The Diet-Heart Myth: How to Prevent and Reverse Heart Disease Naturally

Senior couple on cycle rideThis is the final article in the Diet-Heart Myth series I’ve been writing over the past several weeks. If you missed the previous articles, you can find them on the special report page for heart disease.

Ben Franklin said, “An ounce of prevention is worth a pound of cure.” Heart disease is no exception. According to the INTERHEART study, which examined cardiovascular risk factors in 51 countries, 9 out of the 10 strongest risk factors for heart disease are modifiable by changes in diet and lifestyle. (1)

While taking action now does not guarantee that you’ll never get heart disease (as age is perhaps the strongest risk factor), it does vastly improve your chances of avoiding it or at least delaying it significantly. In this article, I’ll teach you how to do that in three simple steps: Eat a Heart-Healthy Diet, Live a Heart-Healthy Lifestyle, and Boost Your Heart-Healthy Nutrients.

3 simple steps to living a heart healthy lifestyle that your doctor has never told you about.Tweet This

Eat a Heart-Healthy Diet

When most people hear the phrase “heart-healthy diet”, they think of egg-white omelettes, a salad with no dressing or similar low-fat, low-cholesterol fare. But if you’ve been reading this series, or my blog in general, you know better. The “Paleo Template” approach I’ve written about here is an excellent starting place. It includes all of the necessary micronutrients in their most bioavailable form, emphasizes an optimal balance of fats, eliminates highly processed and refined foods, and reduces other food toxins that interfere with nutrient absorption. On the other hand, the American Heart Association’s “heart healthy” diet emphasizes nutrient-poor foods such as whole grains and vegetable oil, and unnecessarily restricts nutrient-dense foods like red meat, animal fat and cholesterol.

But which version of the “Paleo Template” is best for preventing heart disease? In this series we’ve been focusing on LDL particle number as one of the primary drivers of atherosclerosis. We also discussed the five main causes of elevated LDL-P, including insulin/leptin resistance, genetics, poor thyroid function, infections and leaky gut. If you have elevated LDL-P while on a Paleo diet, the key is to first discover what’s causing it and then tailor your diet accordingly. In this article, I’m going to focus on insulin/leptin resistance and genetics, since those are the two most common causes of elevated LDL-P that I see in my practice.

Insulin/leptin resistance

In this case, the best approach is often a low-carb Paleo diet. When I say low carb, I generally mean between 50–100 grams of carbohydrate per day in the form of fruit and starchy vegetables like sweet potatoes, potatoes, plantain, yuca and taro. I do not count non-starchy vegetables toward the carbohydrate intake, because I don’t believe they make a significant enough contribution to matter. The purpose of this approach is to improve insulin and leptin sensitivity and promote weight loss, which will in turn decrease LDL-P.


If you have high LDL-P, but normal triglycerides, HDL, small LDL-P and your lipoprotein insulin resistance (LP-IR) score on the NMR LipoProfile is normal, and you’ve ruled out thyroid problems, infections and leaky gut, than it’s very likely that you have one of the many genetic variants that can lead to increased LDL particle number. In this case, a low-carb Paleo diet will often increase—rather than decrease—LDL-P. In my practice I will often recommend what I call a “Mediterranean Paleo diet” in these cases. This means following the basic Paleo approach, but reducing intake of fat and increasing intake of fruit and starchy vegetables. You can still eat fat as it naturally occurs in food, but try not adding as much additional fat to meals, and using more monounsaturated fat than saturated fat. In many cases this will decrease LDL-P quite significantly.

The trickiest situation is when someone has both insulin and leptin resistance and a genetic issue. A low-carb diet will usually drive up LDL-P in that situation, but it will improve many other markers that are also risk factors for heart disease, including triglycerides, HDL, fasting insulin, fasting glucose, etc. So I will usually recommend a low-carb diet for these patients, and if their LDL-P goes up, try to use natural therapies to bring it down.

Live a Heart-Healthy Lifestyle

Physical activity

Exercise has been shown to reduce LDL particle concentration even independently of diet. (1) Regular exercise prevents the development and progression of atherosclerosis, improves lipids, and reduces vascular symptoms in patients that already have heart disease. The benefits of exercise are related to maintenance of body weight or weight loss, blood pressure control, return of insulin sensitivity, and beneficial changes in lipids, all of which in turn promote endothelial stabilization and vascular health.

In addition to distinct periods of exercise, it’s also important to sit less and stand and walk more. In fact, some research suggests that this “non-exercise” physical activity may have a greater impact on our cardiovascular health than exercise. Dan’s Plan has some fantastic recommendations for physical activity, as well as a great software and hardware-based tracking system.


I have come to believe that chronic sleep deprivation is one of the most pernicious—yet under-recognized—contributors to the modern disease epidemic. Sleep deprivation has been associated with weight gain, insulin resistance, increased appetite and caloric intake, overconsumption of highly palatable and rewarding food, decreased energy expenditure and a reduced likelihood of sticking with healthy lifestyle behaviors. Sleep duration and quality are inversely associated with blood pressure in epidemiological studies, and high blood pressure is one of the strongest independent risk factors for cardiovascular disease (CVD). (2) Finally, the Nurses Health Study found that those who reported fewer than 5 hours of sleep at night had a 38% greater risk of coronary heart disease (CHD) than those reporting 8 hours of sleep. (3)

For tips on how to improve your sleep, see my article “Sleep More Deeply“.

Stress management

Stress increases the risk of cardiovascular disease in numerous ways. It increases intestinal permeability, impairs blood sugar control, depresses immunity (which increases the risk of infection), contributes to fat storage in the liver, and promotes consumption of comfort and junk foods. But perhaps the most significant contribution stress makes to CVD is that it promotes inflammation. Stress has been shown to increase circulating inflammatory markers like C-reactive protein (CRP) and interleukin-6 (IL-6), both of which are associated with heart disease (4). On the other hand, stress management can have a profound impact on heart disease risk. One recent randomized trial showed that regular meditation decreased the risk of death from heart attack, stroke and all causes by 48%—a much greater reduction than what is observed with statins even in the highest risk population. (5)

Boost Your Heart-Healthy Nutrients

In addition to the basic heart-healthy versions of the Paleo template I mentioned above, there are several specific foods/nutrients that have been shown to improve cardiovascular health.

Cold-water, fatty fish

Cold-water, fatty fish are an excellent source of EPA and DHA, long-chain omega-3 fats with several cardiovascular benefits. An analysis of randomized trials since 2003 suggests that regular fish consumption or consumption of fish oil would reduce total mortality or deaths from all cause by 17%. (6) This is remarkable when you consider the fact that statin drugs only reduce total mortality by 15%, and even then, only in certain populations.

Monounsaturated fat

Monounsaturated fats have been shown to reduce LDL and triglycerides and increase HDL. They also decrease oxidized LDL, reduce oxidation and inflammation in general, lower blood pressure, decrease thrombosis, and they may reduce the incidence of heart disease. (7) The best sources of monounsaturated fat are olives, olive oil, macadamia nuts, and avocados.

Antioxidant-rich foods

Antioxidant-rich foods protect against heart disease in a number of important ways. Our antioxidant defense system is what protects us from oxidative damage, which as you now know is a major risk factor for heart disease. Strengthening this system has two sides: reducing our exposure to oxidative stress and increasing our intake of antioxidant-rich foods. When most people think of antioxidants, they think of fruits and vegetables like dark, leafy greens and fruits like berries. But while it’s true that these foods are rich in antioxidants, what a lot of people don’t know is that red meat and organ meats are also very rich in important antioxidants that aren’t found in significant amounts in plant foods, like CoQ10 and retinol, which is preformed vitamin A. A good rule of thumb is to eat the rainbow, choosing a variety of colors of fruits and vegetables, as well as organ meats, meats, eggs, and grass-fed dairy.

Polyphenol-rich foods

Polyphenols are a diverse class of molecules made by plants, certain fungi, and a few animals. They serve a lot of purposes including defense against predators and infections, defense against sunlight damage, chemical oxidation, and coloration. The color, in fact, of many fruits and vegetables like blueberries, eggplants, red potatoes, and apples comes from polyphenols. Some of the best studied polyphenol-rich foods are tea, especially green tea; blueberries; extra-virgin olive oil; red wine; citrus fruits; hibiscus tea; dark chocolate; coffee; turmeric; and other herbs and spices. Polyphenol-rich foods have been shown to have a number of beneficial health effects. For example, dark chocolate has been shown to lower blood pressure and LDL cholesterol and improve insulin sensitivity, red wine has been shown to prevent the increase in oxidized fats that occur after consuming a meal high in oxidized and potentially oxidizable fats, several studies have shown that hibiscus tea lowers blood pressure in people with hypertension, and blueberries have been shown to lower blood pressure and oxidized LDL in men and women with metabolic syndrome. (8)


Some studies have shown that nut consumption may reduce the risk of cardiovascular disease. In a recent analysis of NHANES data from 1999 to 2004, investigators found that nut consumption was associated with a decrease in a wide range of cardiovascular disease risk markers, including body mass index, waist circumference, and systolic blood pressure, compared to non-consumers of nuts. (9) This is observational data so we can’t be sure that it was the nuts, rather than some other factor that wasn’t adequately controlled for, that led to the improvements. That said, a review of five large prospective studies (including NHANES) as well as clinical trials examining the effects of nut consumption on lipid parameters found similar results. (10) I favor macadamia nuts, almonds and hazelnuts because they are lower in omega-6 linoleic acid, which research suggests may contribute to CVD when consumed in excess.

Soluble fiber

In the NHANES study, subjects followed for more than 19 years with the highest quartile of dietary soluble fiber intake had a 15% lower risk of heart disease and had a 10% lower risk of cardiovascular events. (11) Soluble fiber binds bile acids or cholesterol; upregulates LDL receptors in the liver; increases clearance of LDL; inhibits fatty acid synthesis by producing short-chain fatty acids like acetate, butyrate, and propionate; improves insulin sensitivity; and increases satiety with lower overall energy intake. (12)


I hope you’ve enjoyed the Diet-Heart Myth series, and that the information I’ve presented will help protect you and those you love against heart disease. I’ve done my best to cover the most important steps you can take, both in terms of diagnosis and treatment. That said, cardiovascular disease is a complex, multifactorial process and it’s difficult to give it the attention it deserves in a blog series. That’s why I created the High Cholesterol Action Plan. It’s a 9-week, digital course that goes into much more depth on these topics than I was able to go into here, including additional tests that help determine your risk, natural alternatives to statins, and a step-by-step framework that helps you determine your own, customized “action plan”. Click here to learn more about it and sign up.

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Heart Disease

Comments Join the Conversation

  1. Shawn says

    I cannot have animal protein anymore. Causes inflamation for me. No eggs, no dairy, no sugar.
    I drink teas with honey.
    No oils except olive.
    No pasta. It Increases insulin. I can eat real bread with no preservatives. Potatoes bother me at times. What doesnt bother me is: nuts, fish, vegetables, and fruit.
    If I eat like this a lobg time then occasionaly introduced a dairy product or meat. I cant get by but I prefer to feel good all the time and not sacrifice my health for a temporary enjoyment of some food item.

  2. Doctor Vedic says

    Does anyone know of any low carb/paleo studies that have been undertaken in patients with existing coronary artery disease or congestive heart failure (CHF)?

  3. Cappy says

    I was 250 pounds and had a lot of health problems while eating a high protein diet just like the one Chris describes. I counted calories, but continued to gain weight. I had extreme lethargy. After trying a plant-based diet, my weight plummeted, my energy went up, all my health problems disappeared.

    I follow a diet similar to Dr. Esselstyn whom Chris Kessler appears to be trying to mimic but without the street cred.

    I used to have trouble going up stairs, now I skin or hike up 2,000 feet of mountain starting at 8,000 feet almost everyday. All because I found the power of plants.

  4. Dr Johnathan Smith says

    What a load of bunk and junk. VERY BAD ADVICE for people with heart disease. VERY GOOD ADVICE for people who want heart disease.

    • Richard says

      I have no idea what your comment is referring to, the article or a particular comment, Smith…

      I like the comment by Sanders, although I think a big reduction in animal protein consumption is adequate as Dr Ornish suggest and not a total avoidance.

      However, what leaves me guessing is nut/seed consumption. It appears to me that the doctors that actually have experience reversing heart disease such as Drs Esselstyn and Ornish recommend very low fat diets and there is no room to have nuts/seeds or avocado. However, there are studies indicating that people consuming nuts/seeds have less heart disease…. Reason I am still guessing is that disease reversal is different than healthy people avoiding heart disease.

      Can anyone provide a cite on a study concerning heart disease reversal while consuming nuts/seeds? Sorry, I am not interested in opinions…

  5. Greg Hill says

    At the top of page 19 in your excellent “Diet-Heart Myth” eBook you say, “normal triglycerides, HDL, small LDL-P.” I bet this is a typo, and you probably meant to say “small LDL-C.”

  6. says

    Don’t eat fish – they are full of toxins and it harms the oceans due to the overfishing. I study nutrition at Rochester Institute of Technology, have been 100% plant based for almost 3 years and my cholesterol is 150 – no drugs. As an animal eater I went through early menopause and my cholesterol began to sky rocket. I changed my diet because of the harm eating eggs, drinking milk, and eating flesh does to these animals but I took classes at RIT to find out how to do it in a healthy way and I found out that simply leaving all animals and their products off my plate was all I needed to do. Just replace those calories with more of the pasta, grains, fruits and vegetables I was already eating. Voila – I am 100% healthy and I’m living by my values: don’t want to harm others or the environment, live a life of peace not just for myself but for the world.

    • Richard says

      While I appreciate your opinion and your right not to consume fish I will be continuing till there are non remaining without gross amounts of toxins. At this time I do not see anything unhealthy about consuming wild salmon or sardines….of course without added oil, salt or chemicals.

      No doubt the world will run out of fish in the sea not too long in the future. Enjoy while you can because you can be sure many nations are not going to reduce their fishing. Farm fish are not acceptable to me as currently produced but that could change…

  7. Katherine says

    I’m late to the conversation but would love some advice! My husband and I follow the paleo diet. We just had a female friend who suffered a major heart attack. 2 complete blockages. Heart stopped multiple times. She’s back home and recovering. My question is– is there a paleo book that specifically addresses heart disease that I could offer her?

  8. Dan says


    Chris, I am pretty confused about the conflicting advice on lowering LDL-P. I am currently reading “Your Personal Paleo Code” and stopped the 30-Day Reset in it’s tracks when I read your statement: “If you have high LDL-P, but normal triglycerides, HDL, …, than it’s very likely that you have one of the many genetic variants that can lead to increased LDL particle number. In this case, a low-carb Paleo diet will often increase—rather than decrease—LDL-P.” What is this based on?

    My LDL-P is 1733 nmol/L !! Total Chol is 202; LDL-C Direct = 127, HDL-C = 63, TG’s=104. My father has CAD. I took Lipitor for 40 days and developed severe, debilitating muscle pain in my wrists, forearms and biceps. After 2 weeks off it I can start to pick up my 6 mo. old son again. I’m desperate to lower my LDL-P but terrified of going back on statins.

    So many health professionals and other sources, including your book keep telling me to drastically reduce my CHO consumption and go full Paleo.

    I am an amateur road bike racer and think this lifestyle has allowed me to keep my other numbers low but a high CHO diet had always been a prevalent in my lifestyle. Please help?

  9. Wendy says


    I’m currently in school for holistic nutrition. I love everything I’ve learned, and I’m always looking for more. But sometimes I feel like I just don’t know who to trust, as I know we all do. A major thing I’ve made a point in recognizing is who pays for the studies done, and how that would affect the outcome. While the meta-analysis is obviously an in depth study, and I know more and more information is arising, I can’t help but question it’s integrity based off the fact that the National Dairy Council sponsored it. I believe that fat is great. I know for a fact low-fat foods, vegetable oils, and all the like is crap. It’s just that….it’s hard to truly, really, whole-heartedly be confident in information, especially when it’s a matter of the quality and longevity of someone’s life that I make recommendations for. What do you think about the NDC sponsoring this study?

  10. Erika says

    Wow, Just ran into this website looking for evidence of antiaging with the rice diet. I know high carb works, because all of my life I have been told of the glories of high protirn, which hurt me as an athlete when I was younger, since mom firmly believed in high protein . Now that I am older,52.was on a high fat raw vegan, felt awful..fid paleo and primal..same thing. Actually all the fat was clogging my arteries and making things much worse. Been LOW FAT vegan for a year..huge difference. Can chug up mountainsides that most 20 somethings can’t take, never pout of breath and my brain is so clear…wish I knew about it in my 20s..In short, you are lying to people..

    • Bill Dunshie says

      Erika, I agree 100% ! I’ve been on a similar regimen suggested by Esselstyn and Campbell’s work (which I find lacking here, with a prevalence of conjecture). And, I do find the authors name linked to several “buy me” sites, indicating not only a lack of information by the author, but a vested financial interest. Quack. Quack !

      • Joy says

        Erica and Bill, you are so right. I had been on a low fat primarily plant based diet for the best part of 30 years. It had served me well and I knew nothing but good health and vitality during this time. I took up bodybuilding, and was persuaded to add significant amounts of animal protein to my diet. 1g per lb of bodyweight they told me. OMG, after almost 2 years of this I had developed gout, felt terribly lethargic, in fact I felt absolutely awful. Then I discovered the works of Doctors Caldwell, McDougall, Barnard, and the rest of the wonderful PCRM doctors. I dropped all animal products and processed oils. Within days the gout had eased and I have since proceeded to get my life and health back on track. The change in my health and outlook is nothing short of miraculous

      • Michael Sanders says

        This is the diet I am on, I cannot call it a diet but rather a way of life now! I feel great, cheers to Dr. Esselstyn and Dr Campbell. It has been life changing..

        • Richard says

          There are many that have almost the same diets, the primary focus on whole plant-based products and limiting animal products…Just like in the five Blue Zones containing an extra ordinary high number of people long-lived and over 100.
          I like to see more evidence that Dr Joel Furhman can reverse heart disease because his diet is the most flexible in my opinion and allows nuts/seeds and avocado. He is not a proponent of low-fat like Ornish and Esselstyn.
          No long-living cultures has totally eliminated animal products and kept fat at 5-10% of calories.
          Of course, with their diets they did not build heart disease so had no reason to reverse it.
          More studies are needed, anyone denying that knows little about nutrition.

  11. Jan says

    Hi Chris,

    Thank you so much for writing this article. I too just received my results and everything else seemed fine, except for the LDL-P. That was high. I also would like to thank Winslow Strong for bringing in the APOE4 allele into the conversation in conjunction with your findings/causes section in regards to how genetics can play a role in this predicament. Brain vs Heart!

    I was cooking with lard, using more butter for my brain (from the Grain Brain book) and taking in extra coconut oil like many others have been doing (for 3 yrs). I’m grateful that you brought this important information to our attention, as I too will have to adjust to less saturated fats. I’m guessing that it’s ok to still cook with coconut oil, but not to take the extra tablespoon that has been recommended by many. I printed out this article for my functional doctor as well. I hope this isn’t your last article on the subject, Chris. It seems that there are more of us out there that could use some advice. We a grateful for your work and research.


    • Michael A says

      Ive just beem told i have a 30% blockage and i am only 36 yrs old

      How can I unblock my artery. Ive started taking fish oil, magnesium, VC and eating heaps of veggies and zero trans and sata fats. 1 hr per day exercise as well.

      Any advice will be welcome as I will do anything to reverse it…

      • Auggiedoggy says

        There is only one diet that has been clinically shown to reverse atherosclerosis – a low fat vegan diet. Sounds drastic? How does progressing heart disease sound? Eating saturated fat like the people in this forum propose will do nothing but worsen the problem. Look at what Drs. Esselstyn and Ornish have accomplished with their dietary recommendations. I would also start drinking pomegranate juice. I drink a cup a day. Get exercise every day. A daily brisk walk is ideal.

        • Richard says

          I do not know where you get your information but Ornish and Esselstyn with low-fat diets are not the only doctors to reverse heart disease.

          Dr Joel Furhman recently and Pritikan decades ago have reversed heart disease with a less strict diet but 90% of calories being whole plant-based while allowing 15-30% fat calories but only 5% of calories from animal products.

          I am not trying to indicate that the final science on this is complete. I certainly think much more research is needed but it appears there may be more flexibility than only 5% fat calories…

          • Auggiedoggy says


            Maybe I wasn’t clear. I was referring to *published* studies. Did Fuhrman or Pritikin publish their findings? Furhman may allow small amounts of lean animal foods but his ideal diet, the one he advertises and personally follows himself is a vegan diet. Even Ornish allows skim milk and egg whites in limited quantities but that’s about it as far as animal foods are concerned. He too recommends a VLF vegan diet. Esselstyn is stricter as his reversal diet is a VLF vegan diet.

          • Auggiedoggy says

            Please provide the source(s) that show Pritikin and Fuhrman have reversed heart disease. I’d be interested in having a look at it.

  12. says

    Thanks for writing this series. Heart Disease, Obesity, Diabetes… these are all things that can be avoided with the right diet, exercise, and smart supplementation as insurance against imperfect eating. We need more education, actually more wisdom when it comes to nutrition and health. It’s heartening to see the FDA’s recent ban on trans-fats.

  13. Rory says

    So glad to have found your website Chris.

    I had been on a very high carb diet and had low HDL and high triglycerides. TC was 185, so decided to try the Paleo diet. Right away my HDL soared to 67 within 2 months which was great. I always had a high carb, low fat diet and was always puzzled why everything was normal except my HDL which was under 40.

    Now a year after being Paleo, my results are not so good. TC was 240, LDL-156, HDL-57. But what was concerning was that my small diameter LDL was 56 and over 40 was high risk. The very thing Paleo is supposed to reverse? So maybe I went to much to the other side and getting an NMR profile done for baseline peuposes. Now Im going to try the Mediterranean version of the Paleo diet as for some reason my body is not liking the strict Paleo, Strangely I wasn’t really ingesting that much more saturated fat and most of it is already coming from olive oil and avocado.

    Will test again in 3 months.

    • Dennis says

      I have been where you are Rory. After about 8 months on Paleo, my cholesterol went up to 14.2 mmol/L. LDL 12.14 , HDL 1.70, Trigs 0.8 mmol/L (as a vegetarian 10 years ago TC was quite high with over all Cholesterol of 6+ ,but HDL was high and protective, but I felt like shit as a vegetarian).
      It seems I need the carbs because my thyroid TSH was higher at 4.24 miu/L. Maybe hypothyroid is going on here for me, and I am slim at almost 10 stone so the doctor does not recognise a problem.
      I am trying the Ray Peat way this last little while and am hoping to get my numbers re-tested soon, and hope they are better.

    • Rob says

      Seriously? Are you actually surprised that eating more animal fat and protein was going to do anything but adversely affect your cholesterol? I hope you’ve learned your lesson.

  14. Heather says

    Looking at all these LP-IR scores – mine is 44. I’m at the 50th percentile in the reference population. I have a father on dialysis and an older brother who is diabetic. I’m seeing single digit numbers and mine is in the double digits. Is mine bad? I know my pancreas are a bit dysfunctional – I honestly believe that my pancreas just can’t produce enough insulin to handle the healthiest version of the SAD (out of 11 established genetic markers for T2D I have 6 increased and 5 decreased and the increased risk markers seem to center around the amount of insulin my body can produce and my beta cell health). I have a nasty Reactive Hypoglycemia response but I don’t have Metabolic Syndrome. I know I have the potential to become diabetic because I monitor my blood sugars and have seen some crazy numbers and fluctuations. This worries me a bit.

  15. Stephen says

    This is a great article about heart health. But I would have liked to see some mention of oral health. There have been hundreds of studies done linking oral health and heart disease. If you improve your oral health, your outlook for heart disease is much better. A product such as the Beam Brush can improve your oral health literally before your eyes. The Beam Brush is a data collecting manual toothbrush with an Android/iPhone app to help engage, inform, and reward great oral health. Find out more at

  16. rob says


    Do you have specific recommendations about the type of meat people should be eating? obviously, nothing processed…What are your feelings about the studies indicating that those who eat red meat have a several fold increase in CVD risk over those who eat red meat sparingly or not at all–based on some supposed pro-inflammatory effect specific to red meat? There is so much contradictory information out there, hard to know what to believe.

  17. Larry says

    I have been on a low carb diet for 3 years now and on Paleo for about 6 months now. I got my VAP test results today and all of my numbers look good except for LP(a) which is 14 mg/dL and my doctor suggested taking niacin. However, everything I’ve been reading says that taking vitamin C, L-lysine, and L-proline will reduce LP(a). It doesn’t appear that there is any way to change LP(a) naturally. So what is the answer?

    My VAP Cholesterol Test results:
    Directly Measured LIPID

    Total LDL- C Direct – 90
    Total HDL – C Direct – 48
    Total VLDL-C Direct – 16
    Sum Total Cholesterol – 154
    Triglycerides – Direct – 60
    Total Non-HDL-C (LDL+VLDL) – 106
    Total APOB100 CALC – 74

    For Clinical Judgment in Setting LDL C Goal
    LP9(a) Cholesterol – 14
    ILD-C – 7
    Real-LDL-C – 69
    Sum Total LDL-C – 90
    Real – LDL Size Pattern – A

    Remnant LIPO (IDL + VLDL3) – 16

    Consider Insulin Resist/Metabolic Syndrome – No

    Sub Class Information
    HDL – 2 (Large, Buoyant) – 13
    HDL-3 (Small, Dense) – 35
    VLDL-3 (Remnant LIPO) – 9

    • Larry says

      It seems there is no definitive answer for the high LP(a). Some say that anything less than 30 mg\dL is okay while others say 20 mg\dL and my test says less than 10 mg\dL. The more I read about this the more confused I become. Since I have pattern A LDL, I’ve decided to do nothing about my LP(a). I think the treatment to bring down LP(a) is more risky that just leaving it alone, especially if you have pattern A LDL. I suppose I could be wrong about this but there is really no one for me to turn to for answers.

  18. says

    Finally! Thank you, Chris – you have directly and concisely answered the question I have had for a year. Count me in as yet another Paleo eater who had LDL soar after transitioning to lacto-Paleo. I have high TC, high LDL, and high ApoB (which means high LDL-P), but all my other numbers and markers are excellent. In fact, you are describing me perfectly in the “Genetics” paragraph. Now to figure out how to transition to Mediterranean Paleo – I already eat a fair amount of fruit and starch, and mainly have to reduce dairy fat. Sigh.

  19. says

    What a great post, I wish the mainstream media would offer solution orientated advice like this! A few years ago I was told I had a high risk of heart disease due to my weight being out of control. This was the catalyst I needed to turn my life around; through physical activity and eating healthy my life has completely flipped. It’s never too late people :)

  20. pauleis says

    Hi Chris,

    Thank you for providing an explanation of what I have heard called “Paleo-Lipid” syndrome – high LDL-C, LDL-P, TC but good everything else (after going low carb). Per comments on several low-carb/Paleo sites, this is fairly common. (My particulars LDL-P 1850, TG 38, HDL-C 89, LP-IR 3, etc.) My question is this: is there a rule-of-thumb for people with this situation for Fats/Carbs/Protein percentages of calories?

  21. jamesP says

    Great series – very helpful!

    Maybe a closing chapter regarding cardiovascular disease detection would be useful. I’ve heard that a heart CT scan will reveal artery calcification. But is that an accurate methodology/measurement technique? What level of calcification is normal (don’t all people have some calcification)?

    What other viable detection methods are there that a layperson at risk with a high LDL-P could pursue with their MD before an entire lifestyle change is made or statins prescribed?


  22. Heather says

    “…To summarize, I hypothesize that, for the apoE-4 Alzheimer’s patients, defective apoE has led to an impaired ability to transport fats and cholesterol from the blood stream, via the astrocytes, into the cerebrospinal fluid. The associated high blood serum cholesterol is an attempt to partially correct for this defect. For the rest of the Alzheimer’s patients (the ones without the apoE-4 allele but who also have severely depleted fatty acids in their cerebrospinal fluid), we have to look for another reason why their fatty acid supply chain might be broken…” – from the link I posted at the beginning. The essay is hypothesizing. I loved learning more detail about the role of fatty acids and cholesterol in the brain/body.

  23. Adam says

    Thanks for the great info Chris.

    I looked up Soluble fiber & found that each 1 g of Soluble fiber is associated with a decrease of about 2.2 mg/dL LDL-C. Most of the fiber supplements I’ve seen contain about 2 g Soluble fiber per serving. If you consumed it before each meal, that’d be 6 g/day resulting in a reduction in LDL-C of about 13.2 mg/dL. It is something, but it is small. For patients needing just a little help, this seems like a good option. I couldn’t find any info about specific effects on LDL-P, but I’d love to see any data if anyone is studying it.

    Another option I came across is Red yeast rice. One study found that 2.4 g/day resulted in a decrease in Total cholesterol (TC) of ~46 mg/dL with no change in HDL. A Norwegian meta-analysis also found an average decrease in TC of ~35 & an increase in HDL of 6. Apparently it contains Lovastatin, but in a much lower dose than is used in Statin therapy.

    Finally, I found a little bit of info about Berberine, which is mostly used in combination with Red yeast rice, but seems to have effects by itself too. I’m a bit skeptical about Chinese research, but a meta-analysis found an average decrease in TC of ~24 & an increase in HDL of ~2.

    For someone a TC/HDL ratio close to 4, a small reduction in TC & a small increase in HDL could be all that they need. For someone with further to go, adding these small effects together could be an effective option.

    – Adam

    • Pam Schoenfeld says


      My hubby, also named Adam, seems to have genetically high LDL-P with high LDL-C, low triglycerides, good HDL, and IR not a problem. We have been trying to do a more Mediterranean type paleo diet, but it takes some time to undo the WAPF approach that I have been using for the past 13 years, as it works well for me, but perhaps too high in sat fat for him
      Anyway, he started 1.2 g/day of Red Yeast Rice that has 20 mg lycopene and 100 mgtocotrienols in it and we have seen a drop in total cholesterol of 40-50 points in less than 2 weeks, will retest LDL-P in a few months and see if and how that changes. Do you know anything about the mechanism of action for the berberine? I have read that is really helps with blood sugar control, but just wondering how that works on a physiological level.. Also recent study showing that statins (in obese/elderly individuals) reduce exercise benefits has me concerned, despite us increasing CoQ10 to 300-400 mg per day for him.

      • Adam says

        I just learned about Berberine myself, so I only know what I’ve just read, which is not too much.
        Berberine and plant stanols synergistically inhibit cholesterol absorption in hamsters.

        “These findings suggest that the cholesterol-lowering action of BBR might involve a combination of inhibition of cholesterol absorption and stimulation of bile acid synthesis.”
        Extracellular signal-regulated kinase-dependent stabilization of hepatic low-density lipoprotein receptor mRNA by herbal medicine berberine.

        “Our recent studies identified berberine (BBR) as a novel cholesterol-lowering drug that upregulates low-density lipoprotein (LDL) receptor expression through mRNA stabilization.”
        Hepatocyte nuclear factor 1alpha plays a critical role in PCSK9 gene transcription and regulation by the natural hypocholesterolemic compound berberine.

        “PCSK9 is a natural inhibitor of LDL receptor (LDLR) that binds the extracellular domain of LDLR and triggers its intracellular degradation. […] Interestingly, the plant-derived hypocholesterolemic compound berberine (BBR) up-regulates LDLR expression while down-regulating PCSK9.”

  24. steve says

    The title talks about prevention and reversal of coronary artery disease, but i did not see anything that directly discussed reversal. For example, for reversal do you need to be at a lower LDL-P level than for prevention? Should you rather follow one dietary approach over another for reversal?
    An overall question remains as to whether it can be reversed. While improvement in IMT has been shown, there is no similar consistent data with regard to coronary arteries that I am aware of.

  25. jake says

    “’Mediterranean Paleo diet’ in these cases. This means following the basic Paleo approach, but reducing intake of fat and increasing intake of fruit and starchy vegetables. You can still eat fat as it naturally occurs in food, but try not adding as much additional fat to meals, and using more monounsaturated fat than saturated fat.”

    chris, this makes me wonder why this isn’t a perfectly viable option for those of us without a genetic predisposition to high LDLp… seems like this is the diet i eat, and feel best on.

    thanks for writing!

  26. Jenny says

    Chris, In the Genetics section, you say” If you have high LDL-P, but normal triglycerides, HDL, small LDL-P and ….” .
    Is the second one supposed to be LDL-C?

    I think I’m one of the hyper-responders you write about. After going paleo, my cholesterol and LDL-P skyrocketed. I am otherwise healthy, except I need to use bioidentical sex hormones. THIS ARTICLE IS A GODSEND! I am going to adopt a more Mediterranean paleo diet, add more soluble fiber, and learn about which foods to eat containing more monounsaturated fat than saturated fat. You are a blessing!

  27. Steve says

    Thanks so much for this great series. In your practice, have you noticed that reducing a certain type of saturated fat yields better results for people with genetically-driven high LDL-P?

    My LDP-P is 2300 (everything else is great) and I suspect my problem is the copious amounts of pastured cream and butter I’ve been using.

    I see you recommended a more “Mediterranean Paleo diet” approach, but just wondering if you’ve seen a difference in LDL-P when people eat different types of saturated fats, such as coconut oil, versus dairy fats?

  28. says

    I’m really glad I switched to paleo diet. It’s really hard adjusting on the first stage of conversion wherein I could not eat what I usually eat. It feels like I’m torturing myself but willpower is a great factor in this challenge. After reading this post, I feel a sense of satisfaction to all my sacrifices for a healthy lifestyle.

  29. Rodrigo says

    Great posts on CVD! Thank you very much for your work and mainly for share your knowledge!
    Best regards!

  30. says

    Great post, Chris.

    I’ve been wanting to ask you for awhile…many of your posts often refer to what helps to promote weight loss for people, which is very useful for so much of the population.

    I have been chronically underweight my entire life (BMI barely hovering by 18), and I’ve often wondered what is the healthiest way to GAIN weight. Are there particular foods you would recommend for this?

    So far, it seems like sugar and polyunsaturated oils are the only things that succeed in making me gain weight, but I know that is not good. (I used to cook with canola oil before I found out about WAPF.)

    It is certainly not good for heart health, as your post explains. Any advice would be appreciated.

    • says

      Hey JoAnne!

      I can definitely relate! I’ve been underweight my whole life until just recently, and it was always frustrating explaining to people that I eat this way not because I want to lose weight, but for other reasons. How is your gut health? I know I didn’t start gaining weight until getting my chronic digestive issues slightly more under control, but if you don’t have any health problems, that might not be a factor for you.

      In the absence of other health issues or high levels of chronic stress, I think to gain weight you probably just need to eat more food! I think protein is particularly satiating and is one of the main determining factors in appetite, so unless you’re really craving it or you do a lot of weight training, maybe try eating a little less protein and more carbs? You’ll have to assess your individual tolerance for different carby foods, but things like white rice are pretty easy to eat more of, even without significantly decreasing other foods. Dairy too, if you tolerate it well. It’s also quite easy to eat a ton of food if it’s blended, so smoothies can be a useful tool.

      • Heather says

        You can search over at Mark’s Daily Apple (Mark Sisson) for articles about gaining weight on Primal (or Paleo). People who are overweight can lose and people who are underweight can gain. Your body “rights itself”. And Alyssa is correct. Eat more food. Eat more fat – healthy fats – definitely. Eat real whole nutritious foods. It could be gut related even if you don’t feel symptoms. Heal the gut (I’ve had chronic digestive issues also – almost entire life – but I was “chunky” and had a very bloated belly. I was blessed with a Fibromyalgia diagnosis) and you can heal the body. In fact, there was a recent Success story at MDA about someone who gained healthy weight months after starting Primal. You can search that, too. Happy reading!

        • says

          Thanks so much for your advice! I have tried stuffing myself with more food, but it doesn’t seem to do a whole lot for me. I will check out the Mark’s Daily Apple resources. And I have been trying to do more gut friendly eating. I started fermenting vegetables, and my my digestive tract has really improved.

  31. Susie says


    Thank you very much for this. I was wondering what natural therpaies (as mentioned under genetics)you have found to be effective to reduce LDL particle number.

  32. John says

    Re: “dark chocolate has been shown to lower blood pressure and LDL cholesterol”

    The phrase “lowers cholesterol” is often used in articles like this and I wonder if it contributes to the misunderstandings. It seems from the rest of this series and other articles that don’t follow the diet-heart hypothesis that what you eat doesn’t directly affect your cholesterol level. So if these other foods don’t raise cholesterol, is it accurate to say any of them are lowering it?

    Are one of these more accurate? “dark chocolate has been shown to prevent damage that leads to your body generating high LDL cholesterol” or “dark chocolate help heal damage that your body normally heals with boosted cholesterol” or “dark chocolate helps your body repair damage with less cholesterol”

    I feel like it is still hard to reconcile how people talk about cholesterol and what’s really happening so I’m looking for a metaphor that makes more sense

    • Chris Kresser says

      I didn’t say that diet doesn’t affect cholesterol levels, I said that eating saturated fat and cholesterol doesn’t affect cholesterol levels—except in hyperresponders. There are several nutrients that do affect cholesterol levels in most people; soluble fiber is one example, and vegetable oil is another.

      • John says

        I didn’t mean “diet doesn’t affect cholesterol levels” exactly, that’s why I said “directly affect”. I guess I was trying to clarify it from the average person’s perception that cholesterol in their eggs is going straight into their bloodstream. I understand there is an effect but was trying to get a clearer idea of how it worked. If most of the cholesterol in you bloodstream is being created by your body in response to some need, how does a food item raise or lower it? Doesn’t that mean it is causing or preventing whatever stimulus your body uses to determine how much cholesterol to make?

      • Rob says

        Define “hyperresponder”. Is that your term used exclusively for people who are hypercholesterolemic? I’m not hypercholesterolemic but my cholesterol does tend to hover around the high-normal range (190-200mg/dl). A former colleague of mine was truly hypercholesterolemic. Her cholesterol was slightly over 7mmol/L or 270mg/dl and her brother was 13mmol/L or 551mg/dl. Both are on lipid-lowering drugs. My last blood test revealed my TC was 198mg/dl (or 5.13mmol/L). Years ago while experimenting with a LCHF diet it went up to 6.12mmol/L (236mg/dl) and mild angina soon followed. A low fat vegetarian diet brought it down to 180. In my case saturated fat most definitely raises my cholesterol. Given my numbers and how my body responds to saturated fat would you define me as a hyperresponder?

  33. jackie says

    hi chris,
    thanks so much for this article. i just got my blood test results yesterday, and my LDL particle number is 1431. my triglycerides, HDL, small LDL-P, and LDL size are all fine. LP-IR is 10. however, i tend towards hypothyroid, have gut issues, and i may have a chronic EBV infection. AND all my sex hormones are super low, and cortisol is high. could all these issues be the causes of my high LDL particle number? in that case, would you still recommend a lower fat diet with more MUFAs and less saturated fat? i was eating lots of saturated fat in the form of ghee and coconut butter to try to increase my sex hormone production.


  34. says

    Chris, one good source for mono-unsaturated fats you may not be aware of is purified Omega 7. In a small clinical trial run by a board-certified lipidologist, it has shown to reduce C-reactive protein (CRP), a marker for chronic inflammation; the best predictor of heart disease, by an average of 65%, trigylcerides by 35%, and bad cholesterol by 9% — in one month. In the same time period it increased HDL by 4%. It seems to move all the elements of the lipid profile move in the “right directions”. I have more details about the study if you’re interested. Just contact me.

  35. says

    I’m glad that you mentioned the importance of genetic variants with respect to heart disease risk. For example, the ApoE haplotypes seem to be pretty relevant, as evidenced here:
    (see especially Table 4)

    Chris, since many people now have a lot of genetic info at their fingertips courtesy of cheap 23andMe prices, do you have any other specific genotypes to watch for wrt heart disease?


      • jackie says

        hey chupo,

        i’m apo E 3/4. because of this, my practitioner told me to eat lower fat, because i was (still am) eating a high fat diet. what’s your reason behind eating more fat?

        • Heather says

          Same here. Check out the link I posted. Fat and cholesterol are very, very critical to the brain. In Alzheimer’s there’s a break down in the myelin sheath. Fat and cholesterol keep this sheath healthy.

        • Chupo says


          A low fat diet isn’t recommended for ApoE2. We tend to get higher TG and and small dense LDL, which would mean higher LDL-P, on low fat. We are just the opposite of E4 carriers. The link Winslow posted above is a good resource.

    • Heather says

      Thanks. There was a bit of CW in that but it was still some great information there. You got my brain wheels turning, though I ended up doing just a quick search and found this: I’m still reading. It’s a 4 year old essay. And it’s fascinating. I’m a ApoE 3/4 (23andme). 23andme forums is where I heard about the research – using high-fat/cholesterol diets – to treat Alzheimer’s patients…with great progress! I will be researching what references I can but if Dr. Kresser has time in the future I would love for him to look this over. Could if be that high LDL particle number (and high LDL in general – mine’s 150(Fr)/116(Ir); TG = 45) in certain people following the Paleo diet have something to do with ApoE 4? Could it be due to the body needing to produce that much to ensure that enough fat, cholesterol, antioxidants, and nutrients (i.e. vitamin D) is getting to the brain? There’s the possibility that we could also have lower than average HDL (Mine’s 51). ApoE is found in brain HDL and in serum IDL. Could it be that high LDL is beneficial in people carrying the ApoE 4? Back to reading!! {I’m realizing my “journey to health” will never end! There’s just too much to learn!}

      • Chupo says

        It sounds like E4 carriers have to choose between risking heart disease or Alzheimer’s. What a predicament.

      • Heather says

        I had a VAP and NMR done on 6/26 (a little over a month after the CWP). Same blood sample sent to 2 different testing labs gave me different numbers.
        VAP (went to Alabama):
        TC = 220
        LDL = 147
        HDL = 53
        TG = 84

        NMR (went to NC)
        TC = 215
        LDL = 151
        HDL = 53
        TG = 56

        My IR score is 44. I expected this since I do have a dysfunctional insulin response.
        (I will never be veg*n. A TC of 133 is just scary low. I would be really worried about that number. The cholesterol range for lowest all-cause mortality (for men) according to the statin trials was 200-250 for men and 250-300 for women).

    • Jesse Roberge says

      Niacin (standard-flush, not time release, not niacmide) and Fish Oil had wonderful results. Also taking Flaxseed Oil (50% alpha-Linolenic Acid), CoQ10, and Standardized extracts for Hawthorn (Vitexin & Flavenoids), Garlic (Allicin & Allinin), & Olive leaf (Oleuropein). Only the garlic is reducing my blood pressure. My BP without drugs is 145/105. Linsinopril and NIfedipine ER are doing 10pts each. Garlic 5pts. Grapefruit seed extract 5pts (probably from interaction). Gym another 5 pts for about 12 hrs. Trying to push my BP below 115/75 creates elevated heart rate and no net lowering of BP (can only get it down to 110/70 – AHA perfection – going to the gym multiple days succession, and HR stays over 100 for at least 6 hours after workout which it didn’t do prior to durgs+supplements).

      VAP Cholesterol Profile
      LDL Cholesterol 120 =40 mg/dL ZU
      VLDL Cholesterol 16 <30 mg/dL ZU
      Cholesterol, Total 196 <200 mg/dL ZU
      Triglycerides 85 <150 mg/dL ZU
      Non HDL Chol. (LDL+VLDL) 136 <160 mg/dL ZU
      apoB100-calc 91 <109 mg/dL ZU
      LDL-R (Real)-C 99 <100 mg/dL ZU
      Lp(a) Cholesterol 10.0 HIGH <10 mg/dL ZU
      IDL Cholesterol 11 <20 mg/dL ZU
      Remnant Lipo. (IDL+VLDL3) 21 10 mg/dL ZU
      HDL-3 (Less Protective) 43 >30 mg/dL ZU
      VLDL-3 (Small Remnant) 10 HIGH <10 mg/dL ZU
      LDL1 Pattern A 19.7 mg/dL ZU
      LDL2 Pattern A 34.9 mg/dL ZU
      LDL3 Pattern B 34.4 mg/dL ZU
      LDL4 Pattern B 9.7 mg/dL ZU
      LDL Density Pattern A A ZU
      Pattern B Pattern Pattern A
      Small, Dense LDL A/B Large Buoyant LDL

      Seems this is giving densities instead of counts. I don't know if this is saying my small/dense LDL particle count is high or not, but it is definitely saying I have more mass per unit of volume of large bouyant LDL than small dense LDL.

      Diet is unchanged. High fat, high protien, high salt sugar splurges (chocolate). Been going to the gym though.

      9/13/2013 vs 1/11/2014

      Total Cholesteral DOWN from 223 to 194 (196 on VAP)
      Triglycerides DOWN from 185 to 85 (85 on VAP)
      HDL Cholesterol UP from 47 to 64 (60 on VAP)
      VLDL Cholesterol DOWN from 37 to 17 (16 on VAP)
      LDL Cholesterol DOWN from 139 to 113 (120 on VAP)

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