In the fall of 2018, I was diagnosed with Type 2 Diabetes. I was educated enough to know that there was something I could do about it and set out to change the path I was on by adopting a low carbohydrate/Ketogenic Diet to control my blood sugars. Fortunately, it worked right away- but soon after I discovered that I had some red flags on my cholesterol test results. There is a history of Cardiovascular disease in my family and I was disappointed that I might have to yet again make diet changes but was willing to do what was best for my whole health. After an appointment with a local Cardiologist, I felt somewhat confused about how to move forward. I wanted more information and not just a prescription.

I contacted Dr. Scher for a consult because I wanted to confer with someone who not only understood my condition but who could also give me the latest and soundest advice on how I might treat it and move forward in the best way for me as an individual- not as a statistic. I needed someone who came from a low carb perspective as well as a medical background. My interaction with him was positive, informative and went a long way to making me feel like I could make informed choices without the black and white thinking of well-meaning physicians. He sees the WHOLE person and not just one aspect of their health. Wellness is a journey- and having Dr. Scher along the way is a great way to make the trip!

Lisa K.

I recently had a one-on-one Health Coaching Consultation with Dr. Bret Scher. I cannot adequately express the gratitude and respect I have for Dr. Scher. He took the time to consider all facets of my health and really listened to me and my concerns. He was not quick to insist I be on prescription medications, but rather he explored various avenues of suggested treatment/preventative measures I might consider taking…guiding, as opposed to dictating a plan of of action. The consultation was well worth my time and money! Loved his approach so much that my husband and I have decided to work with him long distance.

Jami Miltenberger
MS Counseling Psychology

There’s a common assumption in the medical and nutrition world that a low carb, high fat diet, like a ketogenic diet, will automatically increase one’s risk for heart disease. However, it’s crucial for us to realize that this assumption is inaccurate and not supported by data.

In fact, it’s been well documented that low carb diets can help someone reverse type 2 diabetes and improve metabolic health, changes that dramatically lower one’s cardiac risk. Research and clinical experience supports that a properly formulated low-carb diet can help someone improve, rather than worsen, their heart health.

But many may wonder, how can this be true when I’ve heard that eating fat is bad for us and bad for our hearts?

A big problem comes from assuming that our bodies react the same way to a diet high in carbs + fat as we do to a diet LOW in carbs and high in fat. The truth is that our bodies react dramatically differently to those two versions of a high-fat diet.

How It Works

You see, when we eat lots of carbs, our body uses the carbs as fuel first. Therefore, we won’t burn the fat for energy, and we end up storing it as adipose or fat stores. But when we eat a very low carb diet, our bodies prefer to burn the fat for energy, and therefore there is much less left over to store as body fat. This is dramatically different from a high carb diet!

Studies also demonstrate that people eating a low carb, high fat diet naturally reduce their calories, thus eating less and losing weight seemingly without trying. But those eating high fat and high carb diets tend to eat more calories and gain weight.

So you can see how we can’t just refer to a “high fat diet” as if it is one thing. It makes a big difference if it is also a high carb or low carb diet.

The Main Contributors

Let’s review the main contributors to heart disease, and see how a low carb, high fat diet impacts them.

1- Blood pressure
One study demonstrated a ketogenic diet lowers blood pressure better than the DASH diet, the diet previously felt to be the best for blood pressure management. And others have shown safe and effective blood pressure lowering when starting a low carb, high fat diet that is similar to a low-fat diet.

2- Type 2 Diabetes
Numerous studies demonstrate the efficacy of low carb diets for treating and even reversing type 2 diabetes. Since diabetes is a major contributor to heart disease, reversing it will significantly improve one’s heart health.

3- Inflammation
Ketogenic diets have been shown to reduce many markers of inflammation, including the commonly used CRP.

4- Triglycerides and HDL cholesterol
Having low triglycerides and normal to mildly elevated HDL cholesterol levels are predictive markers of better heart health, likely because they occur with good metabolic health. Numerous studies demonstrate that ketogenic diets reliably help lower triglycerides and raise HDL, thus improving overall cardiac risk.

5- LDL cholesterol
Many assume that high fat diets raise LDL cholesterol. But again, that is not the case. Multiple studies demonstrate no net change in LDL on a ketogenic diet compared to a low fat diet. In fact, one analysis of multiple studies found a net reduction in LDL particles for those following a ketogenic diet.

Important to Note

However, there is a subset of individuals who can see a dramatic rise in their LDL cholesterol when following a ketogenic diet. These so-called Lean Mass Hyper Responders, have unique physiology that predisposes them to an increase in LDL. But it’s important to realize that these individuals are the minority, not the majority. And there’s even emerging evidence suggesting that elevated LDL may not place these individuals at a higher risk, although with much still to learn.

In Summary

The data does not support the assumption that low carb, high fat diets increase heart disease risk. In fact, many studies demonstrate overall improvement in most, if not all, cardiac risk factors. We need to stop assuming all high fat diets are the same, and realize the unique heart health-improving impact of low carb/high fat diets.

If you would like to learn more about the misperception and misunderstanding about ketosis and heart disease risk, please see the video links listed here:

Does Keto Cause Heart Disease?

Debunking a study claiming low carb diets cause heart disease

Analysis of a study demonstrating lowering of cardiac risk with low
carb diets

Thanks for reading,

Bret Scher MD FACC

Can we be certain that elevated LDL (Low-density lipoprotein) particles have no meaning and can be completely ignored?

Certainly not.

Can we be certain that all LDL particles are deadly and need to be treated to microscopically low levels?

Certainly not.

So, what do we do?

I have seen countless second opinion consults and enrolled numerous clients in my Boundless Health Program who have this exact question.  What’s the deal with LDL? Do we worry or don’t we?

Life is much easier when it is black and white, good and bad. I, however, believe in looking for the nuance and trying to understand things a little deeper.

But first, let’s back up a little.

What is LDL and LDL-P?

Cholesterol can be a complex topic that we frequently oversimplify, which I am about to do. In brief, LDL is known as the “bad” cholesterol, the cholesterol that is found in plaque buildup in our hearts. But the truth is that LDL is not inherently bad. In fact, LDL has a purpose in our bodies as part of our immune response and as a fuel and vitamin delivery mechanism to name a few.  If vascular injury and inflammation are present, then modified LDL may invade vessel walls and participate in a cascade of events leading to plaque buildup and an eventual heart attack.

LDL-C is a measure of the total amount of cholesterol in our LDL lipoproteins. LDL-P is the total number of the LDL lipoproteins. Studies show that LDL-P is a much better marker for CVD risk than LDL-C. As an analogy, the number of cars on the road matter more than the number of people in the cars.

What are the risks of LDL-P?

On the one hand, trials in the general population show that elevated LDL-P is a risk factor for cardiovascular disease (CVD).  This includes a combination of observational trials, genetic mutation trials (mendelian randomization), and drug treatment trials.

All things being equal, based on these trials alone, we should want our LDL-P to be low.

But does LDL alone cause heart attacks and death? Or are there other factors involved?

Of course there are other factors involved in CVD. Vascular injury and inflammation being the two most prominent factors.

Can lowering our LDL-P have risks greater than the potential benefits for certain populations?

Absolutely.  Since primary prevention statin trials show we have to treat over 200 people for five years to prevent one heart attack with no difference in mortality, it seems reasonable that certain populations will experience more potential risk than reward.

The Low Carb High Fat Reality

How many LDL or statin trials have specifically looked at individuals on a healthy, real foods, LCHF diet?

None. Not a single one.

How many LDL or statin studies have looked specifically at red headed, left handed boys born the second week of March? 

None, at least to the best of my knowledge.

This seems glib but bear with me.

Is there any reason to think a red headed, left handed boy born the second week of March would behave any differently than everyone else in these LDL studies? Not really. Especially if they are eating a standard American diet or a low -fat diet as was almost exclusively studied in every cholesterol or statin trial.

Here’s the more important question. Is there reason to believe individuals on a healthy, real foods, LCHF diet would behave any differently than everyone else in the decades of lipid and statin studies?

There absolutely is reason to believe they may behave differently. There is not clear proof, but there is plenty of reason to suspect it.

Think about the benefits of a LCHF lifestyle.

• Lowers inflammation
• Reverses insulin resistance
• Naturally raises HDL and lowers TG
• Converts majority of LDL particles to larger, more buoyant particles
• Lowers blood pressure
• Reduces visceral adiposity

Could these create an environment where an elevated LDL is less of a concern?

It sure could.

To be clear, I openly acknowledge that we do not have definitive proof that we should have no concern with LDL in this situation. In my opinion, this is a specific scenario that the existing trials simply do not address one way or the other.

So, it seems we have two choices.

1. Since we don’t have any proof we can ignore LDL in this setting, we plug the numbers into the 10-year ASCVD calculator and start a statin if the risk is above 7.5%, or we ask the individual to change their lifestyle in hopes the LDL will come down.
2. If the individual is enjoying multiple health benefits from their lifestyle, and they are rightly concerned about the potential risks of statin therapy, then we can follow them for any sign of vascular injury or plaque formation, or any worsening of their inflammatory markers or insulin sensitivity. In the absence of any potentially deleterious changes, we can reason that the risk is low, and the benefits of living the healthy lifestyle may outweigh the risks.

The “problem” is that the second option requires a detailed discussion of the risks and benefits. It requires close monitoring and follow up. It requires us to think outside general guidelines and consider everyone as an individual with their own unique circumstance. These are qualities that our current healthcare system sorely lacks.  Yet that is the exact care that each individual deserves.

What do we do in the meantime?

I hope someday soon we will have definitive long-term evidence that a high number of large buoyant LDL particles along with elevated HDL, low TG and low inflammatory markers is perfectly safe.

Until that day, we will have to continue to talk to our patients. To see them as individuals. To weigh the lifestyle benefits with the possible risks. That includes seeing the risks in real numbers- not quoting a 30% benefit with statin therapy. Instead, having a real discussion that statins may reduce your risk a heart attack by 0.6% with an increased risk of muscle aches, an increased risk of diabetes, and a potential increased risk for cognitive and neurological dysfunction.

And we will have to understand that the answer won’t be the same for each person. And we can be OK with that.

So, do you have to worry about your LDL? I don’t know. But I welcome the opportunity to explore the question and reach the best answer for you.

Do you have questions about what your lipids may mean for you? What they mean when taken in the context of your lifestyle and overall health picture? If so, you may want to learn more about my Health Coaching Consult.

Thanks for reading,

Bret Scher, MD FACC

Here it is again. The term “healthy” connected as a descriptor.

We see it all the time. Healthy Whole Grains. It reminds me of the common use of “fruits and vegetables,” as if they are one in the same.

Are whole grains, by definition, “healthy?”

For a full, in depth description, see the Whole Grains Guide on Diet Doctor, where I was the medical editor and reviewer.

For the quick answer, let’s leave it as a “maybe.”

If you choose to eat refined grains, white flour, processed snack foods, in essence the Standard American Diet, then switching to whole grains will almost certainly improve your health. And that is where the majority evidence in favor of whole grains stops. Compared to refined grains, they are great.

Who should eat whole grains?

If you are insulin sensitive, live in a society where you are physically active for most the day, eat fewer calories than most industrialized nations, and maintain a healthy body weight, then whole grains can be a healthy part of your diet. Observation of the Blue Zone countries demonstrate that whole grains can be part of a healthy lifestyle in that setting.

We cannot, however, extrapolate those findings above to apply to all Americans, Europeans, Asians etc. and say whole grains are by definition “healthy.”

Who should not eat whole grains?

If you are metabolically unhealthy with diabetes, metabolic syndrome or insulin resistance (estimated to be 88% of all Americans), then whole grains are anything but “healthy.” Borrow a continuous glucose monitor for a day and see how your blood glucose responds to whole grains. If you aren’t perfectly metabolically healthy, it isn’t pretty.

Instead, if you eat a whole-foods, low carb diet without grains and sugars, then whole grains have no necessary role and no association with health.

Enjoy the more detailed guide from DietDoctor.

Thanks for reading,

Bret Scher, MD FACC