Cholesterol is necessary for life. I learned that if a baby is born without the cholesterol pathway – the ability to make cholesterol – it can’t survive. Cholesterol is that essential to life. How it became thought of as a bad thing, while taught like it’s truth, it really is not the whole picture. That’s my diplomatic way of saying that what we were all taught about cholesterol and if you ask doctors today what does LDL cholesterol do, they’ll say, “Well, it causes heart disease.” No, no. That’s all they’re taught. Spoiler alert, the whole cholesterol class can be condensed into: “You need cholesterol. Cholesterol is not bad.” You really don’t need a statin to lower the cholesterol level or anti-inflammatory effect of the statin. They don’t quite know why it works; you wouldn’t take that unless you had a history of arterial disease – a stroke or heart attack or some evidence that you had the disease – because the primary prevention, meaning you’re taking a pill and you don’t have the disease yet, doesn’t really do much if using a statin drug.
I’m not totally anti-statins by any means. If I was, I would be way out of the mainstream and perceived negatively by my peers. Someone in one of my videos commented, “You’re scared of what other doctors think,” and I wrote back, “Yeah, I am.” I care about what other doctors think because generally, we’re a scientific group of people and if I’m way out on a limb, I’ll get kicked out of my university. While some people are not in a university setting, they’re not even in a private practice with a group, they’re just lone wolves on their own, they can say whatever they want without recrimination. If I’m so far outside what the mainstream thinks, that’s not good for me. I think there is a role for using medication, although I think they’re overused.
Cholesterol is necessary. When someone comes in now (to my clinic) and says, “My cholesterol went up,” I say, “Good,” and just wait for the response. I know most other doctors don’t say that, but the first time I was introduced to this whole (keto) diet, two of my patients did it in front of me. I didn’t tell them to. I was at the VA hospital here in Durham, North Carolina, and when I asked one of the gentlemen what he did, he said, “All I did is eat steak and eggs,” for shock value. The concern was the cholesterol would go up. That patient came back again and I said, the concern is your cholesterol is going to go up and he looked at me and said, “Why don’t you check it?” At the VA lab it didn’t cost anything. It was the VA, the lab was down the hall. Two in a row, people did this way of eating, changing from eating carbs to not eating carbs, and two in a row, the cholesterol levels looked better any way you looked at it – the total cholesterol, the LDL, the triglyceride, the HDL. Now I know that the odds were in the favor, but had I had a bad roll of the dice, I wouldn’t have studied this. Two-thirds of the time now, pretty much across the board, when you look at the cholesterol levels, it’ll look better. A third of the time it won’t if you look at it in the old way.
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Metabolic syndrome
There’s an old way and a new way of looking at cholesterol and cardiovascular risk. What’s ironic is the old way is what everyone thinks now. The new way has actually been around since the 1980s and it was suppressed or marginalized from the medical world. It’s called the metabolic syndrome. Part of the issue was there was no drug to treat metabolic syndrome – it’s a constellation of things. An internist basically, as I was trained, will give a pill for one component of the metabolic syndrome. They’ll give a pill or a shot or multiple pills for high blood pressure, give a pill or a shot for blood glucose elevation, the diabetes part of metabolic syndrome. They pretty much ignore the abdominal circumference, the obesity side of things, although now every doctor is a weight loss expert with the semaglutide that’s in pills and shots. It’s a little concerning because people aren’t taught what to eat and they have their appetite suppressed, so many people are losing weight too fast. But so anyway, doctors are trained to treat each component of the metabolic syndrome out here with drugs, but if you treat the root cause, all of these things will get better. The triglyceride and HDL almost always gets better, triglyceride coming down, HDL going up, and that’s the component of the metabolic syndrome in the blood.
Metabolic syndrome, looking at the blood cholesterol, doesn’t include the total cholesterol and LDL; it’s like we’re speaking a different language. I guess it would be like cars and automobiles where there are rotary engines and there are other types of engines. Do the old engine people say to the new engines, “Those don’t work, they can’t do it”? Well no, it just works differently. The knowledge about metabolic syndrome is spotty, few and far between. Just about every doctor focuses on the total cholesterol and the LDL cholesterol. That’s just the reality we’re in.
Guidelines are overgeneralized
If your triglyceride goes down and your HDL goes up, I don’t really care what happens to your LDL and your total cholesterol, but I know other doctors out there will focus on the total cholesterol and the LDL. If you looked at the type of LDL, you can actually know if you have large LDL particles or small LDL particles. In probably the best study to date about risk prediction using these tests in the blood, it wasn’t the total in the LDL or the particle size or particle number of the LDLs. It was the summary score called the LPIR score that was the best predictor, which summarizes all the metabolic syndrome components. The best way I can think about it is that there’s a different mechanism of reducing cardiometabolic risk like there are different kinds of phones and different kinds of cars. If doctors are only trained in one way, you just have to understand that the doctors are trained to look at the LDL – not even the particle size. The guidelines dumb it down to, “If they’re LDLs, just put people on a pill or a shot.”
Cholesterol is not a disease
You need cholesterol, and an elevated cholesterol is not a disease; it’s a predictor. It’s not a great predictor by itself. What you’re trying to do is prevent the starting or the the continuation of atherosclerosis, which is a process that affects the arteries. Cholesterol is not a disease, but what’s happened is, it’s easier to measure blood so they made the guidelines say “Let’s just check the blood,” and because these drugs are so inexpensive and they make money for so many companies now, let’s just lower cholesterol. Smart people got in rooms and said, “There’s a correlation somewhat between cholesterol levels and heart disease and stroke and if you put people on medicines there’s a small reduction in those things. We won’t even assess if you have arterial disease, we’ll just put you on a pill based on your cholesterol level.” There’s a tension between guidelines – one size fits all sorts of things – and sticking up for the individual health and care of the patient in front of me. That’s my perspective. I was always trained, “How do I take care of who is in front of me?” rather than how do we put all this information into a guideline so that we can have less years in training and just tell people to check their cholesterol and give them a pill.
The risks of medication
If I’m going to give you a medicine to prevent atherosclerosis, I want to know if you have atherosclerosis. Imagine a healthcare professional giving you a drug, a pill, without knowing if you have the disease it’s supposed to treat. Can you imagine if you got chemotherapy for cancer and they didn’t know if you had cancer or not? No, you can’t imagine that. In fact, the cancer practitioners were always the ones in training, as I recall when I was in training, they said, “We need tissue, we need a biopsy, we need evidence that there is cancer.” If it’s not definitive, they’ll do another biopsy, they’ll get tissue and then give a treatment. Now you might say, “Everyone gets atherosclerosis.” It’s not true. It’s an overgeneralization. Or you could say, “A statin drug is not like chemotherapy where there are toxicities.” I don’t practice with a whole lot of doctors but even in my small sphere of other doctors, the one case popped up already where someone was bedridden and it turned out that it was the statin medicine doing it but nobody suspected it. It took someone who was outside, probably older, who said, “Let’s stop all the medicines and see if this person gets better.” No one suspected it even though myopathy, muscle issues, and memory issues are high on the list of statin side effects. In practical reality, most people don’t question whether it’s the cause of a side effect or not.
I’ve fallen out of the world that assumes medications can do no wrong and now I suspect a medication might do anything. Press your doctor on this. If you’re 63 years old, like me, and you haven’t developed heart disease yet, would you want to take a pill that is going to prevent your risk of getting heart disease that you don’t have? The “aha” moment for me was when a family member was told to do a low-fat diet after being hospitalized. He didn’t have heart disease. They thought he did, but it turned out they did a heart catheterization and there were normal coronary arteries, no heart disease. As he left the hospital, the dietitian said, “We want you to do that low-fat diet because it prevents heart disease.” That he didn’t have. This makes no sense. Doctors really aren’t trained to know how to assess you for having heart disease. They’ve all been taught to use cholesterol as the proxy or the intermediate or the correlative measure. It’s not a great correlation measure. I talk about getting your own arteries measured.
Cholesterol – even high cholesterol, if it’s causing a problem – is going to be causing arterial vascular disease. What you want to do is get your carotid, which is your neck arteries, and your aorta, which is your abdominal artery, measured. How do you do that? It’s called an ultrasound, that’s been used for decades in the obstetrics offices. It is used for babies and fetuses to see if the baby grows. When it’s used on the heart, it’s called an echocardiogram. They’ve changed the name there, but it’s still ultrasound technology. Best I can tell in my area and what people tell me, doctors aren’t readily convinced to get a test for this unless you have a symptom. They’re not going to be into the prevention side of assessing things. If the bank was going to give you a loan for a house, you’ve got to get an inspection. They don’t just look from a distance; they go in and inspect your house. You want to know to the degree that it’s easily obtained and safe whether you have vascular disease. There’s a company that goes around called Lifeline Screening, who will come to your area and they put up their equipment in an area in town. You go in, you get your ultrasounds done and they send you a report so you can know if you have atherosclerosis or not. They’ll tell you on this report.
You have to take that into your own hands, go beyond the assumption that high cholesterol means a disease. It’s not. What you’re trying to do is prevent arterial disease. Even if you’re a lean mass hyper responder, your LDL is super high, 350 mg/dL (9.0 mmol/L) or whatever, get a measurement to see if you have arterial disease, the ultrasound I talk about first. No, it’s not testing the heart directly but because the test has no risk really at all, there’s no radiation, there’s no interaction with the health system because with these ultrasound machines, a company will come around and do it without a doctor’s order. I talk about this first so you can get an idea if your body has been affected by atherosclerosis or arteriosclerosis. You wouldn’t want to be put on a pill to prevent narrowing of the arteries if you didn’t have it, regardless of what your cholesterol level is. You can do these tests periodically to see if you’re developing cardiovascular disease.
Is keto risky?
People started asking, “Is this risky? What about the long-term?” There are no long-term studies. In fact, there aren’t great long-term studies of any diet, let alone weight loss, let alone vascular disease. And so how do we measure something to know if something’s changing? You get the ultrasound, you get the CAT scan of the heart – the coronary artery calcium score or CAC score. (It’s a CAT scan that looks directly at the heart to see whether there’s any calcification.) If you follow these tests over time, you can see if whatever you’re doing is causing some sort of vascular problem. So cholesterol itself is not a disease. You need cholesterol. Every cell needs cholesterol. The idea that cholesterol in the blood predicts heart disease and stroke is not a strong correlation. You can actually measure to see if you have the vascular disease.
The easy answer is, if you don’t have vascular disease, your carotid artery and aorta are clean. Calcium comes into these arteries when the arteries heal some damaged area. If you don’t have any coronary artery calcium then you don’t have any plaque that has been built up that heals with the calcium. The calcium score does not show you noncalcified plaque, it shows you areas where you’ve had healing. It’s not perfect either, but in large studies where they’ve done these coronary artery calcium scores in thousands of people, if you have a zero coronary calcium score, the likelihood of you having a vascular problem – a stroke or a heart attack – over the next 10 years is exceedingly low. There’s a group of papers now called “The Power of Zero.” They state that if you have a coronary score of zero, the likelihood of you having a heart problem in the next 10 years is exceedingly low.
It’s percolating into a few guidelines, but not all of them, among cardiologist guidelines, that if you have a coronary score of zero, there’s no need for statin treatment. This is not welcome among cardiologists – to say you don’t need to treat the cholesterol – because that’s what they’ve always been doing and what they’ve been taught. It’s what seems normal and comfortable, like driving on the right-hand side of the road. It would seem odd and uncomfortable if I started driving on the left-hand side of the road. Doctors will introduce fear language and risk, and “You have to do this,” which really is not appropriate. A doctor is an advisor, not a thumb-screw pusher to make you do something like take a pill to reduce cholesterol.
If you do have vascular disease, that’s a different issue. There’s a big gray area where there are no studies. If you have a calcium score that’s low but not super-high, no one really knows what happens when you use medication to treat, regardless of the cholesterol level. So, that is a gray area. Some doctors are just saying, “You have calcium there, you have the disease. We’ll put you on a pill too.” But what’s more solid is if you’ve already had a stroke, if you’ve already had a heart attack, which basically represents you’ve had a problem that was serious enough in these arteries that it stopped the blood flow and it made the heart have not enough oxygen, not enough blood flow, it may have damaged the heart or not, but it means you had a significant narrowing either in the coronary artery or the brain, leading to a stroke.
Studies giving statin medication and/or other medicines and driving the LDL down to almost zero will reduce the events that someone has. The problem with that is, the event reduction is not super high. It doesn’t eliminate risk but it does reduce it. There, the persuasion and the marketing got the companies to start using relative risk reduction as opposed to absolute risk reduction. If you don’t know what that means, it basically means if your risk went from 2% to 1%, the company could say it was a 50% risk reduction, not absolute. 50% relative risk reduction is what they really meant. Some people would respond and say, “Well, 98% of the time I wouldn’t have a problem, and taking this pill reduces my chance of having it to 99% of the time, or increases my chance of not having it from 98% to 99%. Is that worth taking a pill for 10 years or so?” If you have side effects from pills, that’s where maybe even if you’ve had a heart attack or stroke, the side effects may outweigh the benefits. There, you get into a clinical, personal decision.
That is why I’m not anti-statin. The science says yes, there’s a small reduction of recurrent stroke or heart disease with some kind of treatment of the cholesterol level. But whether it’s the cholesterol lowering or the anti-inflammatory effect of the pill that’s doing it is an open question. Steve Phinney, at a recent paper presentation, basically said they’re looking at the data now with their Virta diabetes study, and the effect of the diet alone on inflammatory markers was stronger than medication treatment.
Lifestyle treatment
Now, let’s entertain the idea that a lifestyle change can be a potent intervention. If you have a problem like atherosclerosis or a cholesterol level that’s high, you don’t have to always first go to cholesterol-reducing medication. You could do a lifestyle change. Let’s say you’re in discussion and your cholesterol’s high. Say, “Doctor, I’ve just started a modified Mediterranean diet, and I’m going to treat my cholesterol by lifestyle. I’m going to come back 50 pounds lower, and then I want you to check my cholesterol.” You can barter, negotiate, and buy time. If you’re just getting started, a little known fact – and it’s Steve Phinney who pointed it out years ago: when you’re losing weight, you’re actually pinching off your cells, the fat cells, making them smaller, so that cholesterol is getting liberated into the blood. You can have a temporary increase in your blood cholesterol based on losing weight. It has nothing to do with the diet that you’re on. I saw that years ago in our first low-carb versus low-fat diet randomized trial. There were people on the low-fat diet whose cholesterol went up. Do you ever hear about that in the news? The fact that they were losing weight, I think, is the reason that the cholesterol went up. I didn’t know it at the time. So, don’t check the cholesterol while you’re losing weight. Triglycerides and HDL is my best recommendation. Two-thirds of the time, you roll the dice, your cholesterol is going to look better across the board. Total is going to come down, LDL comes down, triglycerides come down, HDL goes up. HDL will keep going up over time. The longer you stay away from carbs, your system is going to re-equilibrate and the HDL will keep going up.
If you’re one of the one-third who had high LDL and total cholesterol, that’s just the old way of looking at the blood. I want to know what triglycerides and HDL do. 95 out of a hundred times, the triglyceride goes down and the HDL goes up. It’s not 100%. I’ve had people send me their labs and their triglyceride went up. We give these generalizations, but an individual might have an elevation in triglyceride. As long as the HDL is coming up, you have no disease here. Don’t just stick your head in the sand. Keep measuring these things. Keep measuring to see if you get the disease over time.
Lean mass hyper responders
I’m happy to report that based on one individual who had the high LDL, Dave Feldman, he got a GoFundMe together to do a study on people with really high LDL levels. If you’re not familiar or if you really want to go down a rabbit hole on this, the Cholesterol Code is Dave Feldman’s website and the Facebook group is called LMHR, for Lean Mass Hyper Responder. If you have a high LDL, go join that Facebook group. You’ll join other people; many of them have had this for years, and you’ll at least be in a community of people who are wondering and worrying. And yet, it will reassure you that there are other people who have this.
It’s going to be hard without controlled and systematic research to know if this is something harmful. Dave has a coronary CT angiogram study going on now where a hundred people with high LDLs were flown out to LA to probably the world’s best CT angiogram center. Now, CT angiograms are beyond the CAT scan score. It’s not the CAC score. The acronym is CCTA, for coronary CT angiogram. Dave tells me that he bought his own coronary score. He wasn’t in the study. He asked them and they charged him a couple of thousand dollars for it. But he wanted to know. You can go some places and ask for it, pay out of pocket, or you might be able to convince a doctor or cardiologist to order it. Most will not feel comfortable doing it because you don’t have a high-risk profile. Nowadays, some doctors are so afraid of that LDL elevation that you could use that to persuade them. With the CCTA in this study, you can actually see the inside of the artery. It makes sense to be able to see the inside of an artery.
The study enrolled a hundred people at baseline getting this coronary CT angiogram. Now that they’re in the study, they’re required to measure their ketones, write down what they’re eating, and measure their weight. They want to know that over the next year they’re in ketosis, keeping the carbs really low. The question of the study is, baseline data, what happens to people after a year of being on this diet and having high LDL levels? Many of these people came in already knowing that they’ve been on the low-carb diet with high LDLs for three to five years. Dave Feldman hasn’t published it yet, but at baseline, he basically said not many people had disease, even though many of them had high LDLs for years. A hundred people is probably going to protect against the bias that if you only studied five people, what if they were all destined not to have heart disease anyway, regardless of what they did? (Some families don’t get heart disease.) You want to have enough people so that there isn’t some random chance that you’re going to just shoot the bias and the study’s really not detecting or measuring in the right people.
I should give you the backstory of why a year or three years is important with this familial hyperlipidemia. If the doctor says you have familial hyperlipidemia because your LDL is high now (on a keto diet), but you didn’t have high LDL before, you don’t have familial hyperlipidemia. It’s from your diet. You can’t just get it right now. I often hear that it’s all genetic, and that’s not true. It’s the environment that changed. In these lean mass hyper responders, you follow them over a year and they’ll get another coronary calcium score to see if they develop any narrowing inside the arteries. It’s a great study. You don’t need to be in this study – you can get these things measured on your own through the ultrasound and coronary score that I mentioned. You might twist your doctor’s arm to get the coronary CT angiogram, which actually looks inside the artery. If you don’t have arterial disease, it makes no sense to me to be put on medication or an intervention to reduce atherosclerosis that you don’t have. You wouldn’t be treated for cancer unless you had a tissue diagnosis of cancer.
Conclusion on Cholesterol Myths
With that, I can’t be entirely reassuring for everyone. I know there may be some people who don’t respond the same way. The clinical view that I have is that there is not an epidemic of heart disease in people whether the cholesterol is high or not. If anything, these things get better (on a keto diet). I’ve had people with heart disease who have recurrent issues and who get stents, even though they’re on a keto diet and they’ve lost weight. I think it’s more complicated than diet alone. Diabetes, insulin resistance, smoking, BMI, high blood pressure, abdominal circumference, and metabolic syndrome are all the things that are more important than looking at a cholesterol level. If you’re looking at the lipid subtractions, you want to have the higher LDL size and the LPIR as low as you can. That’s the summary of the NMR lipid profile, the factors that have to do with metabolic syndrome. In the Dugani paper from 2021 that was predicting first events in women, first heart attacks in women, it was that LPIR and the presence of type 2 diabetes that were the major risk factors, like five-fold over every other risk factor that was there.
Watch the full video on cholesterol myths here.
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