Cholesterol: Plaque Free or Pipe Dream?

Introduction

Picture this: you’re chowing down on bacon, eggs, and a generous slab of butter while your carb-loving mates clutch their pasta bowls in horror. You’re on a ketogenic diet, feeling like a lean, mean, fat-burning machine. But then, your doctor rings with the blood test results: “Your cholesterol is sky-high!” Panic sets in. Isn’t cholesterol the “bad guy”? The greasy villain clogging arteries faster than a toddler stuffs Lego up their nose? Well, hold onto your avocados, because a new study might just flip that script—and it’s a wild ride.

The Study

Meet The KETO Trial, a research gem published in JACC: Advances (August 2024), led by Matthew Budoff and a squad of lipid-obsessed boffins including Nicholas Norwitz, a great science story teller, who can be found on almost all the (un)social media platforms and well worth a follow.

They dove into the curious case of “lean mass hyper-responders” (LMHRs)—folks who, after slashing carbs to ketogenic levels (think under 25 grams a day), see their cholesterol skyrocket while staying metabolically fabulous. We’re talking LDL ≥190 mg/dL (4.9 mmol/L), HDL (the “good” cholesterol) ≥60 mg/dL (1.6 mmol/L), and triglycerides ≤80 mg/dL (0.9 mmol/L). Basically, they’re the unicorns of the lipid world: lean, healthy, and sporting cholesterol numbers that’d make a statin salesperson faint.

Participants had high LDL, high HDL and low triglycerides

The study rounded up 80 of these keto crusaders, who’d been living the low-carb life for an average of 4.7 years, and pitted them against 80 carb-friendly controls from the Miami Heart (MiHeart) cohort. The keto crew boasted a mean LDL of 272 mg/dL (7 mmol/L)—some even hit a jaw-dropping 591 mg/dL (15.3 mmol/L)—while the MiHeart carb lovers cruised at a modest 123 mg/dL (3.2 mmol/L). Both groups were matched for age, gender, and the usual suspects like hypertension and smoking. The big question: would the keto folks’ arteries look like a cholesterol-fuelled traffic jam compared to their pasta-munching peers?

The Results

Cholesterol showed no correlation with plaque

Spoiler alert: NOPE! Using fancy tools like coronary artery calcium (CAC) scores and coronary computed tomography angiography (CCTA), the researchers peeked inside their ticker-tubes. The result? No difference. Zilch. Nada. The keto group’s CAC score was a median of 0 (basically squeaky clean), while the controls hit a measly 1—not exactly a plaque party either. CCTA plaque scores? Same deal: 0 vs. 1. Even more shocking? Cholesterol levels, high or low, didn’t correlate with plaque buildup in either group.

Now, before you start deep-frying everything in sight, let’s unpack this. The keto squad weren’t just high-LDL outliers—they were healthy. Low BMI, sky-high HDL, and triglycerides so low they’re practically whispering sweet nothings to your pancreas. Compare that to the controls, who were metabolically fine but not exactly poster kids with the keto glow. The researchers reckon that metabolic health might be the secret sauce—or should I say secret butter?—behind why their arteries stayed chill despite cholesterol levels that’d make a cardiologist clutch their pearls.

So, What’s the Deal?

Enter the “lipid energy model,” a theory that sounds like it belongs in a sci-fi flick but is gaining traction with every new study. In healthy folks, high cholesterol isn’t a “villainous clog” but an “energy shuttle,” ferrying fuel to cells around the body. When lean people cut carbs, their liver churns out more LDL to meet energy demands—think of it as a cosmic Uber for fat. Does it clog your pipes? After 4.7 years, apparently not.

The Takeaway

Cholesterol’s story isn’t black-and-white—or should I say, bacon-and-egg-white? Context matters. Maybe LDL’s not the bad guy—just a misunderstood guest at the metabolic party. There are more important markers out there (watch this space for future posts!), so next time your doc freaks over your keto-fuelled cholesterol, flash this study and ask: “Are my arteries really mad, or is this just my body’s quirky energy dance?” Then, politely offer them a keto cookie. Science says it might not hurt.