Thank you very much. More people should know what normal cholesterol levels are for their demographic and the cholesterol levels associated with the lowest mortality risk.
I really appreciated reading this and learning about the demographic data as well. My cardiologist was pushing statins last September when in about 3 months into a relaxed keto diet my total cholesterol went to 230 and LDL to 163, with triglycerides at 46 and HDL at 59. Since then, continuing with my relaxed keto diet and cutting back somewhat on saturated fats and wearing a CGM I brought my total cholesterol levels to 207, my triglycerides to 34 and LDL to 135. I've done blood work with Levels, whose CGMs I use, and my fasting insulin is 2.3, but my ApoB is around 116, when last year it was 90, so I am not sure what role ApoB would have in my doctor pushing statins for that, should I point out the data I learned from your post. By the way, I am in my early 70s, very active too and have a 0 calcium score.
Thanks for sharing. Your trig:HDL, insulin, and 0 calcium score all sound good to me (not medical advice). On a ketogenic diet we expect cholesterol/LDL to go up.
One of the findings is that in this ketogenic population, neither ApoB nor LDL predicted plaque progression.
My personal view is that the mainstream medical views on what these numbers mean simply do not apply when it comes to metabolic states like ketosis. Everything in fields like mainstream cardiology is based on decades of work that never included the study of people in ketosis, and even then things are based on the "diet-heart hypothesis," which from the start was not as well supported as we are led to believe.
Guess I am doing something right- my triglyceride/HDL ratio is .91, long time keto eater (although not very strict about it, actually). Total cholesterol is 297 though, ha
Keto is great for avoiding heart disease, but over time there can be other negative consequences. High cholesterol doesn't raise heart disease concerns for someone on keto, but it does suggest potential hypothyroidism. Avoid PUFA and eat ample fruit like Paul Saladino is doing. (Just my opinion not forcing it on anyone).
Yes, you are right- my TSH tested high during the same blood test. I noticed my doctor seemed to think cholesterol (which she could treat easily with a statin) was far more significant than TSH of 7, which she completely ignored. Hypothyroidism seems like a kind of medical quagmire nowadays
I had a similar experience. In addition to checking T3 and T4, I would have reverse T3 checked. If elevated at all, any supplementation should include T3, not simply T4. Keto elevates stress hormones and sometimes T4 is pushed to Reverse T3. On thyroid supplementation alone (without big dietary changes), my cholesterol dropped.
Thanks so much for this. 77 yrs old woman w/familial hypercholesterolemia. Current TC 296, HDL63, LDL 206. My Dr. ordered LDL particle test which showed I had the largest “buoyant” LDL. Also 0 Calcium Score. No other co-morbidities. Your remarks on the HDL/Triglycerides number though are news to me. On my last test it was 2. So I see I’ve got some work to do. Thank you again for this important information!
Thanks for sharing. If it was me, I'd want my Trig:HDL closer to 1.0. This is often thought of as a proxy for insulin sensitivity / metabolic health.
For LDL, there are two major types: large buoyant and small dense. The former aren't much of a concern. The latter are what you want to minimize. This comes from a vLDL count, which you want as low as possible.
Physical therapist here. I’ve treated too many patients with statin-induced myopathy who is only precipitating factor was beginning of course of Lipitor.
I’m 57 now with total cholesterol of 230+ but my HDL’s are 75+. I exercise regularly at high intensity and I switched away from ultra processed snack foods and red meat.
I’m gonna stay off of statins as long as I possibly can without going against medical advice .
You want to know your vLDL count, not just for total LDL. There are two types of LDL, and the vLDL tells you about the bad one.
Real red meat has nothing substantial to do with this stuff, IMO. Meat from ruminant animals is very nutrient dense, complete in bioavailable protein, etc.
Base don your TC number, I'm surprised you're not already being recommended statins. Make them get you a calcium scan and your vLDL count--that's what I'd do. Also, your triglycerides:HDL ratio should as close to 1.0 as possible, with any >=3 an indication of poor metabolic health.
Cardiologist here. In my opinion it is difficult to make an appropriatere recommendation re statin use for this patient because crucial information was omitted: What is her blood pressure? Is she on antihypertensive medications? Does she have a family history (first degree relative) of coronary artery disease? This information together with her lipid profile would be used to calculate her MESA score (10 year risk of myocardial infarction); if 7.5% or greater based on guidelines she should be on a statin. For more precise calculation she should have a Ct of chest for coronary calcification (5 minute test, no contrast, inexpensive). All of the dietary recommendations are good if a bit long winded. I would add that a very good study showed that adding 4 tablespoons of extra virgin olive oil to an already healthy Mediterranean diet decreased MI and stroke risk by 25% over 3 years.
I had a heart attack at 41. I was placed on a statin (Lipitor), among other things, and took them religiously for a number of years. I stopped taking the statin but continued to take baby aspirin daily. Last week, I had another heart attack (I’m 49 now). My cardiologist blamed it on not me continuing to take Lipitor. The list of drugs I am on now is longer than the list was 8 years ago when I had my first heart attack. I generally am very healthy. Never been obese, don’t smoke, light drinker, exercise often (but it’s not like I’m a marathon runner). My mom said half the people on her side of the family have died of heart problems. It’s so hard to sort out what the best way to care for myself is.
I agree that statins are not indicated in this woman. The diet and lifestyle changes would be more helpful. However, I disagree with the implication that statins are still recommended, as they generate revenue for the pharmaceutical company. They are all generic, and therefore, the companies make very little from a doctor prescribing them.
If a patient has LDL of 140 and subsequently went for a CT calcium score of 335 (almost entirely in LAD, aka "widow maker"), would you still say skip the statin?
This is the BEST summary I've seen to date on this controversial topic. I work within this space daily. I thank you immensely.
Thank you very much. More people should know what normal cholesterol levels are for their demographic and the cholesterol levels associated with the lowest mortality risk.
I really appreciated reading this and learning about the demographic data as well. My cardiologist was pushing statins last September when in about 3 months into a relaxed keto diet my total cholesterol went to 230 and LDL to 163, with triglycerides at 46 and HDL at 59. Since then, continuing with my relaxed keto diet and cutting back somewhat on saturated fats and wearing a CGM I brought my total cholesterol levels to 207, my triglycerides to 34 and LDL to 135. I've done blood work with Levels, whose CGMs I use, and my fasting insulin is 2.3, but my ApoB is around 116, when last year it was 90, so I am not sure what role ApoB would have in my doctor pushing statins for that, should I point out the data I learned from your post. By the way, I am in my early 70s, very active too and have a 0 calcium score.
Thanks for sharing. Your trig:HDL, insulin, and 0 calcium score all sound good to me (not medical advice). On a ketogenic diet we expect cholesterol/LDL to go up.
You may be interested in this new study, which followed people on a ketogenic diet for one year, and looked at ApoB and much more: https://www.jacc.org/doi/10.1016/j.jacadv.2025.101686
One of the findings is that in this ketogenic population, neither ApoB nor LDL predicted plaque progression.
My personal view is that the mainstream medical views on what these numbers mean simply do not apply when it comes to metabolic states like ketosis. Everything in fields like mainstream cardiology is based on decades of work that never included the study of people in ketosis, and even then things are based on the "diet-heart hypothesis," which from the start was not as well supported as we are led to believe.
See this article: https://mindandmatter.substack.com/p/the-cholesterol-cult-and-heart-mafia
Thank you for your response and the links. I will be well prepared for my next appointment with the cardiologist!
Guess I am doing something right- my triglyceride/HDL ratio is .91, long time keto eater (although not very strict about it, actually). Total cholesterol is 297 though, ha
Keto is great for avoiding heart disease, but over time there can be other negative consequences. High cholesterol doesn't raise heart disease concerns for someone on keto, but it does suggest potential hypothyroidism. Avoid PUFA and eat ample fruit like Paul Saladino is doing. (Just my opinion not forcing it on anyone).
Yes, you are right- my TSH tested high during the same blood test. I noticed my doctor seemed to think cholesterol (which she could treat easily with a statin) was far more significant than TSH of 7, which she completely ignored. Hypothyroidism seems like a kind of medical quagmire nowadays
I had a similar experience. In addition to checking T3 and T4, I would have reverse T3 checked. If elevated at all, any supplementation should include T3, not simply T4. Keto elevates stress hormones and sometimes T4 is pushed to Reverse T3. On thyroid supplementation alone (without big dietary changes), my cholesterol dropped.
One wonders why indeed. At best it's due to a combination of overwork and intellectual laziness. At worst it's a case of professional corruption.
Thanks so much for this. 77 yrs old woman w/familial hypercholesterolemia. Current TC 296, HDL63, LDL 206. My Dr. ordered LDL particle test which showed I had the largest “buoyant” LDL. Also 0 Calcium Score. No other co-morbidities. Your remarks on the HDL/Triglycerides number though are news to me. On my last test it was 2. So I see I’ve got some work to do. Thank you again for this important information!
Thanks for sharing. If it was me, I'd want my Trig:HDL closer to 1.0. This is often thought of as a proxy for insulin sensitivity / metabolic health.
For LDL, there are two major types: large buoyant and small dense. The former aren't much of a concern. The latter are what you want to minimize. This comes from a vLDL count, which you want as low as possible.
0 calcium score at your age is impressive.
Excellent breakdown and informative! Thanks.
Physical therapist here. I’ve treated too many patients with statin-induced myopathy who is only precipitating factor was beginning of course of Lipitor.
I’m 57 now with total cholesterol of 230+ but my HDL’s are 75+. I exercise regularly at high intensity and I switched away from ultra processed snack foods and red meat.
I’m gonna stay off of statins as long as I possibly can without going against medical advice .
You want to know your vLDL count, not just for total LDL. There are two types of LDL, and the vLDL tells you about the bad one.
Real red meat has nothing substantial to do with this stuff, IMO. Meat from ruminant animals is very nutrient dense, complete in bioavailable protein, etc.
Base don your TC number, I'm surprised you're not already being recommended statins. Make them get you a calcium scan and your vLDL count--that's what I'd do. Also, your triglycerides:HDL ratio should as close to 1.0 as possible, with any >=3 an indication of poor metabolic health.
I did a calcium scan. 0%
Cardiologist here. In my opinion it is difficult to make an appropriatere recommendation re statin use for this patient because crucial information was omitted: What is her blood pressure? Is she on antihypertensive medications? Does she have a family history (first degree relative) of coronary artery disease? This information together with her lipid profile would be used to calculate her MESA score (10 year risk of myocardial infarction); if 7.5% or greater based on guidelines she should be on a statin. For more precise calculation she should have a Ct of chest for coronary calcification (5 minute test, no contrast, inexpensive). All of the dietary recommendations are good if a bit long winded. I would add that a very good study showed that adding 4 tablespoons of extra virgin olive oil to an already healthy Mediterranean diet decreased MI and stroke risk by 25% over 3 years.
I had a heart attack at 41. I was placed on a statin (Lipitor), among other things, and took them religiously for a number of years. I stopped taking the statin but continued to take baby aspirin daily. Last week, I had another heart attack (I’m 49 now). My cardiologist blamed it on not me continuing to take Lipitor. The list of drugs I am on now is longer than the list was 8 years ago when I had my first heart attack. I generally am very healthy. Never been obese, don’t smoke, light drinker, exercise often (but it’s not like I’m a marathon runner). My mom said half the people on her side of the family have died of heart problems. It’s so hard to sort out what the best way to care for myself is.
Have her testosterone levels been checked?
The usual argument against the U curves is that the causality is the other way round, that disease (particularly cancer) reduces cholesterol.
How high this woman's carb and sugar consumption could be given TG only 84 and HDL of 68?
It appears she was restricting carbs and sugar in particular and consuming significant saturated fats.
Do you know of a doctor in the Seattle area who is good on this topic whom I can consult about my own stats?
I agree that statins are not indicated in this woman. The diet and lifestyle changes would be more helpful. However, I disagree with the implication that statins are still recommended, as they generate revenue for the pharmaceutical company. They are all generic, and therefore, the companies make very little from a doctor prescribing them.
If a patient has LDL of 140 and subsequently went for a CT calcium score of 335 (almost entirely in LAD, aka "widow maker"), would you still say skip the statin?
Better just to order a apoldprotein b