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Keto and cholesterol testing

Cholesterol is essential for a healthily functioning body, is also largely produced by the body itself and therefor humans cannot live without it. For people with an unfavourable cholesterol profile caused by their previous high carbohydrate and processed foods diet, the transition to a keto lifestyle will usually result in what is considered to be a good cholesterol profile. So that is good news! However, it can occur that your cholesterol profile will show up unfavourable with testing after starting a keto lifestyle. I will explain below why this may be the case and if this is cause for concern.

Cholesterol levels are tested in order to assess the risks of cardiovascular disease. It is a fairly standard test that your doctor will request for you. However, testing is only useful after at least six to eight months of continuously following a ketogenic lifestyle and/or when you have reached your goal weight.

An increase in the levels often occurs during that period, especially if you lose a lot of weight quickly, and this makes testing during that time rather pointless. If you have not consistently maintained your lifestyle during that period (in other words: you cheated with non-keto foods) you will also not get reliable results.

Make sure that your doctor always gives you the results of all levels: HDL, LDL, triglycerides and total cholesterol. Total cholesterol alone or LDL alone mean nothing; you need all the test results to calculate the ratios and to see whether your cholesterol has improved or not.

What do the cholesterol levels mean?

Total cholesterol
Your total cholesterol doesn’t tell you anything about your risk of cardiovascular disease. Not even if your total cholesterol has increased or decreased. To be able to say anything about this risk, you need more data: the HDL, LDL and triglycerides levels. It is also important that you have the results of previous testing in order to be able to look at the progress and see whether the ratios have improved or deteriorated.

Triglycerides
High triglyceride levels are usually seen in people who eat a lot of carbohydrates and seed oils: this can say something about the inflammatory processes in the body. Lower values of triglycerides are therefore always better and in most people these values also decrease rapidly when they start a ketogenic lifestyle. But again, these values alone do not tell you anything about the risk of cardiovascular disease.

HDL
HDL is also known as ‘the good cholesterol’: higher values are seen as better. But even these values do not say much on their own. Various studies again show that the ratios are the strongest predictors of cardiovascular disease.

LDL
Although the average result of a cholesterol test refers to one type of LDL, it is important to know there are in fact several types:

  • LDL with large healthy LDL particles (this is called lbLDL-p: large buoyant LDL particles)
  • LDL with small unhealthy LDL particles (this is called sdLDL-p: small dense LDL particles)

A standard LDL result never shows which type of LDL it concerns so the actual result tells you very little. Only further research into the number of LDL-particles can say more about the exact nature of the LDL so ask your GP for further testing.

If you just started a ketogenic lifestyle this general LDL will temporarily increase. There are two reasons for this:

  • because you lose weight, LDL is released along with the fat;
  • the general increase is caused by an increase in the large healthy LDL particles and a decrease in the small unhealthy LDL particles.

Ratios are the best predictors

Studies show that certain ratios can best predict your risk of cardiovascular problems. These are:

Triglyceride/HDL
To calculate this ratio, divide the amount of triglycerides by the amount of HDL (make sure the values for both are the same: mg/dL for USA or mmol/litre internationally). The outcome of this ratio can be a good indication of the risk of cardiovascular disease.
A healthy ratio of triglyceride/HDL is lower than 2, it is even better if the ratio is lower than 1.

Total cholesterol/HDL
To calculate this ratio, divide the amount of total cholesterol by the amount of HDL (make sure the values for both are the same: mg/dL for the USA or mmol/litre internationally). According to research, this ratio can also predict the risk. The amount of LDL in this case does not matter.
A healthy ratio of total cholesterol/HDL is less than 5 but preferably less than 4.

If you prefer to use an online cholesterol ratio calculator, you can do so here:

Cholesterol ratio calculator

Fasting and cholesterol testing

Fasting can influence your test results. In general, longer fasts before a cholesterol test will usually result in lower triglycerides, but higher levels for the other values. Shorter fasts in combination with regular daily keto meals may show higher triglycerides, but the other values may be improved. So this is a matter of experimenting.

What should you do if your doctor is worried about your cholesterol levels?

Many doctors still believe that a high fat diet has a negative influence on your cholesterol and therefore increases your risk of cardiovascular disease. They are also not (yet) aware of the growing research that shows that keto is much healthier and in fact reduces the risk of cardiovascular disease. In addition, they only look at total cholesterol, or only at LDL, and not at the ratios.

It is therefore important that you discuss with your doctor how you follow the ketogenic lifestyle, possibly referring your doctor to the right information sources about keto and also providing information about current insights about cholesterol. Of course, this is only possible if your doctor is open to it.

If you have tested too early, so less than 6 months after starting a continuous keto lifestyle, then suggest repeating the test after three and again after six months. This is the only way to assess the actual progress.

Additional tests

If your doctor is still worried, for example because your LDL has increased, and even insists you start medication, you can first ask for more testing: ApoA, ApoB and Lp(a) determination. In addition, it is also important to have your doctor exclude other factors such as thyroid function issues and the congenital abnormality familial hypercholesterolemia (FH).

The only reliable way to have the condition of your bloodvessels evaluated is the CAC scan (Coronary CT calcium scan), and not the cholesterol test. Again, you can ask your doctor for a referal to have this scan done or you can have it done privately.

Taking your own precautions

If you yourself continue to have concerns, you can make a number of changes to your ketogenic lifestyle:

  • stop consuming keto coffee and fat bombs;
  • replace some of the saturated fats with mono-unsaturated fats: cook with olive oil instead of butter. Also eat some more nuts and avocado;
  • eat fatty fish with a high omega-3 fatty acid content at least once a week. If you cannot or do not want to eat fish, supplement with fish oil;
  • always make sure to get enough exercise, good sleep and try to reduce stress;
  • get tested for possible vitamin- and mineral deficiencies; most people have a vitamin D3 deficiency for example;
  • consider supplementing with ubiquinone or ubiquinol (the second form if you are over 40); note: vitamin K2 is always advised to supplement along with it;
  • a red yeast rice supplement can also be useful; always combine this with Q10.

For a good explanation on how cholesterol works and what to look out for I recommend the book Cholesterol Clarity by Moore/Westman

Other links

https://www.dietdoctor.com/low-carb/cholesterol-basics
https://www.tandfonline.com/doi/full/10.1080/17512433.2018.1519391
https://cholesterolcode.com

Dr Paul Mason
Dr Ken Berry

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