The most important thing you probably don’t know about cholesterol



  • The simplified view of cholesterol as “good” (HDL) or “bad” (LDL) has contributed to the continuing heart disease epidemic
  • Not all LDL cholesterol is created equal. Only small, dense LDL particles are associated with heart disease, whereas large, buoyant LDL are either benign or may protect against heart disease.
  • Replacing saturated fats with carbohydrates – which has been recommended by the American Heart Association for decades – reduces HDL and increases small, dense LDL, both of which are associated with increased risk of heart disease.
  • Dietary cholesterol has a negligible effect on total blood LDL cholesterol levels. However, eating eggs every day reduces small, dense LDL, which in turn reduces risk of heart disease.
  • The best way to lower small, dense LDL and protect yourself from heart disease is to eat fewer carbs (not fat and cholesterol), exercise and lose weight.

Not all cholesterol is created equal

By now most people have been exposed to the idea of “good” and “bad” cholesterol. It’s yet another deeply ingrained cultural belief, such as the one I wrote about last week, that has been relentlessly driven into our heads for several decades.

But once we’ve put on our Healthy Skeptic goggles, which I know all of you fair readers have, we no longer simply believe what we’re told by the medical establishment or mainstream media. Nor are we impressed or in any way swayed by the number of people that tell us something is true. After all, as Anatole France said, “Even if fifty million people say a foolish thing, it is still a foolish thing.”

Words to live by.

The oversimplified view of HDL cholesterol as “good” and LDL cholesterol as “bad” is not only incomplete, it has also directly contributed to the continuing heart disease epidemic worldwide.

But before we discover why, we first have to address another common misconception. LDL and HDL are not cholesterol. We refer to them as cholesterol, but they aren’t. LDL (low density lipoprotein) and HDL (high density lipoprotein) are proteins that transport cholesterol through the blood. Cholesterol, like all fats, doesn’t dissolve in water (or blood) so it must be transported through the blood by these lipoproteins. The names LDL and HDL refer to the different types of lipoproteins that transport cholesterol.

In addition to cholesterol, lipoproteins carry three fat molecules (polyunsaturated, monounsaturated, saturated – otherwise known as a triglyceride). Cholesterol is a waxy fat particle that almost every cell in the body synthesizes, which should give you some clue about its importance for physiological function.

You do not have a cholesterol level in your blood, because there is no cholesterol in the blood. When we speak of our “cholesterol levels”, what is actually being measured is the level of various lipoproteins (like LDL and HDL).

Which brings us back to the subject at hand. The consensus belief, as I’m sure you’re aware, is that LDL is “bad” cholesterol and HDL is “good” cholesterol. High levels of LDL put us at risk for heart disease, and low levels of LDL protect us from it. Likewise, low levels of HDL are a risk factor for heart disease, and high levels are protective.

It such a simple explanation, and it helps drug companies to sell more than $14 billion dollars worth of “bad” cholesterol-lowering medications to more than 24 million American each year.

The only problem (for people who actually take the drugs, rather than sell them, that is) is the idea that all LDL cholesterol is “bad” is simply not true.

In order for cholesterol-carrying lipoproteins to cause disease, they have to damage the wall of an artery. The smaller an LDL particle is, the more likely it is to do this. In fact, a 1988 study showed that small, dense LDL are three times more likely to cause heart disease than normal LDL.

On the other hand, large LDL are buoyant and easily move through the circulatory system without damaging the arteries.

Think of it this way. Small, dense LDL are like BBs. Large, buoyant LDL are like beach balls. If you throw a beach ball at a window, nothing happens. But if you shoot that window with a BB gun, it breaks.

Another problem with small LDL is that they are more susceptible to oxidation. Oxidized LDL, or oxLDL, is formed when the fats in LDL particles react with oxidation and break down.

Researchers have shown that the smaller and denser LDL gets, the more quickly it oxidizes when they subject it to oxidants in a test tube.

Why does this matter? oxLDL is a far greater risk factor for heart disease than normal LDL. A large prospective study by Meisinger et al. showed that participants with high oxLDL had more than four times the risk of a heart attack than patients with lower oxLDL.

I hope it’s clear by now that the notion of “good” and “bad” cholesterol is misleading and incomplete. Not all LDL cholesterol is the same. Large, buoyant LDL are benign or protect against heart disease, whereas small, dense LDL are a significant risk factor. If there is truly a “bad” cholesterol, it is small LDL. But calling all LDL “bad” is a dangerous mistake.

Low-fat, high-carb diets raise “bad” cholesterol and lower “good” cholesterol

Here’s where the story gets even more interesting. And tragic.

Researchers working in this area have defined what they call Pattern A and Pattern B. Pattern A is when small, dense LDL is low, large, buoyant LDL is high, and HDL is high. Pattern B is when small, dense LDL is high, HDL is low, and triglycerides are high. Pattern B is strongly associated with increased risk of heart disease, whereas Pattern A is not.

It is not saturated fat or cholesterol that increases the amount of small, dense LDL we have in our blood. It’s carbohydrate.

Dr. Ronald Krauss has shown that reducing saturated fat and increasing carbohydrate intake shifts Pattern A to Pattern B – and in the process significantly increases your risk of heart disease. Ironically, this is exactly what the American Heart Association and other similar organizations have been recommending for decades.

In Dr. Krauss’s study, participants who ate the most saturated fat had the largest LDL, and vice versa.

Krauss also tested the effect of his dietary intervention on HDL (so-called “good” cholesterol). Studies have found that the largest HDL particles, HDL2b, provide the greatest protective effect against heart disease.

Guess what? Compared to diets high in both total and saturated fat, low-fat, high-carbohydrate diets decreased HDL2b levels. In yet another blow to the American Heart Association’s recommendations, Berglund et al. showed that using their suggested low-fat diet reduced HDL2b in men and women of diverse racial backgrounds.

Here’s what the authors said about their results:

The results indicate that dietary changes suggested to be prudent for a large segment of the population will primarily affect [i.e., reduce] the concentrations of the most prominent antiatherogenic [anti-heart attack] HDL subpopulation.

Translation: following the advice of the American Heart Association is hazardous to your health.

Eating cholesterol reduces small LDL

The amount of cholesterol in the diet is only weakly correlated with blood cholesterol levels. A recent review of the scientific literature published in Current Opinion in Clinical Nutrition and Metabolic Care clearly indicates that egg consumption has no discernible impact on blood cholesterol levels in 70% of the population. In the other 30% of the population (termed “hyperresponders”), eggs do increase both circulating LDL and HDL cholesterol.

Why is this? Cholesterol is such an important substance that its production is tightly regulated by the body. When you eat more, the body produces less, and vice versa. This is why the amount of cholesterol you eat has little – if any – impact on the cholesterol levels in your blood.

Eating cholesterol is not only harmless, it’s beneficial. In fact, one of the best ways to lower small, dense LDL is to eat eggs every day! Yes, you read that correctly. University of Connecticut researchers recently found that people who ate three whole eggs a day for 12 weeks dropped their small-LDL levels by an average of 18 percent.

If you’re confused right now I certainly don’t blame you.

Let’s review what we’ve been told for more than 50 years:

  1. Eating saturated fat and cholesterol in the diet raises “bad” cholesterol in the blood and increases the risk of heart disease.
  2. Reducing intake or saturated fat and cholesterol protects us against heart disease.

Now, let’s examine what credible scientific research published in major peer-reviewed journals in the last decade tells us:

  1. Eating saturated fat and cholesterol reduces the type of cholesterol associated with heart disease.
  2. Replacing saturated fat and cholesterol with carbohydrates lowers “good” (HDL) cholesterol, raises triglyceride levels, and increases our risk of heart disease.

Dr. Krauss, the author of one of the studies I mentioned above, recently said in an interview published in Men’s Health, “Everybody I know in the field — everybody — recognized that a simple low-fat message was a mistake.”

In other words, the advice we’ve been given by medical “authorities” over the past half century on how to prevent heart disease is actually causing it.

I don’t know about you, but that makes me very angry. Heart disease is the #1 cause of death in the US. Almost 4 in 10 people who die each year die of heart disease. It directly affects over 80 million Americans each year, and indirectly affects millions more.

We spend almost half a trillion dollars treating heart disease each year. To put this in perspective, the United Nations has estimated that ending world hunger would cost just $195 billion.

Yet in spite of all this money spent, the best medical authorities can do is tell us the exact opposite of what we should be doing? And they continue to give us the wrong information even though researchers have known that it’s wrong for at least the past fifteen years?


Sometimes it seems like everything is backwards.

How to reduce small LDL

Eating fewer carbs is perhaps the best place to start. Reducing carbs has several cardio-protective effects. It reduces levels of small, dense LDL, reduces triglycerides, and increases HDL levels. A triple whammy.

Exercise and losing weight also reduce small, dense LDL. In fact, weight loss has been shown to reverse the evil Pattern B all by itself.

As we saw above, eating three eggs a day can reduce our small LDL by almost 20%. Interestingly, alcohol has also been shown to reduce small LDL by 20%.

In other words, if you want to reduce your risk of heart disease, do the opposite of the American Heart Association (and probably your doctor) tells you to do. Eat butter. Eat eggs. Eat traditional animal fats. Reduce your intake of carbs, vegetable oils and processed foods, and stay active and within a healthy weight range.

Testing your small LDL level

I’m not a fan of arbitrary testing. Our medical system is obsessed with testing. But where has testing has brought us with cholesterol and heart disease? Has it improved outcomes? On the contrary, we test for a number (total LDL) that tells us very little, and then medicate it downwards recklessly and expensively.

If you’re worried about your small LDL level, my advice would be to eat fewer carbohydrates, eat plenty of saturated fat and cholesterol (instead of vegetable oils), exercise, lose weight if you need to, and have a drink every now and then! Since this is the same advice I’d give you if you took a test that actually showed high levels of small LDL, I don’t see much value in doing the test.

However, if you need to see the test results to get motivated to make the changes I suggested above, by all means do the test. There are a few ways to go about it.

First, keep in mind that a regular cholesterol test at your doctor won’t tell you anything about your small LDL level. The standard tests measure your total cholesterol, LDL and HDL. But they don’t distinguish between the dangerous small LDL and benign or protective large LDL.

The fastest and cheapest, albeit most indirect, route is to test your blood sugar both before and then 60 minutes after a meal (this is called a “post-prandial” glucose test). The reason a post-prandial blood glucose test can be a rough indicator for small LDL is the same foods that trigger a rise in blood sugar also increase small LDL. Namely, carbohydrates.

Blood glucose monitors are readily available at places like Walgreens and cost about $10. You’ll also need lancets and test strips, which aren’t expensive either. If your post-prandial glucose is higher than 120 mg/dl, that may be suggestive of a higher than desired small LDL level. This test is not a perfect approximation of small LDL, but it’s the cheapest and and easiest way to get a sense of it.

If you want to get more specific, there are two tests I recommend for small LDL that use slightly different methodology:

  1. LDL-S3 GGE Test. Proteins from your blood are spread across a gel palette. As the molecules move from one end to the other, the gel becomes progressively denser. Large particles of LDL cholesterol can’t travel as far as the small, dense particles can, Dr. Ziajka says. After staining the gel, scientists determine the average size of your LDL cholesterol particles. Berkeley Heart Lab. About $15 with insurance.
  2. The VAP Test. Your sample is mixed into a solution designed to separate lipoproteins by density. Small, dense particles sink, and large, fluffy particles stay at the top. The liquid is stained and then analyzed to reveal 21 different lipoprotein subfractions, including dominant LDL size. The Vap Test. Direct cost is $40.

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Comments Join the Conversation

  1. OliasofSunhillow says

    Chris could you clear something up for me. There is a big debate over saturated fat. Those in favour suggest that SF is OK because it produces larger LDL particles even if it does increase LDL count. Would you agree that SF does increase LDL count ie the simplistic count you get at your GP. Now if its LDL particle size we need to worry about and SF increases the size then all is good BUT if SF increases LDL particle number (does it ?, perhaps because as you say this is often concordant with LDL count) then we had better be sure that size is more important than LDL particle number. If as some people are saying, that particle number is more important than size and IF SF does increase number then SF could be a road to disaster. please feel free to correct my thinking

  2. OliasOfSunhillow says

    Chris, I wonder if you can help us all here by editing a list of things that generally all ‘experts’ seem to agree on. At the moment some think sat fat is harmless others think we should avoid it so clearly this does not go on the list. If you could put your own personal views aside for a moment and say, these are the things that hardly anybody is arguing against. here is a start, although some may disagree –
    1. Eat oily fish eg salmon, sardines mackerel etc
    2. Exercise moderately but regularly
    3. Avoid sugar and all foods that are high in sugar
    4. Avoid inflammatory food products eg veg oils, trans fats etc

    OK I could go on but maybe that’s a start. Perhaps others would like to add but remember only things go on the list that you would hard pressed to find an ‘expert. who disagrees

    • Danny says

      That’s kind of an odd request IMHO, asking someone to put his personal views aside, then tell us what we should eat?

      Everyone, including Chris, has their personal bias, and just because overall studies may show a certain trend, doesn’t make the flawless.

      Who is ‘an expert’? Chris? Paul Jaminet? Ray Peat? There are extremes everywhere, but who is ‘correct’?

      Peat, by the way, firmly believes that sugar is essential, and that polyunsaturated fats, including omega 3 fats from fish, are extremely harmful to mitochondrial function, among other things. That’s just one example.

      Eventually you end up with folks afraid to eat almost anything, because there are so many health ‘gurus’ out there telling them this is bad, this is good.

      It’s called orthorexia.

      • Oliasofsunhillow says

        I am not asking him to tell us what he thinks we should eat, I am asking him what items of advice seem to be agreed upon by all ‘experts’. He talks to a many people on this subject and reads more than we do on the topic, what I am asking is what seems to be the common ground. For example I doubt anyone would disagree with Fish oil as a useful supplement given the mountain of evidence. If this is the case then any reader should add this as a core addition to their lifestyle

        • Tyler says

          Oliasofsunhillow, I think you will find many experts who don’t agree with fish oil as a supplement (for a number of different reasons). Danny mentioned Ray Peat – I am pretty sure he wouldn’t recommend it, nor Paul Jaminet for that matter. Paul would prefer you ate cold water wild caught fish each week and Ray Peat would prefer you to eat non-fatty fish (too many Pufa’s in fish oil. Not to mention problems others have with mercury levels, quality control, rancidity etc. So, I would say, no general consensus on Fish Oil. You might have better luck with them all agreeing on needing to breath air and drink water – that may be their only common ground.

          • Oliasofsunhillow says

            OK so we strike out fish oil. I will throw another one into the mix for agreement or rejection. Get exposure to daily sunshine. This is based on the evidence that heart disease is more prevalent in the northern hemisphere and the Cholesterol Sulphate idea

  3. DM says

    total cholesterol 116
    LDL-C 55
    HDL-C 44
    Triglycerides 98
    LDL-P 1548 (down from 1870)..
    HDL- P (total) 29.9

    BP- normal

    age 46 (Male)
    exercise 3-4 times per week.
    weight 176

    Been taking Statin 20mg (Atoravastin)
    recently taking 10mg (Zetia), past year. (lowered LDL-P, although not enough)..

    I watch my diet, although am not quite sure what is Best to eat, based on all of the material which is out there? High fat or no fat? Good Fat or bad fat?

    any suggestions would be appreciated.

    thank you

    • Marcia says

      Your cholesterol is WAY too low. Studies show that cholesterol below 175 is highly correlated with suicide and other mental and physical health issues.

  4. says

    The individual studies looking at isolated factors (small/big LDL, oxidized LDL, LDL and HDL levels — especially when done with the typical isocaloric feeding design — where people on the lower fat diets actually feel that they are being force fed, as they tend to naturally consume fewer calories if allowed to eat ad libitum) are very artificial. The best evidence is still population studies (e.g. the impact of replacing the traditional Finnish high cholesterol, high saturated fat, high egg, etc. diet with an AHA type diet dramatically lowered cardiovascular deaths; e.g. despite diminished exercise and massive weight gain, cardiovascular deaths in the USA have fallen dramatically, in concert with the lowering of saturated fat and cholesterol intake; e.g. the Ornish studies on actually reversing coronary vascular disease; e.g the relationship between population diets and coronary heart disease globally, etc. etc. etc. And the other thing is that there is no one size fits all diet. It may well, be (as a thought experiment) that a higher carb diet may be harmful for a sedentary person, yet may be optimum for a person having regular, vigorous exercise. It’s entirely possible to perform a clinical trial with an “n” of 1 and determine, for one’s self, what type of diet is most optimum for one’s individual goals (weight control, reducing cardiovascular risk factors, reducing cancer risk, food enjoyment, etc.). – Larry Weisenthal/Huntington Beach CA

  5. Steve Berry says

    Highly informative article, as usual.
    Update for you on the concept that size of LDL particle has relevance, Peter Attia, M.D., has conveyed this is no longer considered to be accurate, per the following quotes from his article, The Straight Dope on Cholesterol, Part V: “…once adjusted for particle number, particle size has no statistically significant relationship to cardiovascular risk…The number of particles is what increases atherogenic risk, independent of size…Once you account for LDL-P, the relationship of atherosclerosis to particle size is abolished (and even trends towards moving in the “wrong” direction – i.e., bigger particles, more atherosclerosis)…A small LDL particle is no more atherogenic than a large one…A particle is a particle is a particle.”
    Thought you’d find this updated info of value.

    • OliasOfSunhillow says

      Attia says that consumption of Cholesterol has no effect whats so ever on cholesterol levels. Chris Masterjohn says that this is true for 80% of people. I am here to tell you that Chris Masterjohn is correct. Now whether you want to be concerned about levels is up to you but to say Cholesterol consumption for all is irrelevant is simply not true.

      • Dan says

        Agreed. I have a form of venous insufficiency in my legs, which has prevented me from increasing my dietary cholesterol levels, as within hours I’ll develop either worsening cramps or a restless leg syndrome-like sensation. (If I had been properly diagnosed years ago perhaps this could’ve been prevented.)

        My point is that not everyone can just eat whatever types of so-called “healthy fats” and not have at least acute consequences.

  6. Erin says

    Hey Chris,

    I find your post refreshing and validating of my own beliefs about cholesterol. However, I am still struggling with getting my husbands doctor on board as he is a pill pusher. My husband recently had is cholesterol checked and the results were
    total 238 < 200
    LDL-160 40
    Triglycerides – 92 <150

    This is the first time he has had a higher LDL but his HDL has also increased from 35 to 55. His doctor wants to put him on a statin, then his best friend who is also a doctor is telling him that its wise because statins have been shown to increase longevity more so than diet and exercise and that only changing his diet and increasing exercise is pointless. They also told him that his recent diet (aka eating poorly over thanksgiving) would of had no effect on the LDL ( it was drawn 7 days post holiday treats).

    I struggle with this as his primary doc has told him to decrease fats, milk and other dairy and get on a statin. We never drink cows milk, only almond or coconut. We do not eat fried food and most of our fats are from meat, coconut oil, olive oil, grassfed butter, avocados and other good oils like hemp and flax. Yes we do still consume sugar but not a lot as we barely eat refined carbs and if we do eat carbs its lentils, or actual whole grains like farro, quinoa, cous cous etc. The pasta that we eat is usually quinoa or buckwheat but we do sometimes eat WW pasta.

    I am close to becoming a nurse practitioner and greatly dislike pill pushers so any advice would be wonderful. Thanks in advance.

    • OliasOfSunhillow says

      It was wrong of the doctor to say that about the post 7 day. It depends on your husband and how he reacts lipid wise to foods, but I can tell you it is certainly possible that his ‘binge’ for want of a better word would have effected his lipid readings

  7. says

    This has been my most insightful en-vogue dissertation go-to on this subject, particularly since I have atherosclerosis with 4 stents within 2yrs time.

  8. Lisa B says

    I need to help my 82 y.o dad lower his triglycerides… pls any advice is appreciated. History: tia stroke 3 years ago (taking plavix and baby aspirin)), high blood pressure (lisinopril), lipitor (only 20mg because higher he gets sick), borderline diabetis on Metformin.
    levels: triglycerides 339 Yikes! ,cholesterol 182, HDL 34 LDL 80 blood HCT 52.9
    This has been an ongoing problem for him mainly due to diet and lack of exercise. But his cholesterol is at least better now,
    Now that he lives with me and I can see what he eats, I am not convinced this high triglyceride number is just food… his diet includes some bread, he cant break the habit and mentally there are some challenges. Dr wants to put him on Welchol , gradually going up to 6 pills… i know he would not take them.
    I am very interested in the Paleo diet for me too, just starting to learn. But I am afraid of adding fats to my father’s diet with those levels. any advice is welcome.
    Thank you so much

    • Scout says

      Hi Lisa,

      3gr Acetyl-L-Carnitin, 1gr Taurine and at least 3gr EPA/DHA from Fish Oil or 4 capsules of Krill Oil will make a nice stack. And reducing the carbs, mostly important fructose: soda pops, fruit juice (fruits are OK) and sugar. Increase his intake of protein instead!

  9. Joanne says

    Hi, after being on a low carb, and high animal fat diet ( for one month).. I went for a lipogram,
    my triglycerides level dropped from 2,27 to 1,85, so I was happy..
    but why did my HDL levels drop, from 2,04 to 1,79.
    Also my cholesterol to HDL ratio increased from 3:9 to 4:5

  10. Mark says

    I have asked two doctors and two cardio’s here in the Uk where I can get a LDL particle size test and none of them even knew what I was talking about. Where can I get such a test in the UK. I have linked to your excellent blog Dr Kressler via mine which shares my experiences here in the Uk

    • Maggie says

      Hi Mark,
      Re your question on LDL particle size test: I don’t know either where you can get such a test in this country (the UK), but please let me know if you ever find out! I’m desperate to debunk this cholesterol myth that so many of my friends have succumbed to – at a high cost, as the side-effects of the statins they take show. Any argument helps.

      • Mark says

        I have found that BlueHorizon do a particle size test. You will have to go to London to give blood for the test. Google Bluehorizon and give them a ring

  11. Russ Anderson says

    I respect what you have to say and I appreciate it. I also respect what Peter Attia has to say on this subject. He makes a very persuasive case that it is LDL particle count that predicts risk. You seem to indicate that it is LDL particle size. I am therefore confused and would love for this to make sense somehow. As a person with a traditional cardiologist who is anxious to put me on statins, I would really appreciate your comments on this.

  12. Mitch says

    Why didn’t Chris respond to TheVenerableBede
    JULY 15, 2013 AT 10:21 AM about the Esselstyn program for “Preventing and Reversing Heart Disease.” His program even unblocked a Left Main blockage without surgical intervention. Please respond to your readers who are sucking down coconut oil.
    President Clinton is on the Esselstyn program.

    • Dave T says

      Yes, why not comment? I can tell you that following the Esselstyn diet cut my LDL-C almost in half, so the theory that not eating cholesterol won’t lower blood levels of it doesn’t hold true in real life.

      Also, Esselstyn and Ornish diets lower HDL and raise small dense LDL. Guess what else they do? Reverse heart disease!

      Back to the drawing board for you, Chris…

  13. Bev says

    Had labs done with physical 11/24/2013. Reported that had night when tightness of neck for over five minutes so got referred for stress treadmill which i passed with cardiologist in room. Received copy of ? normal labs from NP States below Average risk for heart lipid?
    LDL/HDL Ratio 2.12 <3.56
    LDL Cholesterol 125 <100
    VLDL Calculated 16 7-32
    LDL-P Total CT29 1745 <1000
    Small LDL-P29 462 20.5
    HDL Particle CT29 28.9 >40
    HDL-P Large29 8.1 >9
    Apolipiprotein B 100 60-117
    Cholesterol 200 <200
    Triglyceride 82 50
    HDL as % of cholesterol 30 >14
    Chol/HDL Ratio 3.4 <5.8
    What should I do next 60 year old BMI 26 fatique and exhausted most of time

  14. mal neill says

    why does the doctor want to put me on cholesterol medication my levels 6.9 have not changed for the last 20 years l am 78 y.o

  15. Lisa says

    I’ve seen Extra Virgin Coconut Oil mentioned, but I don’t think I saw the reply. It’s high in saturated fat, but when I took it (approx. 1-2 t. a day) my HDL went from 37 to 66, in about a month.

    So…what is the general consensus about coconut oil? Good? Bad? Indifferent?

    Many thanks!

  16. Sharon Smith says

    Would a traditional low-fat, cholesterol reducing diet contribute or cause hip bursitis. I’m already at a good weight for my height but since being told I had raised cholesterol levels for my age I’ve cut out processed food, chocolate, cakes, cut back on carbs but stopped eating cheese and eggs?

  17. Doreen says

    Hi Kris,

    In 1978 my high school history teacher
    use to tell us the wrongs of society. I remember as early as that he told us hydrogenated vegetables oils and trans fats were the worst things for heart health.

    He knew people within the food and drug industry who said the major companies that produced these fats and sold it to the public was also aware of the unhealthy aspects of their product. They mislead the heart and stroke association to endorse their products, though the association was at fault for following blindly. And who knows, someone’s palms probably was greased with hydrogenated oil to pass inspection..

    Funny, this was one of the few facts that stuck in my memory all those years ago in Mr. Moore’s history class….

  18. lenny matthews says

    Very clear and informative site, one of the best I have yet to find…Thank you! Dropping down on my labs, sub-class section VLDL-3 sits at 12 and should be below 10. Is this why I am Pattern “A” ?

    Additionally, the only “out of line” readings on my lab was “total cholesterol” at 207…7 above
    so I don’t understand…the triglycerides are at 81 or is this why I am Pattern “A” ? It stated Remnant Lipo @ 30 which is the cut off and so was high, advising me to lower my LDL-C

    I’m beautiful with both the LDL 114 and the HDL 73

    I am a 60 year old woman…had this done for my Birthday!

    • Adam says

      I don’t know what apoe is. I miss read my results, they are pattern A. Cholesterol and LDL are high but that doesn’t bother me.

  19. Adam says

    What could be the issue if eating paleo for a year but still have 79.9 pattern B? And 30 pattern A
    Am I reading this right?

  20. TheVenerableBede says

    Interesting article, but let me add some confusion about carbs.

    In 2009, I flunked a stress echo TWICE. I then had a heart CT scan that showed triple blockage, and I was told I needed to be cathed and stented. At one point, my cardiologist suggested a triple by-pass.

    I did intensive research and discovered a wonderful book titled “Prevent and Reverse Heart Disease” by Dr. Caldwell Esselstyn. He’s been unblocking patients at the Cleveland Clinic for close to 30 years (he’s not a cardiologist…by I should not digress).

    I adopted his program with my own modifications in Sept 2009. In Nov 2011 I took a nuclear stress test and passed it, showing my heart was receiving enough oxygen at peak load. Then in January of 2013 I re-took the stress echo that I had flunked TWICE in 2009 and passed with flying colors.

    What do I eat? I follow a low-fat vegan diet. By low-fat, I mean calories from fat cannot exceed 10% of my total caloric intake for the day. Other than my morning oatmeal and my dinner wholegrain, both of which are boiled, everything I eat is either steamed or raw. 95% of what I eat is whole foods, not processed. The only processed foods in my diet are flax milk, OJ, guar gum, nutritional yeast for vegans, apple cider vinegar, and blackstrap molasses, most of these being needed for my homemade salad dressing. Nuts are limited to whatever can fit into the palm of my hand. Now that I have unclogged my arteries, I have added a tiny dollop of coconut oil to my oatmeal.

    Most of what I eat is carbs and protein. My CRP is < .20, which means I have little inflammation going on inside me.

    My new cardiologist (I fired the old one who kept wanting to do invasive procedures) has been blown away with these results and tells me to keep doing what I am doing.

    I HEARTily recommend the book referenced above for anyone who has been told they need an invasive cardiac procedure. Following its principles has been the #1 most intelligent health move I have made in my life.

    • Ryan McDermott says

      Yes, but what did your diet look like before this? If you moved from a highly processed diet to a whole foods diet then that is what solved your problem! Humans are very adaptable. All carbohydrates are not inherently bad, that’s the same kind of dogma that got us into the “fat is bad” mess. If you eat real whole foods, whether it’s high card or high fat, it’s better than eating a processed diet. There are modern tribes that get 90% of calories from fat and tribes that get 90% of their calories from carbs. They are all healthy and free of chronic inflammatory diseases. If you eat high carb though you better have good control of your appetite or work out a lot!

  21. Arjun says

    Hi Chris,

    I had a small query.

    I got my cholesterol tested in Dec-2012 & the results were as follows:

    LDL= 177
    HDL= 39.4
    Triglycerides= 139

    Now after 4 months.. I again got tested in April 2013 & Results are as follows:

    LDL = 157
    HDL = 48.2
    Triglycerides = 274

    So My HDL Increased but so did my Triglycerides.

    Hence I am confused as to should I consider this a step in the positive direction or has it gone worse since my last result ?



  22. Telsown says

    What frightens me is not about myself particularly, for even at 62yrs I have been given the information that I will act upon. What do we do about our loved ones who are the previous generation. They have got this far, how do we even begin to explain to them that what they have been told to eat is gradually going to kill them? eg My mother-in-law is a spritely 77yrs, according to our most recent findings she should either be suffering from a diet related complaint or close to death. However, apart from her arthritis she puts the next two generations to shame, she has the ability to just carry on regardless. I am in awe of her strength and commitment to live life no matter what. At weekends I do try to introduce a more healthier diet to her and although she loves what I cook for her she will still go back to her own way when I have left. I guess to be honest, it is not really about us in our 40’s to 90’s+ but more about our children and their children. Please, someone, take on these multi national companies and expose them for what they are: MURDERERING LOW LIFE!!! Who will continue their evil ways even though they are killing their own flesh and blood.

  23. Arjun says


    This is Arjun from India…. A big hello to all of you !!

    I am 29 Years Old and all my forefathers died of Heart Attacks between the age of 70-88 years.

    Recently My father too underwent an Angioplasty for a single Blockage.

    hence now I feel I have a Genetic predisposition towards heart disease in future and want to start precautions early…. I am currently 29 years of Age.

    I need guidance regarding three things pertaining to Heart health :

    1. What is the truth of Aspirin ? does taking a low dose daily Aspirin help ward off future heart disease ?

    2. Does Apple Cider Vinegar have any positive effects on Blood sugar & cholesterol ? or any benefits at all ?

    3. Currently I don’t consume Alcohol…. Should I start consuming 30 ml Brandy post dinner daily ? will it help regarding Heart Health ?



  24. Guy says

    Hi Chris,

    I am a long-term podcast listener, Healthy Baby Code owner and devoted paleo adherent! I eat a couple of eggs a day, as well as coconut oil in (limited cups of) coffee, plenty of delicious butter, salmon, good quality meat, liver, etc. with an average 1-2 beers/glasses of wine of an evening, with the occasional weekend night on the town (6-7 drinks). I eat safe starches such as rice, sweet potato etc., and only very occasionally touch wheat and other grains. I practice intermittent fasting every now and then, often skipping breakfast for a coffee with coconut oil. I work out in a paleo manner – lifting, sprinting, walking, etc.

    Anyway, I just got results back from a blood panel I was required to do for work, and this indicated very high LDL levels (5.87 mmol/l = 226.99149 mg/dl).

    Other key numbers were:

    Cholesterol (total): 7.7 mmol/l = 297.75715 mg/dl
    HDL-Cholesterol: 1.52 mmol/l = 58.77804 mg/dl
    Triglycerides: 0.95 mmol/l = 84.14526 mg/dl

    I hear what you are saying about the LDL count being of limited use, without measuring the different fractions, but should I be concerned to have a number that is SO high? Is this a normal panel for a person like me?

    I want to look into getting the different fractions tested, but am currently based in China and need to do some research into finding a doctor who could do that for me. Not sure whether it’s something that is likely to be offered as standard?

    The doctor also found that my blood pressure is high – around 140/70. This has been the case for a while and was worse before I started paleo: this is one of the main reasons I got into paleo.

    I would be really grateful for your thoughts on this.



      • Mark says


        Forgive me for repeating this, I think I mentioned it before. I have had some very good results with lowering cholesterol numbers when I switched to taking Krill oil tabs last November. There is a Canadian study which showed much higher reductions from Krill than fish oil. The powerful antioxidant within Krill, Astaxathin, may well be the reason

    • Chris Kresser says

      Guy: I’ll be writing a series of articles that will address your question, at least in part, very soon. You might want to check out the High Cholesterol Action Plan, which goes into excruciating detail on this stuff.

      • Guy says

        Thanks Chris :)

        Looking forward to the articles. I don’t suppose it would be possible to give me a brief teaser? The results are pretty worrying and it would be good to know how concerned I should be before I delve further into the details.



        • Guy says

          Hi Chris,

          I have been reading through your articles and specifically the latest podcast and podcasts with Robb Wolf and Chris Masterjohn and think I have a good grasp of your standpoint on this now.

          From what I’ve understood:

          – LDL cholesterol is much less relevant than LDL particle number, so I should really try to find out that number. The breakdown of LDL into large and small particles is also important, but the absolute number is the more meaningful indicator of risk.
          – Some possible causes of high LDL could be low thyroid activity (possible seeing as I was eating pretty low carb for a while, although not super-low) or familial hypercholesterolemia, followed by increased intake of cholesterol due to paleo-style diet. I’m not sure about my parents’ cholesterol numbers, but I don’t think either of them have ever had a major problem with it, so not sure if this is likely to be the issue.
          – Seeing as I am in China and getting tests is relatively complicated, I think I will up my carbs a bit in case low carb was leading to low thyroid activity, eat a bit more seaweed to make sure I’m getting enough iodine and maybe cut down slightly on the saturated fat (no spoonful of coconut oil in morning coffee, etc.)

          Also looking forward to reading your upcoming articles on the subject.

          Thanks for all the info!


          • Chris Kresser says

            Intake of cholesterol has never been shown to raise LDL-P, to my knowledge. Intake of saturated fat can in some people, though. Other causes for elevated LDL-P are infection, intestinal permeability and cortisol dysregulation (aka adrenal fatigue).

  25. John Spezzano says

    Can you refer me to some good material on “hyperabsorbers” of cholesterol and how to manage healthy LDL-P levels for this type of person? Even just suggested websites and/or medical journals would be fine. I’m glad to do the research myself.

    Thank you.

  26. James says

    Great info, I appreciate it. I also have some strange numbers and may be off topic somewhat. I had a Plac Test which came back at 240. My lipid panel has always been high, the last one done at the same time as the Plac Test showed total chol of 254, HDL 77, Trig 56, LDL 166, and a non-HDL chol of 177. I ask because I am a 43 y/o firefighter in what I consider excellent health, 19% body fat, glucose always tests around 90, BP always 110/70, rhr of 50. I work out 5 times a week, eat a low to mid carb diet depending on my workouts, tons of protein and fats, eggs almost every morning, daily fish oil, vitamin D, greens supplement, whey, cod liver oil with butter oil, etc etc. I feel like I do everything I should and then some, but the Plac test number has me worried, I honestly don’t know what else I could do that I am not already doing short of meds. Any thoughts?

    • Andreas says

      Hi James.

      Your lipid numbers are exactly the same as mine and I can see we eat pretty much the same way too. We’re even in the same business =) Your numbers look fine to me. Remember Total Cholesterol and LDL-C doesn’t tell you much when it comes to predicting atherosclesrosis. Your Trig/HDL ratio is excellent at 0.73! I recently had and ApoB/Apo A-1 ratio done and it came out good (bear in mind we have similar results from standard lipid panel). Ratio was 0.59 with ApoB 1.09 g/L and Apo A-1 1.85 g/L.

      Greetings from Denmark.

    • Sam says

      For the mysterious elevated Plac test – If no other advanced inflammatory markers are elevated ( like MPO which Cleveland labs uses in conjunction with LP Pla2) it can point to bacterial infection of the oral cavity and not just any bacteria but pathogenic gram negative anaerobic bacteria. You could have deep perio pockets ( or a root canal that has gone bad) that is harboring aerobic bacteria or just an over growth of highly pathogenic bacteria no root canal or pockets potentially needed is my understanding as it can happen do denture wearers who don’t have pockets or root canals . This bacteria has the potential to migrate to your arteries via bleeding gums and I suspect deep cleanings, seeding them for arterial plaque formation by eliciting an immune response that drives the plaque formation process. The arterial plaque that is formed from this scenario is not the stable type purportedly but rather the dangerous rupture prone type with a necrotic core (think skin abscess only in your arteries that burst easily which makes them very dangerous) . Getting your gum pocket depths tested to see if you are providing a home for this bacteria is one step however even if they check out ok no 4MM + pockets, then a concurrent step would be to get an Oral DNA test to see if you have pathogenic bacteria in your oral biofilm ( and how much of it ) that is potentially infecting your arteries (arterial plaque has been shown to contain oral bacteria) and elevating the Plac test ( periodontal disease appears to be able to do this) . If you are positive on either or both accounts then you may want to consider taking precautions with dental care until you have corrected the nastiest in your biofilm and or pockets and or root canals to prevent them from continuing to enter your circulator system during deep cleanings where you gums bleed. A potential precaution would be to have a hygienist use a laser (periowave) to disinfect the pockets BEFORE deep scaling and root planning is done so they are not stirring up live bacteria when they dig around in your gums and they bleed. Depending on your oral DNA results it will tell you what specific antibiotics are needed to treat your specific bacteria load if it looks like you should go that route and use antibiotics. At home in between your cleanings you could consider continuing the disinfection on a regular basis by using something like Gly-oxide ( OTC). This would help you keep on disinfecting below the gum line to a certain extent yourself with the help of the point of a gum stimulator and dental floss. Hopefully preventing the oral bacteria from taking hold again in between checkups and professional disinfections. There is also a device called a Perio Tray mouth tray ( think whitening trays but taller to go over your gum line) that you can be fitted for which you put prescribed disinfectant into as prescribed to keep it circulating at the gum line x times per day is my understanding. So if you figure out it is coming from your mouth you can do the treatments and test again ( 1 or so months I think some studies said after your cleaning) to see if you budged the Plac number and got your bacteria under control. Point being just stepping up regular dental cleanings won’t necessarily do if you have pathogenic biofilm that can get into your blood stream during that process. Then keep working it and testing it until you feel confident it is not coming from your mouth.

      IN my personal opinion I feel the Plac test may become a test for sub clinical periodontits or infection of the oral cavity with or without other inflammatory markers but specifically when elevated in relative isolation and backed up with orad bacterial testing. It may also prove out that milder forms of periodontitis that would not land you in a specialist office or even be considered by today’s visual and probing standard to warrant intervention is actually more harmful than we realize and by rooting around in your mouth and causing bleeding in the presence of pathogenic bacteria would no longer be done ( a what were we thinking moment) because it inoculates the arteries with oral bacteria every 6 months. And possibly has the potential to explain what the precise threat from root canals are. That being they have the potential of harboring pathogenic anaerobic gram negative oral bacteria, and the Plac test may provide a novel way to monitor them to see if they have gone pathogenic and need to be looked at because if oral bacteria load is ok and no other arterial markers are up but Plac is on the move it could show you were to look or a smoldering infection.

  27. Arjun says

    I tested my Cholesterol in November 2012 & the numbers were as follows :

    LDL = 171
    Triglycerides = 233
    Hdl = 38

    I was really alarmed at the high triglycerides & took the following steps :
    1. Added 2 Eggs daily to breakfast
    2. added 1 spoon ghee over my curry in lunch
    3. added more walnuts and almonds to diet
    4. ate some raw garlic daily
    5. 30ml virgin coconut oil raw daily
    6. drastically reduced breads, carbs & sweets
    7. 30 Mins walk daily

    I again tested my Lipids in December 2012 that is after 1 month
    Numbers were :

    LDL = 170
    Triglycerides = 134
    Hdl = 40

    In one month Triglycerides fell by 100 Points & Hdl rose by 2 points !!!

    could anyone give thier analysis on this data ?

    • David B. says

      Google “TG/HDL ratio” – it appears to be the best predictor for LDL-P/heart disease that can be gleaned from a standard lipid panel (i.e. LDL-C is discordant with LDL-P, and therefore mostly useless). Without actual LDL-P or ApoB measurements (i.e. the actual number of particles carrying the colesterol vs. the total amount of colesterol) you are really flying in the dark. Having said that, I’ve read that a TG/HDL ratio of above 3.0 is considered at risk – you should be aiming for as close to 1:1 as you can.
      Using your numbers from November, then, yields a HDL/TG ratio of 233/38 ~= 6.1, and after your diet intervention 134/40 ~= 3.35. So, for what it’s worth, it appears you’ve taken a giant leap forward in a very short time!

      • Arjun says


        Checked my Cholesterol again today.

        here are the Results:

        Total: 260
        LDL: 157
        Triglycerides : 274
        HDL: 48.2

        Can you please tell me how this compares with my previous results which you had commented upon ?

        what would be the analysis ? in what direction am I moving ?

  28. says

    Hi Chris,

    I have learned so much from you and can’t thank you enough! Frustrates me when I think about how little I actually learned during my dietetic course work and internship – and I had to pay for that. But I digress…

    I have a question related to HDL. I am currently going through your cholesterol action plan and the podcasts with Chris Masterjohn hoping to hear a discussion on elevated HDL. I have always had higher HDL (70/80) but it is now 135 and has been this high for at least a year. This makes it look as though I have very high total cholesterol so my doc would like to put me on statins (I refuse and am currently looking for a new doc). My mom had the same issue and never went on meds. My question is, what can cause these high levels and is it a concern? I am sure it depends on a variety of factors but if you could just give me somewhere to start, that would be awesome.

    Thanks for all you do!

    • Chris Kresser says

      Hi Michelle,

      HDL over 100 is often a sign of inflammation. I would find a good practitioner to work with to explore potential causes.

  29. Arjun says

    Hi Chris….This is Arjun From India

    I would like to share my cholesterol numbers :

    June-2011 July 2012 October 2012 November 2012

    Total 272 235 255 238
    Ldl 202 151 171 170
    HDl 36.4 37.4 38.4 39.4
    Trigly 163 233 224 139

    Can you please interpret the above numbers to tell me whether I am improving my numbers or is it going worse ?

    I have cut carbs in a big way , started consuming fresh ghee, almonds, coconut oil, fish, nuts, Gugullu & also exercise

    Here are the numbers which I am targetting by June 2013 :

    LDL : 75
    HDL : 75
    Triglycerides : 60

    would the above target be good ?

  30. Kw says

    I have recent labs that my doctor is puzzled by. The two concerning, but not terribly high, labs are LDL-p of 1545 (small 481) and LPIR of 44, which is borderline. The rest of my labs don’t line up with these. Total chlo. 179, HDL 81, LDL 86, triglycerides 58, A1c 4.9, glucose 89. I am a 44 year old female and I am not overweight. This may be of interest, after my daughter was born a postnatal check revealed labs that correlated with metabolic syndrome high chlolesterol (318), high triglycerides (425), low HDL (20’s) . I was probably 15-20 overweight due to pregnancy. After losing the weight, labs returned to normal a few years later (took me a while to lose weight).

    What do you make of these labs? And what do you recommend I do about it?

    • Chris Kresser says

      It’s not unusual to have discordant values of LDL-P and LDL-C/total cholesterol, although that often occurs in people with metabolic syndrome. With your daughter’s situation it seems likely a genetic issue is at play as well.

  31. Jack says

    Chris – just discovered this site and love everything I’ve seen so far. Quick questions:
    1. Still not sure what oxidized means. Do is mean cellar damage?

    2. It terms of energy source is the sat fat will eat different from the stored fat from our bodies?


  32. Mike says


    So I just started checking my blood glucose as a bit of a test, and I’ve seen post prandial BG values 60 min after a meal that are actually lower than before the meal.

    For instance, the other night I came home from the gym (hadn’t eaten in about 8 hours) and was at 94. About 60 min after eating about a pound of ground beef with veggies cooked in ghee and about a half pint of ice cream (it was there, oops) I was at 83.
    Yesterday morning I woke up and was at 106. About 60 min after breakfast of coffee, 4 eggs, bacon, blueberries, and brazil nuts I was at 69

    These seem kinda confusing to me that it drops so quickly, but maybe its a good sign? I have been on a pretty solid paleo and definitely gluten free diet for a while now, though lately I’ve had a bit more sugar than usual.

    Any thoughts? Maybe a podcast question? I plan to track some more numbers and see what happens.

    • Wayne Johnson says

      There’s a difference between Impaired Fasting Glucose, Glucose Intolerance, etc., etc. My fasting glucose is high (some would say pre-diabetic), yet I fail an Oral Glucose Tolerance Test by almost fainting from HYPOglyceria! There’s more than one disease involved in poor glucose metabolism, and sometimes averages are a bad thing to apply to oneself. As for my sdLDL and its relation to post-prandial glucose levels, I would hesitate to assume ANY relation.

      Relating to some of the controversy above, Chris, you haven’t convinced me that because a substance is LESS poisonous than another, that it is protective.

  33. Alex McMillon Jr. says

    Chris, I use extra virgin olive oil on low heat when I cook my egg. If this is not good please give me a better way. I do use better in my grits and oatmeal. Also can I eat an egg for breakfast, lunch and dinner sometimes? And should I discontinue using extra virgin olive oil altogether?



    • Mark says

      My understanding is that rapeseed or Canola oil is better than olive as it is more tolerant of heating and therefore less prone to oxidisation

      • starryice says


        As I understand it, canola and corn oils come under the industrial seed oil category — both are from GMO sources and are high in Omega-6. Regardless of the low oxidation factor, they’re not what I want in my body!

        I use olive, coconut, and avocado oils in moderation. Low heat for olive, medium heat for coconut, and medium-high heat for avocado.

    • says

      Hi Chris!
      So, I’m a bit confused about the part where it says “Reduce your intake of vegetable oils”. From what I gather, reducing intake of carbohydrates (not too much obviously) would raise HDL and lower triglyceride levels. Which would reduce the risk of heart disease.

      My question is, how does reducing the intake of fat received from vegetable oils like, say olive oil, contribute to a reduced risk of heart disease?

      Thanks a bunch for the great article!

        • Jon says

          How do you reconcile your advice to avoid polyunsaturated fats with the large prospective studies that showed better outcomes with the replacement of saturated fats with polyunsaturated fats? Are you aware of the studies showing that below a certain PUFA threshold (around 5-6% dietary intake) more saturated fats increase LDL-C dramatically?

          • Chris Kresser says

            Yes, I am. My answer to that is “so what”? LDL-C is only weakly correlated with heart disease risk; LDL-P is a far more accurate indicator.

            As for the idea that saturated fat is associated with heart disease, a 2010 meta-analysis in the American Journal of Clinical Nutrition showed that:

            …there is no significant evidence for concluding that dietary saturated fat is associated with an increased risk of CHD or CVD.

      • angie says

        i went to the dr.s for my results my scared to death, my ldlp was 1379 and my small ldlp was 612 hdl my large was hdlp was 2.6 she said im at high risk f heart attack plz help,,,

        • Mark Littlewood says

          Hi Angie

          What are you eating, perhaps you could give an account of a typical days food intake. Do you take any dietary supplements ?

  34. Aravind says

    Thanks so much for the quick response Chris!

    Just one last follow-up – is heating/scrambling eggs, which can oxidize the cholesterol and polyunsaturated fat in the egg, the reason you posted above that the better way to eat egg yolks is raw?

    I am just to try understand if dietary consumption of oxidized cholesterol / PUFAs is at all related to the oxidation of the polyunsaturated fat in the LDL membrane that you reference or nothing to worry about. I just love eating my 3-4 eggs per day cooked in butter!

    Thanks so much again for the response

  35. Chris Kresser says

    1) No, not problematic. Studies show that egg consumption (cooked) decreases small LDL, which is the type most likely to oxidize.
    2) When LDL does oxidize (oxLDL), it’s the polyunsaturated fat in the membrane that oxidizes first, not the cholesterol, which is deep in the core of the particle.

  36. Aravind says

    As a follow-up to your comment about eggs – “Cooking will oxidize some of the cholesterol, which makes it less beneficial”. Two questions
    1) Can you explain “less beneficial”? I am incorrect to read this as “problematic”
    2) Related to #1, does oxidized dietary cholesterol having anything to do with oxLDL?

    • Tyler Wilson says

      Agree with you (and many others) on much discussed here. But can’t wrap my head around the “fact” that eating fruit is bad for my heart. Maybe it is our definitions of “large amounts” of fructose that is the problem: What do you mean by large amounts? Are you saying that a person if a person ate grass fed beef and other decent animal protein/fat sources and ate fruit at will, would have an unhealthy heart? In my mind I could not see how a virtual fruitarian – eating at least a small amount of decent protein and fat ( I am not suggesting this is a healthy way to eat) would have an unhealthy heart – MAYBE some other diet induced health issues but not a bad ticker . Please illuminate!

    • Matt Welt says

      I completely agree. Your liver can only store 60g of Fructose at any given time. It is digested differently than other sugars. At my work we push Maximum 2 servings of fruit per day and try to avoid banana’s and push towards berries!

  37. kim says

    Eat less Carbohydrates ???——Like Apples,pears,watermelon,grapes ?
    All Heart Healthy. You better specify for their are Good carbs & bad carbs

  38. Lindsay says

    I guess I am confused… i have read countless articles lately that more or less prove to me that statins are pretty senseless in most cases and that more often than not American M.Ds are clueless as to the genuine affects of saturated fat. So, the confusion is this; why are doctors still pushing statins and telling their patients to eat low fat diets in order to reduce the risk of heart disease? Are they completely unaware of all the mainstream studies that have been published against the use of low fat diets? Or.. more cynically, are they being persuaded by the drug companies to prescribe statins? I guess there could also be another answer; neither.
    Please shed some light.

    • Chris Kresser says

      Most doctors don’t read the scientific literature. They get their information about drugs from the pharmaceutical sales reps. This is a documented fact.

      The drug companies spend billions – literally – each year to perpetuate the myth that statins work. Never underestimate the power of that kind of money.

      The cholesterol hypothesis is part of our cultural paradigm. Paradigm shifts don’t happen overnight. It will take years to reverse the idea that low-fat diets are beneficial.

      One of my favorite sayings is “you can’t fight faith with facts”. Nowhere is it more true than in the case of the cholesterol hypothesis.

      • Mark says

        I think it gos much deeper than a few drug company reps controlling the doctors. No drug company is going to rely on such a flimsy control mechanism. Here in the UK doctors get almost no training in nutrition and their behaviour is controlled by strict guidelines handed down via NICE. It is at this level that the whole show is manipulated

  39. Matthew says

    wow, great article. super informative. I have a question that  just popped into my head. How does cooking effect cholesterol digestion? For example, what is the difference between eating a cooked egg and a raw egg? Does one method make cholesterol easier to digest or more readily available to the body?  Also, great podcast. I hope there’s more coming!

    • Chris Kresser says

      Cooking will oxidize some of the cholesterol, which makes it less beneficial. Raw egg yolks are probably the best way to eat them, provided they come from pasture-raised chickens. Be aware that truly pasture-raised chickens are not available in any stores (including Whole Foods), and must be purchased at local farmer’s markets or directly from a farmer. The ones that say “pasture-raised” at health food stores live in close quarters and don’t actually have access to pasture.

      Glad you liked the podcast. Hopefully more are coming!

  40. says

    I’ve been on a low-carb, high-protein diet since I was diagnosed with hypoglycemia or insulin resistantce in 1973 and consider myself extremely fortunate in having dodged the high-carb, low-fat bullet.  This information about “fluffy” and “dense” LDL confirms my experience that avoiding sugars and high-carb foods is the way to go.  Due to a possible gall bladder problem, though, I’ll continue to go easy on fats.  Overall, a great article.  Thank you!

  41. says

    Carbohydrates are indeed a very broad category and should be “graded” in some manner (another subject). But, as an example, the glycemic index and/or glycemic load is a measure of how fast (or for how long) a food releases sugar into the blood stream.  Whole grain cereals like Cheerios are made from oats and contain relatively little added sugar, but they are classified high glycemic – they raise blood sugar rapidly. Raisins and dates raise blood sugar rapidly. All carbohydrates call for insulin – including unrefined whole grains and fruit. So the issue is blood sugar, which has a very narrow healthy range. I agree that white sugar, high fructose corn syrup, and refined grains (basically just sugar) pose a particular problem because they contain little or no nutirents and metabolizing them causes mineral depletion and adrenal exhaustion. Nonetheless, all carbs – whole grains, legumes, and fruit – eaten in excess – raise blood sugar and cause the liver to manufacture triglycerides and depress HDL. (Triglycerides and HDL have a teeter-totter relationship. When the body manufactures triglycerides, it must dismantle HDL for the proteins.)  Finally, as Chris pointed out above, we vary in our sensitivity to carbs. Dr. Gerald Reaven, the carbohydrate researcher who coined the term “Syndrome X,” now referred to as metabolic syndrome (diet- or diabetes-related heart disease), estimates that at least 25 percent of us are sensitive to carbohydrates in that even eating whole grains and legumes is too much of a carbohydrate load.  Unfortunately, in the ongoing 2010 Dietary Guidelines revision process, none of what we are discussng here is being heard. We are going to get five more years of a carbohydrate-emphasized Food Guide Pyramid and we are going to continue our plunge into the chronic disease abyss –  fueled by too much emphasis on carbohydrates.      

    • admin says

      Thanks for your comments, Alan! Just want to add that it’s very simple and inexpensive to test your blood sugar after a meal. That’s the only way you can truly know how you are responding to various carbohydrate sources. Just buy a blood glucose meter at Walgreens or similar drug store and test your blood sugar about an hour after eating a carbohydrate meal.

      Also, as your metabolic markers improve, you may find that you are able to tolerate more carbohydrate than you previously were without blood sugar spikes. Matt Stone of 180 Degree Health often describes how this happened to him.

  42. says

    According to the late Dr. Robert C. Atkins, citing a Harvard study, the combination of elevated triglycerides and low HDL is the best predictor of risk of heart disease. Also, if your triglycerides are elevated – say over 150 – your LDL will most likely be the small, dense (dangerous) variety. If your triglycerides are below 100, associated with protection from heart disease, your LDL will most likely be the large, fluffy type. Hence, elevated triglycerides – a consequence of eating excess carbohydrates – are associated with small dense LDL and increased risk of heart disease. There’s little reason to argue whether the large fluffy LDL offers protection (in a cause and effect manner) because, in fact, large fluffy LDL is associated with protection from heart disease. What’s wrong with that?     

  43. dan says

    Chris, I’d like to know if by carbs you mean any and all carbs or more the refined carbs.  The studies you mentioned, what kind of carbs did they use?  When I go back to Weston Price, I don’t think he’d have a problem with tubers and starches.  I know you’re familiar with Matt Stone’s 180 degree blog.  I don’t know what his LDL measurements are, but according to him and other anecdotes on his blog who follow the high quality macro diet, he can eat 3 large potatoes and have his glucose postprandial go no higher than 90 or so.  Of course initially, the potatoes spiked his BG levels when he wasn’t properly nourished but overtime his readings fell and fell.  His self-experimentation will need to go on for quite a bit longer, but so far his conclusions are pretty interesting…I mean just as convincing as this blog except with the addition of quality tubers.

    • admin says


      It’s true that there are many healthy traditional cultures around the world that eat starch. For a healthy person who is balancing that starch with sufficient amounts of animal fats and other nutrient-dense foods, it’s fine. But many people in the U.S. are insulin resistant and aren’t able to properly metabolize carbohydrates. A low-carb diet is best for them until they can return to normal physiological function and their insulin/leptin signaling system starts working again. Of course this will vary with each individual. That’s why I like Dr. Davis’s suggestion to check your post-prandial blood sugar after eating certain foods to see what actually happens. I’m going to write a post on this soon.

  44. jegesq says

    Thanks for the links and your thoughts, but again, none of the studies demonstrated that large LDL particles were “protective”.   And Tribble’s study showed more than just size affecting oxidation (recognizing that the study was an in vitro study of the effects of adding copper to unfractionated LDL to induce oxidation).  The question was not simply size but the esterification of the subfraction.   I agree that all studies indicate that the smaller and denser an LDL particle happens to be the more readily it is capable of oxidation, but that’s a far cry from saying that the larger the particle, the more “protective” it is.    Small dense LDL does appear to serve at least some purpose along with larger particles.  More importantly, other factors may be more important, including CETP, and ApoE genotype in terms of the function and predominance of small, dense LDL.  See, e.g.,, in which certain CETP genotype variations in which small dense LDL predominates has been associated with increased lifespans.

    The more important value is not, as you’ve noted, cholesterol, but rather LDL particle count, as in overall particle count.  Virutally all LDL, whether categorized as “large” or small” is fully capable of pentrating the endothelial wall, becoming oxidized and consumed by macrophages, turning to foam cells and eventually atheroma.  The point is that while consuming unlimited SFA’s (particularly from animal sources) will cause a predominance of larger particles, and an increase in HDL, it also causes an increase in the number of LDL particles, regardless of size, and it is the number (not size) which predicts overall risk.  Reduce the number of particles and one reduces risk.  Dr. Davis has recently concluded that it is prudent to consume only between 25-50 grams of fat per meal, rather than unlimited SFA.  Dr. Davis has recently noted:  “Saturated fats have been shown, in controlled feeding studies in which the carbohydrate and protein content of diets have been held stable, to increase intestinal apoB48 production, increase liver apoB100 production, increase chylomicron and chylomicron remnant apoE and ApoCIII content (both of which inhibit lipoprotein lipase, thereby slowing clearance; ApoE increased 2-4-fold) and to have higher levels of chylomicrons and chylomicron remnants, which are also cleared more slowly (Bergeron 1995; Weintraub 1988; Jackson 2005; Thomsen 1999). Compared to monounsaturates like olive oil, saturated fats provoke twice the chylomicron triglyceride response and several-fold greater VLDL response.”   

    I suppose my real quibble is with the term “abundant large and fluffy” LDL.   Abundant suggests that particle number (count, not size) doesn’t matter, and that one can (or should) consume a diet without regard to its effects on particle number, and that just doesn’t appear to be the case.

  45. jegesq says

    A few points:

    1.  Small dense LDL particles tend to oxidize more readily for several reasons, not the least of which is that they remain present in the blood stream longer than larger LDL particles, and thus are exposed to oxidative stresses.   So, the case has been hypothesized that small dense LDL can pose a greater risk.  

    But, in your post above you go beyond simply talking about the increased risk of small LDL-P and instead state that ” Large, buoyant LDL are benign or protect against heart disease”. 

    Do you have any single cite for that to any study, whether a clinical intervention, prospective randomized controlled clinical trial, meta-analysis, lab animal experiments, in vivo or in vitro analysis, etc., which might support the statement that “large fluffy LDL” are in some manner actually protective?     No?   And by citation, I mean to something other than the often repeated statements to the same effect from Dr. BG’s “Animal Pharm” website?    No?   I didn’t think so.    Certainly there is evidence which has tested the hypothesis that small dense LDL-P, or what has been described as “Pattern B” increases the risk of atherosclerotic lesion formation.   But there is not a single bit of evidence which demonstrates the opposite, i.e., that abundant large LDL particles are somehow “protective” or that simply because a person’s LDL consists principally of larger (i.e., >20.6 nmol/l) one need not be concerned with one’s overall LDL-P.   The fact is that LDL-C is a surrogate for LDL-P, and the NCEP ATP III guidelines have been tested over time and in high risk individuals, lowering LDL-C to 70 mg/dl (and the number of LDL-P to <1000 )  has been demonstrated in hundreds of clincial trials to reduce events, reduce the incidence and severity of atherosclerosis and CVD.

    1.  You mention VAP and Berkeley, but there is a third equally effective, and some would say more effective and direct way of measuring LDL particle number and size and that’s with Liposcience’s NMR Advanced Lipoprotein profile.   The method used is nuclear magnetic resonance, different than the methods used by both Berkeley (which as you note uses GGE) and VAP (which uses an ultracentrifugation method).  The cost is about the same as VAP and it’s covered by most insurance.

    3.   Many people have gotten very excited by Krauss’ most recent paper, the one you note was e-published ahead of print.  However, most of the commentators haven’t read it, and are instead relying solely on the abstract.   I find it ironic that most of the critics who are huge proponents of virtually unlimited SFA intake, who frequently criticize such studies as the Nurses’ Health Study, or Framingham, etc., because of what they claim were faulty data collection methods or improper study designs, are now touting this lates Krauss paper, which is simply a meta-analysis using the same data so many have criticized previously.   Meta-analysis can provide greater statistical power, but it also really is only an average of averages, and it doesn’t matter how good the methods used to “scrub” or redefine the data, even the best meta-analysis can’t make bad data into good data.   Moreover, the actual study (not the abstract) concludes that while no association was demonstrated from the data in an epidemiological sense, the authors were also quick to note that absolutely no conclusions could be reached with respect to the effects of consuming sat fats in individuals because the data they were working with was insufficient.   In other words, those who are now claiming that sat fat doesn’t “cause” heart disease are suffering from the same problem that has always been the problem, i.e., there just isn’t enough evidence one way or the other to be certain about causation, and as a result, it would be extremely imprudent to use the latest Krauss study as an excuse to now conclude that eating virtually unlimited amounts of saturated fats, particularly from animals, is “safe” or that it definitely won’t cause heart disease.

    • admin says

      Thanks for your comment.

      I agree that meta-analyses can’t be relied on and often lead to conclusions not warranted by the original study data. I think part of my point in drawing attention to that study is that it was a major study published by a respected researcher in a mainstream peer-reviewed journal exonerating saturated fat as a causative agent in heart disease. That was a landmark event. But we don’t need to rely on it alone to come to that conclusion. There are many, many studies old and new that provide evidence that saturated fat doesn’t cause heart disease. Dr. Eades covers some of the older ones here. Chris Masterjohn reports on a 2006 study in this post. There is the Mozaffarian group’s study published in Am J of Clinical Nutrition in 2004 showing that as the intake of saturated fat increased in post-menopausal women, the progression of atherosclerosis actually reversed. The association was monotonic and continuous. Trials have shown no difference in LDL between people eating more saturated fat and people eating less, on timescales of one year or more (some short trials show a modest LDL-raising effect, but even this appears to be due to an increase in particle size rather than particle number). This study, and others such as MRFIT, the Women’s Health Initiative Diet Modification trial and the Lyon Diet-Heart trial, suggest that reducing saturated fat intake had little or no effect on total cholesterol or LDL (0-3% reduction).

      Then there is the fact that, of the numerous controlled clinical trials examining dietary interventions for heart disease prevention, none has ever demonstrated a beneficial effect of saturated fat restriction. Here is just a sampling of prospective studies spanning half a century showing no association between saturated fat intake and heart disease. Of the twenty-six long-term studies monitoring selected populations for the occurrence of heart disease, only four were able to demonstrate even desperately weak associations between saturated fat and heart disease. Numerous populations consuming high amounts of saturated fat have been observed to enjoy extremely low rates of heart disease. These populations have been consistently ignored by promoters of the anti-fat/cholesterol theory. And there are the studies that I reported on in this post that, when compared with diets high in both total and saturated fat, low-fat, high-carb diets increase LDL-P, increase triglycerides and decrease HDL2b (shifting Pattern A to Pattern B).

      Regarding the protective effects of large, buoyant LDL cholesterol, several studies have shown that oxidized LDL are a far greater risk factor than normal LDL. oxLDL has turned out to be a very sensitive marker of cardiac risk, surpassing traditional markers like LDL, HDL, and triglycerides in most studies to date. This study shows that ox-LDL is more sensitive than the commonly used GRAS criteria. In Meisinger et al’s large prospective study, participants with high oxLDL had a 4.25 higher risk of heart attack than patients with lower oxLDL. oxLDL surpassed all other blood lipid markers by nearly a factor of two. Now, which LDL particles are most likely to oxidize? Numerous studies show that small, dense LDL is more likely to oxidize than large, buoyant LDL. Tribble et all showed that the smaller and denser LDL gets, the more quickly it oxidizes when subjected to oxidants in a test tube. This 1996 study by Savanian showed that lipid peroxides were highest in the dense LDL fractions and lower in the buoyant fractions. Since ox-LDL is one of the most sensitive risk factors for CHD we’re aware of, and since large, buoyant LDL is protected against oxidation when compared to small, dense LDL, then it follows that large, buoyant LDL may be protective against heart disease.

  46. js says

    That your 92 year old grandmother is still alive (thus living MUCH longer than the national median) proves she must be doing something right, or at least that she has good genes.

    • Christopher says

      “She dealt multiple times with clogged arteries and valve replacements.”
      I don’t know about you but I’d like to avoid all that if I could. A change seems like the right thing to do no matter how old you are, it’s never too late. #keto

  47. Forty2 says

    About five years ago I was told that my “cholesterol” was high. Of course my then-MD wanted to put me on a statin drug right away. I also had borderline-high blood glucose levels. I refused the drugs and told him I would treat it with diet. He seemed pretty sceptical but relented. A year later I went back for the checkup and everything was much better, in fact under what’s considered optimal. He asked me what I’d done: cut out all processed food, nearly all grain and grain-based foods, and all sugars. Basically if it didn’t come out of the ground/ocean/farm that way, I wouldn’t eat it.
    Slowly my intake devolved back to including grains, dairy and some sweets and I sure felt it. Recently discovered the so-called Paleo diet which bans dairy, starchy veg, sweets and all grains. Already down about an inch off the waist without exercise, though I kinda miss good hard cheeses. Eh.
    Many conditions can be treated and reversed simply by eating real, actual food, not processed crap. Lean pasture-fed meat, non-farmed seafood, organic fruit and non-starchy vegetables. A bit of a fight to find unadulterated sources, though.
    The USDA food pyramid was brought to you by Con-Agra, Monsanto, and all the other companies with a stake in keeping you fat, stupid, and stuffed with high-margin corn by-products. The profit margin on anything processed is far higher than on real food.

    • Douglas L says

      Watch the movie “Fat Head.” It is usually available free of charge. It is a take off on the movie, “Supersize Me” and it largely debunks “Supersize Me” as it the movie maker filmed his journey through the MacDonald’s menu but with the premise that “I have a brain.” and he would routinely refuse foods that didn’t fit his criteria for a diet that was largely lower in carbohydrates but he ate Big Macs, etc. and surprised his MD by showing weight loss and a drop in Cholesterol, Glucose, and LDL levels. He noted that it shouldn’t surprise anyone that the original protagonist in “Supersize Me”, based on his rules of engagement, ate a diet of about 5000 calories per day. Small wonder he gained weight!

  48. says

    My 92 year old grandmother has been eating low fat her whole life and struggling with high cholesterol her whole life as well. She dealt multiple times with clogged ateries and valve replacements. She’s been baffled because she’s been religious about staying away from the saturated fat and cholesterol and has eaten piles of bran. I think she’s finally starting to relaize it’s not working. She actually went and got some butter.  I told her to add some liver to that as well.

    I have another question to pose about our grand ole food pyramid. We know it’s causing these  problems. I know it’s caused my autoimmune problems and contributed to my childs autism. I’m currently reading Blood Suger 101, and beginning to wonder something else too. Would it be fair to say that eating by the food pyramid also makes diabetes inevitable for some of us?

    • admin says


      There’s plenty of evidence to suggest that a high-carb diet, such as the one recommended for decades by the AHA and ADA, can contribute to diabetes (as well as heart disease). The physiological mechanisms for this are well understood. It’s a tragedy that these high-carb diets are still being recommended.


      • Douglas L says

        The concept of a high carb diet / the food pyramid dates back to George McGovern’s panel on heart disease and sugar. There is a nice article on it done by Mother Jones. Google: Mother Jones Sweet Little Lies .. it’s a good read. I remember well when the whole idea of milk, etc being bad for you because I lived in a rural town and drank milk nearly straight from the cows … and the entire town was pretty skinny. I recall that the “fat girl” in our class was about 5′ 3″ and weighed 135 or 140# .. not very heavy by today’s standards!!

      • Dan says

        Chris, your advice is sound, but every time I try to increase my saturated fat, I get palpitations.

        My blood pressure is high, HDL too low, LDL too high…

        Any suggestions?

    • Arjun says

      The very fact that she has reached an age of 92 means that she has done something right.

      Don’t induce big changes in her life at this age.

      • says

        “My 92 year old grandmother has been eating low fat her whole life and struggling with high cholesterol her whole life as well. She dealt multiple times with clogged ateries and valve replacements.”

        The fact that she has reached 92 doesn’t mean she should just give up on her health and it also doesn’t mean she’s healthy. I know many very old people who are also very sick or bed-ridden or struggle with lots of chronic problems. Doesn’t quality of life matter at all? I say if 92 year old grandmothers want to change their diets, they should. At the very least, she will get to enjoy the wonderful taste of butter again! :)

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