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Cholesterol and the LCHF/KETO diet

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When you tell people that you are on LCHF/KETO diet (or when they find out for themselves, when you politely decline an offered cake or a piece of bread for a cold cut), two questions usually follow, which are:

"And what do you even eat, if you don't eat flour, rice, pasta, fruit, bread...?!"

"Aren't you worried about high cholesterol levels with such an amount of fat you consume?"

The answer to the first question is simple. Same goes for the second question, because I always answer, that I am not worried about cholesterol. To come to this  point it took a lot of time, knowledge, my own blood tests and monitoring the latest research in this field. That's why I decided to write a few words about cholesterol and the LCHF/KETO diet. The goal is that cholesterol and its importance will be easier to understand and that there will be much less doubt about the results of blood tests.

If you are on a LCHF/KETO diet, then at least basic knowledge about cholesterol and the importance of cholesterol is absolutely necessary. It is also necessary to know how the LCHF/KETO diet affects our cholesterol. The following descriptions are intentionally very simplified to make understanding the complexity of the lipid system a little easier. A list of books, websites and articles on the subject is also added at the end of the entry for in-depth research and understanding of the influence of diet and cholesterol.

In the LCHF/KETO diet, the source of energy is FAT

Before dealing with cholesterol, it is necessary to define the source of energy on the LCHF/KETO diet. Of course, the main source is fat or fatty acids (provided that the diet is approached correctly and proportions are taken into account). But how is this fat transported to all the cells in our body that need energy for their functioning?

Like any other living being, our body is made up of cells. Our heart is made of cells. Our brain is made of cells. All these cells need energy to exist and perform their functions. And the vast majority of these cells get their energy from the blood that circulates around the body via the bloodstream.

It is often mistakenly presented that our body absolutely needs carbohydrates for energy. That's not true. There are two sources of energy for the functioning of the organism, namely carbohydrates and/or fat. In today's world, carbohydrates are the source of energy for the majority of the population. Our body converts carbohydrates into glucose, which then travels through the bloodstream and, with the help of insulin, is a source of energy for cells. However, the claim that carbohydrates are absolutely necessary for survival is not true. Certain cells in our body need glucose to exist, but the charm of our organism's genius lies in the fact that it is able to completely provide that portion of the necessary glucose by itself, namely with the help of protein synthesis.

Another important source of energy for our cells is fat, or more precisely, fatty acids. And just like glucose, fatty acids are also obtained by cells from the bloodstream. BUT what is the difference between glucose and fatty acids? The difference is that glucose floats easily in the blood while fatty acids cannot. We can imagine the matter even more plastically: fatty acids and blood circulation are like oil and water, they don't mix well or they don't mix at all. So, if the organism wants to deliver fatty acids to the cells for energy, it has to do two things (and here again the genius of our evolution shows itself):

  • packages three fatty acids into a combined package molecule called a "triglyceride".
  • it makes a kind of transport vehicle for triglycerides and these transport vehicles are called "lipoproteins".

We have now delineated and described the two main sources of energy and their accessibility to cells. Now let's focus on the main actor in the title of this blog.

What is cholesterol?

Cholesterol is a type of molecule known as a "steroidal alcohol." Every cell in the body needs cholesterol. The human body cannot function normally without cholesterol, as cholesterol is necessary for the correct formation of hormones and the synthesis of vitamins. And much more.

Cholesterol's molecular structure resembles a complex 3D network formed by many carbon and hydrogen atoms, which cannot be dissolved in water. That is why cell walls are also made of cholesterol, as this makes the cell "waterproof". This is especially important for the normal functioning of nerves and nerve cells. For this reason, the highest concentration of cholesterol in the body is found in the brain and other parts of the nervous system.

Most people are familiar with two main types of cholesterol molecules: 

  • HDL (High Density Lipoprotein) and 
  • LDL (Low Density Lipoprotein). 

Lipoprotein (HDL and LDL) has only one task, that is to transport cholesterol. So when you hear someone talk about HDL cholesterol or LDL cholesterol, they're not really talking about cholesterol, they're talking about the protein that surrounds the cholesterol molecule. These lipoproteins come in different sizes. And we actually do them an injustice when we label them as good and bad. In fact, they are absolutely necessary for the proper distribution of cholesterol in the body.

We know several sizes of LDL and HDL particles. The most common are two (we know more):

  • large, "fluffy" and floating LDL and HDL
  • small, dense and sticky LDL and HDL. 

Their job is to move cholesterol around the body, and the rule applies here - the bigger the vehicle, the better. Whether we will have more large or small forms of LDL and HDL depends on our lifestyle. If a wild storm of free radicals and inflammation is raging in our body, there will be less large forms in the body. However, since the LCHF/KETO diet is highly anti-inflammatory, there is usually no need to worry about it. But we have to approach nutrition correctly and choose foods that are allowed. Only in this case the real effect is shown and the inflammatory conditions in the body are cured.

The roles of LDL and HDL lipoproteins

Like triglycerides, cholesterol does not float well in the bloodstream. In the medical world, these molecules are called lipids. And lipids actually repel water, which is why we usually call them hydrophobic.

And then how does the cell get the cholesterol it needs for its proper functioning? In addition, there are some other things, such as fat-soluble vitamins (such as vitamin E and D and others), that the body wants to deliver to the cells.

And what does our organism do in such a case? It effectively packs it all into one package, namely low-density lipoprotein (or LDL).

Our organism has developed a kind of delivery service (we can also call them "submarines") for all the hydrophobic elements that our cells need.

LDL "submarines" mainly transport cholesterol from the liver, where most of our body's cholesterol is produced, to peripheral tissues. All cells can produce cholesterol, but if they need more than they can produce, they call in a delivery service in the form of LDL "submarines", which then bring the cholesterol inside the cells. Most of the cholesterol in the blood (between 60 and 80 percent) is transported by LDL. Only 15-20 percent is transported by HDL. The main function of HDL is to transport cholesterol from peripheral tissues, including artery walls, to the liver. Here it is excreted in the bile or used for other purposes, for example as a starting point for the production of important hormones. A small portion of circulating cholesterol is transported by other lipoproteins.

What about ketones as an energy source?

We often find that on the LCHF/KETO diet, we get energy from ketones when we are in a state of ketosis. The fact is that the body produces many more ketones during the breakdown of fatty acids, which are also a source of energy for our cells. This is especially important for proper brain function because ketones have a special (direct) access that lipoproteins do not.

However, despite the fact that many more ketones are produced and consumed on the LCHF/KETO diet, ketones are still a secondary source of energy for the cells. The main source of energy remains fatty acids, which are transported to cells in LDL particles. More about ketones and their characteristics is described in the blog What are ketones?

More cholesterol has its own purpose

By now you probably understand that your body needs higher amounts of triglycerides and fatty acids to supply its cells with the necessary energy. This is especially important when we are on a LCHF/KETO diet where fat is our main source of energy.

The point is to understand the importance of cholesterol:

  • our cells need energy,
  • in the LCHF/KETO diet, the main source of energy for the cells are triglycerides.
  • that our cells get triglycerides for energy, the body sends them packaged in low-density lipoprotein (LDL),
  • all low-density lipoproteins (LDL) contain triglycerides and cholesterol (especially triglycerides) and a bunch of fat-soluble vitamins.

The effect of the LCHF/KETO diet on cholesterol - what are the research conclusions?

There is a lot of research that shows that the LCHF/KETO diet (provided it is properly implemented and low in carbohydrates) has a positive effect on cholesterol and lipid profile. 

  • LCHF/KETO Diet Increases HDL Cholesterol Concentrations (Source 1, Source 2)
  • Reducing carbohydrate consumption in healthy individuals leads to higher levels of HDL cholesterol. (source 3)
  • A high-fat LCHF/KETO diet reduces the concentration of small sticky LDL particles and increases the size of LDL particles (into large fluffy particles that are not dangerous). (source 4, source 5)

And what about the values on the test results? 

Most people are familiar with combined cholesterol, HDL and LDL. 

As we have already learned, there are several types of LDL particles.

Research shows that people who have mostly small LDL particles have a high risk of heart disease, while those with mostly large particles have a low risk (source 6, source 7). It is possible to measure the size of LDL particles in laboratories around the world, but I have no information about this in Slovenia. However, it is possible to calculate and fairly accurately evaluate the size of LDL particles.

On a low-carbohydrate diet, HDL tends to rise and triglycerides fall sharply (below 1 mmol/l), while total cholesterol may rise slightly initially and then level off over time. The reason for this can also be weight loss, where a greater amount of cholesterol is released from fat cells. The size of LDL particles tends to increase and the number of LDL particles decreases. (source 8). Everything described also affects ratios, which can be important predictors of cardiovascular diseases. Namely, it concerns the relations between:

  • HDL and total cholesterol
  • triglycerides and HDL
  • LDL/HDL ratio

But, the above describes a general average. Given how complex the lipid system is, the response of our body to the increased need for fat as an energy source is also complex. So the responses can be extremely individual. However, we must be aware that high numbers do not necessarily mean bad results. Only the correct interpretation is required.

And how do we interpret our results correctly?

The individual numbers on the result report do not tell us much, we need to know the relationships between them. This is done by dividing the HDL value by the total cholesterol value and the triglyceride value by the HDL value. 

THE RATIO BETWEEN HDL AND TOTAL CHOLESTEROL is an indicator for cardiovascular diseases

The rule applies here: the higher the number, the lower the risk of cardiovascular diseases.

Once we have the measured values of HDL and total cholesterol, we can calculate the ratio of HDL to total cholesterol, which is supposed to be an indicator for heart disease. The given proportions apply to adults.

  • A safe ratio value is above 0.24 or higher
  • Values below 0.10 are associated with a higher risk of heart disease.

THE RATIO BETWEEN TRIGLYCERIDES AND HDL tells us a lot about the size of the LDL particles

The rule applies here: the higher the number, the lower the risk of cardiovascular diseases.

  • If your triglyceride/HDL ratio is less than 2, you don't have many small dense particles in your blood. 
  • If the value of the triglyceride/HDL ratio is more than 4, it means that more small, dense and sticky particles are transported in your blood. This is not a very good prediction.
  • If the value of the ratio triglycerides/HDL is more than 6, it can mean a serious risk of cardiovascular diseases.

The given proportions apply to adults.

And the risks?

It makes sense that the news that the need for cholesterol increases on the LCHF/KETO diet can scare us. Unfortunately, we are still burdened with the fact that blood cholesterol is the main culprit in cardiovascular disease and stroke. But if you have carefully read the description above, where it is really clearly described why the body needs fatty acids, then the fear is unnecessary. 

Are you still afraid of cholesterol? If you knew how important cholesterol is, you wouldn't be afraid of it anymore!

  • Without cholesterol, there are no cells.
  • Cholesterol is necessary for the health of the nervous system and brain from conception onwards.
  • Cholesterol is the basic raw material for building hormones.
  • Cholesterol is a precursor to vitamin D.
  • Cholesterol together with other lipids provides protection on the skin
  • Cholesterol is a precursor to bile acids, which are important for digestion.
  • Rather than the value of total cholesterol, it is good to check the value of the ratio triglycerides/HDL.
  • The body itself regulates the level of cholesterol in the blood - by increasing or decreasing production in the liver.
  • It is difficult to determine what a normal value of blood cholesterol is, since our needs for it are constantly changing. Many scientists think that the limits of safe cholesterol, which are defined in modern guidelines, are unacceptable and life-threatening.

Conclusion

For further research and more in-depth reading, I really recommend the book Cholesterol Clarity: What The HDL Is Wrong With My Numbers? (by Jimmy Moore and Eric C. Westman).

Online sources:

http://www.ravnskov.nu/cholesterol/

https://www.ruled.me/the-ketogenic-diet-and-cholesterol/

http://cholesterolcode.com/

http://istineilaziohrani.blogspot.si/2010/08/kolesterol-prijatelj-ili-neprijatelj.html

Lectures and articles concerning cholesterol and LCHF/KETO diet:

Zakaj se lahko na LCHF/KETO prehrani holesterol poviša: Dr. Eric Berg: https://www.youtube.com/watch?v=ZkvxySUd_68

Cholesterol and LCHF/KETO diet:

Short and simple explanation: https://www.youtube.com/watch?v=QoigeW5B5lw

Dave Feldman: https://www.youtube.com/watch?v=jZu52duIqno

Dave Feldman: https://www.youtube.com/watch?v=t_FRo_xbsOQ

Dr. Sarah Hallberg: https://www.youtube.com/watch?v=w8jUmCe3zDs

Sources:

Source 1: Bueno, Nassib Bezerra, et al. “Very-low-carbohydrate ketogenic diet v. low-fat diet for long-term weight loss: a meta-analysis of randomised controlled trials.” British Journal of Nutrition 110.07 (2013): 1178-1187.

Source 2: Brinkworth, Grant D., et al. “Long-term effects of a very-low-carbohydrate weight loss diet compared with an isocaloric low-fat diet after 12 mo.” The American journal of clinical nutrition 90.1 (2009): 23-32.

Source 3: Merchant, Anwar T., et al. “Carbohydrate intake and HDL in a multiethnic population.” The American journal of clinical nutrition 85.1 (2007): 225-230.

Source 4: Wood, Richard J., et al. “Carbohydrate restriction alters lipoprotein metabolism by modifying VLDL, LDL, and HDL subfraction distribution and size in overweight men.” The Journal of nutrition 136.2 (2006): 384-389.

Source 5: Westman, Eric C., et al. “Effect of a low-carbohydrate, ketogenic diet program compared to a low-fat diet on fasting lipoprotein subclasses.” International journal of cardiology 110.2 (2006): 212-216.

Source 6: http://www.sciencedirect.com/science/article/pii/S0167527399001072

Source  7: https://jamanetwork.com/journals/jama/article-abstract/407945?redirect=true

Source 8: http://jn.nutrition.org/content/136/2/384.long

Other sources:

http://www.ravnskov.nu/cholesterol/

https://www.ruled.me/the-ketogenic-diet-and-cholesterol/

http://www.yourmedicaldetective.com/public/523.cfm

Adrijana Dolinar, Sanja Lončar: Resnice in zmote o holesterolu

Gašper Grom, Tjaša Vrhovnik: Bemumast

28.01.2018, Katja, LCHF Style

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