Ketogenic Lifestyle Rule #3: Be BOLD or Be Italic, but never be Regular: Why Size Matters with Cholesterol

On this evenings PeriScope video we talked about cholesterol.  This is the burning question on everyone’s mind who starts a Low-Carb, High Fat or Ketogenic Diet: “What will happen to my cholesterol if I lower my carbohydrates and eat more fat?”

The answer . . . it will improve!

How do I know this?  I’m an obesity specialist.  I specialize in FAT or lipids (to put it kinder scientific terms).  To specialize in fat, one must know where it came from, what it’s made of and where it is going. And,  this has been the case with every single patient I have used this dietary change with for the last ten years, myself included.

Lets start with the contents of the standard cholesterol or “Lipid Panel”:

  • Total Cholesterol
  • HDL-C (the calculated number for “good” cholesterol)
  • LDL-C (the calculated number for “bad” cholesterol).
  • Triglycerides

The first problem with this panel is that it makes you believe that there are four different forms of cholesterol.  NOT TRUE!  Actually cholesterol is cholesterol, but it comes in different sizes based on what it’s function is at that moment in time.   Think of cholesterol as a bus.  There are bigger busses and smaller busses.   Second, triglyceride is actually the passenger inside the HDL and the LDL busses.  And third, Total Cholesterol is the sum of the HDL, LDL, as well as ILDL & VLDL which aren’t reported in the “Lipid Panel” above.

The fourth thing that this panel doesn’t tell you is that HDL & LDL are actually made up of sub-types or sub-particles and are further differentiated by weight and size.

Cholesterol Size

For our conversation, we need to know that the number of LDL particles (LDL-P) can actually be measured in four different ways and these measurements have identifed that there are three sub-types: “Big fluffy” large dense LDL, medium dense LDL, and small-dense LDL.  Research has identified that increased numbers of small-dense LDL correlates closely with risk for inflammation, heart disease and vascular disease (1).

Microsoft PowerPoint - ADA Otvos LDL size talk_modified.ppt [Com

If you’ve been a follower of my blog for a while, you’ve seen this picture before. This picture illustrates why an LDL-C (the bad cholesterol measurement) can be misleading. Both sides of the scale reflect an LDL-C of 130 mg./dl. However, the LEFT side is made up of only a few large fluffy LDL particles (this is the person with reduced risk for heart disease) called Pattern A  or a LDL healthy cholesterol level.  Even though the LDL-C is elevate above the recommended level of 100 mg/dl, the patient on the left has much less risk for vascular disease (this is why you CAN’T trust LDL-C as a risk factor).

The RIGHT side of the scale shows that the same 130 mg/dl of LDL-C is made up of man more small dense LDL particles (called “sd LDL-P”) with a Pattern B type that is as increased risk for heart or vascular disease.  This is where the standard Lipid Panel above, fails to identify heart disease and it’s progression.

Research tells us that the small dense LDL particle levels increase as the triglycerides increase.  And we know that Triglyceride levels increase in the presence of higher levels of insulin leading to a cascade of inflammatory changes.  Insulin is directly increased by the ingestion of simple and complex carbohydrates.  Insulin also increases with the ingestion of too much protein.  So, that chicken salad or the oatmeal you ate, thinking it was good for you, actually just raised your cholesterol.   If you are insulin resistant, your cholesterol just increased by 2-10 times the normal level (see my article here on how insulin resistance causes this.)

Adapt Your Life

“Ok, but Dr. Nally, there are four different companies out in the market measuring these fractional forms of cholesterol. Which one should I choose?”

There are actually five different ways you can check your risk.

  1. Apolipoprotein levels.  This can be done through most labs; however, this test doesn’t give you additional information on insulin resistance that the other tests can.
  2. Berkley Heart Lab’s Gradient Gel Electrophoresis – This test gives a differentiation based on particle estimation between Pattern A and Pattern B
  3. Vertical Auto Profile (VAP-II) test by Arthrotec – This test determines predominant LDL size but does not give a quantifiable lipoprotein particle number which I find very useful in monitoring progression of insulin resistance and inflammation.
  4. NMR Spectroscopy from LipoScience – This test measures actual lipoprotein particle number as well as insulin resistance scores and will add the Lp(a) if requested.  I find the NMR to be the most user friendly test and useful clinically in monitoring cholesterol, vascular risk, insulin resistance progression and control of the inflammation caused by diabetes.  This test has the least variation based on collection methods if frozen storage is used.
  5. Ion-Mobility from Quest – This test also measures lipoprotein particle number but does not include insulin resistance risk or scoring.  Because the test is done through a gas-phase electric differential, the reference ranges for normal are slightly different from the NMR.

In regards to screening for cardiovascular risk, the use of all five approaches are more effective than the standard lipid panel.  However, I have found that clinically the NMR Lipo-profile or the Cardio I-Q Ion-Mobility tests are the most useful in additionally monitoring insulin resistance, inflammation, and disease progression.

It is was the use of these tests that demonstrated to me the profound effect of carbohydrate restriction and ketogenic lifestyles on vascular and metabolic risk.  We talk more about these tests on my Periscope video below:

Hope this helps.

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  1. Williams PT, et al. Comparison of four methods of analysis of lipoprotein particle subfractions for their association with angiographic progression of coronary artery disease. Atherosclerosis. 2014 April; 233(2): 713-720.

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