For more on the influence of the keto diet on cholesterol, check out my FUELED Wellness + Nutrition podcast.
It’s rare that I get an isolated about a wellness topic. If one person asks about it, odds are that others are wondering the same thing. Lately that question has been about cholesterol, somewhat surprisingly from people who are relatively young and fit, including triathletes, personal trainers and yogis.
One common thread is that they each had been diligently following a keto diet filled with foods like butter, bacon and cream sauces, while also steering clear of starchy carbs plus most fruits and vegetables.
I’m not saying that the keto diet is inherently bad for cholesterol or heart and vascular health, but elevated cholesterol is a side effect that is not uncommon with a strict keto diet.
Like anything, we all respond to foods in very different ways, and for some people, following a keto diet may have no impact at all on cholesterol or other adverse health markers.
But for others, it can.
On a related note, another undesirable effect I often see with a rigorous keto diet is loss of muscle mass. Yes, total body weight may drop, along with body fat, but lean muscle tissue is often compromised as well.
For those diagnosed with high cholesterol (keto diet or not), here’s a rundown of what you need to know, plus specific steps for your nutritional plan of attack.
Total cholesterol can be totally misleading
The messaging has been pounded into us that our total cholesterol should be under 200, but don’t immediately panic if yours is higher. When looking at cholesterol, the composition matters – specifically, the breakdown of LDL versus HDL cholesterol.
High levels of LDL (low-density lipoprotein, also referred to as “bad” cholesterol) in the bloodstream contribute to the formation of plaque that builds up inside of vessel walls, raising the risk of a heart attack. Generally speaking, the lower your LDL, the lower your risk of a heart event.
HDL (high-density lipoprotein) has historically been referred to as “good” cholesterol, but a series of well-designed studies have cast a significant question mark over this theory, with data showing that HDL may be cardioprotective in some cases, neutral in others, and actually detrimental in others – all the more reason to know your numbers and to discuss these with your physician, taking other risk factors into consideration.
Also be aware that while LDL contributes to plaque formation in the arteries, a diet filled with refined carbohydrates and added sugars promotes inflammation, and therefore is also a significant risk factor for heart disease. So while it pays to keep an eye on cholesterol numbers, we can’t forget to look at the big picture of whole-body wellness, including the types of carbs we’re eating, our level of stress, daily movement and maintaining a healthy weight.
Ask for a three-month reprieve
If you receive a diagnosis of high cholesterol, talk with your doctor about the possibility of a three-month self-experiment of lifestyle modifications only, no cholesterol-lowering medications.
Here’s why: A diagnosis of elevated cholesterol is often accompanied by a prescription, typically for statin drugs. If you work to improve diet and physical activity yet you’ve also started taking a new cholesterol medication, it’s impossible to know what’s what. Chances are, you’ll see cholesterol levels improve, but you have no way of knowing how much your numbers would have improved with lifestyle changes alone.
After three months of diligent lifestyle modifications, have your labs rechecked and assess the results with your physician to determine if lifestyle-only was enough to make a significant improvement.
To help make things as simple and sustainable as possible, I recommend working closely with a registered dietitian to develop and personalize a nutrition plan to suit your lifestyle and preferences; find a registered dietitian near you at EatRight.org.
What to dial back on:
- Added sugars. Eliminating sugary drinks is collectively the single biggest impact we can make on our sugar intake, since sugar-sweetened beverages are the largest source of added sugars in the American diet. But be mindful of added sugar of all types, including those that seem like “better” options, like honey, agave, coconut sugar, turbinado and organic cane juice. And watch out for even seemingly healthful foods that are loaded with sugar. Yogurt, nutrition bars and many smoothies and juices can easily pack in a day’s worth of added sugar.
- Refined carbohydrates. We’re looking at you, white pasta, rice, and most breads, crackers and snack foods. The majority of these foods are centered on pro-inflammatory processed carbohydrates.
- Deep-fried foods. Not only are they a source of trans fats (which we want to keep as close to zero as possible), they’re also usually high in sodium and coated with white carbohydrates.
- Animal fats. Butter, cheese, cream and fatty meats top the list of animal fats that appear to be linked to an increase in LDL.
What to get more of:
Plant-based fats. Fortunately for those who feel that they respond well to a keto diet, it’s easy to do a modified version that’s more of a plant-based approach to keto (learn more about incorporating plant-based keto in my podcast with cardiologist and keto researcher Ethan Weiss). Bump up your intake of non-starchy vegetables like broccoli, cauliflower and leafy greens – trust me, this won’t add a significant carb load to your diet. And as much as possible, trade out those animal fats for plant-based fats like olive oil, avocados, nuts (macadamia nuts are particularly ‘keto friendly’) and nut butter. I like to use coconut oil in place of butter; there’s even an all-natural, organic butter-flavored coconut oil by Nutiva that works well when a dish really just needs a bit of buttery flavor.
Soluble fiber. It helps to block cholesterol absorption, which can help to reduce LDL levels. Aim for at least 10 to 25 grams daily for the most benefit. Oats and Cheerios tend to get the glory when it comes to soluble fiber, but they have just one to two grams of soluble fiber per serving. Instead, focus on incorporating an array of soluble fiber top sources like legumes, berries and vegetables – all of which contain compounds in addition to soluble fiber that promote whole-body wellness.
Psyllium, however, is by far the best source of soluble fiber. it’s available in powdered form as a nutritional supplement with an average of six grams of soluble fiber in every tablespoon. Instructions often suggest stirring it into water, but I think it’s much better blended into a smoothie.
Monounsaturated fats. A cornerstone of the Mediterranean diet, a diet rich in monounsaturated fats can help to lower LDL cholesterol without impacting HDL or triglycerides. Olive oil, avocado and avocado oil, nuts and seeds and their corresponding nut butters are all high in monounsaturated fats.
Omega-3 fats. Linked to a lower risk of heart disease and stroke, omega-3s can help to raise HDL and reduce blood pressure and triglycerides. Best food sources include salmon, tuna, sardines, flaxseeds and walnuts. Supplementing with fish oil is also an option; I typically recommend supplementing with 1,000 mg per day of EPA + DHA (the two main types of omega-3 fats in fish oil, both of which are also available in vegan supplement form).
Movement. Physical activity can boost HDL cholesterol. Aim for at least 30 minutes on most days, always checking with your physician before beginning any type of new exercise program.
When diet & exercise just aren’t enough
Natural alternatives to statin drugs. Red yeast rice and niacin both offer benefits similar to statin drugs, including comparable reduction of LDL cholesterol. But they are not without side effects. Red yeast rice can cause muscle pain and weakness while niacin can lead to flushing or tingly skin, and both can be damaging to the liver. If you’re considering taking supplements instead of statin drugs, do so only under a physician’s guidance.
The bottom line is that nutrition and wellness are deeply personal and incredibly individualized. It’s important for us to recognize that what works for others may not work for us, and what works for us may not be a fit for everyone else in our lives. Our best approach is to continue to educate ourselves, gather evidence-based information, and continue to have an open mind when it comes to our own health and the health of those around us.
Molly Kimball, RD, CSSD is a registered dietitian + nutrition journalist in New Orleans, and founder of Ochsner’s Eat Fit nonprofit initiative. Tune in to her podcast, FUELED | Wellness + Nutrition and follow her on Facebook, Instagram and Twitter at @MollyKimballRD.