The Definitive Guide to Cholesterol

guide to cholesterolContrary to what we’ve been told, cholesterol didn’t evolve to give us heart disease. It’s not here to kill us. The actual roles of cholesterol in the body include insulating neurons, building and maintaining cellular membranes, participating in the immune response, metabolizing fat soluble vitamins, synthesizing vitamin D, producing bile, and kick-starting the body’s synthesis of many hormones, including the sex hormones. Without cholesterol, it’s true that we wouldn’t have heart disease, but we also wouldn’t be alive.

Given all the work cholesterol has to do, the liver is careful to ensure the body always has enough, producing some 1000-1400 milligrams of it each day. Dietary cholesterol is a relative drop in the bucket. And besides, the liver has sensitive feedback mechanisms that regulate cholesterol production in response to how much you get from your diet. Eat more cholesterol, make less in the liver. Eat less, make more in liver.

Now, if cholesterol is so important, why do we worry about it at all? How has it garnered such a bad reputation for giving us heart attacks?


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History of Cholesterol and Heart Disease

Heart disease took off in the early part of the twentieth century, and doctors frantically searched for the cause throughout the next several decades. Early studies in rabbits found that feeding them dietary cholesterol reliably increased blood cholesterol levels and induced atherosclerosis that very much resembled human atherosclerosis. Human tests in the fifties initially showed an association between early death by heart disease and fat deposits and lesions along artery walls. Because cholesterol was found to be present in those deposits and because researchers had previously associated familial hypercholesterolemia (hereditary high blood cholesterol) with heart disease, they concluded that cholesterol must be the culprit.

And while it’s true that cholesterol is involved in heart disease, the direct cause-and-effect relationship has not been established. The reality is far more complicated. To get closer to the reality, we must first understand what these cholesterol numbers actually mean.

Cholesterol versus Lipoproteins

Back in those early rabbit studies, researchers discovered a curious thing: even though feeding the rabbits cholesterol spiked their blood cholesterol and gave them heart disease, bypassing the first step and injecting it directly into the blood had no effect. It was completely harmless.

As it turns out, cholesterol doesn’t normally float around the blood by itself. It is contained within lipoproteins. You can think of lipoproteins as delivery vessels. They contain cholesterol, antioxidants, and fatty acids and along the surface have various proteins that direct the lipoprotein to different sites around the body. It’s not the cholesterol that is involved with atherosclerosis. It’s the lipoprotein.

Let’s play the freeway analogy game. Both LDL-cholesterol (LDL-C) and HDL-cholesterol (HDL-C), the standard, basic readings you get from the lab, do not reflect the number of LDL or HDL lipoproteins, or particles, in your serum. Instead, they reflect the total amount of cholesterol contained in your LDL and HDL particles. Hence, the “C” in LDL/HDL-C, which stands for “cholesterol.” Measuring the LDL/HDL-C  and then making potentially life-changing health decisions based on the number is like counting the number of people riding in vehicles on a freeway to determine the severity of traffic. It’s data, and it might give you a rough approximation of the situation, but it’s not as useful as actually counting the number of vehicles. A reading of 100 could mean you’re dealing with a hundred compact cars, each carrying a single driver, or it could mean you’ve got four buses carrying 25 passengers each. Or it could be a couple buses and the rest cars. You simply don’t know how bad (or good) traffic is until you get a direct measurement of LDL and HDL particle number.

How does this relate to heart disease?

In my opinion, the most convincing heart disease hypothesis goes like this:

  1. LDL receptors normally “receive” LDL particles and remove them from circulation so that they can deliver nutrients and cholesterol to cells, and fulfill their normal roles in the body.
  2. If LDL receptor activity is downregulated, LDL particles clear more slowly from and spend more time in the blood. Particles accumulate.
  3. When LDL particles hang out in the blood for longer stretches of time, their fragile polyunsaturated fatty membranes are exposed to more oxidative forces, like inflammation, and their limited store of protective antioxidants can deplete.
  4. When this happens, the LDL particles oxidize.
  5. Once oxidized, LDL particles are taken up by the endothelium – a layer of cells that lines the inside of blood vessels – to form atherosclerotic plaque so they don’t damage the blood vessel. This sounds bad (and is), but it’s preferable to acutely damaging the blood vessels right away.
  6. So it’s the oxidized LDL that gets taken up into the endothelium and precipitates the formation of atherosclerotic plaque, rather than regular LDL. OxLDL, poor receptor activity, and inflammation are the problems.

If that’s the case, what exactly is the deal with traditional blood lipid numbers—the ones you get on a standard blood test?

This information is how I view cholesterol as it relates to my individual biology. If you have questions about your cholesterol numbers, discuss them with a qualified health professional. 

Total Cholesterol

Standard view: Get that TC below 200, or else you’ll have a heart attack or you’ll have to pay a higher health insurance premium, if the insurers take you on at all.

My take: Mostly meaningless. Even though the epidemiological evidence suggests a TC between 200 and 240 mg/dl is best for all-cause mortality,1 we can’t hang our hats on it. First off, total cholesterol is limited because it’s only telling us the amount of cholesterol contained in all our lipoproteins without saying anything about what kind of lipoproteins we have or how many there are. Second, total cholesterol is limited because it’s determined by a bizarre formula – HDL-C+LDL-C+(Triglycerides/5) – that reduces various types of blood lipids, each with a different role in the body and a unique impact on our risk for illness, to mere numbers. Someone with low HDL and high triglycerides could easily have the same TC as someone with high HDL and low triglycerides, so long as the numbers work out. Whether it’s being used to predict wellness or disease, total cholesterol by itself is mostly meaningless.

HDL Cholesterol

Standard view: “Good” cholesterol. It’s the “garbage truck” that cleans up “excessive” cholesterol and fat from tissues, so the higher the better! Though men and women should strive for levels exceeding 60 mg/dl, above 40 is acceptable for the former and above 50 is acceptable for the latter.

My take: Higher HDL-Cs correlate strongly with better cardiovascular health. No real argument here. Higher HDLs are desirable. Just remember, it’s only a snapshot of a glimpse into the cholesterol content of your HDL particles. Among most groups tested, the TC:HDL ratio is actually a strong indicator of heart disease risk, with higher ratios corresponding to higher risks. Note, though, that no Primal Blueprint adherents were among the groups analyzed, ever.

LDL Cholesterol

Standard view: Get it as low as humanly possible! I want that low density lipoprotein so low as to be nearly nonexistent. Your body obviously hates you; otherwise, it wouldn’t be producing a potently toxic substance and sending it directly into your endothelial cells to form atherosclerotic plaque! Of course, we’re not actually measuring the number of low density lipoproteins, just the amount of cholesterol contained in them, but still!

My take: While a high LDL-C may indicate a problem, remember that LDL-C only indicates the total amount of cholesterol in your LDL particles. You could easily have a few large particles (good) or a bunch of smaller, denser ones (bad, might indicate poor LDL receptor activity and an LDL that likes to hang out in the blood), but LDL-C alone isn’t enough to know. It’s also just a moment in time, whereas what you’re interested in is the trend. If the trend indicates a steady rise in LDL-C, however, that could hint at poorer LDL clearance and lower LDL receptor activity (and greater susceptibility to oxidation).

Triglycerides

Standard view: Lower would be better, sure, but you really gotta do something about that LDL! Anything less than 150 mg/dl is fine.

My take: High triglycerides correlate strongly with low HDL and smaller, denser LDL. High triglycerides, then, could indicate more oxidized (or oxidizable) LDL. The triglycerides of most Primal eaters, especially those on the lower carb side of things, usually hover well below 100 mg/dl. Triglycerides come packaged in VLDL, or very low density lipoproteins (which are calculated by dividing your triglyceride count by 5).

So, what can we learn from a standard lipid test? If we take a series of regular ol’ lipid measurements, preferably one pre- and several peri-Primal, we can get an idea of our metabolic health. Look for:

  1. Trends – Are your triglycerides going down over time? That’s great. Is your HDL trending up? Also good.
  2. Normal fluctuations – Your numbers can jump around 20-30 points in either direction between readings without it necessarily meaning anything.
  3. TC:HDL-C ratio – Lower is better and indicates fewer LDL particles.2
  4. Triglyceride:HDL-C ratio – Lower is better and indicates larger LDL (and, usually, fewer) particles. Ideally, this will be close to 1 or lower; one study (PDF) found that 1.33 was the cut off.34

There is an advanced lipid test that’s worth getting: ApoB.

Apolipoprotein B 

Every single LDL particle has a single ApoB, making ApoB an effective measurement of LDL particle count. By all accounts I could find, ApoB is reliable and accurate. Every LDL particle has one ApoB, and along with TC:HD ratio, ApoB count is a strong predictor of heart disease risk (again, with the caveat that these studies are on populations leading a decidedly unPrimal and highly inflammatory lifestyle).5 If you have a lot of ApoB, you have a lot of LDL particles, which could mean the LDL receptor activity is down-regulated. Or, it could mean you’re losing weight, which can affect lipid values in multiple ways. Or, it could mean that today was a particularly “high ApoB day” and that getting it tested next week will give a different result, simply due to natural fluctuations. You just don’t know.

And that’s actually the main issue with all cholesterol readings, however advanced: They are snapshots in time. They do not capture the natural fluctuations and trends of the biomarkers. Your cholesterol was elevated today at 12 noon. What does that say about your levels tomorrow at six in the evening? Next week? Nothing. To account for natural fluctuations, get tested at regular intervals and observe the trends.

If you can’t get the ApoB test, total cholesterol/HDL ratio is a good indicator of how long LDL is hanging around in the blood and remains the best standard assessment of heart disease risk. Another good one is triglyceride/HDL ratio, which is a strong surrogate marker for insulin resistance. In both cases, lower is better. An ideal T/HDL ratio is 1:1; 2:1 is about as high as you want to go. An ideal TC/HDL ratio is 3.5:1 or lower.

Okay, so by whatever metric you want to use, your numbers are “elevated” and you’ve taken enough readers to get a general trend. It’s not just an isolated number. Should you worry?

Is High Cholesterol a Problem?

Oh, boy. There’s the million dollar question.

First off, let’s go back to the evolutionary prism. As a naturally self-regulating system, the body isn’t going to produce something that is intrinsically pathological. Maybe that could happen in really rare genetic mutations, but everyone produces, utilizes, and relies upon cholesterol. It simply doesn’t make sense that cholesterol is evil.

Adequate cholesterol isn’t available for the body’s repair system, for the uptake of serotonin, for the full initiation of Vitamin D and hormone production and their regulation of blood sugar and inflammation, etc., etc. What does your logic tell you here? Yup, nothing is running the way it should.

Let me also add that everyone’s cholesterol profile is going to be different, no matter what. And I acknowledge that a very small percentage of people out there genuinely have *true* hereditary high blood cholesterol, familial hypercholesterolemia, a metabolic condition with impaired or even lack of ability to metabolize cholesterol. This condition can have serious health consequences. By the way, this condition, in its heterozygous form affects at most 1 in 500 people. Total serum cholesterol in these folks is in the 400 mg/dl range (as opposed to the 200 recommended). The homozygous form affects about 1 in 250,000. You likely don’t know anyone in this category because their disorder almost always ends their lives at a very young age. But even the heart disease common in familial hypercholesterolemia might not be caused solely by high LDL, but by poor coagulation.6

But if you’re eating a healthy diet, your performance is good, your body comp is good (or trending that way), your energy and sleep are rock-solid, you don’t have any familial hypercholesterolemia genes—is it really dangerous to have elevated cholesterol numbers?

I don’t know. But I’m skeptical.

For one, “elevated” cholesterol isn’t necessarily linked to heart disease. Sometimes it’s even linked to lower mortality. For instance, in people older than 60, high LDL is associated with lower all-cause and cardiovascular mortality.7 That’s right: higher LDL, less heart disease deaths. Plus, most people who have major heart attacks have “normal cholesterol.”

I’ve said it before, and I’ll say it again. Sound and reliable medical research hasn’t proven that lowering (or low) cholesterol in and of itself reduces risk of death from heart disease across a population. What does this tell you? There must be some other piece or pieces to the cholesterol/heart disease story.

Based on my examination of the evidence over the years, it all boils down to oxidative stress and inflammation.

The inflammatory response and subsequent oxidative stress load is ultimately responsible for the oxidation of the LDL, while inflammatory cytokines produced at the atherosclerotic site can weaken and loosen the plaque, thus setting the stage for (and even causing) a rupture. In fact, inflammation is intimately involved in nearly every aspect of heart disease.89

Furthermore, nearly every study suggests that LDL is only a true threat when it’s oxidized. What increases the risk of oxidized LDL?

  • Having LDL particles that hang out longer in the blood.
  • Eating too much linoleic acid (it’s the polyunsaturated fat in the lipoprotein that oxidizes).10
  • Being deficient in vitamin E.
  • Having type 2 diabetes and/or high blood sugar.11
  • Failing to eat grass-fed dairy.12
  • Not exercising.13
  • Not eating extra virgin olive oil and fish oil.14

To name a few. Could “high” LDL particles be closer to benign if they’re more resistant to oxidation? I would imagine so. Does resistance mean immunity to oxidation? Absolutely not. Don’t get cocky.

Substantially “elevated” cholesterol, low HDL or high LDL can be a real problem, but they may also just be a symptom of the larger concern rather than the main issue itself. Cholesterol profile can be impacted by other conditions such as hypothyroidism, untreated diabetes or pre-diabetes, pregnancy (surprise!), lactation, stress, liver conditions, heart disease (symptom, not cause of). Even weight loss or fasting can spike cholesterol numbers (turns out burning all that animal fat off your body can have a momentary effect on blood lipids). Talk to your doctor about what your numbers mean in the grand scheme of your health. And see if you can get a read on other markers, like C-reactive protein (an inflammatory indicator), oxidized LDL, and ApoB (or some other marker of LDL particle number).

High cholesterol shouldn’t be ignored, but it’s not the only thing that matters. You have to look at the whole picture. You have to take a step back (or several steps back) and consider everything—not just numbers on a readout.

If you have any more questions about this topic, drop them down below. Thanks for reading, everyone. Take care.

About the Author

Mark Sisson is the founder of Mark’s Daily Apple, godfather to the Primal food and lifestyle movement, and the New York Times bestselling author of The Keto Reset Diet. His latest book is Keto for Life, where he discusses how he combines the keto diet with a Primal lifestyle for optimal health and longevity. Mark is the author of numerous other books as well, including The Primal Blueprint, which was credited with turbocharging the growth of the primal/paleo movement back in 2009. After spending three decades researching and educating folks on why food is the key component to achieving and maintaining optimal wellness, Mark launched Primal Kitchen, a real-food company that creates Primal/paleo, keto, and Whole30-friendly kitchen staples.

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156 thoughts on “The Definitive Guide to Cholesterol”

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  1. Very interesting article, and fun to read.

    As you pointed out heterozygous Familial hypercholesterolemia affects about 0.2% of the US population. For these people it is important to known it is genetic. It will affect treatment and it also means the issue is with you for life (or as long as you have your genome). And then there is sex, if you have FH confirmed by a genetic test then any children you have will have a least a 50% chance of having it. And don’t forget your siblings and parents, same gene pool.

    John

  2. Pretty comprehensive. It surprised me to find out heart disease has decreased by 50% since the 1950’s.

    1. I would argue that that statistic is misleading. I’m a fan of MDA and doing Primal myself, but the actual stat was “Death from heart disease, according to the CDC, has declined over 50% since its peak in the 1950s.”

      Part of the reason death from heart disease has dropped is that bypass surgeries and other post-heart-attack procedures have become commonplace. The statistic alone doesn’t tell the whole story (though this also does not negate anything in the article).

      In fact, I would suggest that it’s rather upsetting that we’ve gotten so good at fixing heart disease that CW is blind to its causes in the first place. Grok on!

      1. Lurker, you are spot on. Modern medicine has masked so many health issues that people are not taking care of themselves and hoping a pill will solve there ills

  3. John O,

    There’s a distinction to be made here: heart disease hasn’t decreased, only deaths from heart disease. We’re getting better at keeping sick people alive through advanced (and extremely expensive) medical technology.

  4. Well not only is lowering cholesterol not necessarily going to decrease heart disease, lowering it too much increase vulnerability to colorectal cancer:

    http://high-fat-nutrition.blogspot.com/2008/01/colorectal-cancer-and-cholesterol.html

    “Surprisingly, a strong association between increased LDL levels and decreased risk of colorectal cancer was identified. The explanation for this finding is unclear.”

    That’s it.

    That’s the total discussion of their most statistically significant finding. Possibly their most biologically significant finding.

    The lowest quartile for men had LDL-C below 100mg/dl, women below 110mg/dl. Those were the ones most likely to get bowel cancer. I think it’s worth pointing out that the average cardiologist would consider an LDL-C of 100mg/dl or above as a peracute statin deficiency. That lowest quartile is where your cardiologist wants you to be.

  5. Mark, this is why we all love your blog so much. This was a terrific read that is absolutely correct. Great job.

  6. Excellent post!

    Unfortunately, too heterozygous Familial hypercholesterolemia isn’t the only “hereditary” form of hypercholesterolemia today according to the medical establishment. There are something like 5 types now….if you’re HDL is low it’s one type, if it’s high LDL it’s another…and of course all are treated with statins!!

    There’s been a lot of discussion in the medical world about the “disappointing” results of the recent study indicating lower LDL may not always be good. This is good!!

    1. The funny thing about familial hypercholesterolemia is that in a Dutch study, they found that vascular problems were independent of cholesterol. Yet no one would ever publish an article about that little detail. There’s tons of stuff out there against the cholesterol myth, like lower cholesterol is actually more dangerous than high by far, and that low cholesterol can cause serious depression and heighten the risk of hemorrhagic stroke.

  7. Funny how cholesterol helps to keep the brain active in older people…and then come statins and lower cholesterol… and then a huge rise in alzheimers…anyone? anyone?

    1. After people ask doctors about why they should stay on statins, they say “oh, they also have anti-inflammatory effets” go figure. All studies done usually use arginine (a friggen amino acid? Sure it creates nitric oxide and all but come on) as a reference point to test statins’ anti-inflammatory process.

  8. Wow, very comprehensive you guys! Thank you for parsing all that for me. I feel like I really learned something today. But now my brain hurts and I’m going to bed:)

    1. “But now my brain hurts and I’m going to bed”

      Uh-oh, sounds like you need more cholesterol and Omega-3s… 😉

  9. Nice summary. With high cholesterol and extremely high triglycerides, I’ve been on Lopid for years mainly to protect my pancreas. No health issues other than these symptoms. And then muscle soreness at the gym finally got my GP’s attention that statin side-effects may be something to watch. Finally we get to fish and flax seed oil, reducing carbs, etc. Family history confirms it’s genetic, with lifespans into the 80’s with stroke over heart failure. Dispensing nutrition and exercise prescriptions need at the least same emphasis in western medicine as big pharma.

  10. Hi Wayne,

    Lifespans into the 80s? that’s pretty darn good. In the US average lifespan for a male is a shade over 72 years. Maybe you have Japanes ancestry, Japanese men are the longest lived at 76 and a bit. Why? Probably a combination of many things, public health access, genetics, diet, environment, treatment of elderly, etc. Before I get off topic I will say that family history is one piece of the puzzle and is not necessarily your predetermined destiny.

    John

  11. Hmm, I have a question. when they talk about inflammation, what are they talking about exactly? So, let’s say I am somewhat active, but keep getting little inflammatory problems (like twisted ankle, sore muscles and joints after working out etc). Will that sort of thing ultimately end up affecting my heart health?

  12. Hi Raj,

    That’s an excellent question. Inflammation is often mentioned and not often explained. Getting bruises and twisting your ankle isn’t what he’s talking about here. He’s talking about systemic inflammation.

    My limited understanding is that the word, in this context, refers to the presence of certain harmful biological markers. Things like C-reactive protein and interleukin-18. These are cell stress molecules that are a sign of damage.

    So it’s not inflammation in the sense of “tissue swelling” necessarily; the term has expanded.

  13. Very great article – thank you. When I tried to talk with my doctor about statins and asked about the inflamation thing he said “statins reduce inflammation”. I hadn’t heard that – have you a comment about this? thanks!

  14. Mark, excellent, readable overview on an important topic.

    I’m an MD, and have been concerned about the possibilities you noted: decreasing the serum cholesterol levels impairing the other beneficial cholesterol functions (neural, regenerative, sex hormones, etc). Especially when cholesterols are driven way down, in folks considered at high cardiovascular risk.

    Are you aware of any studies that actually show impairment or negative outcomes, however?

  15. Really enjoyed the read! We’re starting to get a better understanding of cholesterol and its role in heart disease. I’ll bookmark your blog and I’ll be back.

    Thanks

  16. John O.:
    That’s life expectancy at birth. It takes into account people dying very young of accidents and homicides and wars and suicides and goodness knows what else. Your life expectancy as a man at this moment is probably not 72. For example, according to the Centers for Disease Control, in 2005 a 65 year old woman could expect to live another 20 years.

    1. The theory is sound and spotprued. The goal was to put out the information in an easy to read and understand way without all the medical and scientific jargon. It has worked for me and others.Thanks for checking it out

  17. Completely agree about the drugs. Our healthcare system is going down the wrong road by encouraging people to treat everything with drugs and by using drugs as the first line of defense rather than as a last resort.

  18. over 10,000 people a year die from prescribed medications, i was diagnoed high choleterol, have kept it better by exercise and whole grain bread, not much red meat, turkey chicken instead, just had bout with intestinal blockage
    cleared with distilled water, fruits,
    chicken noodle soup. cons also causes high blood pressure. now i am back to 116 over 67 with a 55 heartbeat. i found the article very good thank you. i am going to start a website on natural health, be 70 in five months,
    don’t like that 72 age for death reference lol. i weigh 142 and i am 5ft 10.

    1. James, are you still alive. As t 81?
      This post is 11 years old.
      Give a shout and health report if you see this. I hope you knocked off with the whole grain bread ?

  19. I’m still a little confused.

    as someone who wants to both gain weight and eat low carb, i eat 4 eggs a day.

    is it logical to say that as the liver produces 1400mg of cholesterol, and each egg contains 200mg, that you can safely eat 7 eggs a day?

    In your recent weight gain post you recommend a dozen eggs a day…how come that is safe and healthy?

    Is there a limit to how much dietary cholesteral should be consumed, and is there a direct link between dietary cholesteral and indicators of bad health?

    1. Cholesterol absorption is non-linear at as dietary cholesterol increases. The absorption pathway becomes saturated and a lower relative amount actually gets absorbed as the amount eaten increases. What’s not absorbed passes through in the end (pun intended).

    2. Low intake of dietary cholesterol causes more cholesterol to be produced.

      High intake of dietary cholesterol causes less cholesterol to be produced.

      (If you want, you can ask Uffe Ravnskov or get his book, it’s truth)

  20. Google searches show numerous references that dietary cholesterol increases blood cholesterol, and increased blood cholesterol has been proven to increase the risk of heart disease.

    You seem to be saying (correct me if I’m wrong) that cholesterol is not the cause of heart disease, but inflammation is? Is that to say that there is no limit on cholesterol s long as you keep inflammation at bay?

    very confusing and feels like I am gambling with my health by eating contrary to ‘common knowledge’

    1. I recommend in addition to reason more of Mark’s blog to take a look at “Good Calories, Bad Calories” by Gary Taubes which gives further details as well as an explanation of how the lipid hypothesis became “common knowledge” despite being erroneous.

  21. Mark,

    Can you clarify the following:

    “Triglycerides are essentially the form that fat takes as it travels to the body’s tissues through the bloodstream … A high triglyceride level, which is unequivocally fueled by a high carb diet…”.

    Wouldn’t a high fat diet contribute to a high triglyceride be attributed to a high fat diet as well? I am a little confused.

    1. Mark,

      That’s false. Case in point is myself.

      I changed the way I ate years ago after patching things together through my own research. At the time my TG fairly high. My other blood markers were approaching the medical establishments marks of ‘high cholesterol’. I also have a family history of heart disease and high cholesterol.

      Fast forward 6 or 7 years. My last lab test showed extremely low cholesterol levels. In fact my TG’s were 33. Nobody would have believed me had I not had the lab papers in my hand.

      One of the surest ways to lower TG is, in fact, through an all natural high fat diet.

  22. Alex, there actually IS no evidence that cholesterol causes heart disease!

    Here is the first in a series of videos that explains it all: http://www.youtube.com/watch?v=XPPYaVcXo1I

    The whole cholesterol = heart disease theory is based on unsound evidence!

    As for dietary cholesterol, it has little or no effect on blood levels of the average person. There are some that are sensitive, but most of us, at most, will see a very slight change (2-5 points maybe) with a higher level of dietary cholesterol!

    Also, read these articles about the original Framingham Heart study:
    http://www.proteinpower.com/drmike/cardiovascular-disease/framingham-follies/
    and
    http://www.proteinpower.com/drmike/cardiovascular-disease/framingham-flip-flop/

    Often cited, but no real evidence of a correlation or a danger of eating sat fats
    This is one of my favorite quotes:
    “For example, in Framingham, Mass, the more saturated fat one ate, the more cholesterol one ate, the more calories one ate, the lower the person’s serum cholesterol.”
    This is from the then Director of the study!

  23. Someone please help me on this typical argument I get caught in:

    “If you eat a big juicy steak (even grass fed), it has so much cholesterol it will kill your arteries.”

    I try to respond “But blood cholesterol and dietary cholesterol are not the same.”

    Am I correct?

    1. Yes. That is a very simplistic argument. It’s even joked about: “Call your cardiologist before you eat KFC’s Double-Down sandwich! They took out the bread!”

      But, the body first processes all the food you take in. It’s not like the fat and cholesterol that you eat immediately goes directly to the blood stream.

  24. Hey Mark,

    I’ve been on the primal diet for about 4 months and I’ve lost30 pounds.

    Ive been super happy with the results.
    However at my last physical I had got my bloodwork taken and found out that my cholesterol levels were worse than my last test about a year ago 30 pounds heavier!
    My ldl’s were significantly higher.(94 to 166)
    My HDL’s were significantly lower.(73 to 51)
    The only thing that improve was my tryglicerides (160 down to 78).

    I feel I have been following the plan.
    Do you have any ideas on what could have possibly gone wrong?

    1. Not to worry – most of your lipid markers will read high (and often VERY high) while losing weight quickly. When you keep your serum insulin levels low and are in ketosis for an extended period of time your fat stores are releasing tons of FFAs, as they should. When your weight levels off you should see levels normalize quickly. I went through the same situation recently – lost 80 lbs (from 272 to 182 at 6′, 2″) in about 9 months. Doc was super concerned about cholesterol and trig levels and wanted to statinize me after about 30 lbs of loss. I respectfully declined, kept on losing and feeling great, and have maintained the same weight for about 6 months now. Last test results came back two weeks ago with trigs at 48 and cholesterol levels perfect. When I told the doc it was all to be expected based on how the body liberates FFAs from fat stores and that it was a good thing I didn’t go on a statin (at age 28 mind you!) he said it could’ve only helped! Very frustrating.

      I asked for his email address so I could keep him abreast of the latest research on lipids and he said no thanks. The only thing worse than a doctor that doesn’t know what he’s doing is one that’s unwilling to learn. 🙁

      1. Thank you so much for sharing this story. This happened to me EXACTLY today (same age and after 30lbs of loss) and at first I allowed myself to be ashamed or felt like I had made some kind of mistake.

        1. SO SO GLAD to see this cuz I just had a blood work screening thing after about 30-35# loss and was lectured how paleo is not healthy, I need this drug and that and whatnot and it really put me thru hell because even though I was losing, it really tripped me up into doubting what I was doing. But the reasoning here makes sense, especially seeing others who lost about the same amount of weight and had the same issues with these tests. Phrew.

  25. Mark,
    I have the EXACT same question as Rob… I have been eating primal for 3 months(lost 22 lbs so far and am doing Crossfit). my data are as follows:
    2007 2010
    Total 234 274
    LDL 135 202
    Trig 225 97

    I have asked for a blood test to directly test LDL particle size, but doesn’t sound like that is possible though the system I am in. Thoughts on how to bring down the LDL primally(I have read Dr. Eades’ take –don’t get me wrong- i am not looking for crazy low, but getting it down to the 130 range?)? what would grock do?

    1. I understand that the research linking cholesterol to heart disease is flawe, however numbers like this still represent significant deviation from average.
      Ibelieve there is some optimal range and if going significantly above that we are getting to the unknown zone. I had LDL of 200 after 1 year on primal eating (gaining weight not loosing) si I adjusted my butter and coconut oil intake got to 100 6 months later.

    2. If you are still following this, my LDL went way up and the doc was panicked of course. I got the VLDL breakdown (very low density lipoprotein) and my VLDL was very low so little risk. Triglycerides super low. HLD healthy. Of course he recommended statins. For the record if this is my family level that is good as there is no history of heart disease at all in my family.

  26. apparently saturated fat raises BOTH HDL and LDL, polyunsaturated fat LOWERS both (but may have links to inflammation and cancer), and monunsaturated lowers HDL and increases HDL – the perfect solution.

    perhaps the ratio between hdl and ldl is more important than the absolute numbers – if they have both

    In rob’s example:the ratio did get worse, which seems worrying. Maybe sub out some saturated fat and polyunsaturated fats for monounsaturated fats?

    1. Fish oil is part of the PUFA family..I’ve been supplementing with it for a little over a year.
      Is this something that should possibly be changed?

  27. Excellent read. Love these definite guides as it truly tells the true tale among topics that people just simply do not understand.

    Thanks Mark!

  28. Peer-Reviewed Science

    Mark.

    As a strength trainer, I think this is the best site I’ve seen that focuses on proper exercise and a dietary practice that makes sense.

    Since inflammation appears the culprit in cholesterol problems (and many other problems) I would like to suggest a single link where only peer-reviewed studies that support the inflammation hypothesis (in all its forms) be listed.

    Perhaps you have this here already and I have not found it yet. The peer reviewed studies provide suitable ammo to address the many professionals I train (including MDs) who are still tethered to antiquated dietary beliefs, that nonetheless, have “papers” to provide support by Big Pharma.

    In just 2 months, my own results, following guidelines much as you recommend, have produced much lower LDL, Total Cholesterol, and Triglycerides (all now in good ranges)–while maintaining my bodyweight at 195lbs such that my MD is surprised when I told him I swapped out many carbs for protein and fats. Indeed, if this keeps up, I will remove the 10MG of LIPITOR I have used for years.

    But peer-reviewed work speaks more powerfully to many professionals. Peter Beck, above, who is an MD, also seeks peer-science, likely for the same reasons. This can only help…

    Thanks,

    Roy

  29. I’ve often heard the line, repeated above, that dietary changs have only a minimal (5%-10%) impact on blood cholesterol levels, despite the evidence of many people, including myself. After switching to a Paleo diet for about 3-4 months prior to a recent fasting blood cholesterol measurement I went from a Total of around 160 to a toatl of 231. HDL went up to 87 and TriG’s were super low at 27, so I know I have nothing to worry about, but just wanted to point out that dietary changes can have huge impacts on blood cholesterol.

  30. I just got blood work done:
    total:206
    tri: 53
    HDL: 54
    LDL: 136

    My doctor want says this is a bad place to be and I need to lower my LDL to below l20. All my other numbers on the list of acronyms are in the normal range. Any thoughts or comments? Or can I tell my doc where to go next we meet. I really like to tell people to where to go when they try to tell me how to live or what to do. (Prior military)

  31. @hunter: Your doctor is…well…nuts.

    Triglycerides under 100? HDL and TG about the same?

    With TG of 53, nearly ALL of your LDL is going to be the large, fluffy, healthy type.

    If your doctor is so adamant about your LDL, have him test for LDL fractions. It could be educational for him when they all come back as Pattern A (the good stuff).

    People would kill for your lipid profile…

  32. Thanks for clearing that up. I was really upset after leaving the doctors office that day. He made it seem like I was about to have a stroke during the check up and I am only 25.

  33. I’ve been on the PB for 80 days, before these were my lipid levels:

    Cholesterol: 241
    HDL: 49
    LDL: 177
    Tryglyceride: 75
    Weight: 194 pounds

    And in the latest results:

    Cholesterol: 385
    HDL: 66
    LDL: 307
    Tryglyceride: 64
    Weight: 175 pounds

    The 385 + 307 numbers freaked me out. I’ve been eating losts of bacon (uncured) (probably half a pound a day) + coconut oil + 6-8 eggs (grass fed) daily + grass feed beef hamburgers (2 – 3 daily) + lots of vegetables (Kale, broccoli, asparagus…)

    I’m thinking about cutting a bit in those fats (mainly bacon and Coconut oil)…

    Thoughts anyone?
    Thanks,

    Andres

    1. has anyone gotten back to you on this? i’m having the same kind of problem. i just had blood work done and my Dr says i have high blood pressure too. i don’t have old test results to compare with, but as of now…

      HDL- 85
      LDL- 155
      Cholesterol- 250

      she told me my cholesterol should be under 200 and that i need to stop eating as much fatty foods. the article above said that “230 or even 250 might not be dangerous at all if your HDL is high and your small particle LDL is low”. i don’t know if i fall into that category. i want to fix any problems that i might have before it’s too late. Can anyone give me advice or point me in the right direction?

      Thanks,

      Jess

      PS, I’ve been primal for about 3 months.

      1. Hey Jess,

        Did you get a reply on this one? I just got my bloodwork done and my doc said everything looks great, except my cholesterol it was 240. I told her about being PRIMAL and that is what I have been doing for about 5 months now…and she specifically said I need to cut back on red meat and bacon! I have been eating TONS of bacon… but I thought that was ok? I am confused, because I thought I was doing everything right…

        Thanks,
        Alisha

        1. Doctors are still on the “red meat is evil” phase, when you know, red meat can help with hypertension, is lower in dietary cholesterol than chicken ounce-for-ounce, and even when grainfed, have just as much “healthy fats” as “bad ones.” Not to mention that CLA (the true “trans fat” is a possible anti-cancer treatment) is also pretty high even in grainfed.

          Interesting note on “healthy” versus “non-healthy” fats:
          When compared to normal tissue, according to research done by Anthony Colpo, the scientists saw that 50% of the plaque was polyunsaturated, 30% monounsaturated, and 20% saturated. A bit backwards isn’t it?

          And if you get your bacon orgnic, that’s even less to worry about. The low-fat craze won’t end any time soon until anyone has the balls to say “uh, we got it backwards… Sorry for the billions dead… MY BAD”

  34. I’ve been studying diet and cholesterol for several years now and I’ve learned quite a bit about how I react to different diets.

    On a SHAD (standard American healthy diet) with lots of cardio, fruit, grains, and vegetables, my cholesterol rarely went above 200. However, my HDL constantly hovered around 30. I have a very strong history of both heart attack and stroke in my family with every man having either a stroke or heart attack before the age of 50, so I thought I was genetically screwed. I accepted the fat-heart disease hypothesis.

    I then made every attempt to reduce my cholesterol as low as possible by eating “right” and taking niacin. Keeping saturated fat to an absolute minimum and eating a lot of fruits, I dropped my total to 97. At that time, I had visited a cardiologist to get evaluated before I had my first heart attack. He was thrilled at my numbers, especially my LDL at 46!

    Shortly after that I read GCBC and started to move toward a lower carb diet. It took me six months to get my fat intake above 60% and carbs below 10%. A lipid panel showed my HDL increased to 71! My cardiologist still wanted me on a statin because my LDL was elevated at 84! I pointed out that there’s never been a study showing that lowering LDL decreased heart disease and he reluctantly agreed. At that point I fired him.

    Six months ago I gave up any type of artificial sweetener, and a weird thing happened to my taste buds. I started reacting to sweets with aversion. Anything sweeter than a berry was unpleasant. Although I never considered moving to Paleo, I made a decision a couple of months ago to not eat anything that could only be produced in an modern industrial process. That rules out any processed food and vegetable oil (except olive oil).

    I eat around 3500 calories a day (2750 are fat) and lift weights for 4 hours a week and walk my dogs about 3 hours a week. I walk around my office at work and everybody has sweets and processed carbs sitting around. I’m the weirdo that refuses to eat that stuff. Oh well

    1. *insert YO DAWG WE HEARD joke that I can’t be arsed to think of here*

      Anyway, I eat about 80% fat and 15-20% protein (carbs are in there still) on most days, I don’t even bother getting my cholesterol checked, my CRP is hovering around .7 (1 mg/dl is seen as “the upper limit”), I eat all naturally raised meats, so it actually makes it harder to get the fat. But I commend you on not taking the USDA’s foiled attempt to make you sick and eat about 16 ounces of rice a day.

      I’m trying to stay off anything that will lower my lipids. I honestly don’t care about lipids anymore, I’m not worried about insulin and leptin concerns that would oxidize LDL in my body… I am only concerned about: Getting enough exercise (not a problem), homocysteine, and C-reactive Protein. Anything else to me is a waste of time, imo.

  35. Just got my blood work done.

    Total: 225 (considered High)
    Tryglycerides: 96
    HDL: 72
    VLDL: 19
    LDL: 134 (considered High)
    LDL/HDL Ratio: 1.9

    What do you all think?

  36. Can someone please answer Alex’s questions, asked on July 15th, 2009.
    I’m worried about that too

  37. “You seem to be saying (correct me if I’m wrong) that cholesterol is not the cause of heart disease, but inflammation is? Is that to say that there is no limit on cholesterol as long as you keep inflammation at bay?

    very confusing and feels like I am gambling with my health by eating
    contrary to ‘common knowledge’” ^

    1. Our current “common knowledge” is created by advertisers to sell processed foods, degraded meats, fruits and vegetables, and medicines. Not so good, huh? The idea here is to find comfort in the foods human beings ate safely and productively for millenia and to determine whether or not your genetics enable you to tolerate some of the things that came along in the last few thousand years. So you’re really returning to common knowledge, not flouting it.

  38. Thanks Mary. What’s worrying me is I’m trying to put on a little weight, but how can I do it without worsening my cholesterol. E.g. the 12 eggs on the other post. My cholesterol’s borderline high already, but wouldn’t eating all those eggs make it even worse? I read through this page and the posts, and it’s the posts where people’s bad levels of cholesterol went Up that worry me, because how would you ignore That? I know cholesterol is beneficial for different things, but too much of anything, esp HDL isn’t good!

    1. Every day for breakfast I have a four-egg omelet that has coconut oil, bacon, cheese, and sun-dried tomatoes (& occasionally freezer-dried blueberries- don’t laugh until you’ve tried it.)

      My total cholesterol is under 160. I’m trying to increase mine to 180.

  39. Thanks Ed. What’s your cholesterol like? I’d still love to gain muscle /weight without going too far in the wrong direction. Should I just go crazy on the fats? Does anyone have meal ideas for a healthy weight gain? I’m 128 lbs (female), trying to gain a little weight

    1. I’m a bit of a geek, so I already had a spreadsheet with food values from the USDA National Nutrient Database. With that spreadsheet and a set of scales, I was able to determine how much fat (& which types), protein and carbohydrates I ate.

      I pretty much eat the same breakfast, lunch and snacks everyday, so I decided to change my diet slowly. This was important for me because adding fat to my diet allowed my body to handle the additional load intestinally.

      Gaining weight has never been my goal (just the opposite). I can provide advice on unhealthy ways to gain weight, so I can’t help you there.

  40. Have you read Anthony Colpo’s “The Great Cholesterol Con?”

    Not to mention the simple fact that 75% of people who have heart attacks have normal cholesterol. The lipoid hypothesis used 7 countries when there were 22 countries with data available. Also, if you look at MONICA, the fact you can keep the cholesterol myth alive is just astonishing, as there is little-to-no correlation between deaths and cholesterol.

    Other good reads were Dwight Lundell’s “The Great Cholesterol Lie” and Uffe Ravnskov’s “Fat and Cholesterol are good for you.”

    I haven’t believed the cholesterol myth for quite some time, nor the “Metabolic Syndrome” or “Syndrome X.” There was also a post in the Colombo Herald where I read they were going to put statins in our fast food! What in the world? And also they recommended kids as young as 6 have statins, sure, money is definitely not a factor.

  41. I’m not buying the whole ‘anti-oxidant’
    hype. The ant-oxidants found in plants are FOR THE PLANTS! Cancer, tumors, bacteria,fungals, and whatever other bad guys are anaerobic by nature, not aerobic. Anaerobic=no oxygen, aerobic=oxygen. So why would you take
    “anti” oxidants?

  42. Well, looks like I’m not alone in this. 🙂
    After about 2 months in a non-radical Primal lifestyle:
    # Fasting Glucose = 86 [mg/dL]
    # Blood Pressure: 90 / 50 [mmHg]
    # Total Cholesterol = 275 [mg/dL]
    # HDL = 56 [mg/dL]
    # LDL = 210 [mg/dL]
    # Triglycerides = below 90 [mg/dL] (too low for the chemist’s machine to get right)

    Now, I’ve stumbled upon a very interesting article that clarifies that the most telling indicator of CVD risk is actually TG/HDL. If you’re below 2.0, you’re ok.
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2664115/

    Assuming a TG count anywhere between 70 and 90, this yields for me:
    # Trigl./HDL = 1.25 ~ 1.60

    So, although the doctors in my family are scared about my LDL=210, I’m ok with it because I know that I have a pretty low Trigliceride level and a relatively good HDL. Plus, the blood pressure is pretty low. And, of course, I’ve become pretty leaner and stronger too.

    The reason I speculate a 70 < TG < 90 is because I had TG=73 a couple of years ago when doing Paleo (without sat fat). And now that I'm doing Primal with lots of sat fat and very little carbs, I expect to see the TG drop even lower.

    So, Mark and all the guys and gals here, what do you have to comment on this study I linked up?

  43. Mark, There has been substantial evidence that saturated anima fat promotes arterial disease. Even so-called grass fed beef. There was a man who was on the Atkins diet who sued Dr. Atkins when he developed heart disease after 1 year on his high fat animal diet. For that reason I do not eat red meat, instead I eat lean turkey breast which I boil in hot water to reduce the fat even more. I do think your understanding of the correct diet for the human specie is right on the money.. However, too many carbs can easily sabotage this diet. Grok was, after all ,on a very low carb diet with only seasonal fruit as his main carb. Please respond, thank you

    1. I just ate a big steak, a bunch of kale wilted in cocunut oil with some whole cream dripped over it.

      Everyone (mostly coworkers)comments on my physical improvement as I am obviously leaner, more muscular and strongerthan severalmonths ago. Then they don’t believe me despite my improved lipidprofile over last year before transitioning to primal.

      Then they gawk when we go out to eat and I get a 16 ounce pork chop T bone and put butter on top! .

      Thanks Mark for helping shatter a myth.

    2. Charles, please don’t come in here and rant about “substantial evidence” that you don’t bother to provide links for. It’s rude.
      Also, I hope you enjoy that boiled turkey breast. Yes, indeed, that just sounds yummy! You know, even if Mark and the hundreds of thousands of paleo/primal eaters in the world, not to mention the millions of ancestors throughout history turned, out to be wrong, I’m OK with it. I’d rather die young, happy, and well fed than live to be a 100 eating the disgusting crap you just described.

  44. Of course, what is so scary about all this cholesterol con is now the ‘scientists’ are using teleoanalysis to prove that cholesterol causes heart disease. Teleoanalysis “provides the answer to studies that would be obtained from studies that have not been done and often, for ethical and financial reasons, could never be done.” Law and Wald – Combining data from different types of study. So this means that you can prove things you know to be true despite there being no studies done. Awesome.

  45. I just had my results having eaten high fats, higher proteins, low carb for a year and a half or more, and my total cholesterol is *very* high. 433 in American money. Any thoughts, anyone? Here are the numbers;

    Total 433
    HDL 73.5 (rounded up)
    Tri 50.3 (rounded up)

    That means my Tri/HDL ratio is very low (0.68), but I must have loads of LDL going on.

    1. I’m in the same boat, after almost two years being primal, my numbers are extremely similar to yours. I feel great, and I’m stronger than ever, the problem is that last month I left my 8-5 job to start my own company, and I could not get any insurance company to insure me (so I’m under the expensive COBRA)… Rats!…

      1. Interesting. Sorry about the insurance thing, but good to hear you feel well.

        In my case, I wonder whether the cholesterol is elevated because there’s some sort of healing going on, or whether I do just eat too much for me at the moment. My results were marked “severe hypercholesterolaemia in the range associated with FH (familial hypercholesterolaemia)..but noted “normal trigylcerides, TSH and glucose”, so as to underscore for my GP it’s not being down to issues with diabetes or thyroid, I would think.

  46. I’m in the same boat guys. I got blood work done last week & my Dr called me very concerned by the results. It actually scared the heck out of me. He wanted me on Crestor the next day for a least a month. I’ve been full paleo/primal for the last 18 months & he spooked me so much, that I don’t know what to do.

    Total Cholesterol 471
    HDL 66
    LDL 391
    VDL 14
    TRG 68
    Chol/HDL Risk Ratio 7.1

    I’ve been having chest discomfort of and on for the last few weeks. Even moreso after my Doctors message. I feel completely torn. I stopped eating whole eggs immediately & switched back to egg whites out of shear fear. Can anyone please help shed some light on this & help me, my family feel more at ease. Thank you-JC

  47. I have been following this discussion with great interest. I am not a doctor, and I don’t think you will get a doctor or Mark to comment on the cholesterol numbers reported here. But I say that if you have total cholesterol in the 300 and 400 range, you are in trouble, and are either doing something wrong or this is not for you. No Grok ever ate a steak with butter, or butter for that matter. They were all lactose intollerant. And they never ate coconut oil, olive oil or any other kind of oil. These are all refined foods that strip one element from its dietary context. How many olives do you have to eat to get 2 tablespoons of olive oil? Not that a Grok ever ate an olive, because you can’t eat them off the tree.

    I think its a huge mistake to conflate the low-carb thinking with paleo. Low-carb accepts many western diet precepts (e.g. refined oils and factory meat) that paleo does not.

    I drove my total cholesterol from 214 to 141 in 8 mos. on grass fed buffalo and beef and fish no more than twice a week, oat bran and berries for breakfast everyday, zero dairy, very little sugar, and otherwise cooked whole grains and tons of vegetables and beans (almost every meal). Basically, I tried to zero out saturated fat from sources other than fish and meat, and boost fiber to 50 – 60 grams per day. It was easy, but it’s only the starting point. I think paleo may offer the long term solution and I am going to work this to see what effect it has on my physiology. One of these days I will post my food logs.

    Don’t trick yourself into thinking you can survive with blood chemistry that far out of whack. This is supposed to solve the western diet problems, and if it is not, don’t stick with what you’re doing.

    I hope this isn’t seen as negative, it’s not meant to be, but some commenters are reporting serious health concerns, and they should not be glossed over or ignored.

    1. fyi … low cholesterol (generally defined as less than 160, more likely less than 180) is not good for you. Increases risk of hemorraghaic stroke, vitamin d deficiency , problems with hormone production, etc etc. you might try letting your cholesterol go back up a bit.

      Here’s an article from aha (1995 no less!) to back up what i’m saying. you can google cholesterol deficiency too: http://circ.ahajournals.org/content/92/9/2365.full

      1. “We observed a significant risk of cancer, noncardiovascular noncancer, and all-cause mortality in men whose TC levels changed to low (<180 mg/dL) from the middle (180 to 239 mg/dL) level at baseline. The above finding for cancer mortality agrees with results from the Multiple Risk Factor Intervention Trial,4 in which participants who died of cancer experienced within 1 year of death a fall from baseline in serum cholesterol level that was 22.7 mg/dL (0.59 mmol/L) greater than that of surviving participants of the same randomization group and smoking status. These results also support longitudinal data published by Pekkanen et al57 from the Seven Countries Study in which a decline in TC also tended to be associated with death caused by cancer among the older cohort. A decreasing TC also was associated with elevated overall mortality and cardiovascular mortality in both men and women in the 30-year follow-up of the Framingham Study.58"

        http://circ.ahajournals.org/content/92/9/2396.full

        Not trying to scare you, just better that you hear it now than later, since a doctor will NEVER point this out to you.

        1. I don’t know what to make of that correlation. Borrowing from another blog, the following was reported:

          Numbers for males:

          Hadza 114
          Kalahari San (Bushmen) 130
          Congo Pygmies 101
          Australian aborigines 146
          Canadian eskimos 141

          Eaton SB, Konner M, Shostak M. Stone agers in the fast lane: chronic degenerative diseases in evolutionary perspective. Am J Med. 1988 Apr;84(4):739-49.

          Obviously, these are lower than 170. I think its tough to draw conclusions (for oneself, it appears impossible on a scientific basis) except perhaps that the SAD is problematic regardless how your cholesterol reacts.

        2. 1) Using sick and/or dying people to try to establish a baseline for healthy people is fallacious.

          2) I think that the subjects’ TCs fell due their oncoming cancers, not that the drop in TC caused their cancer deaths.

    2. Having been put on statins and egg-whites only with white meat occasionally, for some 10 years, my LDL came down from approx 200 to 86 last year. I thought it’s the time to try out whether I was one of the minority who was a hyper-responder to dietary chol, with 1 whole egg daily and red meat occasionally. Turns out I was, for LDL went to 175 in a year, TC to 250, and HDL only marginally from 44 to 49.

      I now feel the urge to try out the theory that it’s inflammation that should be monitored, not chol. Have found CRP is -ve, and if homocysteine is also low, I’ll feel free to carry on with the modified diet.

      However, at what stage should one think that the blood chemistry is “…blood chemistry is (too) far out of whack…”. Should it be at TC of 300, and LDL of 200, or what? Would appreciate views and guidance.

  48. I’ve always maintained a healthy diet and have been pretty athletic. This year, at age 52, I a had a stent placed for a coronary plaque. I had chest pain while on a group training ride on my road bike ! I’m now on 40 mg Lipitor, which I freakin’ hate – my neuromuscular system has gone way down hill (many crashes on rides I used to have no difficulty with on my mountainbike) My cardiologist won’t decrease my dose because of the whole stent thing. I take coQ10 and pycnogenol. Do you have any other recommendations ?

  49. Been trying to get my head around this subject of cholesterol. I finally understand! This article is Brilliant!!! Thank you. I am emailing it to a number of ppl 🙂

  50. I’m checking back into this discussion because 4.5 months after adopting the Paleo diet, I got some blood work done and wanted to share the results. Unfortunately, this same time frame has been exceptionally sedentary, but I am just starting to ramp it back up, and am looking forward to incorporating some Mark’s idea’s into the mix.

    2/5/2010
    Weight: 200
    Total: 189
    LDL: 132
    HDL: 42
    Trig: 74

    4/17/12
    Weight: 165
    Total: 144
    LDL: 97
    HDL: 39
    Trig: 41

    So far, so good! If (and its a big if) a lower cholesterol profile means there’s less chance of CAD, then this approach to diet and nutrition appears to be the answer, at least for me. And this should keep the MD’s from trying to get me on a statin which they were threatening several years ago when my totals were over 200 and trigs around 100. Oh yea, age 50.

    The remarkable thing is the lower Trigs. It appears the critics may be correct and that sugar and refined carbs drive that (and LDL) higher, not dietary fat.

  51. I am 37yo, 155lbs, 5’11”.
    I have always lived in Italy, using a pretty diversified diet, no excesses, no sodas, and you can imagine a lot of “pasta”.
    From 2006 to 2009 I lived in the US, where I had plenty of meat-burgers-steak-porterhouse, etc etc, terrific meat.
    I took my blood test in 2009 and both my total col. and trig were pretty high.

    After I got back on track with a diversified mediterranean diet (no excess of read meat, no more than 2 eggs per week) my levels improved, and all the “ratios & indexes” are ok. My latest results are the following:
    Col ToT: 260
    HDL: 90
    LDL: 167
    trigl: 67

    I’d like to lower my LDL, but I dont know where to tackle my diet, which seems pretty good. I dont even eat pasta that often anymore, once a week at most. Not a big eater of cheese either.
    I spoke with many australian friends, and they all eat 2 eggs every day for breakfast and they are fine. I read that 20% of our Col. comes from food, and the other 80% is ereditary.

    1. Dr. Krauss, who originally discovered the subcomponents of LDL, indicated that LDL count – as derived by current lab tests/procedures – is basically a useless number. He states it would be better to pay attention to your HDL number.

      HDL counts were inversely related to the small-partical dense LDL. So, high HDL corresponds to low small-partical LDL. Low HDL corresponds to high counts of small-particle LDL.

      The interview can be found here:
      http://www.msnbc.msn.com/id/35058886/ns/health-heart_health/t/small-ldl-particles-pose-biggest-risk/

      I haven’t read anything newer (the interview is 2010), so I’m unsure what new research he’s done.

  52. I’ve read thru these replies until my head hurts, and I’m a paramedic. I just never cared much about the finer points of cholesterol when someone is bleeding to death. My question is simple: Can eating the healthier PB diet with foods such as avocado’s, nuts and organic proteins in higher quantities (because I don’t eat carbs and I get hungry!) cause your overall cholesterol to rise? Mine did about 50 points after eating primal/lower carb for about a year. Everything else measured great but total cholesterol went to 228. I’m not worried but I am curious and I’m sure others are also. I do love avocado’s and I have been known to make a meal of them. I also eat salmon and fish very regularly.

  53. Great article! I have just recently listened to audio talks of Dr Ross Walker (Aus Cardiologist), Prof Peter Dingle (Aus Toxicologist & Author), and especially Bill Davidson (Naturopath and Chiro) who ALL subscribe to this theory. Davidson almost word for word (without the humour) describes this very phenomenon. Just to add some more advise, if your ratio of HDL:LDL is 1:5 (e.g. cholesterol level is 7 but with 2 HDL to 5 LDL) it is perfectly normal. Yet a doctor would say a level of 7 is bad. Like Seth Godin would say, BROKEN. Let’s keep the Grok health community alive.

  54. Yes! I have the same problem with my doctor, refusal to learn anything he doesn’t read in a biased medical journal. Even the great Dr. Oz is seeing the cholesterol myth exposed for what it is which I give him so much credit for his willingness to correct a wrong way of thinking.

  55. After 3 years of lowcarb/primal eating (around 185g proteins + 170g fat + 140g carbs daily for the last 8 months), my lipid profile looks like this:
    – TC 220
    – LDL 106
    – HDL 110
    – Tri 22
    Also, no more running, only walking 5 km/day and strength training 2 x 1 hour/week.
    Of course, the TC value of 220 was underlined by the doctor for being too high 😀

  56. I have been following the Primal/Paleo lifestyle now for 2 years and it has been great. Last year our work decided in order to be eligible for insurance we needed to have health screenings. My numbers in October 2013 were great 82 LDL, 82 HDL, 48 Triglycerides, and 173 total cholesterol. Went back a year later October 2014 and my results for LDL 100 and HDL 86 went up but not much. However, total cholesterol 223 and Triglycerides 184 went through the roof! my LDL and HDL ratios are fine. My question is “how in the world do my tri’s spike 136 points without changing my lifestyle? the same with my total cholesterol, a 50 point increase. I was told to reduce my red meat intake. I follow paleo/primal rarely indulging in foods high in carbs or processed sugars. Any suggestions, is there a cause for concern?

    1. There’s not enough info in your post to respond. Age, height, weight, and activity level, and diet composition (daily intake of meat/fat (quality of sources?), plant, carbs (grains and sugars), and ETOH) would help. Do you test only once a year? Could be an outlier. You might want to have it done again.

  57. My cholesterol is in the optimal range, Total: 158, LDL: 91, HDL: 61, Tri: 97 but my LP(a)-P is high risk at 177. Anyone have any suggestions to address the LP(a) issue? Thanks!

  58. If you have the bad genetics for cholesterol can you eat a high fat low carb diet and improve your cholestrol?

  59. Yes, I have been on keto, and just recently introduced carbs. I’m talking sweet potato, more vegetables, and little fruit. My blood test for work was done, and they gave me weird results in my opinion, but if they are true I may need to see a cardiologist. I had total at 124, HDL at 18, LDL < 50, Triglycerides < 50, glucose 90. It just seemed weird to me that I couldnt get a direct number from them on LDL and TG. But to have my HDL so low, as well as everything else rather low, I feel the test results may have been inaccurate. I Was 12 hours fasted and It was done from finger prick. Looking to get actual blood drawn for testing to compare the two and find out whats going on. Hope its not something to worry about. I hear low HDL can be signs of CAD.

    1. You have low LDL as well. That’s not an issue. You may have hereditary low cholesterol which has been shown to reduce the risk of heart disease by 88%.

  60. “LDL rises directly not with the amount of saturated fat you eat but with rising levels of inflammation caused by carbs and trans fats.”

    Umm yeah it does. Many studies shows that saturated fats raise LDL, that’s how it contributes to heart disease.

    I notice you post any references to back up any claims you stated here. Good job.

  61. Just got out of Chem class and today’s lecture included how dietary cholesterol causes atherosclerosis. I’d like this to be my topic for our research project. Is there any peer-reviewed articles or scholarly journal publications I could reference? I understand it’s still not mainstream but hoping there’s credible sources I could cite. Thanks!

  62. Do you have a source for why the liver is operating under hardship mode when our dietary cholesterol intake is low?

    Or do you know of any studies that show that it is stressful for the body to produce 100% of cholesterol (as opposed to 75%-80%, in the context of a diet that contains cholesterol)?

    This makes a lot of sense to me and have personally benefited from including cholesterol in my diet. I’m just struggling to find any studies that support this. Thanks!!

  63. Those with ApoE4 may not eat a high cholesterol and high saturated fat diet because cholesterol and saturated fat increases LDL particles and because the E4 allele cannot clear out the LDL particles quick enough, they become oxidized and cause heart disease. If you have the normal ApoE2 or ApoE3, then you clear them out quickly.

    So if you have E4, DO NOT HAVE CHILDREN!

  64. I’ve been following the arguments of LDL denialism and LDL harm for a long time. You seem to be merging the opinions of Dave Feldman and Chris Masterjohn and dismissing the bulk of evidence from the lipid authority consensus that suggests apoB and LDL in circulation is sufficient to aggregate and cause pathology. Adherence to the endothelium isn’t dependent on Oxidation. Oxidation is a consequence not the cause. But yes LDL time in circulation increases risk of Oxidation and aggregation. Subclinical hypothyroid (keto) is also a risk and T3 levels should be optimal (eat carbs) to support LDL receptor activity to reduce LDL time in circulation.

  65. I am a nurse and works in the cardiac field. I was always against statins as I felt lifestyle was more important. I would see patients come back in meeting more stands because they never change their lifestyle. Even though their LDL cholesterol was 40. I developed LADA which is adult onset type one diabetes. I resisted statins from my endocrinologist. But recently added a cardiologist who pointed out that I did have some blockage in my heart and talked me into statins. I still don’t feel comfortable with them. I am slender and I exerciseIn my hemoglobin A-1 C is 5.7. I eat low-carb. Tried keto but it raises my blood sugar at night. I guess my comment is that I am nervous about taking statins still not sure they are necessary.

  66. What if you
    *Have been eating paleo for years and
    * Have reached equilibrium weight and
    * Are burning fat as a fuel most of the day.

    Will cholesterol levels be elevated in this state?

    I imagine it needs to be in the blood in order to burn it in the cells?

  67. “The Great Cholesterol Myth” is a great read for those who do not understand that one should never mess with their cholesterol numbers, they are natural no matter what, and statins are 100% not necessary for anyone, are actually dangerous, and do not do what doctors inform their patients they purportedly do. Also read “The Paleo Cardiologist” by Dr. Jack Wolfson. His story is fascinating, which includes his father, and his way of treating patients is cutting-edge.

    1. Read that book. Great read.make every doctor I’ve been to head spin when I start talking about how I’m not too concerned about my cholesterol because my ratios are good.

  68. I have high cholesterol. I also have a 0.6 Trig:HDL ratio. This is the first I am hearing to the Total Cholesterol:HDL. But my C-Reactive protein is 0.7. All this being said anytime I go to the doctor with my numbers they want to put me on a statin because my total cholesterol is high and LDL is high. I try pointing out everything else like I’ve stated up top and it is crickets. So I’ve switched doctors so many times its unreal. I point out other concerns that I have about my blood test like hormone levels and all they want to talk about is Total and LDL. It is very annoying. Been trying to find a doctor that is a little more up to date on the times when it comes to Cholesterol and no luck yet.

  69. There is little evidence to suggest that lowering ldl is extending lives. What you are saying is we should be taking statins and the data suggest we would live an extra 2.5 months longer by lowering ldl.

  70. Great Mark; except for the suggestion that those who don’t eat dairy are at an increase risk for heart disease. And the same for olive oil which didn’t exist in the Americas and other places until fairly recently.

  71. Mark – it would be really good if you could remember that many visitors to your site and readers of your articles are not in the USA and if you could also include the units of measure used outside the USA it would make your articles much better. (Just put them in brackets after the measures you use that are the USA units – cholesterol isn’t the only one – Vit D comes to mind as well).

  72. What about increasing readings for LDL and having one variant of ApoE4 gene and eliminating MCT, coconut oil, coconut milk, ghee and animal fat?