Answer Day: What Causes High LDL on Low-Carb Paleo?

First, thank you to everyone who commented on the quiz. I enjoyed reading your thoughts.

Is High LDL Something to Worry About?

Perhaps this ought to be the first question. Jack Kronk says “I don’t believe that high LDL is necessarily a problem” and Poisonguy writes “Treat the symptoms, Larry, not the numbers.” Poisonguy’s comment assumes that the LDL number is not a symptom of trouble. Is it?

I think so. It helps to know a little about the biology of cholesterol and of blood vessels.

When cells in culture plates are separated from their neighbors and need to move, they make a lot of cholesterol and transport it to their membranes. When cells find good neighbors and settle down, they stop producing cholesterol.

The same thing happens in the body. Any time there is a wound or injury that needs to be healed, cholesterol production gets jacked up.

When people have widespread vascular injuries, cholesterol is produced in large quantities by cells lining blood vessels. Now, to repair injuries cells have to coordinate their functions. Endothelial cells are the coordinators of vascular repair: they direct other cell types, like smooth muscle cells and fibroblasts, in the healing of vascular injuries.

To heal vascular injuries, these cells not only need more cholesterol for movement; they also need to multiply. It turns out that LDL, which carries cholesterol, also causes vascular cells to reproduce (“mitogenesis”):

The best-characterized function of LDLs is to deliver cholesterol to cells. They may, however, have functions in addition to transporting cholesterol. For example, they seem to produce a mitogenic effect on endothelial cells, smooth muscle cells, and fibroblasts, and induce growth-factor production, chemotaxis, cell proliferation, and cytotoxicity (3). Moreover, an increase of LDL plasma concentration, which is observed during the development of atherosclerosis, can activate various mitogen-activated protein kinase (MAPK) pathways …

We also show … LDL-induced fibroblast spreading … [1]

If endothelial cells are the coordinators of vascular repair, and LDL particles their messengers to fibroblasts and smooth muscle cells, then ECs should be able to generate LDL particles locally. Guess what:  ECs make a lipase whose main effect is to decrease HDL levels but can also convert VLDL and IDL particles into LDL particles and remove fat from LDL particles to make them into small, dense LDL:

Endothelial lipase (EL) has recently been identified as a new member of the triglyceride lipase gene family. EL shares a relatively high degree of homology with lipoprotein lipase and hepatic lipase …

In vitro, EL has hydrolyzed phospholipids in chylomicrons, very low density lipoprotein (VLDL), intermediate density lipoprotein and LDL. [2]

Immune cells, of course, are essential for wound healing and they should be attracted to any site of vascular injury. It turns out that immune cells have LDL receptors and these receptors may help them congregate at sites of vascular injury. [3]

I don’t want to exaggerate the state of the literature here:  this is a surprisingly poorly investigated area. But I believe these things:

1.      Cholesterol and LDL particles are part of the vascular wound repair process.

2.      Very high LDL levels are a marker of widespread vascular injury.

Now this is not the “lipid hypothesis.” Compare the two views:

  • The lipid hypothesis:  LDL cholesterol causes vascular injury.
  • My view:  LDL cholesterol is the ambulance crew that arrives at the scene of the crime to help the victims. The lipid hypothesis is the view that ambulance drivers should be arrested for homicide because they are commonly found at murder scenes.

So, to Poisonguy, on my view high LDL numbers are a symptom of vascular injury and are a cause for concern.

Big-Picture View of the Cause of High LDL

So, on a micro-level, I think vascular damage causes high LDL. But what causes vascular damage?

Here I notice a striking difference in commenters’ perspectives and mine. I tend to take a big-picture, top-down view of biology. There are three basic causes of nearly all pathologies:

1.      Toxins, usually food toxins.

2.      Malnutrition.

3.      Pathogens.

The whole organization of our book is dictated by this view. It is organized in four Steps. Step One is about re-orienting people’s views of macronutrients away from high-grain, fat-phobic, vegetable-oil-rich diets toward diets rich in animal fats. The other steps are about removing the causes of disease:

1.      Step Two is “Eat Paleo, Not Toxic” – remove food toxins.

2.      Step Three is “Be Well Nourished” – eliminate malnutrition.

3.      Step Four is “Heal and Prevent Disease” – address pathogens by enhancing immunity and, where appropriate, taking advantage of antibiotic therapies.

So when someone offers a pathology, any pathology, my first question is: Which cause is behind this, and which step do they need to focus on?

In Larry’s case, he had been eating low-carb Paleo for years. So toxins were not a problem.

Pathogens might be a problem – after all, he’s 64, and everybody collects chronic infections which tend to grow increasingly severe with age – but Larry hadn’t reported any other symptoms. More to the point, low-carb Paleo diets typically enhance immunity, yet Larry had fine LDL numbers before adopting low-carb Paleo and then his LDL got worse. So it wouldn’t be infectious in origin unless his diet had suppressed immunity through malnutrition – in which case the first step would be to address the malnutrition.

Step Three, malnutrition, was the only logical answer. The conversion to Paleo removes a lot of foods from the diet and could easily have removed the primary sources of some micronutrients.

So I was immediately convinced, just from the time-course of the pathology, that the cause was malnutrition.

Micronutrient Deficiencies are Very Common

In the book (Step Three) we explain why nearly everyone is deficient in micronutrients. The problems are most severe for minerals:  water treatment removes minerals from water, and mineral depletion of soil by industrial agriculture leads to mineral deficiencies in farmed plants and grain-fed animals.

This is why our “essential supplements” include a multimineral supplement plus additional quantities of five minerals – magnesium, copper, chromium, iodine, and selenium. Vitamins get a lot of attention, but minerals are where the big health gains are.

Copper Deficiency and LDL

Some micronutrient deficiencies are known to cause elevated LDL.

Readers of our book know that copper causes vascular disease; blog readers may be more familiar with an excellent post by Stephan, “Copper and Cardiovascular Disease”, discussing evidence that copper deficiency causes cardiovascular disease. As I’ve just argued that cardiovascular disease causes high LDL, it shouldn’t be a surprise that copper deficiency also causes hypercholesterolemia:

Copper and iron are essential nutrients in human physiology as their importance is linked to their role as cofactors of many redox enzymes involved in a wide range of biological processes, as well as in oxygen and electron transport. Mild dietary deficiencies of both metals … may cause long-term deleterious effects in cardiovascular system and alterations in lipid metabolism (3)….

Several studies showed a clear correlation among copper deficiency and dyslipidemia. The main alterations concern higher plasma CL and triglyceride (TG) concentrations, increased VLDL-LDL to HDL lipoproteins ratio, and the shape alteration of HDL lipoproteins.  [4]

The essentiality of copper (Cu) in humans is demonstrated by various clinical features associated with deficiency, such as anaemia, hypercholesterolaemia and bone malformations. [5]

Over the last couple of decades, dietary copper deficiency has been shown to cause a variety of metabolic changes, including hypercholesterolemia, hypertriglyceridemia, hypertension, and glucose intolerance. [6]

Copper deficiency is, I believe, the single most likely cause of elevated LDL on low-carb Paleo diets. The solution is to eat beef liver or supplement.

So, was my advice to Larry to supplement copper?  Yes, but that was not my only advice.

Other Micronutrient Deficiencies and Elevated LDL

Another common micronutrient deficiency that causes elevated LDL cholesterol is choline deficiency that is NOT accompanied by methionine deficiency. That is discussed in my post “Choline Deficiency and Plant Oil Induced Diabetes”:

Choline deficiency (CD) by itself induces metabolic syndrome (indicated by insulin resistance and elevated serum triglycerides and cholesterol) and obesity.

A combined methionine and choline deficiency (MCD) actually causes weight loss and reduces serum triglycerides and cholesterol …

I quote both these effects because it illustrates the complexity of nutrition. A deficiency of a micronutrient can present with totally different symptoms depending on the status of other micronutrients.

Julianne had a really nice comment, unfortunately caught in the spam filter for a while, with a number of links. She mentions vitamin C deficiency and, with other commenters, noted the link between hypothyroidism and elevated LDL. As one cause of hypothyroidism is iodine or selenium deficiency, this is another pathway by which mineral deficiencies can elevate LDL.

UPDATE: Mike Gruber reduced his LDL by 200 mg/dl by supplementing iodine. Clearly iodine can have big effects!

Other commenters brought up fish oil. They may be interested to know that fish oil not only balances omega-6 to modulate inflammatory pathways, it also suppresses endothelial lipase and thus moderates the LDL-raising and HDL-lowering effect of vascular damage:

On the other hand, physical exercise and fish oil (a rich source of eicosapentaenoic acid and docosahexaenoic acid) suppress the activity of EL and this, in turn, enhances the plasma concentrations of HDL cholesterol. [7]

Whether this effect is always desirable is a topic for another day.

My December Advice to Larry

So what was my December advice to Larry?

It was simple. In adopting a low-carb Paleo diet, he had implemented Steps One and Two of our book. My advice was to implement Step Three (“Be well nourished”) by taking our recommended supplements. Eating egg yolks and beef liver for copper and choline is a good idea too.

Just to cover all bases, I advised to include most of our “therapeutic supplements” as well as all the “essential supplements.”

Since December, Larry has been taking all the recommended supplements and eating 5 ounces per week of beef liver. As I noted yesterday, Larry’s LDL decreased from 295 mg/dl to 213 mg/dl, HDL rose from 74 mg/dl to 92 mg/dl, and triglycerides fell from 102 to 76 mg/dl since he started Step Three. This is all consistent with a healthier vasculature and reduced production of endothelial lipase.


Some people think there is something wrong with a diet if supplements are recommended. They believe that a well-designed diet should provide sufficient nutrition from food alone, and that if supplements are advised then the diet must be flawed.

I think this is quite mistaken. The reality is that Paleolithic man was often mildly malnourished, and modern man – due to the absence of minerals from treated water and agriculturally produced food, and the reduced diversity and higher caloric density of our foods – is severely malnourished compared to Paleolithic man.

We recommend eating a micronutrient-rich diet, including nourishing foods like egg yolks, liver, bone broth soups, seaweed, fermented vegetables, and so forth. But I think it’s only prudent to acknowledge and compensate for the widespread nutrient depletion that is so prevalent today. Even when nutrient-rich food is regularly eaten, micronutrient deficiencies are still possible.

Eating Paleo-style is not enough to guarantee perfect health. Luckily, supplementation of the key nutrients that we need for health and that are often missing from foods will often get us the rest of the way.


[1] Dobreva I et al. LDLs induce fibroblast spreading independently of the LDL receptor via activation of the p38 MAPK pathway. J Lipid Res. 2003 Dec;44(12):2382-90.

[2] Paradis ME, Lamarche B. Endothelial lipase: its role in cardiovascular disease. Can J Cardiol. 2006 Feb;22 Suppl B:31B-34B.

[3] Giulian D et al. The role of mononuclear phagocytes in wound healing after traumatic injury to adult mammalian brain. J Neurosci. 1989 Dec;9(12):4416-29.

[4] Tosco A et al. Molecular bases of copper and iron deficiency-associated dyslipidemia: a microarray analysis of the rat intestinal transcriptome. Genes Nutr. 2010 Mar;5(1):1-8.

[5] Harvey LJ, McArdle HJ. Biomarkers of copper status: a brief update. Br J Nutr. 2008 Jun;99 Suppl 3:S10-3.

[6] Aliabadi H. A deleterious interaction between copper deficiency and sugar ingestion may be the missing link in heart disease. Med Hypotheses. 2008;70(6):1163-6.

[7] Das UN. Long-chain polyunsaturated fatty acids, endothelial lipase and atherosclerosis. Prostaglandins Leukot Essent Fatty Acids. 2005 Mar;72(3):173-9.

Leave a comment ?


  1. Hey Paul,

    I thoroughly enjoyed reading this. I love the top-down approach to nutrition. As a medical student, I often find the “evidence-based medicine”/bottom-line approach very frustrating. One thing I’d add to your three concepts of healthy nutrition (remove toxins, eliminate pathogens, prevent malnutrition) is the concept of hormonal regulation. I know it’s not a novel concept, but I think it belongs with the others in the overall concept of healthy eating.

    Thanks again for the great read.

  2. Hi Ilya,


    Hormonal regulation is very important, but it’s more of internal issue; the others – nutrition, pathogens, toxins – are things that enter the body from outside and thus are fundamental causes of ill health. I generally believe that if you remove these exogenous causes of harm, the body will self-regulate to health.

    If you remove a pathogen or a toxin, or fix a nutrient deficiency, health will almost always improve. However, if hormones are dysregulated and you move them toward “normal” with an exogenous intervention, you’ll often make health worse. The hormonal dysregulation is part of the body’s method for coping with a pathology, and by altering hormone levels you may disrupt the body’s response to the disease, allowing it to do more harm.

    So I would not put hormonal regulation on a par with those three as a cause of disease, or as a target of therapy. Of course, for doctors it is important to know how to read hormonal patterns for clues to what is going on in the body.

    Best, Paul

    • Hi Paul, I’m a bit late to this subject, but am glad I found it, great work by the way. But here’s my issue, if it’s true that low copper serum ( mine has run low for years 25-65 ug/dL) , and that the byproduct of that is high LDL, ( mine runs high between 125-225 mg/dL) and isn’t it also be true that high cholesterol feeds muscles, so in theory, a persons body is trying to heal itself, and although the risk of a heart attack is present of course, the alternative isn’t great either, so what I’m trying to say is that supplementing a body might not be wise, maybe the low copper in the blood is because the body is trying to fix itself and supplementing those lows or highs are actually negating the body’s natural safe guarding systems. Just throwing that out there 😀

      • Hi Glenn,

        LDL of 130 is normal, not high; over 150 is high. So I would say you’ve fluctuated between healthy and unhealthy levels of LDL. The level of LDL cholesterol is inversely correlated to how much cholesterol is being taken up by tissue; when LDL is high it usually means your tissues are not taking up as much cholesterol as they should. So for healthy tissue aim for normal LDL.

        Copper generally shouldn’t be supplemented if you are eating liver, as you should. Even if you aren’t, supplement cautiously.

  3. Hi Paul,

    Hope you had a great New Year. It sucks that I have to post here again with some unexpected test results. Got these in just yesterday:

    TC: 380 (up from 280 on 15th Oct 2011)
    HDL: 84 (up from 81)
    TG: 68 (up from 60)
    LDL (Iranian): 240 (up from 155)
    Total/HDL ratio: 4.52 (up from 3.46)

    I’ll walk you through some of the changes I made between these two sets of tests:

    1) Reduced and eventually eliminated nut consumption

    2) Increase dairy consumption to about half a litre of full cream fresh milk per day

    3) Eliminated olive oil completely and started cooking with coconut oil. Previously, I’d use coconut oil solely for frying omelettes and kebabs.

    4) Consumed an average of 1.5 cans of sardines a day instead of supplementing with fish oil (one can supplies 1.8g of omega-3).

    5) Increased egg consumption from 3 to about 4.5 per day.

    6) Started Intermittent fasting (16hrs everyday) about 8 weeks ago to improve body composition, basically following a slightly altered (higher fat) version of Martin Berkhan’s Leangains approach ( This entails cycling carbs, but I still averaged about 100-150g per day.

    I think I may have gone overboard with the omega-6 reduction and ended up with a very low Polyunsaturated/Saturated (P/S) ratio. Also, my MUFA consumption was also reduced because of the elimination of both olive oil and nuts, while SFA consumption increased (more coconut oil and dairy).

    Stephan mentions the P/S ratio in this post:

    Chris Masterjohn, in an answer to a comment on his blog, says:

    “In your case, maybe the coconut oil is ramping up cholesterol production but you aren’t necessarily having a problem clearing LDL. Coconut really throws the whole “marker” issue out of whack because it increases the energy state of the cell, which increases cholesterol synthesis.”

    He again mentions coconut oil raising LDL:

    ‘There are a number of things that could raise LDL-cholesterol indefinitely and would still be good things. For example, coconut oil will do this, but it will tend to increase HDL-cholesterol much more, so that the total-to-HDL-cholesterol ratio actually decreases. Also, in about 30% of people eggs will do this, but they will tend to increase HDL-cholesterol proportionately so that the ratio doesn’t change, and they will tend to shift LDL particle size toward the “good” “pattern A.” ‘

    I have decided to:

    1) Re-introduce almonds in my diet, around one ounce a day.

    2) Supplement with some fish oil to counteract the omega-6 from the nuts.

    3) Reduce egg consumption to about 2 a day.

    4) Increase starch intake a bit on Workout days while reducing fat (mainly saturated) proportionately.

    I am resisting switching back to olive oil as my cooking oil because I really like coconut oil and have felt great ever since I started using it. It’s winter here and I don’t even feel cold like I used to before. Also, it’s been a year and a half since I was sick.

    Any input would be appreciated, especially if you could comment on my plan of action.



  4. FACTS:
    Male, white, 52
    approx. 130lbs fat-free mass
    Bodyfat: approx. 19%

    GOAL: <10% bf using a LC PaIeo diet combined with Intermittent Fasting which means I must lose at least 17lbs of bf, both subcutaneous and visceral.

    Resistance train 4xs/week
    Cardio interval train 2-3xs/week

    I was dx'd via ultrasound with non-alcoholic fatty liver disease (NAFLD) two years ago. It is indeterminate how long I've had it. Liver enzymes continue to remain within normal range and I notice no symptoms

    I am hypothyroid and have been taking 75mcg of sustained-release T3. My latest thyroid numbers are posted in the link below [p2, 3, 10].

    TSH has improvement over last labs. Both T4 and T3 show depressed, however, I was fasting for nearly 20 hours on the first day. rT3 is less this time, which is a good thing.

    Have been on LC Paleo diet for last three months and doing between a Lean Gains [ ] 16/8 IF protocol to as much as 20/4 IF protocol. I do mini-carb refeeds (about 50-60g) on my workout days only. If I increase carbs more than this, my post-prandial BG will exceed 125.

    What's freaking me out are my latest lipid tests. I had the top three done in a matter of two consecutive days [p2, 5, 11-14].


    If we’re clearing lipids from the liver, then this is a good thing, but HOW CAN I DETERMINE THAT IT'S THIS AND NOT FROM THE DIET ITSELF?

    In other words, is the increase due to CREATION or CLEARANCE (resolution of NAFLD)?

    I have not changed any macros in my diet, maybe slightly more lean grass-fed animal protein, but saturated fat intake has remained constant throughout. And most of the saturated fat is drained because I steam all my meats, so how can it be CREATION?

    The only other fats I eat with frequency are O3s (2-4g), coconut, flax, macadamia and olive oil.

    What evidence supports this unconventional theory?

    I understand that one of the key problems with fatty liver disease is that the lipids get stuck in the liver and they’re not being released into the bloodstream.

    How could this be the case when taking liver support supplements like milk thistle, dessicated liver, choline, lecithin, etc.? Why wouldn't such intervention spur on the purge also?

    Why wouldn't free fatty acids (FFAs) from stored subcutaneous fat be released into the bloodstream as well?

    Could this explanation be the mechanism behind the clearance of FFAs: During fasting or starvation, free-fatty-acids are released during lipolysis into the liver and muscles to be burned as energy, this is called fat-oxidation. During the fed-state and especially while eating a starch-based-diet, fat-oxidation is inhibited and replaced with carbohydrate-oxidation, insulin is what mediates this shift. When carbohydrate-oxidation is taking place, fatty-acids are shuttled back and "locked away" in adipose-tissue… where they belong.

    In addition to LC Paleo/IF, I also began taking 1g of choline nearly a month before the labs + 3mg methylfolate/day to help with a genetic methylation defect.

    Could the above combination have created a mega-purge?

    Could the answer be that the best predictor of fatty liver is obesity and insulin resistance?

    Another thing:
    I have been on warfarin for 3 months and must remain on it for another 3 months. This was the only thing I could find on warfarin and its effects on blood lipids:

    Coumadin binds to bile acids in the intestine leading to increased excretion of bile acid in the feces leading to increased oxidation of cholesterol to bile acids resulting in increased numbers of low density lipoprotein receptors with increased hepatic uptake of LDL and lower serum cholesterol levels

    Anomalies to purge theory:

    Why the decreased HDL when I was making nice progress before?

    Lastly, I had been fasting for 18-20 hrs prior to my blood being drawn. My fasting insulin was only 5.2. Then why an elevation in HbA1c (5.8) and FBG (95)? Should've been in the low 80s, especially when fasting for LONGER periods AND on LC Paleo.

    This even when on a broad range of BG-lowering natural agents including corosilic acid, chromium, cinammon, etc.

    So, why is my insulin sensitivity is taking a nosedive during this so-called healing crisis as well [see Insulin Resistance Score – p12, 14]?

    Can someone please interpret my lipid profiles, especially the NMR LipoProfile and tell me what is going on?

  5. Paul –

    To quote you: “So, on a micro-level, I think vascular damage causes high LDL. But what causes vascular damage?”

    Add a DVT (deep vein thrombosis) a direct hit to vascular integrity.

    You bring up an interesting point here I just caught that might be yet another factor in my elevated lipids.

    My recent DVT was dx’d in March.

    So, if a DVT causes vascular damage, we can then assume from your view above that my increase in LDL was a result of the recent injury.

    If you look at my prior lipid test in March (drawn immediately following the dx), my lipids were just starting to increase. I then was just beginning anticoagulant therapy (warfarin). 3 months later, I had the second test which showed a further increase in LDL & TRIGS and decrease in HDL, as the damage was “entered” and I was well into the healing process.

    The only questions are why my HDL would drop and TRIGS increase and
    whether we can assume the spurts in LDL were continuing as a result of reparation of the damage to the vessels and if 3 mos. is within that time frame. If we take the standard anticoagulant prophylaxis of 6 mos. total to treat and prevent a DVT, we could theorize this to be the case.

    As for adding nutrients, I started choline @ 7501-1000mg daily 1 month prior to the last test in June. I read that choline itself can purge lipids from the liver (especially if one has fatty liver), dumping them into the bloodstream.


    • Hi Mark,

      I wouldn’t say that DVT causes high LDL, rather the same problems that cause high LDL will cause DVT.

      Choline does promote purging of lipids from the liver. The question then would be why other tissues, like adipose tissue, don’t take them up.

  6. Paul – Great question about why there would not be lipid resorption. Assuming the purge is a slow, continuous release, perhaps the lipid panel is picking them in a transient state before they eventually become metabolized.

    In this podcast transcript featuring Chris Kresser had Chris Masterjohn cover reasons why cholesterol would increase after going paleo, and why it may not be bad. Again, my hopes are that this is the main reason for the increase:

    Masterjohn mentions that a transitory increased blood lipids could be a sign that fatty liver disease is being reversed. But no where does it address your question. I will try to pose it to him.

  7. Hello – I’m currently chasing my tail on a few issues related to ApoE and I’m hoping someone can share an opinion. I understand the rationale behind low carb and copper deficiency but after researching my E4/E4 ‘situation’, I’m lead to believe that E4 is unable to bind to copper due to lack of the cysteine amino acid. Alzheimer’s sufferers apparently have a build up of copper in the brain.

    I’m one of the people whose LDL shoots to the moon on LCHF so I’m hesitant to try increasing copper until I’ve got my head straight on the issue.

    I guess I just wanted to check if the suggestion to supplement copper is also suitable for E4 people.

    BTW Paul, I’m half way through your book and am enjoying it. Thanks for all of your hard work.

    • This paper suggests copper supplements are harmful, especially on high fat diets.

      The Risks of Copper Toxicity Contributing to Cognitive Decline in the Aging Population and to Alzheimer’s Disease

      Free copper is the 5-15% of copper in the blood that is loosely bound and potentially toxic.

      Inorganic copper, such as copper in drinking water and supplements, enters the free copper pool directly, whereas organic copper in food is first processed by the liver.

      Trace amounts of copper in drinking water greatly exacerbated the disease in Alzheimer’s disease animal models.

      Alzheimer’s disease patients have an increased free copper level in the blood.

      Normal people in the highest quintile of copper intake, who also ate a high fat diet, lost cognition at over three times the normal rate.

  8. What are the man’s LDL and HDL levels now? Its Aug 2012. A follow up would be great …

  9. Main Atkins Diet Forum good news and bad news.......... - Page 2 - pingback on September 3, 2012 at 12:31 pm
  10. I have a question about starting Iodine Supplements. I am in good health, have been on PHD for about 5 months now with very good results. The only supplement I have not integrated into my daily/weekly routine is iodine because I occasionally have gluten. I work in a profession where I occasionally dine with folks from other countries, and it would be rude to refuse anything offered, which means I eat whatever they put in front of me. Is it a problem to be taking iodine supplements if I am still eating gluten 1 to 2 times per month? Thanks in advance for the advice.

  11. Hi Paul and Happy New Year!
    I have always had conventional perfect lipids and suspected borderline low T4 for my sudden increase in LDL
    this past year(Paleo, VLC ,<50 Gm until you advised us to knock that off)
    My TC went from 160-70 to 240 all due to a rising LDL (HDL 80-90, TG 50's) NMR LDL-P is 1400 so I guess I will try some copper, that is all that is left to try except a more serious exercise daily program. 5'9" 140 #

    • Hi Catherine,

      Well, everything may be normal now. Lowest mortality range for TC is 200-240 mg/dl, and that’s with lower HDL than you have. Lowest mortality for LDL is 130 mg/dl — what’s yours?

      TC of 160-170 is too low and indicates a problem.

      You might want to read our cholesterol posts:

      Beef/lamb liver is the best source of copper and it is highly recommended. Exercise is good too. But your cholesterol numbers should not frighten you.

  12. Hey, Paul –

    I have a couple of questions about copper intake and supplementation. You establish the optimum copper intake at 2-4 mg per day, and recommend daily supplementation for people that do not consume beef liver on a weekly basis. You also note that 1/4 lb of beef liver contains 12-16 mg of copper – which averages to the daily rate of about 2 mg per. You also note that the tolerable upper limit for copper is set at 10 mg per day by the U.S. Food and Nutrition Board.

    That raises two questions for me:

    (1) If you consume all your liver in one meal (4 ounces of liver paté can go down pretty quickly) does that create any problems? Beyond concerns about toxicity limits, is copper a micronutrient that your body can store and use as required?

    (2) If plan to eat liver but just don’t get to it in a week, would it be helpful to increase your supplementation to get closer to the full week’s copper intake? For example, if you go through 5 days and realize that you just won’t get to your liver for the week, would it be wise to take 6 mg of copper on each of the last two days to get close to the 2 mg per day average? I also wonder how that works with the zinc supplementation of 50 mg per week (which is based on the average copper intake) — if you take your zinc supplement earlier in the week but don’t achieve the planned copper intake, does that have negative consequences, or can it be mitigated by larger doses of copper later in the cycle?

    My goal is to keep liver in our diet (I found that your liver paté, with a little hot sauce thrown in, is very tasty on rice crackers!) but I can’t guarantee it will happen all the time. Given the severely negative consequences of copper deficiency, I’d like to make sure I find the right way to maintain the required balance.



    • Hi Jim,

      I don’t think it’s a problem to consume 16 mg of copper one day and none the rest of the week. it gets taken up by cells that need it, and it takes a lot longer than a week to generate a deficiency.

      I think if you’re not going to make up the copper deficit with liver, then you should make it up with supplementation.

      You can balance less copper with zinc or more copper with more zinc, within some limits.

  13. Where can I get more choline from foods if I am not able to eat eggs due to egg sensitivity?

  14. I greatly appreciate your insights on an astonishing range of topics. What is your view of the literature on copper toxicity in the CNS? The evidence seems to be mixed, inorganic copper seems to be a greater concern, and I wanted to make sure that you’d weighed the evidence. Here are some papers I’ve examined — I’ve highlighted words in titles that point to discussions that focus on questions beyond too-much-v.-too-little.

    Scariest first:

    “The Risks of Copper Toxicity Contributing to Cognitive Decline in the Aging Population and to Alzheimer’s Disease” (2009)

    A correlation confirmed:

    “Copper in Alzheimer’s Disease: A Meta-Analysis of Serum,Plasma, and Cerebrospinal Fluid Studies” (2011)

    “Copper and Oxidative Stress in the Pathogenesis of Alzheimer’s Disease” (2012)

    Increasing Cu bioavailability inhibits A? oligomers and tau phosphorylation” (2009)

    “A Bioinorganic View of Alzheimer’s Disease: When Misplaced Metal Ions (Re)direct the Electrons to the Wrong Target”

  15. Hi
    I’ve just got back from my appt with a senior pathology specialist about my high cholesterol.

    Here are my recent numbers:

    Total 10.26(396)
    HDL 2.35(90.8)
    LDL 7.59(293)
    TRIGS 0.70(62)
    APO A 2.28
    APO B 2.14

    Cpr <1
    Vit D 59(148)

    My numbers have been increasing since I went high fat, low carb a few years ago.
    Previously my numbers were a lot lower, though trigs were slightly higher and HDL a bit lower.

    This is the first time I’ve had the Apoliprotein A & B tested, the specialist said he’s concerned about the high LDL, and the Apo B numbers.

    I’m male, 46, 5’9”, 138lbs, very active, run, cycle or weights most days.

    I eat a fair amount of fish a week, salmon, mackerel, cod.
    Lamb and Beef once a week.
    A small amount of lambs liver twice a week.
    8-10 eggs a week.
    Little dairy,a bit of greek yoghurt and raw cream.
    Lots of veg with lots of butter and EVOO.
    Avocadoes, 1 piece of fruit a day
    Coconut oil and milk regularly.
    Macadamia nuts(50g a day) and 1 or 2 brazil nuts a day.
    1 small sweet potatoe a day.
    A couple of glasses of red wine a week.
    Small amount of dark chocolate.
    No caffeine at all, just herbal teas and water.

    All my other labs were excellent, he said the Vit D and B were very high.
    He checked me over for cholesterol deposits, none anywhere. He ruled out FH.
    He listened to my arteries and heart, all excellent.
    He was desperate to put me on statins, but has given me 4 months to sort via diet.
    He’s sending me for a scan to check for any furring in the arteries.

    Any feedback or advice would be greatly appreciated

    • Hi Dave,

      This happens very commonly when you’re too low-carb. Especially if you are hypothyroid to some degree.

      The best thing you could do is add starches. Add a pound per day of white potatoes or white rice. That alone would probably fix the problem.

      Add in some seafood for iodine and you’ll probably be all set.

      You might want to read the rest of our cholesterol category, also the “safe starches debate” posts. There were a few other “High LDL on Paleo” posts after this one.

      Best, Paul

      • Hi Paul,
        Just comparing one pound of white potatoes and white rice, in regards to their starch content & calories…

        do you think it’s just not worth ‘stressing’ over the differences?…

        ie. for the same weight, cooked white rice can have a fair bit more calories & starch (varies depending on the rice variety) than cooked white potatoes.

      • Hi Paul

        Many thanks for the reply, I will up the starches, I love sweet potatoes.
        I have a fair amount of fish a week, mackeral, salmon and cod. I also have a drop of lugols 5% Iodine in water most mornings.
        I will check out your other debates on high LDL.


      • Hi Paul,

        Just heard from the doc after he had me do an ultrasound on my arteries in the my neck. He found slight furring in the arteries and has prescribed a statin, and wants me to start taking it straight away.
        Now I’m worried, I assume the high cholesterol is causing this?!
        Any suggestions as to what to do? Could it be I’m just not meant to eat a higher fat diet?

        • Hi Dave,

          Yes, it’s possible the high cholesterol is a causal factor.

          I think you want to eat a balanced diet — less fat, more carbs, more micronutrients. Liver, bone broth, shellfish, potatoes, salmon, beef/lamb, vegetables. Supplement D and K2 as needed to get serum 25OHD in 35-45 ng/ml.

          Personally I would not take a statin, but I would get cholesterol retested monthly or every other month to make sure it is getting back to normal, and then after it’s back to normal for a while, try another ultrasound to see if arteries are back to normal. However, this is not medical advice, it is just my opinion of what I would do if I were in your situation.

          • Hi Dave
            My experience with cholesterol may be of interest to you. My total cholesterol rose about 60% above the previous normal (210 mg/dl) over a period of 12 months after reducing carbs to about 100-150gm/day. Subsequently total cholesterol has declined to former level after another 12 months of the same diet. I was concerned and so had blood panels done every 5-6 months. Individual response to diet change I believe is highly variable but that is a vast and complex subject. The key, I think, is to experiment safely, observe and adjust. Easier said than done but it has worked well for me and in large measure due to Paul’s framework for experimentation. Good luck.

          • Hi Paul

            Thanks for quick reply, I will now have more carbs from sweet potatoes, rice and fruit.
            Should the fat I do have be mainly mono in my case?
            What sort of carb levels do you recommend? I’m fairly active, so shouldn;t be a problem higher carb.
            I am getting my blood checked again soon,and after a few months of lower fat I will push for another ultrasound.
            I taken Vit D3 for a fair while, and have just started taking vit k2 as well

            Thanks for the replies Morris and Travis, good to hear from others will cholesterol stories.
            Travis, what source of carbs do you use to reach 300g p/day?


          • Hi Dave,

            No, keep the fats balanced. Dairy fat, coconut oil, and other saturated fat rich oils are fine. The key is to add more starches as in white potatoes and rice, and to eat a nourishing diet, possibly with some supplements of zinc, copper if you don’t eat beef or lamb liver, magnesium, vitamin D, vitamin K2, and low doses of iodine.

          • Thanks again Paul, ok, will keep the fats balanced.
            I have organic beef and/or NZ lamb once a week, so ok there, the rest of week I eat cod, salmon, mackeral, tuna and prawns now.
            I have a small amount of NZ lambs liver once a week too.
            BTW my vit D level at last test was 59.
            Thanks again for your advice.

          • “Yes, it’s possible the high cholesterol is a causal factor.”

            Paul, have you not said elsewhere that cholesterol doesn’t cause heart diseases?

          • No, I didn’t say that. I have said that the “normal” range for cholesterol in doctor’s reports is too low, so they label normal as high, but truly high cholesterol is risky. Low cholesterol is risky too.

          • “…truly high cholesterol is risky.”

            Got it. But could it be that high cholesterol is a symptom of a problem (or even body’s remedy to the real problem) instead of a cause of the problem?

          • It is both, a symptom of a problem and the cause of other problems.

    • Hi Dave-

      I had the same thing happen to me as a result of a lot of butter and cream and lower carb as recommended in the PHD. I cut it all out and increased carbs to 300g/day and my cholesterol dropped from 393 to 190. My HDL is currently in the 80s and my TGs are in the 30s.

      Instead of continuing to take the reckless advice of this fool, try to rollback your diet to something that is reasonable.

      Good luck.

  16. I have an issue too with high LDL on a low carb diet. My LDL was at 262 back last July after 6 months of very low carb and soaking everything in butter and coconut oil. A CIMT ultrasound found plaque in one carotid artery so I was very concerned. That plaque may have been there since before I started eating Low Carb but I thought it wouldn’t be a good idea to just carry on.

    This was my first cholesterol test so unfortunately I don’t know what my values were before.

    After reading Paul’s articles about the LDL issue I implemented some of his advice. I ate somewhat more carbs (sweet potatoes, white potatoes and rice) and cut back on the fat a bit.

    A few months later, in December, my numbers were still high:

    Total chol. 8 mmol/l (309 mg/dl)
    HDL 2.08 (80)
    LDL 5.3 (205)
    Trig 1.01 (89)
    ApoB 1.16 g/l
    VitD 23.7 (very low)

    Certainly an improvement but my GP sent me to a lipid specialist for further examination. The lipid specialist looked at my numbers briefly, asked a few questions about my family history and diagnosed me with FH. She didn’t run any further tests.

    I thought that was strange because my family history doesn’t show any cases of high cholesterol or early heart disease except for my grandfather who was a heavy smoker.

    Now I was really horrified and implemented everything I found which would bring down my numbers while still being Paleo.

    So I ate even more carbs: 1 Banana, 1 Orange for breakfast, 200g rice or potatoes for lunch and for dinner.

    Fats: no butter, no cream, just one tsp coconut oil per day for cooking, but olive oil instead. One egg only every other day instead of 1-2 per day before. Salmon 3 times per week, 120g beef liver once a week. I switched to lean meat like chicken breast and lean beef cuts. I cooked all meats and fish with very little fat and only added some olive oil after cooking.

    Treats: 1-2 handful of macadamia nuts and bit of dark chocolate per day. One glass of red wine once or twice a week.

    Supplements as recommended by Paul: 2000 IU Vitamin D3, 90mcg Vit K2, 400mcg Iodine, Magnesium, 500mg Vit C

    To be sure, I added 3 tsp of psyllium per day.

    Despite less fat and more carbs I wasn’t hungry and even lost some weight.

    After just 4 weeks that brought down my numbers significantly:

    Total chol. 5.2 mmol/l (200 mg/dl)
    HDL 1.2 (46)
    LDL 3.53 (137)
    Trig 0.96 (85)
    ApoB 0.97 g/l
    VitD 26.2

    After all I’ve read that should rule out FH, so I was really happy with this result. My diet is now a bit higher in fat because I feel much better that way. I am having my numbers tested every few weeks and try out how my eating affects them.

    Now I don’t recommend a low carb/high fat diet to friends and family any more like I did before. For most it is a very healthy way to eat, I am sure. But some people obviously seem to react differently to high saturated fat, or even worse, have FH without knowing it.

    • Hi Rico,

      Thanks for sharing your experience, quite a few similarities with mine.

      A few of my thoughts:
      1. I’m curious if you have an ApoE4 gene
      2. With low fat, HDL is dropping pretty low and TC:HDL ratio is getting worse (3.9 vs. 4.3)
      3. Wonder if lipids would change if VitD level was increased into 40’s


      • Hi Mark,

        Thanks for the tip. My ApoE is 3/3, so that’s not the reason.

        Yes, HDL dropped a lot. That’s another reason I added more fat again. At least I have proof now that I can have lower LDL just based on diet which wouldn’t be possible with FH. I wonder why the TG are still high, maybe because of the rice/potatoes.

        I hope I can get my VitD to the 40s in the summer. Obviously 2000 IU per day was not enough and I am reluctant with more supplements. I’ll see how that influences my numbers.


    • Hi Rico,

      Thanks for sharing your experiences, that’s interesting data.

      I would say your LDL is now perfect but HDL was better on the higher fat.

      I think the optimum might be a middle ground. You might be able to end up with LDL of 130, TC of 230, HDL of 70-80 which would be perfect all around.

      You didn’t report any thyroid numbers (eg TSH) which would have been helpful. You should ask your doctor to monitor that also.

      Best, Paul

      • Hi Paul,

        Thank you. Your articles and comments in the blog were really helpful. Hopefully I can further improve my numbers.

        I actually had my thyroid numbers tested, I just forgot. My TSH was 1.15 when I had the much improved cholesterol numbers.

        On the first test last July, with the LDL of 262 my TSH was 1.57. So that looks like an improvement too.


      • Hi Paul,

        I have an update. It might be premature but I think it might help some readers so I am posting it already.

        After ruling out FH after my blood test in January I left out the Psyllium and went up with the fat a bit because I really didn’t like that low fat food.

        I bought a cholesterol analyzer so I was able to test more frequently. The next test I took was in the beginning of March with the following values:

        TC: 281
        HDL: 85
        Trig: 96
        LDL: 177 (calc)

        The LDL went up but I wasn’t afraid because the ratios were better. After another 3 weeks the numbers were:

        TC: 273
        HDL: 84
        Trig: 73
        LDL: 174 (calc)

        Even better Trigs and I thought I could further improve my numbers once I could go out in the sun for Vitamin D again.

        Then, two weeks ago, I had another ultrasound of my carotid arteries done. Plaque had grown from 1.3 mm to 1.5 mm on one side and from almost zero to 1.3 mm on the other side! This happened in 9 months only. I am 40 years old and this is too much for this age the doctor said. He wanted to put me on statins instantly.

        I was really horrified and went back to my diet from January (very low fat and psyllium). After thinking about it again I suspected it was my thyroid although my TSH was perfect back in January. But I was frequently feeling cold and had cold hands.

        So I had my thyroid numbers checked one week ago and included FT3 and FT4 (I got only TSH on my last checks). RT3 would be helpful but is not available at the lab.

        The numbers were:

        TSH: 1.97 (!)
        fT3: 3.38 (2.2-4.4)
        fT4: 1.62 (0.9-1.7)

        I haven’t read much about thyroid numbers but this now looked like hypothyroid to me even when looking at TSH only. I read that fT3 should be in the upper third of the range but it was only at half.

        So I increased my carb calories a lot as you suggest. I also realized I got too little protein so I increased that too. Now I eat 3 bananas a day instead of one and have 200g potatoes or rice each for breakfast, lunch and dinner together with plenty of vegetables, lean meat and some olive oil.

        It seems to work quickly as my hands are not feeling cold any more. Yesterday I took another cholesterol test and was quite amazed at the numbers:

        TC: 209
        HDL: 72
        Trig: 100
        LDL: 117 (calc)

        So I am cautiosly optimistic that I have the solution now. And it was there all the time, I read it in your articles months ago but was too afraid to increase my carbs enough! I can’t thank you enough, Paul. You were 100% right with the thyroid.

        Actually, when I asked my doctor months ago about my thyroid numbers she said they were fine and I had an inherited condition of high LDL! My TSH was 1.57 back then but my fT3 was even lower at 3.02. But within lab range, so for here it was normal.

        Looks like I almost put myself on a path of early heart disease thanks to a passion for very low carb (almost a fear of carbs) and ignorant doctors.

        I am going to get a complete blood test including Vit D and inflammation markers in 4 weeks and another ultrasound in 3 months. The ultrasound specialist said, this plaque (not calcified) can still regress so I hope it does with my better numbers.

        These are the things I learnt so far, I hope it may help others:

        – If for whatever reason you go very low carb keep an eye on your thyroid and any hypothyroid symptoms.
        – Don’t be afraid of safe starches. I still lost weight eating rice and potatoes every day and was not feeling hungry.
        – When Paul says eat more starches he really means it. 😉 Even 1 pound of cooked rice and potatoes a day is moderate/low compared to the SAD.
        – If you do cardio exercise eat starch (I think 45 minutes of cardio 3 times a week depleted my glycogen stores).
        – An LDL around 200 is not harmless even if the ratios look good.


        • Paul,

          here are my latest numbers:

          Total Chol.: 182 mg/dl
          Trig.: 51 mg/dl
          HDL: 58 mg/dl
          LDL: 108 mg/dl

          My Vit D is still low though with 36 ng/ml despite getting plenty of sunshine around noon. So I am adding 2000 IE Vit D per day as suggested by my new doc (finally I found a really good one).

          I am eating pretty close to PHD now but use moderate amounts of olive oil instead of coconut or butter and add psyllium husk for additional fiber. I also do light endurance excercise (30 mins for 4-5 times a week) but am now starting with resistance exercise again in order to push my testosterone (and HDL), which is too low.


        • TSH is also dependent on the time of day it is measured. I try and get my blood taken at 8.30 am so it is a fair test. Later on in the day, the TSH level will drop.

      • That’s too early to say for sure. I had it measured last summer, this April and this August. It definitely grew from last summer to April with LDL above 200 (eating paleo). It didn’t grew from April to now with LDL around 120-130, was maybe a little less. But what’s a few tenth of a millimeter, it could also be measuring tolerance.

        The cardiologist said it will regress if I keep my LDL in that range and do a lot of exercise. But it will take 1-2 years. He had cases where it regressed. He favors Vitamin D, lower carb and is hesitant to prescribe statins so I would consider him a good one.

        When it is said that higher LDL on a high-fat paleo diet is not a problem, I think they talk about a range up to 150-170. Above 200 is a different story I think, especially when you come from a standard diet (junk carbs, junk fats, little to no sports) and have plaque already.

  17. Paul –

    I see that you recommend high glycemic carbs like white potatoes and rice which runs counter to most other paleo advocates. What about those that are leptin and/or insulin resistant??? Rice is still a grain, and even though it doesn’t contain gluten, it contains many other anti-nutrients and haemagglutinin-lectin.

    Also, consuming in excess of 50g/day of carbs takes you out of ketosis which prevents fat-burning. I have personally observed an increase in trigs eating these foods and especially fruit when it’s in excess of 15g fructose.

    Please advise.

    • This is discussed in our book and in various places on the blog. Key points:
      – Eating moderate amounts of starch (eg 25-30% of energy) increases insulin sensitivity.
      – Providing the glucose nutrition the body needs will generally reduce cravings and appetite, aiding weight loss.
      – The toxins in white rice are generally destroyed in cooking.
      – Being out of ketosis does not prevent fat burning. Most tissues prefer fat and eating 30% of energy as glucose will not provide any glucose for metabolic use outside the brain, it will all be used for other purposes (brain metabolism, extracellular matrix and mucus/saliva/tears production, immune activity, etc). So you will still be fat-burning on any diet that is 30% carb or less.

      If you see an increase in triglycerides eating small amounts of carbs, it suggests you are nutrient deficient. Eating more phospholipid sources like liver and egg yolks may help.

  18. Cholesterol is not your enemy.

    Hypothyroidism causes higher LDL numbers.
    VLDL may be normal even when LDL is 150 or higher [but below 200]. This is the important number along with low triglycerides, high HDL 70-80 and 50-70ngl D numbers.

    Dr. Mercola’s article “Cholesterol Myth” is chock full of good information. So is his website on Vitamin D.

  19. I do not believe that everyone with elevated LDL-C should consume more carbs to increase thyroid function. For one, if you’re >15% bodyfat, you don’t need and should not consume extra carbs since there is more than enough bodyfat stores from which to burn for fuel. Eating too many carbs will defeat the purpose for these types and just contribute to more insulin resistance which was part of the original problem to begin with.

    At most – only have a small amount of carbs post-workout – like 35-40g – and that it’s. Once your bf gets closer to 10%-12% you can then start incorporating more carbs. And to prevent possible depletion of T3 and elevated rT3 and TSH, why not just take some T3 or even T2 (which is available OTC) for added insurance which with T3 shows direct LDL-lowering effects:

    Getting the majority of calories from healthy fats (mostly SFAs and MUFAs) will also prevent hypothyroidism. With excess bf, it’s a very fine line. Balance is the key!

    Check your bodyfat and go from there before jumping blindly into adding more carbs!

    • Hi Mark,

      re: why not just take some T3 or even T2

      Sounds easy, do you have some tips on dose, where to buy, and common pitfalls?

      My impression has been this isn’t quite DIY, like say vitamin C.


    • Thanks Mark. I know taking thyroid meds would help too but I’d rather not go that path unless I have a real thyroid problem which is not just caused by diet.

      I’m also skinny and have never been overweight so I am not worried about putting on weight with more carbs. I hope I can reduce my carbs back to PHD levels soon without going hypothyroid again. But after my experience with very low carb I am not sure any more that eating carbs far below PHD levels is healthful in the long run for people like me who see their LDL shooting up above 200.

      I read the book by Phinney and Volek you recommended some time ago but they only say there is nothing to worry about if LDL-C goes from, say, 100 to 125 on low carb. Well, no problem, I agree with that. But what about 265? Unfortunately I didn’t find anything about the hypothyroid issue in their book.

  20. T3 is by prescription only, but you can purchase Cynomel T3 via online foreign websites. It’s the only brand I know that’s reputable. In my case, I have a prescription from the doc I work with and have a compounding pharmacy make it up for me. You have to really know how to dose this watching your basal body temp, pulse, BP, etc. so you don’t OD. T3 is way more potent than T2 which you can order online without a scrip because it’s considered a food ingredient. The ones I’ve tried are Alpha-T2 and TT-33. I don’t take anything unless I’ve tested for it. That and how I feel by keeping a daily log of any changes.

    Somewhere I read that 60% of the world’s population is genetically hypo anyway no matter how many carbs they eat because they inherited the starvation gene (mostly Irish and Northern Europeans). Plus eating all those carbs will just make the insulin resistance worse. With few exceptions (i.e. marathon runners), we really don’t need more than 50g/day.

    Read this book:

    • I appreciate the additional info, Mark. I don’t think I could get my doc to support it … my thyroid numbers are in range (TSH 1.57 fT3 3.25 fT4 1.04 rT3 17), as well as good pulse, BP, FBG. My temp, taken randomly throughout the day, tends to be upper 97’s, maybe 98, but never >=98.6. My only lab values out of range are high LDL, TC.

      PHD recommends about 150g/day net carbs (30% of 2000 calories), so there seems to be evidence to support various macronutrient levels. I suspect individual circumstance and genetic variation play factors.

      That’s interesting about the starvation gene, I’d like to learn more about it.

      • As with many theories, there is obviously much debate about this topic:

        Here’s an especially good one:

        And this one with Chris Kresser: with a comment disputing his findings below:

        “There’s a popular meme in the Paleo community that says eating a very low-carb diet leads to a diminished capacity for T4 to be converted into T3 thyroid hormone because of the lack of glucose consumed by low-carb dieters. This concept is promoted by practioners like Chris Kresser who sees patients from what he describes as “the dark side of Paleo and low-carb” dealing with hair loss, cold extremities and other such negative manifestations of a low thyroid function.

        However, two of the top low-carb nutrition researchers in the world — Dr. Stephen Phinney and Dr. Jeff Volek from — say this phenomenon with low thyroid while on a low-carbohydrate diet has not manifested itself in any of their countless studies of people following this way of eating over the past three decades. Dr. Phinney notes that consuming adequate calories with your low-carbohydrate intake will actually normalize thyroid and metabolic function without the necessity for consuming added sources of dietary glucose. Dr. Volek concurs stating that it’s calorie-restriction that brings on this low thyroid effect, not limiting carbohydrates.”

        With respect to LDL at the end of the day, it is the particle size of the LDL that matters. The best tests I know of: NMR, APO B, Lp(a). Standard lipid profiles are absolutely worthless. You should also measure your bodyfat, as there it’s what’s called “skinny-fat”. Also, NAFLD (fatty liver – which can be caused from too many carbs) can transiently elevate LDL on VLC because of the FFAs getting purged from the liver. This is a good thing:

        Based on anecdotal evidence, I think there are arguments for both sides. Erring on the side of caution, I think going somwhere in the middle with a moderate LC or cycling carbs diet is the wisest approach. That way you still get enough carbs, but not so much as to cause other problems.

        • I was content to live with high LDL and high TC as long as my trigs were low and HDL climbing. I was also content with an FBG of 120 because there is also evidence to show that is ‘normal’ on LC.

          I added 1 pound of starch per day on 1 Jan this year (almost 5 months now) and my FBG is now in the 85-95 range, TC down from 220 to 204, LDL down from 155 to 144, HDL up from 49 to 53, and Trigs went from 56 to 53.

          I don’t think we should be content with bad labs.

          I have never met a doctor yet who would order the VAP or other direct measuring for LDL. They want to treat any TC over 200 with statins.

  21. MarkES – You know that potato starch trick we talked about on the potato thread? It works for cholesterol, too! My LDL and Trigs decreased and HDL increased since last fall, only difference is going from LC Paleo (under 50g) to PHD starches with a focus on RS.

    In rats:

    “RS…diets were effective in lowering plasma cholesterol (about ?40%) and triglycerides (?36%). …RS…[was] very effective to depress cholesterol in d<1.040 lipoproteins (especially in triglyceride-rich lipoproteins). Fermentable polysaccharides counteracted the accumulation of cholesterol in the liver, especially cholesterol esters."

    • RS certainly is compelling. I admit I haven’t read into it nearly as much as you have.

      The LDL lower effects reminds me of psyllium husk soluble fiber … I could get much more soluble fiber by taking psyllium husk supplements, but I haven’t …

      One thing that bugs me a bit, is that I tend toward eating whole foods as it just seems the most natural. So, I wonder if getting large quantities from say 4TBPS daily raw potato starch powder is okay … e.g. it looks favorable in short term studies, but how about over the long term in real people? I’d be interested to learn how you’ve been okay with it?

      • Understandable…you could get 20-40g/day of RS with natural foods if you were to eat 2 green bananas a day and about 1/2 a raw potato in addition to normal PHD starches.

        • Thx for the tip, tatertot.

          When I look for safety info on eating raw potatoes, I find many recommendations similar to below – what are you thoughts on it?

          If you eat a raw potato on occasion, it’s unlikely to harm you, but it’s best to not make a habit of munching on raw tubers since alkaloids can accumulate in the body over time.

          • I think it is just an old wives tale. Raw potatoes are fine. Just peel them and remove any green spots.

            Raw potato eating is self-limiting, in that it would be hard to eat a lot. They aren’t very good. Still, it’s easy to munch a few slices when cutting up potatoes to cook.

  22. Dr. Peter Attia, in his speech ( has said that increasing consumption of saturated fat increases LDL, but this applies to the large buoyant (supposedly, harmless). He says that the small dense LDL doesn’t rise. This was in the context of using a LC-HF diet.

    If he is right, then maybe trying to reduce LDL by supplementing with copper and what not isn’t necessarily useful.

    How do we know if we are simply making numbers conform to an expected amount or actually improving our health?

  23. In, Jeff Volek provides his explanation why LDL sometimes goes up (temporarily) on a low-carb diet. He says that this is due to a release of cholesterol stored in fatty cells. He says this happens sometimes after about 30 to 50 pounds of weight is lost. After a relatively short period of time, LDL goes down to normal, he says.

  24. What Are My Goals? | Lost In The Maize - pingback on August 30, 2013 at 4:47 pm
  25. just had blood test results by life insurance company, results show ldl/hdl ratio of 0.70 low. Is this too low?

    • It is abnormally low LDL, or perhaps unusually high LDL, or both. What were the specific numbers? Generally speaking LDL should be above 100 and HDL above 60 mg/dl.

      • Thank you. For getting back. The results are:

        cholesterol 151
        high density lipoprotein (HDL) 81.00
        Low Density lipoprotein (LDL) 57
        Triglycerides 64
        Cholesterol / HDL Ratio 1.86
        LDL/HDL ratio 0.70 low

  26. Paul et al:

    First thanks for all your fabulous work on perfect health!

    I understand the argument that nutritional deficiency might explain a spike in LDL on a paleo diet, but am wondering how that would explain my husband Bruce’s situation.

    He has been on a Paleo diet for over 2 years, following the PHD model except not quite as high on carbs (but still over 50g-70g ie definitely not in ketosis). This includes weekly bone broth, eggs, liver, seafood, lots of leafy greens/salads/veggies including carrots/beets/occasional potatoes, fermented foods, etc. (we live in Puget Sound so getting good food is easy). In addition, we supplement with D3, K2, and Magnesium. (Iodine didn’t seem important given the very regular seafood consumption.) He’s felt great.

    But 1 year ago, he decided to experiment with stepping down the carbs by cutting out daily nut snacking and turning to cheese instead, and switching from olive oil for cooking to coconut oil/lard/tallow. We take this as an “increased sat fat” change, but otherwise don’t think our nutrient situation would have changed much. He’s continued to feel great and has had no issues with dry eyes, lips, etc. or frankly any other health complaints.

    The result on his blood tests from last year (pre-change) to this year (post-change):

    Total Choleterol 214 –> 312 mg/dl
    Triglycerides 108 –> 70 mg/dl
    HDL-c 43 –>49 mg/dl
    LDL-c 149 –> 249 mg/dl
    And btw TSH 2.85 –> 1.43 uIU/mL

    As you can see, most markers in better place, other than LDL. It’s hard to believe this is a result of malnutrition, since dropping out nuts and maybe cutting back on starches can’t really represent a significant loss of nutrients, can it? Again, the rest of the diet has been good quality and has stayed that way, as well as our supplementation.

    His doc’s response (he is a Paleo doc) is that this likely is result of the increased consumption of saturated fats in place of other things. And so the doc’s recommendation is to dial back the sat. fat – eg increase the MUFA (avocado oil for cooking) and eat more nuts and less cheese. (Doc also recommends an Apo B test just to see if LDL-p is up, which he believes is more important marker for problem than LDL-c).

    Of course there’s not reason not to try the doc’s suggested food change – as well as no reason not to try the alternative PHD recommendation of fully supplementing all micronutrients (and increasing carbs) – but I am still trying to see if there might be some other way of understanding this phenomenon, since again he feels great and we’d just as soon not race around if all is well.

    ANyway – any thoughts or suggestions are much appreciated.

    • Hi Msku,

      I would just add carbs and also phospholipid components like choline and inositol (or fewer oils, more whole foods). It does look like he’s made improvements, the drops in TSH and trigs are good to see. I think the saturated fat is good although it will raise LDL more than monounsaturated fats when carbs are low. But cutting back the saturated fat is an option.

      • Thank you for your suggestions.

        It is really comforting to have this site as a resource as we all explore better health and nutrition. Particularly given how grounded and reason-based your approach is!

  27. Hi. I would like you to know that this thread and the problems you describe fit me to a Tee. I was using the primal blueprint faithfully for three years and each year my cholesterol was creeping up. In Dec. 2012 my LDL was 243 and my Total was 309; then for whatever reason it ballooned to LDL of 300 and Total of 410. Seriously panic stricken. Both my Wife and my Doctor as well.

    Suffice it to say, I found your blog through a google seach of “High LDL on Paleo” or something similar.

    We read through everything and then went and got the book. We immediately began following the principals and got on all of the supplements. I am happy to say that yesterday, March 3rd, My Total Cholesterol was down to 254 and my LDL was 180. That’s a remarkable improvement and I want to thank Dr.J.

    You noted somewhere in here that the cause must be lack of carbs or being malnourished of certain elements in the diet or both. Your cure was my cure. Thanks so much.

  28. Hi. I want to know why do you think that Lary had a low LDL before low carb paleo diet if he posibly also had malnutrition.

    Thank you! Your blog is so good for me! I´m learning about paleo low carb diet.

  29. 5 Overlooked Foods And Nutrients - pingback on July 9, 2014 at 1:40 pm
  30. Hi Paul.
    Cholesterol level is too high 262 with high ldl.

    The doc suggests stopping coconut oil (2tbsp per day) and egg yolks daily to avoid gallbladder and arteries damage..

    Any thoughts Paul would be appreciated…maybe olive oil or /and less egg yolks or leaner meats ?

    Thanks , Best


    • Hi Maya,

      Go ahead and stop the coconut oil, but keep the egg yolks. Also, try supplementing a bit of vitamin E (mixed tocotrienols are best).

      262 is not that high so I think only minor tweaks are needed.

      Best, Paul

      • Paul, why did you recommend stopping the coconut oil? Do you agree with her doc about the oil’s ability to damage gallbladder and arteries?

  31. Good question Roman, I have a good bit of coconut oil in my diet as well.

  32. De waarheid over cholesterol (7) - Project Gezonder - pingback on July 27, 2014 at 2:31 am
  33. Paul,
    Thanks for this. My total cholesterol recently came back at 317 with LDL at 257 – up from a total cholesterol of 190 almost two years ago. I have a much better lifestyle now than I did when my cholesterol was lower.
    One possible culprit is that I have been very aggressively supplementing with Zinc for about the past 9 months to a year. I have been taking about 50mg PER DAY. I have not been doing anything for my copper, iodine, or selenium.

    Is there are an accurate test to diagnose the extent of my copper deficiency?
    If my zinc supplementation were leading to significant copper deficiency, is it wise to aggressively supplement with copper for a temporary period to get back to a point of balance?
    What should my supplementation look like in that temporary period of aggressive supplementation (beef liver 3 – 4 times a week?)
    How would I know if and when that zinc/copper balance is reached?

  34. 5 Overlooked Foods And Nutrients | Eat Clean, Train Clean® - pingback on December 21, 2014 at 1:39 pm
  35. So, high LDL is caused by wide-spread vascular damage. But does that still hold if the LDL is only high when eating a high-fat diet? I ate about 40% protein and 30% each of carb and fat most of my adult life. All natural stuff, no added sugar etc, no transfats. My total C was always around 185, HDL 75m LDL 105, I forget the rest but triglycerides, sugar and insulin were all low. I went on a high fat diet, cut my protein down to about 20% and my only plant foods were leafy and cruciferious veggies and occasional nuts. My fat was about 75% of cals and most of it was saturated. Fatty meats, egg yolks, coconut oil, butter, extra V olive oil, cream, cheese.
    My total C went to 404, my LDL 308 and my HDL 87. I figure if it was diet induced, then reversing the diet will reverse the numbers pretty quick. I am two weeks into a low fat diet, to retest next week and anticipate the numbers will go low- because years ago I experimented with a low fat diet and my total C was 150 with a 80 HD.
    If they do go down, I have to figure what diet I will stick with – I was an exercise/nutrition nut all my life and am sick of it all. I want one diet for life and to stop reading about it, thinking about it and worrying about it. I thought I had that with the high fat diet, but I was wrong.

  36. De waarheid over cholesterol (7) - - pingback on February 21, 2015 at 10:02 am
  37. I guess I’m like Joe (Feb 18). The last time I had my cholesterol checked was about 2 years ago, and TC was 200 (can’t remember the other numbers). I’ve been on PHD for 3 months, and here are the results after 15 hr fasting:
    TC 409
    Triglycerides 45
    HDL 95
    LDL 307
    TC/HDL 4.3*
    LDL/HDL 3.2*
    *Atherosclerosis Risk below average, per Castelli

    1) If my atherosclerosis risk is below average, is there really anything to be concerned about?
    2) I may actually have wide-spread vascular damage. I have varicose veins in my calves, one of which was treated about 2 years ago. Does that count?
    3) If I decide to try lowering my LDL by supplementing, I’d like to minimize my supplementation. I think I get plenty of cu (I eat .4 lb lever per week). What would you recommend I try next, and how often should I test my cholesterol.

    • yes, first time 12 hr fast, this time 18 hrs, basically the same.
      Total C: 383
      HDL 87
      LDL: 285
      vldl: 15
      trigs: 64
      I did not LDL-P but ApoB is 184 (bad) and ApoA-1 is 198 (good)
      diabetes markers all good
      inflamation markers all ‘borderline’

      I went two weeks low fat, but ran into scheduling problems to test again, then I noticed ‘swollen glands’ in my throat and my doc recommended waiting. I am 4 weeks on this crappy low fat diet. If not ‘better’ by mid week, I will test anyway with a slight cold – don’t know how that will affect my inflammation markers.

      Even the low carb crowd is split on this. Some say its a numbers game, the more LDL particles crashing the walls of the arteries… some say the LDL is only a sign of vascular damage, but if my LDL goes down on a low fat diet, then that is bs, some say that it may be a problem metabolizing LDL, intake/production is outpacing LDL receptor activity, some say its not LDL but LDL that stays in the blood too long and oxidizes, some say about 20% carbs (I was less than 5%) will produce just enough insulin to help metabolize cholesterol, but the hard core low carb guys, say the whole cholesterol thing is a scam and cholesterol under 500, without insulin resistance is nothing to worry about. (one author said that if you subtract the insulin resistant patients out of the high LDL folks, LDL no longer is a factor – but who knows…

    • Hi Leo, Joe,

      Something has clearly gone wrong for both of you. The super-high LDL indicates a small intestinal bacterial overgrowth causing a leaky gut and endotoxemia; possibly also of hypothyroidism or being too low carb; possibly also iron excess.

      Be sure to donate blood, eat liver and egg yolks and vinegar, do intermittent fasting, get enough carbs and seafood, eat more vegetables and spices, and get your thyroid status tested. Most important supplements – vitamin A if you don’t eat liver, choline if you don’t eat enough egg yolks, vitamin D, vitamin C, iodine.

      • Paul, Thank you for commenting. Would all you said still hold true if LDL is only high on a very high saturated fat – very low carb diet?
        On a diet of roughly even ‘whole food carbs’, fats leaning toward monousaturated, and protein I always maintained about 185 total and 105 LDL.

        Prior to the low carb diet I fooled around with a very low calorie diet and excessive exercise, driving my body fat from my norm of 12-15% to 3%. My total was 145, LDL 55 or so and my HDL 85 or so (I forget exact numbers)and trigs in the 40’s.

        Other times my total seemed to mirror my weight; ‘bulking up’ power lifting only and driving my weight up to 220, my total would be right around 220. cutting cals, increasing ‘cardio’ and dropping to 190, my total would end up around 190.

        I fully expect my total and LDL to drop on a low fat diet. If so, does that mean that the problems you describe are still there and just prevent me from handling a high fat diet, or does it indicate those problems are not the case with me and I am just not genetically programed for a ultra high fat diet?

        I have never eaten a high sugar or fructose or junk diet or had any other habits that would cause leaky gut


        • You shouldn’t be on a very low carb diet, and if saturated fat raises LDL it means you are eating too many calories. Being too low carb will raise LDL and is unhealthy in many ways. The healthfulness of saturated fat is context dependent.

          • sorry, one other comment in response to ‘if sat fat raises LDL, too many cals’, my weight was low and steadily dropping – I normally held 190, most of my adult life with 220 and 170 possibilities if bulking up or going for very low body fat – recent years 185 has been my norm. On this diet it started at 185 and slowly lowered to 180. So it does not seem that my cals were too high,,, unless I am meant to be a skinny guy.

      • Oh yes, I forgot to mention, I have already been eating egg yolks, a half dozen a day and supplementing with high vitamin butter oil and fermented cod liver oil. Also my thyroid tests came out ‘optimal’

        I credit the cod liver oil with not getting a cold in two years after coughing up phlegm half the winter for most of my adult life

        On first test (the 404 total) I had been on the cod liver oil. If fact that was the reason for the test. I had begun getting acne on my nose and thought it was an overload of vit A resulting in liver problems (like alcoholics get red nose) But liver functions were all good and the acne persisted after going off cod liver oil – and on the low fat diet.

        On the second test, [to verify the first] (385 total) I was off cod liver oil and stayed off it for a month – then I just happened to get the swollen glands. Hmmm. There is a sore throat going around – I was not the only one

        • got it – My plan is to retest on a low fat diet, just to prove it was the diet.
          My plan was then to do the 20% carbs like you have discussed and Masterjohn seems to concur with.

          I am toying with a few steps in-between eg: a low carb diet but with high monounsaturates instead of saturates, then maybe a high saturated fat/ low carb diet but with all grass-fed, free range, raw dairy etc as opposed to supermarket stuff.

          Maybe I will save those tests for another time – I just want normalcy. I think your 20% carbs (safe starches)and maybe adding back in fish oil (cut it out after hearing Sally Fallon say most of it is over-processed and rancid and the need for omega 3s are exaggerated)will be similar to my old diet of 1/3 each of carb, fat and pro.

          I want a steady, exercise program and a steady diet. I have also been experimenting with Doug McGuff’s approach to exercise, short, infrequent high intensity strength training. The experiment consists mainly of testing recovery time or frequency of workouts. 1 day off, record the results, 2 days off and record, 3 etc up to 13 days off. Then back down, 12, 11, 10 etc. I narrowed it but still not clear. over 5 days off is too much; under 2 days off, not enough. I think it will settle between 2 and 4 days off. But going from daily exercise to an average of once a week may also have a negative affect – I read that exercise increases HDL.

      • Hi Paul, thanks for your reply.
        On the plus side, I eat liver, eggs, do intermittent fasting, get enough carbs, eat salmon, eat a lot of vegetables, all per your book. My thyroid is fine.

        On the minus side, I can’t donate blood because I lived in Africa as a PC volunteer for 3 years. Also, one of the reasons I switched to your diet is because 3 months ago I found out that I had (slightly) low blood pressure and red cell count. I was often dizzy. I had other symptoms too – nausea and diarrhea.
        1) In my case would you say a blood letting is a bad idea?

        When I started your diet, I ate vinegar in my salad dressing, but it seemed to make me feel a little nauseous, so I stopped.
        Salmon is the only seafood I eat regularly.
        2) I don’t eat many spices. What do you recommend?
        3) Can the small intestinal bacterial overgrowth be killed by antibiotics?

        • [I don’t know what Paul would say, but I’ll take a stab at answering your questions anyway.]

          (1) I would say you should first have your doctor measure your ferritin (iron storage protein) levels, before making that decision. Personally, I would have my own blood drawn if my ferritin was over 100 ng/mL, but I don’t have a low red blood cell count or low blood pressure. So your situation may be unique; you should discuss it with your doctor.

          (2) Just experiment and see what tastes good — spices and herbs were selected by our ancestors to be healthful in proportions that are tasty. Here are a few examples of ways I typically use spices: In salads, add some fresh basil, and make a dressing with olive oil, vinegar, garlic, and salt. When making homemade kimchi, use ginger, garlic, and green onion (see When making broccoli, try stir-frying with ginger, fennel, garlic, onions, and coconut milk. When making lamb, add thyme, rosemary, garlic, salt, and black pepper. Green onions and parsley make a great garnish for bone-broth soups.

          (3) Yes, antibiotics (rifaximin is typically used) can kill the small intestinal bacterial overgrowth (SIBO); the other treatment option is a short-term elemental diet. I suggest you see a doctor both to confirm you do in fact have SIBO (it is possible your symptoms are due to something else entirely), and to discuss and supervise treatment (assuming you do in fact have SIBO).

          • Thanks Eric. I’ll talk to my doctor. On (3), is this SIBO most likely caused by malnutrition? I’m just wondering if killing it with antibiotics might only be a temporary solution.

          • Yes, it is certainly possible for the SIBO to come back following antibiotic treatment, if some underlying cause persists.

            And you are right that malnutrition is a possible underlying cause, although I have no idea if it is a cause for you. Another possible cause is food toxins; I assume you’ve eliminated grains and legumes, but dairy looks as if it might be problematic for some fraction of the population, so you might try an elimination trial to see if it’s an issue for you. There are also other infections, such as H. Pylori, which could cause SIBO. These infections would require different antibiotics than SIBO, so you should have your doctor test for H. Pylori (and maybe other gut infections too).

            If malnutrition is a cause for you, I have no idea which nutrient you would likely be deficient in. It might be prudent to follow all of Paul’s micronutrient recommendations (, including his optional and therapeutic supplements. Since you say you want to avoid taking too many supplements, you might instead keep a log of everything you eat for a week, look up how much of every nutrient in Paul’s list of supplements you are getting from food on average, and supplement only those nutrients where you fall short of Paul’s peak health range (or US RDA for those nutrients he does give a peak health range for). Don’t confuse the peak health range with the recommended supplement dose; the later is intended only to make up the difference between the former and what you get from food.

            By the way, you should think about whether or not you want to also moderately restrict fiber (e.g. eat Jasmine rice instead of Basmati rice, white potatoes instead of sweet potatoes, strawberries instead of bananas, spinach instead of kale, etc.). This could aid in treatment by starving the bad bacteria of food. However, restricting fiber also decreases the food available for good bacteria, which could be problematic. My guess is that fiber restriction is not a good long-term plan, but may be helpful in the short term.

          • Thanks again Eric. I’ll let you know how it goes.

          • Eric/Paul,
            I’ve been looking at the short-term elemental diet. The standard one, which claims a pretty high success rate, isn’t real food. I saw a home-made version from Dr. Allison Siebecker which has a few items I wonder about (honey, dextrose and Nutrient 950 Multivitamin). Is there a PHD short-term elemental diet? Is it the same as the ketogenic diet on pg 158?

          • No, an elemental diet and a ketogenic diet are two entirely different things.

            An elemental diet works by providing purified nutrients (which can be immediately absorbed by the body), instead of food (which must first be digested and therefore remains in the digestive system long enough to feed bacteria as well).

            So an elemental diet will, by necessity, not consist of real food.

            I have no idea what would happen if you used a home-made approximation made with real foods. It might help, it might have no effect, or it might make your problem worse.

          • Alright, time for an update. Because I’m about to go on a 3 month vacation in Thailand, I decided not to try the short-term elemental diet for the time being. I don’t want to mess up my health before traveling. Plus, because I believe the leaky gut/SIBO theory, even if I clear out the SIBO with the elemental diet, I’ll eventually have to address the leaky gut. So I’m going to try supplementation here for 2 weeks before vacation, then put it on hold until I get back. I don’t want to carry a ton of pills with me. In July, after I return, I’ll decide if I want to do the elemental diet to clean out my system, but either way, I’ll do supplementation for several months from that point on.

            My goal is become well nourished for long enough to allow everything to recover and operate normally, then take myself back off the supplements. Actually, I got this idea from reading about the elemental diet. There are quite a few people who do it once every several years. They say it takes that long for symptoms to get bad enough to do it again.

            I have no desire to be supplementing all my life, and as far as I can tell, I only have 2 signs of danger. First, my high LDL, which my doctor says isn’t anything to worry about due to all my other blood work and my lifestyle being very good. Second, once a day I get some mildly painful gas. I massage my gut, burp, and it goes away. This is always immediately before the end of my 16 hr fast.

            It’s possible my gut health will fall apart in Thailand, but I’ll do my best to stay on the PHD. I’ll continue to update this thread.

          • Something bizarre happened this evening. I take my 6 daily supplements every day, plus one of my 8 weekly supplements. I only take zinc on days I eat liver. Anyway, I’ve gone through a whole week, and today was the first day to take boron. Boron was the only supplement I hadn’t tried. I forgot to take my pills during the meal, but I took them immediately after, and ate a mango after that. The bizarre thing – my stomach ceased all the mild gurgling that takes place after every meal. I’m stunned, but wondering if it’s going to last. And if it does, was it due to the boron, completing the whole course of supplementation, taking the pills after the meal, or the mango? Time may tell.

            The other thing I wanted to note is that I really don’t like B-2. Turned my pee bright yellow, which shocked me, but on that day I had moderate nausea after my bike ride. I’m not sure it was due to the B-2, but that’s my gut feeling (pun intended).

          • Yep, riboflavin (B2) will do that, esp when more than 27 mg in one go


          • here’s the ref for the 27 mg number;

          • Thanks Darrin. So then I have a question for Paul. If we can only absorb 27mg per dose, why are you recommending a single dose of 100mg per week?

          • Ok, I spoke too soon. Although the recommended supplements are 100mg, in the book he recommends 50mg. Here is an Amazon Prime 50mg option, for example:

          • Hi Eric,
            I just got my ferritin checked and it was 204. I assume this was ng/mL, but I wasn’t given the units (long story). They told me the normal range was 40 – 400, so I’m normal. What are you basing your 100 number on?

          • Roman,
            I usually try to cook below 300f but I also like to have oil with the highest smoke point as possible for insurance. I’ve managed to smoke extra virgin olive making eggs on moderate temperature. So I’ve switched to a higher temp oil.

            Leo, I just don’t understand people telling you to lower your carbs for someone with a profile like yours. Not only does it put your body into a stress state (keto is a stress state) which likely will raise LDL (or at least not help it), but will likely also increase your endogenous insulin resistance. I dunno, I find extreme low carbers to be a nutty and ideological group who think lower is always better. I’d be careful listening to these folks. I’d go vegan before I’d go ultra low carb, and I am no fan of the vegan diet. Sorry I sound harsh, but I feel like you can seriously damage your health listening to some of these folks.

          • Steve,
            I felt the same way as you before I got diagnosed with diabetes, and started checking blood sugar. I respect your opinion, but it’s pretty hard to argue against meter results. Like it or not, if I want to avoid diabetes symptoms or medicine I need to stay low carb. There is no other way.

            That being said, I can handle up to about 100g/day if I’m careful. Looking at my history (on cronometer), I’d been averaging about 80, so taking it down to 50 to stay ketogenic doesn’t scare me. I’ll be curious what the results show in February.

    • Ok, I’m on vacation in Thailand now and I decided to get my cholesterol tested. Before coming here I was on full supplementation for 2 weeks. This test was done 6 weeks after arrival. I get a lot of exposure to the sun here. I’ll summarize the main changes in my diet. I eat one or both of my daily meals in a restaurant now. They normally use palm oil here rather than coconut oil, but when I cook I use coconut oil. I’ve been eating a little more sugar, in the form of ice cream, chocolate and sweet coconut milk desert, and eat pizza or burgers twice a week which means I’m breaking the grain rule somewhat. I’m eating a little less vegetables, much more seafood, and a little more rice than potatoes etc. Here are the numbers:

      TC 359 (was 409)
      Triglycerides 47 (was 45)
      HDL 73 (was 95)
      LDL 248 (was 307)

      These numbers look pretty normal to me. I wish the HDL hadn’t dropped, but it’s still acceptable. Huge change in LDL. I’m hoping that it was mostly due to supplementation. When I get home I’ll probably go back to my pre-thai diet, finish off my existing supplements then retest.

      If the numbers look good, I’ll probably stay off supplements for a year and retest. If necessary, I’ll go back on them at that point. I still want to avoid long term supplementation because I think it isn’t healthy.

      • Leo,
        Those numbers have improved but I would still be concerned about the high LDL. I think Paul has a post somewhere that suggests that LDL>160 indicates a problem. Perhaps consume more monosaturated fats rather than coconut and palm oil. I have found tiger nut oil to be a fairly good cooking oil that is resistent to smoking. Sisson recommends high oleic sunflower oil.

        Also, did you get a glucose reading or get a sense of your insulin sensitivity? Stephen Guyenet just posted two studies showing that insulin resistance is a strong independent predictor of age related diseases.

        • Steve,
          Thanks for your response. I’m not concerned about the LDL, at least not to the point where I’d swap low omega 6 with high omega 6 fats. I’m on vacation now, so I don’t have the book with me, but I think it states LDL should be over 160, with no mention of an upper limit. But I could be wrong about that.

          My blood sugar level wasn’t measured this time unfortunately; forgot to request it. But the last 2 times it was at the very top, or slightly over, the “acceptable” range. Don’t remember the exact numbers. At the times of those tests I was eating about the amount of fructose Paul recommended, which isn’t very much, so I think it points out that I’m pretty sensitive. My grandfather was diabetic. I’m not, but I definitely feel lousy during periods of eating a lot of added sugar. I’ll check out the Stephen Guyenet posts. Thanks for the info.

          • Hi Leo,
            Yes in the book, Paul states LDL should be 100 or higher with no upper limit. But in his recent Jimmy Moore post, he did state that LDL above 160 indicates that something is wrong.

            Also, monosaturated fats (olive, avocado, tiger nut, high oleic sunflower) are not omega 6 fats, which are polysaturated fats. I think you can feel reasonable safe that you won’t be significantly increasing Omega 6 consumption by substituting some monosaturated fats for saturated. When I did it, my LDL came down while my HDL stayed high. I think Peter Attia, definitely a high fat dieter, even mentioned doing some substitution from saturated to monosaturated.

          • My bad on the 160 vs 100. Thanks for the additional info!

          • Hi Steve,
            It’s been 7 months since you suggested switching out some of my saturated with unsaturated fat, so I thought I’d give you an update.

            In November I had my lipids taken again, and they were almost back to where they were before Thailand, which makes sense since I went back to my previous, much better controlled, diet. In addition, they did an A1C, which revealed I’m pre-diabetic (5.8 or equivalent to 120 average BG). I was shocked.

            I made my lifestyle changes to control my BG, which was pretty easy to do. But I was determined to see if saturated fat was the villain of my LDL, and I did the funnest test possible. I ate tons of saturated fat for the next month, which means I went from about 50g to 70+g/day. I took my lipids in December and my LDL had skyrocketed! Here is a summary:

            Feb 2005 (70% carb diet)
            Total 195

            Feb 2012 (70% carb diet)
            Total 205

            Feb 2015 (3 months after going phd, 40% carb diet)
            Total 409
            LDL 307
            HDL 95
            Tri 45

            Jun 2015 (7 months phd, 40% carb diet)
            Total 359
            LDL 246
            HDL 73
            Tri 47

            Nov 2015 (1yr phd, 40% carb, 50g sfa)
            Total 376
            LDL 292
            HDL 79
            Tri 34
            A1C 5.8(lab)

            Dec 2015 (1yr 1m phd, 20% carb, 70g sfa)
            Total 527
            LDL 437
            HDL 81
            Tri 58
            A1C 4.8(meter)

            1) I needed to stay at about 20% carbs because of my diabetes, and I didn’t want to reduce my meat or eggs, so that left dairy and coconut oil to cut. Therefore my sfa is now 25g. Immediately after I made this change, I noticed increased muscle cramps, especially leg cramps when I sleep. I’ve heard this is often a side effect of statins too, and nobody knows why, so I’m hoping that it’s just what happens when LDL is rapidly reduced. This has subsided, and seems to be lessening with time. Did you get this right after you cut sfa?

            2) Because of all the dietary restrictions I have now, I find it necessary to add oil (olive and avocado as of today) to my food. Actually, I really like it, but I worry a little about how safe it is. I feel I’m already pushing my limits regarding fresh avocados and nuts, so oil seems to be a better alternative. Are you aware of any other high(non-saturated) fat foods?

            3) I want to add the 2 oils you recommend to give my diet more variety. I’ll read what Mark Sisson has to say about them; thanks so much for the information. In case I can’t find it there, are you saying these oils are safe for frying? I know olive and avocado aren’t supposed to be, so I use a little bit of my remaining coconut oil.

            Thanks again for your help,

          • Hi Leo, this is a reply to your latest post of Jan 8 2016, but for some reason there is no “reply” button next to it.

            Your health situation sounds very complicated and beyond my expertise. Hopefully, Paul can offer some suggestions. I do recall reading an Anthony Colpo post about the blood sugar issue:

            Colpo doesn’t think low carb helps with insulin resistance and my personal experience is that my ability to tolerate carbs crashed when I was low carbing.

            As for the specific question about oil, Tiger nut oil has a very high heat tolerance. According to Vitacost, it is 460F. I have not been able to cause it to smoke while making eggs in a pan. I easily get olive, avocado and high oleic sunflower oil to smoke. So go with the Tiger nut oil. It’s expensive but it’s the only oil I use for high temperature cooking. Vitacost sells it at a competitive price.

          • Steve,
            Thanks for the info about oils. Sorry if I made it sound like I was looking for a lot of advice; the other two questions were just whether you experienced leg cramps when you went to less sfa and if you knew of any other good high non-saturated fat foods. But I completely understand if you’d rather not answer.

            The linked article was interesting, and I’ll look into low glycemic index diets. Low carbs (50-100) control my blood sugar really well; I doubt if eating the amount I was before (200+) would work with my diabetes, regardless of the glycemic index, but I will investigate.

          • I don’t recall leg cramps from reduced sfa. But I did get it when low carbing and my recollection is my sfa was pretty high at the time.

            As for other high fat non-sfa foods, you might want to look into raw tigernuts. You can get them at amazon or vitacost. I like the unpeeled or sliced as regular tiger nuts have tough chewy skins. It’s high in monosaturated fats. But its also high in iron so I would eat them with coffee or tea to block the iron absorption. They are good for you because they are full of fiber and resistance starch.

          • Steve, why look for high temperature cooking oil? Isn’t low temperature cooking better, overall?

          • Steve – Thanks for your answers. Maybe it was just the low carbs from a week prior, rather than switching out fats a day before, that caused the cramps. Do you know where I can get a full nutritional breakdown on tiger nuts? All I can find is basic info.

            Roman – I can’t speak for Steve, but although I try to cook stuff at low temperature most of the time, sometimes I want to fry the heck out of something, and it’s usually liver. I used coconut last night, but I’d rather use a non-saturated high temperature oil in the long run.

          • Hi Leo,

            It looks like you decreased carbs while increasing saturated fat. So how do you know the increase in cholesterol was due specifically to the increase in saturated fat, as opposed to the replacement of carbs with fat in general?

            If you wanted to figure this out, you could try replacing monounsaturated fat by saturated fat. For example, you could do PHD with lean meats plus saturated fats (butter, coconut oil, etc.) for a month and measure cholesterol; then PHD with lean meats plus the same quantity of monounsaturated fats (olive oil, macadamia nut oil, etc.) for a month and re-measure cholesterol.


          • Eric – That’s a good point, and one that others have drawn my attention to. I might try your suggested experiment next time I’m in Thailand, since I can just go in any time and get reasonably priced tests there. Due to insurance issues, frequent testing for me in the US isn’t convenient.

            I’ve got quite a few people telling me I haven’t gone low enough with my carbs. I’ve heard that 50-150g is a danger zone, and now I’m doing more research. I’m also dropping to 50g just to make sure I’m ketogenic (sp?). I probably shouldn’t be doing more than one new thing at once, but if my lipids show a decent improvement by my February test, I’ll stay with it and eventually try working in more saturated fats.

          • Hi Leo,

            My guess is that lowering carbs will not help, and is likely to make the problem worse (see

            So some experiments you might consider:

            Higher carb intake. Note that your personal best numbers were on a 70% carb diet, your numbers were intermediate on a 40% carb diet, and your numbers were worst on a 20% carb diet. That certainly doesn’t suggest lowering carb intake further is likely to be beneficial!

            – Experimenting with monounsaturated versus saturated fats, as you mention above.

            – Emphasizing foods rich in phenolic compounds which are reported to lower cholesterol (like tea, chili peppers, turmeric, cranberries, anthocyanins pigments in deep blue/purple foods, etc.).

            – Higher intake of fiber, especially soluble fiber, which is supposed to lower cholesterol.

            – Supplementation of Pantethine, which is also reported to lower cholesterol.

            During any experiment, I would suggest using nutrient-tracking software like to plan your meals ahead of time to make sure only one factor is changing (e.g. if you experiment with increasing net carbs, make substitutions as necessary to ensure fiber intake stays the same, etc.).

            Probably multiple factors are at play, and long-term you will want to change multiple factors; but changing more than factor at once will leave you unsure of what was responsible for any improvement you see.


  38. Just thought I’d share my experience. I did low fat vegan (borderline fruitarian) for about 8 months and had these numbers:

    TC: 180
    Trygl: 108
    HDL: 45
    LDL: 113

    Switched to Paleo with carbs around 15-20% for 6 months
    TC: 344
    Trygl: 57
    HDL: 68
    LDL: 265

    Got alarmed and came across Paul’s site and added carbs. Also modestly reduced saturated fats though I certainly didn’t cut them out entirely.

    TC: 294
    Trygl: 66
    HDL: 81
    LDL: 205

    While I was happy with the decrease in LDL, I was still concerned that it was high. In the mean time, I also got a ferritin test of 240 which is high. I came across Anthony Colpo’s site about using IP6 to chelate iron. So over the last year, I have experimented with the following:
    1. IP6 3 times a week in the morning at least an hour before first meal.
    2. Followed a PHD type diet but I stopped counting macros and calories and just went with “intuitive eating”. Listened to my body. I didn’t track macros but my guess is I’m in the neighborhood of 50-60% of whole food carbs, 10-15% protein from fish and grass fed meats, and about 25-30% fats (about 80% of which is monosaturated fats and 20% saturated). Oh and I also worked on getting 8 hours of sleep and reducing stress.

    So here are my latest numbers:

    TC: 180
    Trygl: 83
    HDL: 74
    LDL: 92

    I think those number are pretty good but am open to thoughts. I’m particularly blown away by how much LDL has dropped and told the nurse it must have been a mistake. But they retested and it was confirmed. Note that this is lower than my LDL from my low fat vegan diet.

    Paul do you think that kind of drop in LDL can come from the large increase in carbs or do you think the reduction in iron from IP6 chelation has something to do with it? Thanks.

    • Hi Steve,

      The increase in carbs would lower LDL, but it shouldn’t lower it that much. LDL of 92 is too low and it’s likely you may now have an iron deficiency anemia. I would stop the IP6 and get iron status tested. Also be sure to eat liver to get iron in, and donate blood to get it out. Chelation is not the best way to manage minerals.

      • BTW Paul, what is the mechanism that links iron to LDL?

        Thanks again.

        • Hi Paul,
          I got my iron tested and my ferritin is 165 (down from 240 one year ago from ip6 chelation), UIBC 117, TIBC 219, %Saturation 47, and Iron 102.

          You were right that I may now have anemia but it looks like I have anemia of chronic disease given the high ferritin and low TIBC.

          FYI I have also been doing HIT stair climbing and resistance exercise with weights every other day over the last year. Lately I’ve been feeling very fatigued after the stairs which is consistent with the anemia.

          Could the combination of IP6, and increased exercise intensity have caused the anemia of CD or do you think it’s something else? Does reversing it involve stopping the ip6?
          Thanks for any advice you can offer because I have not found any research articles on these issues so I am at a loss. I have stopped the ip6. Should I stop the workouts for a while?

      • Paul,
        Rehash: I always had a TC of about 180, HDL 60ish LDL 105 or so Trigs 50 or so, glucose 85-90, crp 0.3 to 2.
        After a few years on a very low carb, very high fat diet, me TC went to 400, LDL 300, trigs 64, HDL 87, CRP 2.4, glu 98.
        I made a temporary switch to a very low fat diet for a month and my TC dropped to 198, LDL 127, HDL 56, trigs 47, glu 91 (glu dropped on a high carb diet) lipid-wise, my bad got better, but my good got worse, my ratios went from all good or borderline to all good with one high risk (apob/apoa)
        Here is the kicker: my inflammation markers skyrocketed from ‘borderline’ to high risk. Fibrinogen 507, hsCRP 12.3, LpPLA2 266. CRP tripled! I was coming off a week of swollen glands in the neck but felt good that day. Two weeks later had a slight cold. Maybe that was it?

        I am on a balanced diet like in the days with 185 TC.

        But meanwhile I wondered about this: I went from hard, traditional lifting 6 days a week to short, less frequent ‘high intensity lifting’. 6 exercises, one set each, very slow reps, to failure and forced reps, to isometric failure. I read that slow reps causes more micro tears in the muscle. I wonder if that could be it? But on test day, I had been off three days. One other thing, as soon as I started the HIIT, I started getting rosacea on my nose.

        Also, I had been on the HIIT when on the high fat diet and my CPR was 2.4.

        It does seem that I am not alone in going to higher fat and LDL jumping from normal to high. Maybe some of us aren’t meant for it.

        One last thing; is a month enough to get all the ‘change’ that will come from a diet switch? I expected lower LDL after a month of nearly non-fat.

  39. Thanks for the advice Paul. That is good to know. I can’t donate blood because I have traveled internationally so they won’t take my blood. So IP6 is it.

    As usual, I greatly appreciate your knowledge and helpfulness.

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