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Short Summary
Main recommendation: Dr. Eric Westman says a high LDL cholesterol level on a low-carb keto diet should not be treated as an automatic danger, because cholesterol is a marker rather than a disease, and the real concern is atherosclerosis. He presents baseline results from the Cholesterol Code / Lean Mass Hyper Responder keto study, which found no more coronary plaque in long-term keto dieters with high LDL than in age- and sex-matched healthy controls. The one-year follow-up results are still pending.
Key Points
- Westman says most of his patients (about two-thirds) have normal or reduced LDL on low-carb diets, with triglycerides falling and HDL rising, while a small minority—maybe 5% or less—have extreme LDL elevations.
- Westman distinguishes cholesterol from atherosclerosis: cholesterol is a predictor or marker, while atherosclerosis (narrowing or hardening of arteries) is the disease that can cause heart attacks, strokes, or kidney failure.
- The study was observational: participants self-reported following keto for about 4.7 to nearly 5 years, with mean LDL of 272 compared with 123 in the Miami Heart Study comparison group.
- Baseline CT coronary angiogram scores showed no significant difference in total plaque between the keto group and the Miami Heart controls; 42 of 80 keto participants had a score of zero.
- Westman notes that HDL (about 90 vs. 63) and triglycerides were markedly more favorable in the keto group, which he argues matters for overall cardiovascular risk.
Details Worth Noting
- The plaque score runs from 0 to 45 across 15 coronary artery sites, each scored 0 to 3; in the keto group, 42 people scored zero, about 30 scored 1 to 5, about 8 scored 6 to 10, and one scored 13.
- The study was run by investigators including Dave Feldman and Nick Norwitz, with Dr. Budoff performing the CT scans in Los Angeles; participants were flown there, and the one-year follow-up scans are still to come.
- Westman frames the study as a test of the "old way" (lower LDL with drugs) versus the "new way" (food-based change and avoiding medication where possible), and says he will report whatever the follow-up shows, including any plaque increase.
- Westman's comments are his personal interpretation and clinical experience; he does not present them as professional medical advice for any individual.
Bottom Line
The baseline findings suggest that elevated LDL alone on a long-term keto diet, in this small self-selected group, was not linked to more coronary plaque than in healthy controls, but the one-year results will determine whether that holds.
