Ketogenic diet and blood bio-markers
The last post was about the benefits of ketones and a well formulated ketogenic diet (WFKD) for health and fitness, now let’s take a closer look at how a WFKD affects lab markers. The literature is pretty clear on the benefits of weight loss and ketogenic diets. But there are many more effects of a ketogenic diet, namely on blood bio-markers such as cholesterol, LDL, HDL, and triglycerides.
Triglycerides and a WFKD
High triglycerides are a hallmark of metabolic syndrome; likewise, the reduction in triglycerides in response to a low-carb diet is a hallmark for having metabolic syndrome. A ketogenic diet is by far the most potent tool we have to reduce triglycerides; better than a drug, better than exercise, better than fish oil. A WFKD lowers triglycerides a lot. Since elevated triglycerides are a very strong predictor of atherogenic heart disease, a WFKD is one way to correct high triglycerides. And the higher the triglycerides, the more dramatic the response in the drop in triglycerides, and rarely do they ever go up on a WFKD. It is not uncommon to see a 50% reduction in triglycerides in patients with atherogenic dyslipidemia. Finally, a lot of people of with hypertriglyceridemia have vascular impairment. Decreasing triglycerides also improves vascular function.
HLD and a WFKD
HDL (High Density Lipoprotein) aka “good cholesterol,” is affected by a WFKD, but HDL is a rather stubborn lipoprotein in the sense that it is probably more tied to genetics and gender than the others. HDL is hard to move up, especially if you have low HDL to begin with, but a well formulated ketogenic diet is more potent than anything else that we have at this time. Most studies show consistent 10-15% increases in HDL and sometimes much higher (especially athletes). There may even be a gender effect as women more consistently have higher HDL cholesterol; and they usually start at higher levels to begin with. In individuals who have atherogenic dyslipidemia / metabolic syndrome along with high triglycerides and low HDL, get better across the board on a ketogenic diet versus a low-fat diet.
Fasting insulin and blood sugar also improve on a ketogenic diet. This is due to lower insulin levels that ketogenic diets produce. In some diabetics, a WFKD is proving to be as good as medications in treating the disease. In fact, there are even some people who are cured from their diabetes in anecdotal reports. Medications used to treat diabetes have never been shown to cure the disease. More research is warranted is this area for sure.
Blood Pressure and a WFKD
Vascular function and blood pressure get better with a well formulated low-carb diet. Part of the reason for this is the salt wasting effects of a WFKD. Removing most carbs from the diet causes the kidneys to aggressively secrete sodium and excess fluid – this is called natriuresis. This is one of the reasons for weight loss in the beginning of a WFKD.
This drop in sodium is also one reason people get the “keto flu” the first weeks after starting a lower carbohydrate diet. The other thing that can happen is that blood pressure can go lower than it supposed to; this happens when someone is taking a blood pressure lowering medication in addition to a low carbohydrate diet. In fact, there are reports of people passing out unexpectedly! The solution is to decrease or stop the blood pressure medication; which is a good thing (work this out with your physician first!)
LDL and a WFKD
LDL (Low Density Lipoprotein) cholesterol turns out to be a pretty complex particle and we really oversimplify it when we just indirectly estimate LDL from our standard lipid panel. The LDL-C is really the total concentration of LDL that is measured. And the LDL may be high because the particles are large and fluffy (good), or the LDL could be low and have a lot small dense particles (bad). So the test is far from perfect. The response from a WFKD is basically a coin toss. LDL cholesterol goes up in half of the people or goes down in half of the people. Again, this is only the LDL cholesterol concentration. To get a better picture of what is going on, you need to look at LDL cholesterol particles separately. LDL particles (and HDL) are very heterogeneic which varies in size and composition. We have really good evidence now that it’s the small dense LDL particles that are mainly found in the atherogenic plaques and are highly associated with risk for heart disease, whereas the large LDL’s are not. A low-carb diet consistently decreases LDL particles independent of the response and LDL cholesterol concentration. So if you happen to be one of those people that get the hypercholesterolemia response to a ketogenic diet, there is a very good chance that the atherogenic particles actually went down. The only way you can test LDL heterogeneity is by getting advanced lipid testing like an NMR lipid profile or anionic mobility testing (see below).
It is pretty archaic to just look at the lipid panel anymore. Even with that being said, a WFKD is intimately linked with triglycerides going down, and there is a 90+ percent chance that your LDL particle size increased and your small dense LDL went down because they are metabolically linked through the intravascular processing of lipoproteins.
LDL particles: Pattern A and Pattern B
Ron Krause M.D. has really been a pioneer in this area (see this video for more info). He studied individuals with different percentages of carbohydrate and he found the high carbohydrate groups to have a pattern B; which is the small dense LDL phenotype and increases the risk for heart disease by 3 times. So the higher the percent carbs in the diet (especially refined), the higher the percent of individuals who have pattern B which is the unhealthy profile. In individuals who eat a WFKD, there is an incredibly uniform response in almost every single person in that we see a decrease in their small LDL particles. It is still a bit controversial, but every day we’re seeing more evidence that these small LDL’s are more prone oxidation and they penetrate the arterial wall more easily; they are really the bad guys.
A very interesting thing about the use of statin medications to lower LDL cholesterol is that it does not improve the LDL particle size, and the small dense particles stay around, a pattern B response.
Even with all that being said, the evidence is weak that LDL is really a major predictor of heart attacks. The diet-heart hypothesis is for all intents and purposes been disproved. Three different meta-analyses all show no association between dietary saturated fat intake and risk for heart disease. Yet, the 2015-2016 dietary guidelines are still continuing to promote decrease saturated fat as a carte blanche recommendation.
We tend to focus a lot on cholesterol lipoprotein particles and concentration, but at the end of the day lipoproteins are just the trucks that are carrying lipids around in circulation from place to place. What might be really important is to look what’s inside those trucks; the fatty acid composition and lipoproteins just a few of those things.