The benefits of nutritional ketosis and low carb diets are plenty, however, a percentage of people will experience super high cholesterol on keto. This is the first in a series of articles to share my experiences in order to help fellow cholesterol hyper-responders.
22-Apr 2017, by Lee Sandwith
Only a few months back I was so hot for low carb that I professed my undying love for all things for keto, but, most unfortunately, we’ve had a bit of a falling out. We haven’t completely given up on the relationship yet but we’re most definitely on a break. Every gram of carbs feels like infidelity so I’m desperate to get things back on track; the guilt is unbearable!
So what’s the problem, I hear you ask?
Cholesterol, that’s what…
Not just the run of the mill, just ‘outside the reference range’ cholesterol, we’re talking off the charts super high scary level cholesterol.
At a macro level, it definitely seems to be related to my switching to the ketogenic diet, however, from the research I’ve been doing, it’s clear that it runs much deeper than that and there’s still a long way to go before I work out exactly what’s going on.
Although I don’t have all of the answers, I thought it may be beneficial to share my experiences with a view to helping others in a similar situation (there are many) and through the process, hopefully widening the net so I can get some feedback which may help me in return.
Note: I put together an article a while back to cover the ketogenic diet so if you haven’t checked that out please do as I don’t intend to repeat the information here.
Also, in this article, I don’t intend explaining what cholesterol is. If you can’t wait until then, here’s a link to one of the best articles I’ve come across which covers this, written by Mark Sisson of Mark’s Daily Apple.
Super High Cholesterol on Keto: My Backstory
In previous articles I’ve shared how my experience with elevated cholesterol on keto made me rethink things a bit, however, since that last post I’ve had a result that was so off the charts it’s making me question whether keto is the right diet for me at all.
According to some rather decorated scientists, keto isn’t for everyone and, unfortunately for me, I may well be one of those unlucky souls (1,2,3). But, I’m human after all, and being told I can’t have something makes me want it more than ever, so, the quest continues…..
The below chart shows my results between 2015 and March ‘17:
The first time I ever had a cholesterol test, or ‘lipid panel’ as they are known in the field, was in September 2014, aged 37, following my Dad’s heart attack. Back then my Total-C was 212 mg/dl. Interestingly, my Doctor at the time was slightly concerned that it was over 200 mg/dl but just advised me to keep an eye on it and get another test done in about 6 months time as it wasn’t high enough to worry about any corrective action.
In fact, I parked it for about 18 months and didn’t schedule a follow up until March 2016, after which I’d been wildly experimenting with the ketogenic diet. So the major variable between those two tests was that I had moved from what I considered, and would still consider, a ‘typical’ healthy diet to the wonderfully exciting world of the ketogenic diet.
To qualify the typically healthy part, the carbs I included in my diet were always of the wholesome, complex nature; no simple carbs, no white bread or white rice, and definitely no processed foods or anything which included refined sugar.
Fast forward to my first post-keto test in March 2016 and my Total-C had bounced up to 302 mg/dl. My GP at the time, GP#2, had a very different reaction than GP#1. She was gravely concerned and promptly scheduled a second test to double check the results. Having only a broad knowledge of cholesterol at the time, I was of the opinion that the association between high cholesterol and heart disease risk was unequivocal and I was a tad worried. I was, after all, getting tested given that my Dad had recently had a heart attack.
The second test proved to be even worse with Total-C coming in at 309 mg/dl and GP#2 was even more concerned and wanted to refer me to a ‘heart specialist’. She was so worried that she was concerned about the risk of me having an imminent heart attack: at this point I was, quite frankly, shitting it!
I vividly remember having the sensation of dread wash over me. I kept chasing GP#2 for support but, alas, the promised referral didn’t come and I was left to flounder. It was a rather uncomfortable time but, as I look back, I recognise this as the exact point in time where my journey of self discovery began.
More on that later….
I decided right then to press pause on the ketogenic diet and went back to the old faithful typical healthy diet. After all, as outlined in my eBook, I’ve had some pretty amazing results with the old faithful 40-20-20 diet (protein-carbs-fat)so it wasn’t a big deal. I was disappointed not to be benefiting from some of the upsides of the ketogenic diet, such as greater control over satiety and enhanced cognitive performance, however, I wasn’t prepared to trade those off with a potential heart attack so I went back to the drawing board.
Having given my cholesterol a couple of months recover, in June 2016 I scheduled another test. The results were pretty good with my Total-C coming down to 216 mg/dl; still above the widely accepted ‘optimal’ reference range but good enough for me to give the ketogenic diet another shot.
The new consultation was with a new GP, GP#3, a quietly unassuming chap from Bulgaria. GP#3 was of the new school in that he wasn’t so concerned about cholesterol and was fully supportive of the ketogenic diet: a rare breed!
He said he wasn’t even concerned about the 300+ level and introduced me to the concept of the 10 year risk assessment model which, incidentally, put me at 4% even with the 309 result (more on this later).
I was ready to start experimenting again.
Mistakes were made, and definitely by me
Let me take this opportunity to digress from the story slightly and share my thoughts on some of the mistakes I made during my first experiment with keto.
First and foremost, when I first set out, I went crazy with the cream, butter, cheese and coconut oil. I was sold the idea that I could pretty much eat what I wanted and I wouldn’t gain weight so I went a bit crazy with the good stuff. I still tried to keep a loose handle of the number of calories I was consuming but, on reflection, it was very uncontrolled.
Second, I didn’t track anything related to nutrition, which is very strange for me as I’ve been tracking things for years. I had a rough meal plan which kept the carbs low but I failed to track to a detailed level so I don’t have any detailed nutritional information available, for example, saturated fat, cholesterol and the like.
Third, given what I now know, I should have been tracking some very important bio-markers such as blood glucose, CRP, and Thyroid function. I’ll come back to why these metrics are important in a future article.
Last but not least, I didn’t even track blood or urine ketone levels, duh!!
Given my experiences, my overarching advice would be to educate yourself on the ketogenic diet before you dive in. Have a consultation with your GP, get some of the critical bio-markers checked and build a solid nutrition plan. Then, check in after a month or two to make sure nothing is going haywire.
The Big Ketogenic Diet and Cholesterol Experiment
The first round of experimentation qualified the benefits of the ketogenic diet, especially the cognitive enhancement and the satiety management side of things, as covered in my previous article.
The second round was more about specifically experimenting with the ketogenic diet and cholesterol and my plan was to get much more scientific about it, tracking my nutritional intake at a detailed level with MyFitnessPal, and measuring some important biomarkers, especially blood ketone levels and fasting blood glucose.
Following comments from a couple of names in the field, I suspected that saturated fat may be the issue. Despite the opinions of many, there are still lots of unanswered questions about the relationship between saturated fat and cholesterol, especially when the more granular aspects are in question, such as lipoprotein subtypes, size and density (4,5).
At the very least, there are enough articles out there from trusted sources to encourage an open mind so, to that end, I designed a meal plan which kept the saturated fat at around 30g per day, pretty much in keeping with what I’d be consuming on my old faithful 40-40-20 diet.
As an exception to this, and given some extremely positive feedback from Dr.Dominic D’Agostino on the role of MCT Oil in accelerating the elevation of blood ketone levels (6,3), I built a keto coffee into my meal plan. I didn’t want to go full bore bulletproof coffee so I designed a recipe which added a teaspoon of coconut oil and a scoop of Quest Nutrition MCT Oil Powder to my daily americano.
I kept this up for about 5 months and I was flying in ketosis, consistently around 1.2 mmol/dl and fasting glucose typically well under 100 mg/dl. I was in deeper than ever before, the benefits exceeding those past by an order of magnitude. Super steady energy levels, satiety well under control and cognitive performance which took me by surprise every day.
Although difficult to measure, the cognitive enhancement benefits were so prominent that I’d find myself analysing the contents and structure of sentences as they moved from my depths of my left hemisphere into the ether, quietly congratulating myself on the quality of elocution. My day job (work) was becoming a much more enjoyable endeavour.
In December 2016, about 5 months in, I scheduled a routine lipid panel with a new GP, GP#4 as, unfortunately, Uncle Bulgaria had left for pastures new. I was quietly expecting to see an improvement, however, to my astonishment my Total-C had skyrocketed to 455 mg/dl. My (new) GP was even more astonished with this being the highest ever reading she’d ever seen.
The topic of statins was raised, however, my new GP is very open minded and was happy to consider my views. I had a strong gut feeling that the dramatic increase was in some way linked to the keto coffee and my increased use of coconut oil in cooking as these were the two main nutritional variables. As such, I scheduled a follow up panel in two weeks time to see whether I could recover the situation just by making some nutritional changes.
My new GP agreed, albeit skeptically.
To try to isolate the keto coffee and coconut oil as the culprits I made only two changes. I cut out the keto coffee altogether, switching back to a black americano, and I replaced coconut oil with olive oil for cooking.
The results were dramatic with Total-C dropping to 329 mg/dl after just a couple of weeks. Granted, 329 is still high, however, I’d reduced Total-C by around 25% within two weeks after making only a couple of minor tweaks to my diet. This alone is astonishing as it’s widely accepted that it takes months for any nutritional interventions to have an impact. The skeptic in me was starting to fire up!
Following the scary 455 result I decided to take a break from keto and after another two months on the old 40-20-20 my cholesterol came back down to 214, phew! Another amazing turnaround in just a very short period, dutifully surprising my new GP!
But here’s where things start to get really interesting.
My GP scheduled another follow up test, just to make sure, and after only 3 weeks my Total-C was back up to 294 mg/dl!!
And this pretty much brings us to the time of writing.
Having thought I had a handle on the whole ketogenic diet and cholesterol thing, I’m left utterly bewildered. And so is my new GP but fortunately, I think she’s just as curious about all of this as me so our investigations continue.
So what’s going on?
I have my suspicions, but I’ll get to those in a follow up article.
Education, education, education.
Back when I started Ingfit, if I’m honest, I thought I had this fitness and nutrition thing nailed down. I’d had some pretty good results on the weight loss front and having helped lots of people follow in my footsteps, I put together a very simple guide on the basics.
However, the more time I spend on research, the more it dawns on me that I know nothing. It’s quite humbling but it has made me question whether I’m qualified to run a health and fitness website, especially as I’m not super decorated like some of the names in the field.
However, I think there’s a clear role for websites like this as much of the content online is written by scientists with impressive credentials and there aren’t many around with the ability to bring things down to layman level.
Going forward, my approach will be continue learning as much as possible, always keep an open mind and share the balanced opinions of the real experts so you can make your own mind up. Think of it like curation of the good stuff, weeding out the tedious ‘here’s something interesting about cholesterol, and you’ll be totally surprised’ style articles. Yuk!
Circling back to the ketogenic diet and cholesterol, two years into my journey of discovery, even though I’m slightly better educated, I still lack a tangible intervention to tackle the issue of high cholesterol. This is partly due to the complexity involved and the constantly changing landscape of scientific discovery.
However, a major, often overlooked reason is that there is so much variability between individuals that it’s almost impossible to prescribe a ‘one size fits all’ approach.
You probably know more than your own GP, and so you should!
If you’re in a similar position to me with high cholesterol, if you follow my trail of articles, I’ll take you on a brief journey which will almost guarantee that you’ll be better educated than your own GP: there will be exceptions, of course, but GPs who are hot on this subject seem to be very few and far between. A brief Google search will quickly corroborate that.
As outlined above, I’ve had several different lines of advice from four GPs. Normally, in my experience anyway, GPs are concerned when Total-C exceeds 200 mg/dl, which, to be fair to them, has been the ‘party line’ for decades.
Real concerns are raised and the topic of drug treatment is opened when the threshold of 300 mg/dl is breached, and if you come anywhere near 400 mg/dl you’re well and truly into the Cholesterol Twighlight Zone.
Rarely, you may encounter a GP who reassures you that cholesterol is just one risk factor among many when considering the risk of coronary heart disease (like my Bulgarian GP#3), however, it’s more likely that your encounters will be less than reassuring and that sound, actionable advice will be nowhere to be seen.
I find this confusion extremely frustrating; however, it’s not exactly unexpected as we engage in discussions of this nature with a GP (General Practitioner) who is typically several years out of training and hasn’t spent an awful lot of time on the very specialised topic of cholesterol.
Given that there are new developments coming out on cholesterol almost every week, unless your GP is keeping up with the latest developments, that is, by regularly reading the latest published papers/journals, then the chances are they’ll be just as in the dark as you.
Still, there’s an ongoing debate on whether high cholesterol is anything to worry about at all and it’s the work of some esteemed names in the health and fitness game, namely Dr. Peter Attia and Mark Sissons of Mark’s Daily Apple, who have provided some well needed reassurance.
What is abundantly clear to me is that cholesterol is one of a number of factors which should be considered in the grand scheme of longevity. There are so many other things which come into play that any recommendation of drug intervention should be treated with the utmost caution: after all, as demonstrated by my results, simple nutritional interventions can do wonders.
That said, there are a few other names out there who are adamant that high cholesterol is something that you should definitely pay attention to so I have never exactly been comfortable just letting the LDL rip (7).
So, the long and short of this is that, after over two years of seeing doctors and doing retests, I am still void of a reasonable explanation or solution, so, the journey of discovery continues.
My ultimate objective is to be able to confidently answer the following question: “is my current lipid profile an issue”?.
And, if it is an issue, my objective is to find a solid, drug free intervention to reduce my cardiac risk and, ideally, continue with the ketogenic diet.
As with all complex things, the path towards understanding involves breaking things down, starting with the more straightforward, simple concepts, working up to the more complex and advanced stuff later.
The next few articles cover some of the important things that you need to educate yourself on if you find yourself in a similar situation.
If you find this article interesting and are waiting with baited breath for the next installment, please sign up to my email list and I’ll let you know when it’s available.
Finally, if you’re generally healthy and have had a similarly ‘bad’ cholesterol result, chill out, it’s probably meaningless and can definitely be addressed without drugs.
- Diabetes Daily
- Chris Kresser
- The Power of the Ketogenic Diet, The Tim Ferriss Show: Dom D’Agostino
- Whole Heath Source
- Diet Doctor
- Beyond Weight Loss and into Longevity
- Why Low Carb Diet’s Don’t Suck
- What is the Ketogenic Diet?
- The Ketogenic Diet and High Cholesterol (The Hyper-responder’s Ultimate Guide)