…I’m 58 female…both parents same numbers…but I’m a little afraid …I know from past experience that you can drop weight easily without being hungry but I am not trying to commit suicide here either….your opinion appreciated…thanks!

    • 425 is in the FH range I think. Are your parents still alive? Do you have any more details on the numbers, like HDl-C, LDL-C, TG, LDL-P etc?

      Even most anti-statin people like Dr Mercola say to take a statin if TC is over 330.

  22. I’d been on a mostly vegetarian (occasional fish and beef) diet for about 2 years. Lots of raw food, greens, grains, veggies (Forks over Knives poster-child). I decided to see what kind of awesome results my near perfect diet would produce. To my shock my scores looked bad. I also did the NMR test and I had high scores in all the wrong areas.

    Total – 222
    Ldl – 146
    HDL – 47
    Tg- 146

    After three weeks on a Ultra-LCHF diet, (still was taking Lipitor and 500mg niacin).
    Ldl: 65

    Two Month later on LCHF (Off Lipitor and niacin for 2.5mths):
    – no more love handles. More energy. Better sleep. None of my clothes fit. No longer need my GERD meds. No longer lactose intolerant. Improved endurance in work and exercise….but… High LDL is back.

    Total: 249
    Ldl: 181

    So the multi-billion dollar question(s) is:
    – Is LDL really a bad thing?
    – When it’s fairly clear that someone’s high saturated fat diet is the cause of the high LDL, do you change the diet because it’s bad for you or do you take a pill or two get perfect scores?

    • I can’t tell you how to interpret your results, but if these were my own results, I would look at TG, HDL, and TG/HDL ratio. TG is very low (excellent), HDL is good, TG/HDL is excellent. Those numbers alone would make me very comfortable. I personally wouldn’t do anything to lower total cholesterol (or LDL) because I don’t think they correlate very well with cardiovascular risk. I might be interested in knowing the total LDL particle count since that seems to be a good metric as well, but I would not dwell on the LDL-C number after seeing the low TG/HDL ratio.

  23. Way to make the switch on the diet. That must have been hard. To answer your question, we have to define what perfect or ideal is. The guideline ranges for blood lipid are based on a sampling of people who may have been healthy or unhealthy. Probably unhealthy and on the SAD diet. We hear about normal ranges. That does mean ideal for health. Dont take the pills.
    I went through a similar thing. I ate healthy exercised a lot but numbers weren’t too good. I switched to a vlc diet and trig were 47 hdl 100! However my TC was 300 and ldl 200. Is that bad? I tested my thyroid and I had low T3. I was exercising a lot. Lots of endurance training and the combo stressed my system. A few carbs added back in should do the trick. I havent had it retested yet. But my fasting glucose also told the story. It was in the upper 80s or low 90s. Then it crept up to 105 and then 112. My muscles were saving the glucose for the brain and not absoring it. They were running on fat. A few carbs added in to the diet has gotten my fastin BG back down. Did I need to do that? Chris Kresser has some good info about thr thyroid. Did I have to add a few carbs back in? In my opinion, if I wanted to continue exercising the same amount then yes. I still under 100 total carbs a day sometimes around 75. I had dry eye lids and reduced sex drive too. For me I could tell I was over doing it with the level of carbs. Ex I did a half ironman in a fasted state and didnt eat at all during it. So I just had dinner the night beforeand it was just a normal meal because I wasnt olanning on doing the event.

  24. I posted earlier today my results and questions…. but for those of you who want to see what a LCHF did to my NMR profile in 3 weeks (while still on statin and niacin):

    Pre-LCHF (mostly HCLF):
    LDL-P 2053
    LDL-C 146
    HDL-C 47
    Triglycerides 146 Cholesterol, Total 222
    HDL-P (Total) 35.1
    Small LDL-P 1037
    LDL Size 21.0

    After 3 weeks on LCHF (but still taking Lipitor and niacin):

    LDL-P 789
    LDL-C 65
    HDL-C 59
    Triglycerides 64
    Cholesterol, Total 137
    HDL-P (Total) 40.7
    Small LDL-P 378
    LDL Size 20.8

    My plan is to keep up the LCHF lifestyle for a while longer while off the drugs. I will then do another panel just to see if LDL drops or particle counts change much in the areas of small and large particle sizes.

  25. A physician recommending a high fat low carb diet, such as the Atkin’s diet, is absolutely inexcusable given the totality of nutrition science that has been published over the past several decades.

    Does the human body resemble a carnivore in any way whatsoever? The human body is designed to consume complex and simple sugars (carbohydrates) as its primary fuel. This is absolutely scientifically indisputable. Our taste buds are designed to primarily seek out sugars and salts. We have no taste buds designed to taste specifically for meat, unlike your cat. Since we have no meat specific taste buds, most of the flavor of meat comes from the potentially carcinogenic sugars that are created from the Milliard reaction. Most humans find the taste of raw unseasoned flesh to be unappetizing.

    Our digestive track contains relatively huge amounts of amylase, an enzyme that’s designed to breakdown starchy sugars, which is why we can live off potatoes but gorillas can’t. The length of our digestive tract is identical to a chimps, as is the structure of our teeth. Our digestive tract is 12 times the length of our torso, compared to a 3 times length for carnivores. Humans have convoluted complex colon walls designed to extract maximum nutrients from fibrous plant matter, unlike carnivores that have smooth straight colons. Our metabolic system is optimized to burn sugars over protein, unlike a carnivore.

    We have no teeth designed to tear flesh from hide or impale animals. Humans have no talons or claws designed to rip or slice flesh from bone. Our jaws move side to side which allows for the chewing and grinding of fibrous plant matter, unlike carnivores who can only move their jaws up and down. Carnivores do not grind their food, they rip and gulp.

    Meat and dairy have no fiber, so consuming them causes humans to have constipated stools. The consumption of meat and dairy is the number one cause of constipation in humans. Most carnivores can digest microbes that would kill a human, such as botulism, which is why humans are forced to cook meat before consuming it. All known carnivores pant to dissipate body heat, while plant eaters have sweat glands. For most people, the sight of a bloody dead animal is naturally repulsive. I don’t know a single person that would consider popping a live mouse into their mouth. I could keep going on listing differences in physiology between carnivores and humans until I had an entire novel.

    Since the human body is optimized to burn carbohydrates first, before burning fat and protein for energy, low carb high fat (LCHF) diets, such as the Paleo or Atkin’s diet, cause the body to enter a state of ketosis to obtain the energy it needs. Ketosis is a starvation response mechanism humans have that allows us to survive extended periods of famine. When humans stop consuming carbohydrates for energy, the glycogen stores in our liver get used up, forcing our bodies to consume fat. This is a starvation response mechanism = FOR EMERGENCY USE ONLY.

    Studies indicate that high protein diets, which can induce long term ketosis, lead to a higher incidence of cardiovascular disease and cancer. One particular study of 43,000 Swedish women spanning 16 years found, “A one tenth decrease in carbohydrate intake or increase in protein intake or a 2 unit increase in the low carbohydrate-high protein score were all statistically significantly associated with increasing incidence of cardiovascular disease”.

    Another study involving 73,000 people over 6 years found that, “Vegetarian diets are associated with lower all-cause mortality and with some reductions in cause-specific mortality.” These are not your typical 24 week bullshit 100 participant studies touted by the people pushing ketogentic diets. These are some of the most comprehensive dietary studies ever conducted in the history of modern medicine.

    When the body enters a state of ketosis, hunger is dissipated. Again, hunger is dissipated because this is a starvation response mechanism. The body figures you must be living in an area that is subject to a famine since there are no carbohydrates being consumed, so it also reduces your hunger. Thus, you have the ability to think clearly about finding new sources of carbohydrates to fuel yourself while you manage to get by on proteins and fats during a period of famine.

    Ketosis causes a build up of acetone in the body, which is dissipated through the breath and urine. Let me say that again. Ketosis causes a build up of nail polish remover in your blood stream, causing your breath to stink. Anyone think this is a healthy state to maintain for years on end? Your body can end up cannibalizing your bones to buffer this acid build up.

    Whenever someone points to studies saying a chronic state of ketosis is not harmful, all you have to do is look at the duration of the studies to see they are severely lacking as evidence. Studies that take place over the course of 6 months to a year aren’t going to show any serious side effects because that’s the duration of time the body is supposed to be able to cope with a famine. Further, since ketosis induces weight loss, people are going to initially feel better if they were overweight to start with. Cardiovascular health will improve in the short term simply due to the weight loss, but as the Swedish study shows, those benefits don’t last over the long term.

    Over the long term, it’s simply not possible to achieve sustained weight loss eating a diet of virtually no carbohydrates simply due to the calorie densities of the foods involved. Pure fat, such as any refined oil, contains 4000 non-nutritional calories per pound. A tablespoon of oil contains 100 calories, which is the same as an entire apple or banana. Of course, the apple or banana also comes packed with a ton of phytonutrients that will keep us healthy.

    It’s worth taking a look at the people who peddle ketogenic diets – most of them are fat! Do you want to end up looking like them? Atkin’s died weighing 258 lbs. Here’s what Jimmy Moore looks like today. The low carb gurus who aren’t fat are all young men who probably exercise like crazy. When was the last time you saw a fat vegan?

    Every large civilization on the face of the Earth has fueled itself primarily on starches. We know a low fat high carbohydrate diet leads to healthy slim populations of people – without any calorie counting. A billion Asians eat a diet primarily consisting of rice and vegetables. Asians who eat this traditional diet have virtually non-existent levels of obesity or metabolic disease. The same is true of any indigenous population of people who eat a starch based whole food diet. Do you honestly think all those skinny healthy Asians would be healthiereating a big fat steak every night with their bowl of rice?

  26. All you clever people. I was diagnosed with FH Cholestrol 8.50 LDL 5.9. which differ from normal cholestrol. Please tell me which diet to follow to lower my LDL? As I almost eat NO FAT and NO saturated fat food at all. It is quite an emergency as my son is also no diagnosed with fat around his liver.
    Your soon response would be appreciated.

    • I also have Heterozygous FH. Sorry to tell you this but you need to be on meds. I tried every statin and could not tolerate any. I’m now on a PCSK-9 inhibitor- Praluent at the highest dose. I was on the Dean Ornish heart Reversal diet- extremely low-fat (7% of total calories) vegetarian diet and after 1 year every lipid was terrible. A diet won’t work for FH. Before Ornish diet- Total- C, 289, LDL 162, HDL 40, Trig.90. Then at 8 months on diet-an improvement- Total C 212, LDL- 106, HDL 30, Trig. 150. At 1 year- Total-C 278, LDL 156, HDL 21, Trig. 402. Also my blood Total Protein was very low and a few other blood tests were ”off”.I felt very ill at that point, so added fish, nuts, olive oil back to my diet and all labs went back to normal except Total-C, and LDL. At that point I was able to get on Praluent. After 2 months of eating a normal diet all my lipids and other blood tests were in normal range and I felt great. Diets won’t work for you -you have a genetic disorder that puts you at extremely high risk for a fatal heart attack. I hope you get this post. Probably no one answered you because they don’t know what FH is and also you posted your lipids using a different measurement system. Please go to a cardiologist and get on statins and/or a PCSK-9 inhibitor. It’s still important to exercise and eat sensibly but only meds will lower your cholesterol.

    • When I went on a ketogenic/ atkin type diet, my total cholesterol went up to 350. I would not ever go on that type of diet again. By eating much less fat, proteins, vegetables, oatmeal and whole wheat types of carbs, I’ve managed to keep my cholesterol to 220. That, I guess is good for me. I’ve known about the tendency for my body to manufacture cholesterol for 40 years. Lucky that I found out about so I am still here, not fat, and can effectively keep my total cholesterol to an acceptable level for me.

  27. I’m skeptical about high fat diets lowering cholesterol. I’ve had a milk allergy since birth, and I recently discovered that I could tolerate ultra-pasteurized dairy products (the extra boiling time alters the proteins so that my body doesn’t recognize them as allergens). Anyway, I went crazy, scarfing down heavy cream, whip cream, milk, etc. As a result, my cholesterol sky rocketed to 200–and it has never been high before.

    I saw this happen in a dog I had years ago as well. She had kidney disease, and there were few foods that I could give her, but I could increase her fat intake to give her greater satiation. So I started making her salt-free butter cookies. We were getting labs on her every two weeks to monitor her chemistry, and her cholesterol soared from that butter.

    I really wish there were better studies on the affects of carbs versus fats in the diet. My worry is that the low carb diet is a fad and that some studies are geared toward supporting it. Perhaps the truth is somewhere in between with a balanced diet being the best choice.


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