Don’t blame the eggs, when the toast did it!
This article written by Skip Franzsen (South Africa) & Linda Komesaroff (PhD), Deakin University (Australia), originally titled ‘Concerns about cholesterol and those very small LDL particles’ and published on my website 1 Dec 2015 (updated 6 Jan 2016).
The question of raised cholesterol often comes up in a Banting, low carb high fat and moderate protein, diet. Blood tests are done routinely in medicals. Doctors spot higher cholesterol and LDL counts and many will routinely propose statins and other remedies.
It is important to understand that cholesterol is essential for a healthy, functioning body. Often LDL cholesterol increases on a high fat diet. As Professor Ken Sikaris (2015a) explains in his talk ‘Does LCHF improve your bloood tests?’ at Low Carb Down Under, LDL cholesterol moves fats within the body, so if you are eating higher fats you can expect that LDL will increase simply because of ‘volume’ (Sikaris, 2015a). If you are ‘fat-adapted’ you are moving more fats through the body via LDL cholesterol, so expect the score to be higher.
This begs the question. If you are Banting, what is good and what is bad in terms of cholesterol and triglycerides? If the norms used are calculated against the general population who are not on a low carb high fat diet, how relevant are the standard norms to your Banting lifestyle? In another excellent Low Carb Down Under presentation, ‘Medical aspects of the low carbohydrate lifestyle’, Professor Tim Noakes (2014) makes the point that most markers – including small LDL cholesterol – improve on a low carb diet.
How concerned should you be? Obviously we all want to lower our risk of cardiovascular disease (CVD). There are many videos available on YouTube that show that Banting is good for creating good, fluffy LDL and works against forming the very small LDL (vsLDL) that increase CVD risk. A summary of the issues identified in the documentary ‘Statin Nation II’ and discussed by Dr Joseph Mercola in his article ‘Statin Nation II: What really causes heart disease?’ is essential viewing/reading for anyone who wishes to know more or has concerns about cholesterol.
The main concern would be the very small LDL (vsLDL) that potentially can do real damage to the body. At the time of writing this article, none of the tests normally done in South Africa test vsLDL so in effect the proponents of low total cholesterol are guessing if they use an overall cholesterol score or HDL or even LDL markers to make decisions about medication (note, this testing is currently available in Australia and some other countries). vsLDL is a special subset of LDL. It is a modified oxygenated hard LDL particle that has lost its fat load. LDL should be good, fluffy, healthy LDL, but containted within the LDL can also be some vsLDL – the troublemakers. The very small LDL test can be done but at expense because it requires somebody to actually count the vsLDL under a microscope. (In the movie ‘Cereal Killers: Don’t Fear Fat’, Professor Tim Noakes states that it is close to malpractice for judgements to be made on high total cholesterol without knowing the vsLDL score.
The overall hope of cholesterol tests is that by lowering total cholesterol, you lower the vsLDL and therefore your CVD risk. This is really an assumption, especially if we rarely measure it. Why would a lower overall cholesterol score significantly lower vsLDL? And how much vsLDL do you need to increase CVD risk?
What is important is really this. Do you manufacture these tiny vsLDL particles? Many doctors will tell you that on a very low carb and high fat diet (such as Banting) you manufacture LDL that is fluffy, healthy and good. Professor Sikaris’ recent presentation ‘Does LCHF improve your bloood tests?’ (Sikaris, 2015a) makes this very clear. Professor Sikaris points out that a high carb, sugar type diet you get those hard vsLDL particles that are oxygenated, too small to be recognized by the liver and, as a result, don’t get processed out of the body easily. They linger and can be dangerous to artery health, causing inflammation, blockages, strokes or heart attacks – they are indeed very unhealthy and ‘beasty’ things that we all want to avoid.
Professor Sikaris estimates that around 5% of people who switch to LCHF experience an exaggerated increase in cholesterol, some of whom may have ‘familial hypercholesterolaemia’, a genetic disorder that results in very high levels of LDL, in particular vsLDL (see his excellent presentation ‘Cholesterol – When to Worry?’, Sikaris, 2015b).
So how do you know if your body manufactures the good, fluffy LDL or enough of the bad vsLDL to be at risk?
In ‘Sugar and fat metabolism’ Professor Sikaris (2012; go to the 12 mins mark), shows us Pattern A, with good, fluffy LDL. In Pattern B, you can see more of the bad vsLDL – the ‘beasty-type’ cholesterol (our term for them!). You can tell if you are Pattern A or Pattern B by looking at your triglycerides score:
- if your triglycerides score is less than 1 millimoles per litre (mmol/L), you are good Pattern A; everything is fine as you are producing high levels of good LDL and little or no vsLDL (which is a key marker of heart health).
- If your triglycerides score is more than 1.5 mmol/L, you will be producing more vsLDL particles and you would be at greater CVD risk (see video at the 25 mins mark).
Note: Some sources accept a higher threshold for ‘normal’ triglyceride levels in the blood. For example, MedicineNet.com (see ‘Triglyceride Test: Lowering your Triglycerides’) recommends keeping triglycerides below 150 mg per deciliter (mg/dL) which equates to approximately 1.7 mmol/L.
Risk markers identified in ‘Statin Nation II’ and discussed by Dr Mercola (2015) in his article ‘Statin Nation II: What really causes heart disease?’ can also be assessed using the ratio of HDL/Total Cholesterol and Triglycerides/HDL. These ratios are far better indicators of heart disease risk than ‘total cholesterol’ or ‘LDL cholesterol’ by themselves (see Sikaris, 2015b).
- Your HDL/Total Cholesterol Ratio:
HDL percentage is a very potent heart disease risk factor. Divide your HDL level by your Total Cholesterol. This percentage should ideally be above 24%. Below 10% and it’s a significant indicator of risk for heart disease.
- Your Triglyceride/HDL Cholesterol Ratio (TG/HDL-C):
Firstly, check to see if your blood results are provided in mg/dl (used in the US) or mmol/L (used in Australia, Canada and most European countries).1. If lipid values are expressed as mg/dl, a ratio of less than 2 is ideal, above 4 is too high and above 6 is much too high.2. If lipid values are expressed as mmol/L:
- multiply this ratio by 2.3 and use the reference values above (ie < 2 is ideal).
- Alternatively, multiply this ratio by 0.4366 and if the resulting TG/HDL-C is less than 0.87, this is ideal. A result above 1.74 is too high and above 2.62 is much too high.
(Sigurdsson, 2004, no page number).
The following results provide examples of improvements in blood markers from three long-term Banters (including both authors).
Tommy: Lost more than 87kg and halved his triglycerides
A blog post by Tommy (no surname, 2015) from Sweden called ‘Cholesterol after 6 years LCHF’ shows his blood readings after tracking a low carb diet for six years. He reports a steady decrease in his triglycerides from 1.1 to 0.55 and a decrease in LDL from 3.2 to 2 over a five year period. In the first picture, Tommy is 174.4kg (in 2009) and reduced his weight to 87kg (in 2011) after switching to LCHF. He halved both his weight and his triglycerides, significantly reducing his risk of CVD.
Skip: 23% improvement in triglycerides after 12 months of Banting
During his own years of ‘Insulin Resistance Madness’, Skip (first author) credits his doctor with keeping him alive for 20 years. Skip requested that his doctor take biochemistry (blood test) scores and after 6 months of Banting, and now at 12 months, he has followed Tommy’s example and created a spreadsheet that allows him to check his progress. He can happily report that under Banting all three of the key markers discussed above have improved:
- Triglycerides have improved by 23.1%
- HDL/Total Cholesterol has improved by 3.0%
- Triglycerides/HDL-C has improved by 20%
Linda: Increased cholesterol but decreased risk of CVD
Since beginning Banting in late 2014, Linda (second author) has compared her blood tests results from 2015 (three months post-Banting) with results from 2012 (before giving up sugar when she was eating a high carb, high sugar diet).
As expected (see Sikaris, 2015a) after three months of eating LCHF, there was an increase in cholesterol, both HDL and LDL:
- HDL increased from 1.67 in 2012 to 2.89 in 2015, and
- LDL increased from 3 in 2012 to 4.6 in 2015.
On the basis of this increase, Linda’s GP recommended that she start taking statins to reduce her level of cholesterol. She did not follow this advice, explaining to her doctor that the increase was expected but did not indicate an increased risk of CVD. This is borne out in the following analysis of the ratios between triglycerides and HDL, and between HDL and Total Cholesterol. When calculated, these markers show no cardiovascular risk:
- Triglycerides decreased from 0.7 mmol/L in 2012 to 0.6 in 2015.
Both figures are below 1 mmol/L, indicating high levels of good LDL and little or no vsLDL.
- HDL/Total Cholesterol increased from 36% in 2012 to 39% in 2015.
Both figures are more than 24%, as recommended.
- Triglycerides/HDL decreased from 0.42 mmol/L in 2012 to 0.21 in 2015.
Converted to mg/dl, this equates to a decrease from 0.96 in 2012 to 0.48 in 2015 (where less than 2 is ideal).
If you have concerns or believe you are at a higher risk of CVD – or if you have been prescribed cholesterol-lowering medication without the above calculations being made – take control of your health and check your blood markers (download our free Blood Test Calculator.
Mercola, Joseph (2015). ‘Statin Nation II: What really causes heart disease?’, Mercola.com, 21 Nov 2015, http://articles.mercola.com/sites/articles/archive/2015/11/21/statin-nation-2.aspx?e_cid=20151121Z2_DNL_art_1&utm_source=dnl&utm_medium=email&utm_content=art1&utm_campaign=20151121Z2&et_cid=DM90526&et_rid=1225691550, accessed 28 Nov 2015.
Noakes, Tim (2014). ‘Medical aspects of the low carbohydrate lifestyle’, presented at Low Carb Down Under, 21 Sep 2014, https://www.youtube.com/watch?v=fL5-9ZxamXc, accessed 28 Nov 2015 (go to 24 mins for specific reference to atherogenic dyslipidaemia and 35 mins for reference to very small LDL).
Sigurdsson, Axel F (2014). The Triglyceride/HDL Cholesterol Ratio, Doc’s Opinion, blog about heart disease, nutrition, healthy lifestyle and prevention of disease, http://www.docsopinion.com/2014/07/17/triglyceride-hdl-ratio/ accessed 15 Nov 2015.
Sikaris, Ken (2012). ‘Sugar and fat metabolism’, presented at Low Carb Down Under, 14 December 2012. https://www.youtube.com/watch?v=E57cFhjpxgw, accessed 28 Nov 2015 (go to 9 minutes for explanation of the creation of vsLDL in high carbohydrate diets).
Sikaris, Ken (2014). ‘Blood tests to asses your cardiovascular risk’, presented at Low Carb Down Under, 10 Oct 2014, https://www.youtube.com/watch?v=9BFRi-nH1v8, accessed 28 Nov 2015 (go to 12 minutes for discussion of triglycerides as a marker for vsLDL and 25 mins for triglycerides score).
Sikaris, Ken (2015a). ‘Does LCHF improve your bloood tests?’ presented at Low Carb Down Under, November 2015, https://www.youtube.com/watch?v=MXkE8_NdAyQ&list=PLrVWtWmYRR2BB5UPx8lkTe5iQevHxHDOb, accessed 28 Nov 2015 (see around 18 mins for explanation of blood test results).
Sikaris, Ken (2015b). ‘Cholesterol – When to Worry?’ presented at Low Carb Down Under, 25 Oct 2015, https://www.youtube.com/watch?v=OyzPEii-wo0&feature=youtu.be, accessed 3 Dec 2015.
Smith, Justin (2015). ‘Statin Nation II’, documentary available at https://vimeo.com/ondemand/sn2/121690414, last accessed 6 Jan 2016.
Tommy (no surname) (28 Sep 2015), ‘Cholesterol after 6 years of LCHF’, blog post on Eat Low Carb High Fat, http://www.eatlowcarbhighfat.com/?p=7040, accessed 28 Nov 2015.
Wedrow, Benjamin (no date). ‘Triglyceride Test: Lowering your Triglycerides’, MedicineNet.com, http://www.medicinenet.com/triglyceride_test/article.htm, accessed 1 Dec 2015.