Does Keto Cause Heart Disease?

Aug 26, 2023

Does Keto Cause Heart Disease?

There’s a common belief that being in nutritional ketosis or following a ketogenic diet increases your risk of developing heart disease. But the reality is there is no such evidence. Instead, the incorrect belief is based on inaccurate and misleading data and the assumption that LDL cholesterol increases in everyone on a keto diet. But, as board-certified cardiologist and lipidologist Dr. Bret Scher explains in this video, there’s far more to the story.

Studies referenced in this video:

Cardiovascular disease risk factor responses to a type 2 diabetes care model including nutritional ketosis induced by sustained carbohydrate restriction at 1 year: an open label, non-randomized, controlled study
https://www.ncbi.nlm.nih.gov/pmc/arti…

Effect of carbohydrate-restricted dietary interventions on LDL particle size and number in adults in the context of weight loss or weight maintenance: a systematic review and meta-analysis
https://pubmed.ncbi.nlm.nih.gov/34159…

Effect of the ketogenic diet on glycemic control, insulin resistance, and lipid metabolism in patients with T2DM: a systematic review and meta-analysis
https://www.nature.com/articles/s4138…

Citizen Science Foundation’s Lean Mass Hyper-Responder Study
https://citizensciencefoundation.org/

Follow our channel for more information and education from Bret Scher, MD, FACC, including interviews with leading experts in Metabolic Psychiatry.

Learn more about metabolic psychiatry and find helpful resources at https://metabolicmind.org/

About us:
Metabolic Mind™ is a nonprofit initiative incubated by Baszucki Group. Our mission is to provide education and resources in the emerging field of metabolic psychiatry, including ketogenic interventions for mental disorders.

Our channel is for informational purposes only. We are not providing individual or group medical or healthcare advice nor establishing a provider-patient relationship. Many of the interventions we discuss can have dramatic or potentially dangerous effects if done without proper supervision. Consult your healthcare provider before changing your lifestyle or medications.

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0:00 - Intro
2:28 - Disclaimer
2:51 - The existing evidence
4:08 - Being in Ketosis is a Physiological state
5:30 - Healthy user bias
6:30 - LDL and the ketogenic diet
9:58 - What to do regarding nutritional ketosis?
11:11 - Benefits of nutritional ketosis
12:45 - The answer to the big question
14:00 - Outro

Content

0 -> if a doctor falsely believes keto will

2.52 -> cause a heart attack of course they're

4.319 -> going to be hesitant to recommend it but

6.48 -> if they knew the potential benefit and

8.22 -> knew that there was no evidence showing

10.019 -> increased heart disease then they'd be

12 -> much more willing to consider

13.38 -> nutritional ketosis as a therapeutic

15.719 -> intervention in the right setting does

17.46 -> being in nutritional ketosis or

19.26 -> following a ketogenic diet increase your

21.96 -> risk of developing heart disease that's

24.6 -> certainly something we hear quite a bit

26.58 -> and many doctors and dietitians believe

29.039 -> a keto diet is proven to increase

31.94 -> cardiovascular disease but the reality

34.559 -> is there is no such evidence so let me

37.26 -> explain there are no intervention trials

39.84 -> measuring cardiovascular outcomes with

42.12 -> nutritional ketosis meaning no Studies

44.7 -> have started subjects on a keto diet and

47.7 -> found they have more heart disease heart

49.559 -> attack Strokes Etc not one study has

51.66 -> been done to demonstrate this so we

54 -> can't say with certainty that

55.079 -> nutritional ketosis increases

56.879 -> cardiovascular events now to be fair we

59.699 -> also don't have studies showing

61.26 -> nutritional ketosis decreases cardiac

63.48 -> events so it works both ways so in the

66.479 -> absence of outcome data how do we make

68.76 -> sense of all this right it like leaves

70.32 -> us in the Snowman's Land and how do we

72.6 -> know what effect nutritional ketosis may

74.64 -> have on our cardiovascular risk that

76.38 -> would be an important thing to know when

77.939 -> to measure what we have to use what's

80.04 -> called surrogate outcome data which our

82.56 -> results believed to increase or decrease

84.9 -> the risk of heart disease since we don't

87.42 -> have data evaluating heart attacks or

89.88 -> who lives or who dies we have to fall

91.86 -> back on this surrogate data such as the

94.02 -> most commonly used LDL cholesterol and

96.72 -> while LDL is traditionally the most

98.64 -> often used cardiac risk factor LDL is

100.86 -> not the whole story we should also

103.32 -> consider markers of metabolic Health

105 -> such as glucose hemoglobination insulin

107.579 -> and markers of inflammation such as CRP

110.399 -> and and more specific lipid measures

112.5 -> such as apobv vldl and others and and

115.2 -> don't worry I know these are a lot of

116.7 -> terms I just threw a lot of acronyms in

119.04 -> terms of you but we'll have a separate

120.899 -> video discussed in the labs in more

122.64 -> detail so keep an eye out for that one

124.2 -> but in this video we're going to explore

126.78 -> the options for evaluating

128.819 -> cardiovascular risk with nutritional

131.16 -> ketosis and also talk about some of the

133.56 -> evidence people use to falsely believe

136.26 -> that there's an increased cardiac risk

138.239 -> with ketosis and we'll talk specifically

140.4 -> about the lean mass hyper responders

142.02 -> near the end so stick around from that

143.58 -> and really sort of talk about different

146.04 -> way is to see this issue but before we

148.98 -> get into the details please remember our

150.959 -> channels for informational purposes only

152.819 -> we're not providing individual or group

155.16 -> medical or Health Care advice or

156.84 -> establishing a provider patient

158.22 -> relationship many of the interventions

160.02 -> we discuss can have dramatic or

161.519 -> potentially dangerous effects if done

163.08 -> without proper supervision consult your

165.78 -> health care provider before changing

167.459 -> your lifestyle or medications

169.44 -> okay now let's start with the existing

172.5 -> evidence why do some people believe

174.66 -> doctors included that low-carb and keto

177.48 -> diets increase the risk of heart disease

180 -> while many Publications or clinicians

181.92 -> might cite large observational studies

184.08 -> showing that eating more fat are lower

186.18 -> carbohydrates increases the risk of

189 -> heart disease or death now that sounds

190.92 -> scary right

192.18 -> the problem is that most of these

194.28 -> studies Define low carbohydrate as 40

196.5 -> percent of your calories or recently one

198.659 -> study May headlines defining low carb is

200.94 -> 25 percent of calories but we have to

203.4 -> understand that is not nutritional

205.8 -> ketosis 40 of calories from

208.44 -> carbohydrates on a 2 000 calorie diet is

211.44 -> 200 grams of carbohydrates per day and

214.98 -> 25 percent of calories represents 125

217.5 -> grams of carbohydrates per day that's

219.959 -> more than someone in nutritional ketosis

221.819 -> will eat an entire week let alone a day

224.28 -> so the way we can interpret this is that

226.379 -> individuals in those studies ate lower

228.18 -> carb diets compared to the standard

229.98 -> American you know the 55 plus

232.08 -> carbohydrate diet but they weren't in

234.659 -> ketosis so does that matter should we

237.42 -> care that they weren't in ketosis I mean

239.159 -> they ate lower carb isn't that the same

240.72 -> thing no absolutely not is not the same

244.019 -> thing and we should care whether or not

246.239 -> they were in ketosis

247.799 -> being in ketosis is a physiologic state

250.56 -> that changes your metabolism it's almost

252.9 -> like an on off switch you're either in

254.4 -> nutritional ketosis where you're burning

256.38 -> fat for fuel primarily and you produce

259.199 -> ketones which can also be used as fuel

261.299 -> fuel especially by your brain or or

263.46 -> you're not right you're not in that

264.9 -> state you are you aren't so being close

266.82 -> or closer doesn't really count

269.1 -> especially in these studies of the

270.6 -> general population so so yes it does

272.759 -> matter whether someone's in ketosis plus

275.1 -> another issue here is that diet quality

277.979 -> is essential if someone's eating less

280.139 -> than 20 or 30 grams of carbohydrate per

282.12 -> day and is in ketosis it's kind of tough

284.94 -> to fit in processed or sugary Foods or

287.88 -> you know the high calorie high carb high

290.46 -> fat foods but compare that to someone

292.259 -> who's eating 100 or 150 grams or 200

295.38 -> grams of carbohydrates per day lower

297.419 -> than the standard American diet but much

299.28 -> higher than nutritional ketosis well in

301.56 -> that setting those Ultra processed or

303.3 -> high calorie foods containing carbs and

305.22 -> fat become much easier to fit in

307.56 -> so the greater the carb reduction the

310.08 -> lower the risk of adding those

311.46 -> potentially concerning Foods and that

313.86 -> doesn't even get into the low quality

315.78 -> data that comes from these observational

317.52 -> studies with food frequency

319.139 -> questionnaires which some studies will

321.06 -> measure once at the beginning of the

322.979 -> study and then never again over 10 years

325.02 -> now does that sound like an accurate way

326.82 -> to collect data of course not no it's

329.039 -> not there's also the concept of healthy

331.199 -> user bias

332.699 -> um you know the common health message in

334.74 -> the 1990s and early 2000s was that low

336.9 -> fat is healthy so who was eating low fat

339 -> generally those who wanted to be

340.8 -> healthier and those weigh more fat

342.9 -> probably weren't so interested in health

344.52 -> advice no that's not always the case but

346.56 -> in these studies it tends to be true for

348.479 -> the general population those who ate

350.52 -> more red meat are more saturated fat

352.199 -> also tended to smoke more drink more

355.02 -> alcohol exercise less and have other

357.3 -> unhealthy life habits and there are more

359.16 -> issues that we won't get into in this

361.02 -> video but we'll Explore More in

362.699 -> dedicated future videos about the

364.199 -> difference between observational

365.28 -> nutritional studies and randomized

367.02 -> controlled trials but as you can see

368.94 -> relying on this level of evidence to

371.22 -> tell us anything about the health

372.78 -> benefits or risks of nutritional ketosis

375.12 -> is I guess pretty useless at best and

377.759 -> potentially incredibly misleading

380.22 -> but as I mentioned now when we don't

382.44 -> have solid outcome data which we don't

384.36 -> we fall back on surrogate outcomes and

387 -> specifically it tends to focus on LDL so

389.22 -> it's important to remember though the

390.72 -> LDL is only one of many cardiovascular

392.819 -> risk factors many clinicians believe LDL

395.819 -> is not something we should ignore but

397.68 -> it's also not something we should

399.12 -> interpret in isolation instead we should

401.94 -> regard it as one cardiovascular risk

404.1 -> factor as I said and put it into the

405.96 -> context of the overall cardiovascular

408.18 -> risk assessment and analyzed

410.52 -> specifically for each individual so

412.139 -> here's one example which I really like

414.36 -> virta Health published a paper on their

417.12 -> one-year Continuous Care intervention

418.8 -> with the ketogenic diet this was in

420.84 -> patients with type 2 diabetes looking to

424.08 -> treat their diabetes specifically with

426.66 -> nutritional ketosis now on average

428.759 -> participants saw their LDL go up by 10

431.639 -> percent however

433.74 -> the 10-year calculated cardiovascular

436.259 -> risk went down by 12 percent now some

439.02 -> may see that statistic and wonder how

441 -> could that be the LDL went up with the

442.56 -> cardiovascular risk went down that's

444.06 -> like not what we're told well it turns

446.639 -> out there was no change in apob which is

449.22 -> a better marker than LDL really there

451.74 -> was a decrease in blood pressure and

453.539 -> triglycerides in vldl an improvement in

456.06 -> many other metabolic Health markers so

457.919 -> according to that calculation there was

459.84 -> an overall reduction in cardiovascular

462 -> risk and that's a clear example of why

464.46 -> it's best to interpret LDL within the

466.8 -> context of overall cardiovascular risk

469.86 -> but here's another issue with assuming

472.139 -> that keto increases LDL and therefore

474.9 -> must increase cardiovascular risk it

477.18 -> simply isn't true right multiple

478.979 -> meta-analyzes show that on average

480.96 -> there's no net increase in LDL in

484.02 -> studies using nutritional ketosis for

485.94 -> weight loss or treating type 2 diabetes

487.68 -> no net increase yet yet somehow some

491.58 -> people including doctors believe LDL is

494.039 -> bound to go up in everyone starting a

496.8 -> keto diet the reason that eating that

499.259 -> much fat must increase LDL but as the

502.56 -> literature demonstrates that simply

504.12 -> isn't true now that being said we have

506.46 -> to acknowledge there is a population

507.66 -> termed hyper responders where LDL does

509.94 -> go up substantially but again these tend

511.86 -> to be the exception not the rule in

514.38 -> addition those with the greatest

515.76 -> increase while following a ketogenic

517.8 -> diet tend to be leaner and more

519.419 -> metabolically healthy engineer and

521.88 -> citizen scientist Dave Feldman along

523.68 -> with Dr Matt budoff Dr Nick norovitz and

525.72 -> others have published on this topic and

527.76 -> are currently studying hyper responders

529.56 -> with a study involving CT angiograms and

532.5 -> extensive blood and genetic testing so

534.3 -> there's there's definitely more exciting

535.92 -> information to come one way or the other

537.779 -> now Dave Feldman and Dr budoff reported

540.3 -> their preliminary data at a conference

542.519 -> in Denver in February 2023. on the

545.399 -> surface the preliminary data is really

547.32 -> encouraging but but we have to

549.24 -> acknowledge its only preliminary data

551.04 -> it's a small sample size and is yet to

552.779 -> be published so it is too soon at the

555.24 -> timing of this recording to say much

557.22 -> conclusively about this patient

558.66 -> population But please understand the

560.64 -> lean mass hyper responders which we hear

562.5 -> so much about are the exception not the

565.92 -> rule and it's more common that if

568.08 -> someone's LDL is going to go up which by

570 -> no means is a guarantee because most

571.44 -> people it doesn't remember but if it

573.42 -> does it's more likely to go up like by

575.88 -> 10 or 15 percent rather than the 50 or

578.16 -> 100 percent or more increase seen in the

580.56 -> lean mass hyper responder population

583.38 -> okay so now we've reviewed the lack of

585.42 -> outcome data the faulty and misleading

587.459 -> observational data and the caveat of the

589.62 -> lean mass hyper responders but now we're

591.48 -> at this place wondering where does that

593.76 -> leave us right how do you as an

595.68 -> individual or a clinician know what to

598.08 -> do regarding nutritional ketosis LDL and

600.839 -> cardiac risk well we can see this as

603.66 -> sort of two ways there are two potential

605.58 -> ways to approach this question in my

606.899 -> mind the first is that since no outcome

608.64 -> data exists on those in nutritional

610.38 -> ketosis then they should be treated just

612.18 -> like everybody else even though they're

613.98 -> metabolically different and their

615.3 -> dietary makeup is drastically different

616.98 -> from the general population many

618.899 -> Physicians prefer caution until you know

621.3 -> more definitive Definitive data exist so

624.72 -> for them guideline medicine still

626.279 -> applies but the other approach is that

629.04 -> since this population is clearly

630.6 -> physiologically unique they should be

632.58 -> treated differently this population

633.72 -> should have its own guidelines that

635.58 -> reflect their metabolic health and

637.14 -> unique physiology of being in ketosis

638.88 -> now this isn't evidence-based but

640.56 -> neither approach really is for that for

642.6 -> this specific population at this point

644.94 -> we can't say which is right or wrong

646.74 -> these are preferences reflecting the

648.899 -> opinions of both the provider and the

650.88 -> individual but either way I think it's

653.22 -> still crucial not to use LDL as a

656.94 -> solitary measure or to ignore it

658.74 -> entirely either approach but instead to

661.019 -> factor it into the overall health and

662.88 -> benefits the individual has achieved

665.16 -> through nutritional ketosis now speaking

667.56 -> of benefits this is a crucial point to

669.06 -> make we have to know the benefits the

671.279 -> individual has seen through nutritional

673.14 -> ketosis in a prior video I was somewhat

675.66 -> critical of Dr Christopher Gardner who

677.579 -> was quoted in an article saying the

679.38 -> risks of a keto diet outweigh the

681.66 -> benefits

682.68 -> of course first he wasn't even talking

684.24 -> about a keto diet this was the keto-like

686.16 -> diet study with 25 of calories from

688.32 -> carbs so it's entirely off base to begin

690 -> with but but my biggest problem is this

692.399 -> how does he know what the benefits even

694.56 -> are how can he say the risks outweigh

697.56 -> the benefits when he has no idea what

699.72 -> benefits and individual experiences

702.38 -> understanding the benefits to the

704.339 -> individual is crucial to interpreting

706.68 -> the risk benefit ratio I mean what if if

708.899 -> someone had Decades of anorexia with

710.76 -> absolutely no improvement except for

712.92 -> when they started nutritional ketosis

714.66 -> that's pretty crucial to know or if

717.12 -> someone has struggled with finding

718.56 -> adequate treatment for bipolar disorder

720.42 -> and nutritional ketosis help put their

722.82 -> symptoms into remission

724.5 -> that has to weigh heavily on your

726.3 -> decision as you evaluate a risk benefit

728.16 -> ratio

729.36 -> what if someone put their type 2

731.399 -> diabetes into remission how would that

733.5 -> change your perception if their LDL went

735.48 -> up by 10 or 15 or even 50 percent again

738.3 -> I'm not sure there's an automatic answer

740.04 -> to whether that's good or bad but it

742.019 -> needs to be individualized and that word

744.779 -> individualized sort of exemplifies where

746.88 -> medicine should go of course we should

748.98 -> be individualized for each patient but

750.779 -> unfortunately busy doctors tend to want

752.94 -> to use guidelines in our Medical

754.14 -> Practice tends to encourage treating

756.48 -> people similarly I guess you can say but

758.339 -> that's a trap I hope we can avoid by

761.22 -> continuing to discuss the unique

762.72 -> physiologic state of nutritional ketosis

765.18 -> so how do we answer the question does

766.68 -> nutritional ketosis increase

768 -> cardiovascular risk the answer is we

770.339 -> don't know at least not from concrete

772.2 -> outcome studies and even with surrogate

774.54 -> studies there's still no convincing

776.399 -> evidence we have to acknowledge there's

778.38 -> a small population where LDL can go up

780.54 -> dramatically and we shouldn't take that

782.1 -> lightly rather we should Factor it into

784.079 -> the patient's overall health and overall

785.82 -> progress or their reaction to

787.56 -> nutritional ketosis and we need need to

790.019 -> deeply understand the benefits for each

792.12 -> individual to be able factor in a risk

794.7 -> benefit ratio

796.079 -> but I think it's clear the evidence does

798.12 -> not support the automatic assumption

800.1 -> that nutritional ketosis increases

802.32 -> cardiovascular risk or even

803.76 -> automatically increases LDL and changing

806.76 -> this mindset is crucial so that

808.139 -> clinicians might be more willing to try

810.18 -> nutritional ketosis as a therapeutic

812.1 -> medical intervention especially for

814.5 -> those who have tried multiple different

816.06 -> interventions for their type 2 diabetes

818.04 -> or their Alzheimer's disease or their

819.48 -> psychiatric condition or other health

821.399 -> issues if a doctor falsely believes keto

824.04 -> will cause a heart attack of course

825.779 -> they're going to be hesitant to

827.04 -> recommend it but if they knew the

828.959 -> potential benefits and knew that there

830.519 -> was no evidence showing increased heart

832.44 -> disease then they'd be much more willing

834.6 -> to consider nutritional ketosis as a

837.06 -> therapeutic intervention in the right

838.56 -> setting so what do you think how do you

840.3 -> see the issue of cardiac risk with

841.98 -> nutritional ketosis leave us a comment

844.2 -> as we would love to hear your take on

845.94 -> this issue and if you found this video

847.68 -> helpful please click the Thumbs Up And

849.3 -> subscribe button so you won't miss any

850.8 -> of our future content and please share

852.42 -> this video with anyone you think May

854.1 -> benefit including your physician and if

856.86 -> you want to understand the potentially

858.48 -> profound effects of nutritional ketosis

860.76 -> on Mental Health please watch this

862.74 -> incredible story of one family's

864.72 -> reversal of dementia and regaining their

867.42 -> lives back after beginning nutritional

869.22 -> ketosis and keep an eye out for our

871.56 -> future video of what you can do about

873.779 -> elevated LDL while in nutritional

875.88 -> ketosis which sort of ties into this

877.68 -> whole concept of cardiovascular risk and

879.54 -> whether LDL is important or not but

881.339 -> there are tricks you can do to manage it

882.839 -> and maintain nutritional ketosis because

885 -> for some The Importance of Being in

887.639 -> nutritional ketosis outweighs any

890.1 -> potential changes in LDL so thank you

892.92 -> for watching thank you for listening I'm

894.3 -> Dr Brett Sher and I look forward to

895.98 -> seeing you again here next time at

897.3 -> metabolic mind

Source: https://www.youtube.com/watch?v=pKmNhQbtDLI