High cholesterol meets ketosis: an update

A couple of years ago I started using the ketogenic diet to manage my blood sugar as a type 1 diabetic and to enhance my athletic performance. I wrote a series of blogs and an ebook to share that experiment because adopting a low carb high fat (ketogenic) diet has become the single most beneficial thing that I’ve done for my diabetes management and my ability to be active in the 20 years I’ve been living at this difficult metabolic crossroads. Eating ketogenic has improved my life and my ability to make photography, climbing and moving around in the outdoors the center of my life rather than fleeing the complications of diabetes.

I didn’t expect those posts to take off because I’m not a dietary blogger. I just wanted to share the ups and downs of what I was trying in hopes that it would help other people. One of the major issues I encountered was the sharp increase in my LDL (“bad”) cholesterol and initially I considered abandoning the ketogenic diet because I feared that I was just trading one risk factor for another. If you want to read that post and the comment thread check it out here!

I am writing this post to update you since two years have passed and I have found some information that I believe is useful. I also want to clarify my current position on the cholesterol issue and why my LDL is still high and why I’m not letting that fact deter me from eating ketogenic. In fact, I am going to share a couple more blog posts in the future detailing some new experiments I’ve been doing using intermittent fasting and exogenous ketones which has been nothing short of mind-blowing!

Exhibit A: Biohacker’s Lab podcast (non-iTunes) or Biohacker’s Lab (iTunes) : Ep8: High Cholesterol Levels on a Keto Diet Experiments by Dave Feldman

If you have concerns about the impact of high cholesterol on your health-specifically if your cholesterol values have increased as a result of a ketogenic diet that has otherwise improved all the “other” health markers you monitor then this podcast has some very important considerations to add to your risk management assessment.

If you’ve done even a tiny bit of searching about the topic of cholesterol and it’s impact on health you’ll know that it’s incredibly complex and there’s a great deal that is not known. There’s also a lot of passionate exploration of opinion and theory without true authority because very few cholesterol studies have been done on people who are ketogenic. These are the realities of the murky water in which we swim as we make life and death decisions.

My own position is what I’m sharing here. This isn’t my advice to others determining their position. I have measured the risk of high cholesterol against the risk of high and/or unstable blood glucose and I am willing to accept the worst case outcomes of high cholesterol over the worst case outcomes of high blood glucose. I don’t say this to be flippant about risk but to clarify that risk cannot be avoided, it must be managed. I don’t eat to live forever, I eat to live well first and to live long secondly. I’d like to think that eating to live well would enable me to live for a longer time but that exact dichotomy is what we are wrestling with when we discuss high cholesterol and the ketogenic diet.

I’ve gotten angry emails predicting my demise from people accusing me of preaching recklessness since my “cholesterol numbers are s-t”. I’m still here and I’m not changing the way I eat for the sake of my cholesterol levels. I briefly tried swapping out saturated fats for unsaturated fats in hopes that this would allow me to stay ketogenic and bring my LDL down. It didn’t make a huge impact on my cholesterol-and it made ketosis much less effective and it cause my blood sugar to fluctuate more. I chose to refocus my efforts on stable blood glucose, ketosis and energy production instead of sacrificing all of those markers for a minimal reduction in my cholesterol.

I made that choice long before finding the podcast I recommended above. The podcast presents evidence that would seem to validate my choice and shed light on it. I will summarize a couple of the most significant points below.

Hyperresponders are people who experience significant spikes in their cholesterol after adopting a ketogenic lifestyle for no apparent reason. Many people eating an identical diet will experience the opposite-an improvement in their lipid profile after going ketogenic. (I happen to be a hyperresponder in case that wasn’t apparent thus far.)

The overwhelming majority of cholesterol hyperresponders encountered seem to be thin and athletic (like me), which would fly in the face of expectations associated with a “high cholesterol” diagnosis. This makes sense when you consider the fact that a fat adapted athlete needs to mobilize LDL for energy rather than glucose. In the absence of stored body fat the body produces more LDL to satisfy the need for energy.

The presence of cholesterol means different things depending on the context. Elevated blood cholesterol in a fat-adapted athlete signifies an up-regulated metabolism that is geared to meet higher energy demands associated with diet and activity. Elevated cholesterol in a non-fat adapted, non-athlete would signify something totally different since that cholesterol wouldn’t be there for energy. It could indicate some sort of inflammation or reparative event that would correspond to atherosclerosis and cardio vascular disease-thus explaining the correlation between elevated cholesterol and heart disease. LDL isn’t the culprit itself-it’s the event triggering the production of LDL that is more telling.

Looking at other factors which would illuminate the context and significance of LDL elevation (A1C, belly fat accumulation, blood pressure, inflammatory markers etc) can help us more accurately assess if our cholesterol is indicative of risk or not.

These are a few brief takeaways that really stood out to me because they offered an explanation beyond the typical refrain of “it’s the particle size that matters” and looks at the different contexts that can lead to increased LDL for very different reasons. My understanding of the concepts is certainly truncated and incomplete, however these points made a great deal of sense to me given my own experience and the experiences I’ve had with others. I encourage others to assess and manage risk carefully according to their own research and so I hope that I have added some more perspective to consider.

I am a big fan of simplicity. I believe in working with what we know to surmise about what we don’t know. As a diabetic I know what happens when my blood glucose is elevated and volatile. As an athlete I know what happens when I am sedentary and unable to exercise effectively. There is very little question about these things. Making use of a questionable diet to mitigate two very clearly known risk factors seems like a good call. To put it otherwise, if I eat a diet that helps me maintain a healthy body weight, good blood pressure, stable blood sugar in a normal range and energy enough to train hard and often-how could that possibly be bad for me?

Anything is possible, but it seems unlikely.

Stephen Richert is a photographer, filmmaker and climber who happens to live with type 1 diabetes. You can see his professional portfolio here.

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