Has Diet Doctor changed its view on LDL Cholesterol?

We have gotten a few questions about our stance on LDL cholesterol since our recent article on the genetic study showing lower cardiovascular risk in those who have a genetic predisposition to lower LDL cholesterol. It’s a good question and, as Medical Director of the site and a board-certified cardiologist, I will do my best to clarify our position.
First, has Diet Doctor had an official position on LDL? While things change over time as new evidence emerges, I think our most consistent position has been that we don’t know everything we need to know about LDL. I will summarize what we do and don’t know as follows:
- Most epidemiology studies (including genetic studies) show a consistent association between higher LDL and higher cardiovascular risk for those under 60 years old; among those over 60, this relationship varies based on age and gender.
- Drug therapies (like statins, PCSK9 inhibitors, and ezetimibe) that lower LDL also lower the risk for heart attacks with a small but statistically significant risk reduction.
- Most subjects included in the drug intervention and epidemiology studies were following a standard Western or low-fat diet.
- We do not know if or how those results would change for those following low-carb diets.
- When controlled for HDL or triglyceride to HDL ratio, which both typically improve when following a low-carb diet, much of the risk of elevated LDL and the benefits of statin therapy decreases or disappears. However, we have to acknowledge the strength of this data is not as high as we would like it to be.
- There are mechanistic reasons to believe that an elevated LDL in a low-carb, fat-adapted individual could be less of a concern than for the general population. However, we do not have convincing clinical trials to confirm or refute this.
- Because of the conflicting data and the holes in our long-term data, we still need to acknowledge that this is an individualized decision.
The genetic study we recently wrote about was interpreted in accordance with our standing position on LDL. For the population studied, LDL appeared to matter. As we pointed out, the average triglyceride to HDL ratio was 2.5. That is a far cry from the usual 1.5 or less that we see in most low-carb eaters who experience an elevation in their LDL. (And remember, most low-carb eaters do not experience a significant elevation of LDL.) Would LDL matter in those with better metabolic health and low-carb lifestyles?
We don’t know, since it hasn’t been studied.
At Diet Doctor, we know you look to us for trustworthy and useful information to empower you to improve your health and your lives. But at the same time, we have to be honest about what we know and what we do not know, and the strength of the evidence. LDL is a perfect example of the difficulty in that.
So, how are we doing? Please give us feedback if you think we can improve how reliable and trustworthy our information is. We want to help everyone make low carb simple.
Thanks for reading,
Bret Scher MD FACC
More


Cholesterol and low-carb diets
GuideCholesterol is often viewed negatively due to its historical association with heart disease. However, its role in heart health is controversial. Read on to learn what cholesterol is, how your body uses it, why low-carb and keto diets may lead to a change in blood cholesterol levels.
From those details on cholesterol I learned so far, I can combine many claims into one big but detailled "picture".
This is however incompatible with any simplified claims about all categories of LDL together.
I'll wager there are significant differences in the conclusions of the two categories and we should keep in mind which group is being spoken about.
Only one problem, my husband suffered a massive heart attack last week and has had three stents inserted. Now my questions are: Was the cholesterol that was found blocking his arteries caused by the high fat content of our diet; or was it due to a lifetime of bad eating choices? Although my husband was on medication for hypertension, he wasn't diagnosed with high cholesterol before. Do we continue with Keto but on a lower fat basis? I'm really not sure how to proceed from here. Please help.
I'm sorry to hear that and I hope your husband is doing well!
Generally speaking, heart disease normally takes decades to develop, not weeks. So it seems safe to assume that whatever risk factors he has had during the last few decades has affected his risk.
We can't give personalized medical advice here for legal and ethical reasons, and can only recommend that you follow the prescriptions of your husband's doctor.
However, regarding naturally lowering cholesterol on a low-carb diet, here's our guide:
https://www.dietdoctor.com/low-carb/side-effects#cholesterol
Best,
Andreas
I was on a statin for 3 years and felt terrible. After reading a ton of literature on colesterol (which took an awful lot of time) I stoppped taking it and rather live with the risk that this was the wrong decision.
With the low carb diet and some other rather small adjustments to my lifestyle I was able to improve and eliminate other risk-factors. My LDL however increased considerably. So I am very interested on new findings on LDL and on other causes of heart desease as well.
she gave up all of her many medications gradually after lowering carbs more than a decade ago when she was in her 80’s when she was not well at all.
now she is 97 without any medications and she has no disease and enjoying her life.
my total cholesterol is in mid 200’s. calc ldl above 150 and trig/hdl is around 1. as she has no need for a diagnosis I do not bother her for labs.
How does one know if it is a hereditary type cholesterol problem and that I do need to go back on a statin for life? Is there a specific blood test that would tell me yes, I should be on, or do I just go by the standard test and my doctors advice. As a note, she is the one who recommended keto to me for other issues (obesity, T2 diabetes and arthritis, which it has pretty much fixed all three). I see people commenting in the FB page “do not take statins” and wonder if I should be so focused on going off them or not. (I know this is asking medical advice kind of ... thus wanting to know which blood test to look for). I love this site and all the people who are working at DD. This has been a huge life changer for me and I am really enjoying life today! It was not always that way 🥰
His family doctor wanted him back on statins but he refused because of the side effects and also because I told him he had the right to decide for himself. She says that HE IS A TIME BOMB! I am a retired nurse and I am passionate about nutrition and health (I read a lot and listen to many podcasts about nutrition and health) and he follows my advice because he trusts me.
I feel a bit anxious about that and ask myself how I would feel if he had a heart attack. I know I would feel guilty a lot. Our doctor always says that in his family, they all had heart attacks (in their sixties) and that he is at risk even more (there is no diagnosis of FH) and I tell her that they all ate high carbs high fat. Also, he has a small aneurysm of the infrarenal abdominal aorta (2.6 cm x 2.7 cm) but his blood pressure is very good even if he doesn’t take any medication. He has good results in his blood tests (TG/HDL and Total cholesterol/HDL). After talking to him, I suggested that he ask our doctor for a calcium score and he is waiting to get one at the Montreal Heart institute but it will take one year or more before he is evaluated. In the meantime, I cross my fingers. Reading your article makes me think that all I want is reassurance but I will not be able to get it since there is no certainty about what we are doing and the effect on our health (especially my husband’s health).
Cholesterol increased 116 points
LDL increased 16 points
Non HDL increased 120 points
Chol/HDL Ratio increased 1.8
Triglycerides increased 18 points
I feel wonderful on Keto however since my father died of a stroke at the age of 46, While I don’t wish to be... I am now on statins. The risk is too high for me.
I would think you can get it done privately and it would bot cost very much. Have a holiday to the US and get it done perhaps. They are cheap.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4113756/
Also, iron dyshomeostasis or iron overload, may disturb lipid metabolism and calcium metabolism.
Do these ratios change when using different units of measurement? My triglycerides and HDL are measured in mmol/L. The ratio of my results is 0.4. I simply don't believe that my cholesterol levels are that good!
I think you know better than trying to take the middle of the road after talking with Dave Feldman and being very aware of his work particularly with lean mass hyper responders as well as Ivor Cummins work investigating calcium plaques. As many people die of atherosclerosis with low LDL as high LDL.
Blaming LDL for being Found with arterial plaque is like blaming the fire department for being at a fire. As well there is the problem of hyperglycemia and glycated and oxidized LDL.
LDL is not used in risk calculators. The big push has always been by statin manufacturers. It’s also a remnant of the ‘fat makes you fat and clogs your pipes’ mantra and since increased consumption of saturated fat increases LDL it was automatically vilified, without any actual scientific evidence.
You may find this helpful:
https://www.dietdoctor.com/should-you-be-on-statins
since this post is almost 3 yrs old, has DD considered any update to this information, in light of more recent studies?
Thanks!
We have several recent articles regarding LDL that you may be interested in. None of them contradict anything in this guide though.
https://www.dietdoctor.com/search?s=ldl&t=all