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If You’re Keto, Your Lipids May be Misleading
New Report Suggests (April 2020)

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Quick Summary tl;dr

In this report, the subject adopted a ketogenic diet that put his inflammatory bowel disease into remission but also causes his total and LDL cholesterol levels to increase dramatically.

A standard lipid panel (total cholesterol, LDL, HDL, and triglycerides) would have predicted an increase in heart disease risk. However, an in-depth lipid panel revealed that the cholesterol and blood lipid changes were presumably healthy.

In future, doctors caring for people on ketogenic diets should order more in-depth testing, so as not to misdiagnose and mistreat their patients.

In science and medicine, your conclusions are only as good as your tests.

You don’t need to be a researcher or doctor to understand this concept. Take the simple example of body weight. If I tell you only that someone weighs 207 lbs and ask you to tell me about the mystery person’s health, what would you say?

You could make a guess based on population averages, but it would be a pretty poor guess. If I forced you to guess, you’d probably comment that this person is overweight or obese and may recommend that s/he try to lose a few pounds. But, of course, your guess and advice are handicapped by your lack of relevant information. Is this person tall? Muscular? Pregnant? This last would be unlikely, as the person I had in mind was Usain Bolt.

Let’s alter the scenario such that I tell you the person wasn’t 207 lbs, but rather had a cholesterol of 450 mg/dL (for reference, “high cholesterol” is considered to be anything over 200). Similarly, if I forced you or a doctor to tell me about the mystery person’s health, you could make a guess based on population averages and would probably comment that this person is at high risk for heart disease.

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This was precisely the scenario in a new report entitled, “A Standard Lipid Panel is Insufficient for the Care of a Patient on a High-Fat, Low-Carbohydrate Ketogenic Diet,” published in Frontiers in Medicine ( 1).

This report shows how, just like by only knowing Usain Bolt’s weight you could misdiagnose him as overweight, standard lipid panels (which include total cholesterol, LDL, HDL, and triglycerides) can lead to misdiagnoses and harmful medical recommendations.

The subject of this report was a young man who adopted a ketogenic diet to treat his inflammatory bowel disease. Just before he started the diet, he had an in-depth blood lipid panel. He then had the in-depth lipid panel redone seven months later. Strikingly, the ketogenic diet made the subject’s total cholesterol almost triple from an “optimal” 160 mg/dL to a “high-risk” 450! His LDL cholesterol also jumped from an “optimal” 90 mg/dL to a to a “high-risk” 321. I place “optimal” and “high-risk” in quotes because the report explains how these changes from “optimal” to “high-risk” might not actually be bad, but good!

When the subject changed his diet, his body responded by shifting his metabolism from carbohydrate-burning to fat-burning, which required an increase in his total and LDL cholesterol levels. Importantly, the in-depth lipid panels revealed that the specific types of cholesterol-containing particles that increased were all the healthy forms (like HDL and big fluffy LDL), whereas the heart-disease-causing particles (small and medium LDL) actually went down!

In our weight analogy, it was as if someone gained 10 pounds, but that plus 10 pounds was actually plus 12 pounds of muscle and minus 2 pounds of fat.

Whether or not you choose to delve into the nitty-gritty details found in the report itself, I recommend  downloading the PDF and keeping in your back pocket, if you are someone on a ketogenic diet. I know far too many people who have improved their chronic diseases by choosing to eat a ketogenic diet, only to have their doctors order a standard lipid panel and then suggest they abandon the life-improving diet when their total and LDL cholesterol levels increase. But, as we now know, there may be more to the metabolic story and more rigorous testing may be required.

So, if you’re on a low-carb diet and had such a discussion with your doctor (or anticipate one), perhaps hand your doctor this report and simply ask, “Do you mind taking a look at this? Do you think I could get some more in-depth testing?” A responsible doctor should be open-minded and receptive.

A standard lipid panel (total cholesterol, LDL, HDL, and triglycerides) may not be sufficient to determine heart disease risk in those who follow a ketogenic diet.

For more science-backed articles related to this topic, read the posts below:

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Comments (18)

Hello Nicholas
Has the keto diet been shown to help with mild gastroparesis?  My daughter suffers from a sore tummy at times.  She doesn't think the food she eats has any effect.  It is interesting to note that she always feels better after a period.  The normal tests such as endoscopy, blood tests, nuclear medicine have not shown anything other than slow movement of food from her intestine.
Thank you

Dear Sue, this is actually my particular area of expertise. If I may share something personal with you, I adopted a Ketogenic Diet for for ulcerative colitis in associated with intermittent severe IBS-C (irritable bowel syndrome with constipation). If you go to a gastroenterologist, most will say that there are no controlled clinical studies demonstrating that changes in diet truly resolve IBD/IBS (there is some data on SCD and FODMAP diets, but these are more symptomatic bandages than proper cures). However, in my professional and personal opinion, that's because we are all so remarkably individual with respect to our microbiomes. While you and I share over 99% similarity in your DNA, our microbiomes are only about 15% similar. How then could one expect that I single intervention would have a significant effect on a large cohort of heterogenous people? It's almost a laughable thought. Furthermore, there have been no clinical trials on well-formulated ketogenic diets for IBD or IBS. However, at medical conferences and discussions among low-carb educated practitioners, resolution of IBD/IBS when someone adopts a Ketogenic Diet is more common than not. I'm not saying it's a silver Bullet. Typically, there is a long period of trouble shooting (e.g. when switching to keto someone might end up eating too much A1 cheese, or phytate-rich nuts, or soluble fiber, or lectin-rich foods, etc., all of which can offset the improvements). However, if these speed bumps can be identified and removed, a whole-foods nutritionally complete Ketogenic Diet is probably the best thing for IBS and IBD. This is speaking from personal experience, conversations I've had with other practitioners, and our trial with this subject.

Thats great to hear
Thank you very much!

Nick, I am one such person who screwed up his gut because of eating lot of A1 cheese, almond, coconut flour like you mentioned above. I got constipation soon because of it in keto. I fixed my constipation by changing to a non-keto diet avoiding the nuts and cheese completely, taking osmotic laxative and doing exercise.  My HS-CRP is currently just 0.4 but my bowel movement still doesn't happen freely if I don't take the osmotic laxative. I am worried that I still couldn't fix my gut motility issue without using laxative. My gut is still depending on the laxative for the bowel movement to happen smoothly. Could you please suggest what medical tests I can take to find out the underlying issue that I might have because of which gut motility is still low?
You said you used to have IBS-C. After doing keto and fixing your issues, were your bowel movements exactly like how they were pre IBS-C?(Assuming that you are not taking laxatives). I am basically wondering if my constipation affected gut can ever come back to its pre IBS-C state without the use of laxatives.

First and foremost, yes, your gut can recover. But, honestly, in my experience working with clients, constipation is one of the trickiest issues to troubleshoot because there are so many different types. it could be an issue of electrolyte balance, autonomic nervous system imbalance, dysbiosis and the production of certain gases, etc. etc. You can go to your GI doc as have them order a test for slow GI transit or SIBO, if you want, but this might not end up being super helpful. I'd recommend the following courses of action as first steps.
Make sure you're getting enough magnesium and potassium (800 mg and 3.5g, respectively daily).
Don't depend on stimulant laxatives (including Senna and bisacodyl).
Consider 24 hours fasts. Weirdly, I never have better bigger poops than after a 24 hours fast. When I feel clogged up, that's what I do. I find higher blood ketones correlate with better poops for me. I can't tell you why, they just doo (pun intended because one is never too old for a good poop joke).
Make sure your poop position is on point! Google pooping technique and maybe invest in a squatty potty.
Practice deep belly breathing on the toilet/squatty. 4 second inhale, 3 second hold, 7 second complete exhale. Really think about your belly moving up and down.
And, finally, be observant. Are your poops clay colored? That could mean a bile production/accumualtion issue.
Are they hard and lump and dry? That could mean you need more fluids.
Are they thin? This could mean a tight anal sphincter secondary to high sympathetic tone.
Unfortunately, there's not so much I can offer in the way of help here because the suggestions one would make aren't that generalizable but specific to the specific case on constipation.
Lastly, this is a paper that people like to toss about (consider it)...

I think it's more important to live a metabolically healthy life than it is to chase metrics.

Very much agreed Joey! The thing is, so many people are so far removed from a "metabolically healthy life" they need the metrics as a stepping stone. Biofeedback is a great way to help people change their behaviors. I don't expect a type II diabetic to completely go against conventional wisdom based purely on trust when there is so much he said she said. But if s/he could see her HbA1c drop on a Ketogenic Diet, or if someone with a family history of death from heart disease could see her/his HDL rise and sdLDL drop when eating a Whole Foods low carb diet, that's the inspiration to initiate change. Eventually, the ultimate goal should be healthy intuitive eating and activity. But if you tell most people to give their bodies what they need, in our current food/lifestyle climate, that's more an excuse to "treat yourself" than a piece of true health wisdom. Step 1. Use metrics and biofeedback to gain insight. Step 2. Achieve an intuitive metabolically healthy lifestyle. And, as a post script, of course stressing about metrics to the point that your cortisol spikes is not healthy.

Yes very good point. Our brains are amazing, but sometimes they get in the way. They've been steered into consuming unhealthy addictive foods and now need to be convinced into eating a evolutionarily metabolically appropriate diet to achieve wellness. How do we do that? Medical metrics. And if that's what it takes, then great. Note, no other non domesticated organism on this earth requires this. Probably no surprise that pet chow spikes insulin and inhibits autophagy in pets too.

I love this - I have been low carb/keto for 10 years & have seen my cholesterol rise each test. I always have an argument with the nurse about it - my doctor fortunately has not even brought the subject up as that would probably end in an argument as well! My total cholesterol is 11.5 mmol/l, HDL 2.4 mmol/l, triglycerides 0.5 mmol/l & my "bad" LDL is 8.5mmol/l! I have never felt better - I haven't been sick in 10 years - no colds etc & no need for antibiotics! In fact the only time I go to the doctor is to get my prescription for sotalol which I take for an irregular heartbeat!

Of course, we cannot here offer direct medical advice. However, we're certainly glad that you found this report interesting and hope that it may be useful as a tool to help you get some proper testing.
-- "I have never felt better" -- that's important! Only you are living your life, not your doctors or nurses 😊

Yes Nicholas - I am more healthy now at 65 than I was at 45! The deed bonus is that I haven't had anywhere near the medical bills I had prior to changing my lifestyle!

So great! And I hear what you're saying! Sometimes people ask me, "Nick, isn't it expensive to buy the nice olive oil and the good grass fed meat or wild fish." To this I respond, "Yes, but you pay now or pay later in medical bills. I used to cheap out on food and ended up spending thousands out of pocket to have doctors stick probes up my bleeding butt (sorry to be explicit, but it's true). I'd much rather pay more to get tastier healthier food than pay more than more later for medical care." Best to you Anne!

Thanks for this, it's really reassuring. My cholesterol (total and LDL) is what many consider to be 'above normal', not too high but some doctors would still give you statins. Luckily my doctor is up to date with latest research and I got additional tests for particle size and count and also inflammation. All are perfect and I have no inflammation either. These tests can be really expensive, I was lucky I didn't have to pay!

Happy to hear you have an informed GP!

So perfect! My I'm an LMHR and my doctor has been freaking out trying to get me on a statin but I don't want to go on one or go off keto. This is just what I need to get some better tests! Thank you!

What is LMHR? You need to find another doctor!

LMHR = lean mass hyper responder

Gotcha! This sounds so much like me. Thanks