How Fat Makes You Skinny . . . (Eating Fat Lowers Your Cholesterol?!)

Diseases seem to arrive in three’s each day in my office.  Today I had three different patients with cholesterol concerns who were notably confused about what actually makes the cholesterol worse, and what causes weight gain.  Each of them, like many patients that I see, were stuck in a state of confusion between low fat and low carbohydrate lifestyle change.   My hope is to give my patients and anyone reading this blog a little more clarity regarding what cholesterol is, how it is influenced and how it affect our individual health.

First, the standard cholesterol profile does not give us a true picture of what is occurring at a cellular level.  The standard cholesterol panel includes: total cholesterol (all the forms of cholesterol), HDL (the good stuff), LDL-C (the “bad” stuff) and triglycerides.  It is important to recognize that the “-C” in these measurements stands for “a calculation” usually completed by the lab, and not an actual measurement.  Total cholesterol, HDL-C and triglycerides are usually measured and LDL-C is calculated using the Friedewald equation [LDL = total cholesterol – HDL – (triglycerides/5)].  (No, there won’t be a quiz on this at the end  . . . so relax.)

However, an ever increasing body evidence reveals that the concentration and size of the LDL particles correlates much more powerfully to the degree of atherosclerosis progression (arterial blockage) than the calculated LDL concentration or weight (1, 2, 3).

There are three sub-types of LDL that we each need to be aware of: Large “fluffy” LDL particles (type I), medium LDL particles (type II & III), and small dense LDL particles (type IV).

Lipid Planet Image

Weight & Size of VLDL, LDL & HDL


Misleading LDL-C

Why LDL-C is misleading: Identical LDL-C of 130 mg/dL can have a low risk (Pattern A) with a few “big fluffy LDL particles or high risk (Pattern B) with many small dense LDL particles.

Second, it is important to realize that HDL and LDL types are actually transport molecules for triglyceride – they are essentially buses for the triglycerides (the passengers).  HDL can be simplistically thought of as taking triglycerides to the fat cells and LDL can be thought of as taking triglycerides from the fat cells to the muscles and other organs for use as fuel.

Third, it is the small dense LDL particles that are more easily oxidized and because of their size, are more likely to cause damage to the lining of the blood vessel leading to damage and blockage.  The large boyant LDL (“big fluffy LDL particles”) contain more Vitamin E and are much less susceptible to oxidation and vascular wall damage.

Lipid Danger Slide

Eating more fat or cholesterol DOES NOT raise small dense LDL particle number.  Eating eggs, bacon and cheese does not raise your cholesterol!  What increases small dense LDL particles then?  It is the presence of higher levels of insulin.  Insulin is increased because of carbohydrate (sugars, starches or fruits) ingestion. It is the bread or the oatmeal you eat with the bacon that is the culprit.  The bread or starch stimulates and insulin response.  Insulin stimulates the production of triglycerides and “calls out more small buses” to transport the increased triglyceride to the fat cells (4, 5, 6, 7).

Fourth, following a very low carbohydrate diet or ketogenic diet has been demonstrated to decreased small dense LDL particle number and correlates with a regression in vascular blockage (8, 9).  So, what does this really mean to you and me?  It means that the low-fat diet dogma that that has been touted from the rooftops and plastered across the cover of every magazine and health journal for the last 50 years is wrong. . . absolutely wrong.

I talk about this and answers questions on today’s Periscope.  You can see the recording on with the comments in real time here:


Or, you can watch the video below:


  1. Superko HR, Gadesam RR. Is it LDL particle size or number that correlates with risk for cardiovascular disease? Curr Atheroscler Rep. 2008 Oct;10(5):377-85. PMID: 18706278
  2. Rizzo M, Berneis K. Low-density lipoprotein size and cardiovascular risk assessment. QJM. 2006 Jan;99(1):1-14. PMID: 16371404
  3. Rizzo M, Berneis K, Corrado E, Novo S. The significance of low-density-lipoproteins size in vascular diseases. Int Angiol. 2006 Mar;25(1):4-9. PMID:16520717
  4. Howard BV, Wylie-Rosett J. Sugar and cardiovascular disease: A statement for healthcare professionals from the Committee on Nutrition of the Council on Nutrition, Physical Activity, and Metabolism of the American Heart Association. Circulation. 2002 Jul 23;106(4):523-7. PMID: 12135957
  5. Elkeles RS. Blood glucose and coronary heart disease. European Heart Journal (2000) 21, 1735–1737 doi:10.1053/euhj.2000.2331
  6. Stanhope KL, Bremer AA, Medici V, et al. Consumption of Fructose and High Fructose Corn Syrup Increase Postprandial Triglycerides, LDL-Cholesterol, and Apolipoprotein-B in Young Men and Women. The Journal of Clinical Endocrinology and Metabolism. 2011;96(10):E1596-E1605.
  7. Shai I et al. Cirulation. 2010; 121:1200-1208
  8. Krauss RM, et al. Prevalence of LDL subclass pattern B as a function of dietary carbohydrate content for each experimental diet before and after weight loss and stabilization with the diets.  American Journal of Clinical Nutrition. 2006; 83:1025-1031
  9. Gentile M, Panico S, et al., Clinica Chimica Acta, 2013, Association between small dense LDL and early atherosclerosis in a sample of menopausal women, Department of Clinical Medicine and Surgery, University “Federico II” Medical School, Naples, Italy Division of Cardiology, Moscati Hospital, Aversa, Italy A. Cardarelli Hospital, Naples, Italy

10 Comments on “How Fat Makes You Skinny . . . (Eating Fat Lowers Your Cholesterol?!)

  1. Dr. Nally
    “Eating more fat or cholesterol DOES NOT raise small dense LDL particle number” How would you address the issue for the small group of people like me that had the opposite in the ketogenic diet? My LDL-P skyrocketed to 2697 (2014) and 2125 (2015) all other markers where fine except for LDL-P and low Vit D. What would be the protocol to lower it? I’m not overweight (5′ 102lbs) nor have metabolic issues, exercise regularly and eat low carb paleo but with a family history of CVD.

    • Jacqueline, great question. You’re not alone and your not “a small portion of the population.” LDL-P is not the same as the small dense LDL. LDL-P is the measure or sum of the Big “fluffy” LDL + medium sized LDL + small dense LDL. I commonly see the LDL-P go up with a Ketogenic or low carbohydrate diet because there is an increase in the number of Big “fluffy” LDL (which is actually the “good” bad LDL). LDL-P is just a measure of all the LDL particles. As was mentioned in the video, LDL-P is not what you should be watching. As long as the small dense LDL are below 500 and the triglycerides are below 100, I’m not worried, because clinically, I see notable improvement the metabolism, weight loss and regression in atherosclerosis by ultrasound. (We still don know what the LDL-P should be, so the lab made and educated guess and put down < 1500 as normal range. However, this is an arbitrary experimental number and still unknown. That is why some insurance companies still consider this test "experimental.") Now if the small dense LDL are ALSO elevated with an elevated LDL-P, it means there is still something in the diet stimulating an increase in insulin. It is usually, in my experience, that the carbohydrate intake level is still too high, an artificial sweetener like acelufame potassium or a coffee creamer containing a sugar alcohol.

  2. Thank you so much! Now, I have a better understanding my Small LDL-P was 231 (2014) and 90 in (2015).

    Thanks again!

  3. Hello again Dr. Nally,
    I had my physical last week and got my results back all seem within normal range however you mentioned in this periscope that in your practice a person with a Ha1c higher than 5 is insulin resistance; mine was 5.5 (5.3 2014), glucose 66 (77 2014). Do I fall into that category or am I within the normal range?
    Cholesterol small LDL-P 90, Tryg 24, HDL 113, LDL 144, H-CRP 0.66, LP-IR score<25, TSH 1.66, T4 1.10 only a mild anemia. No family history of diabetes.
    Should I lower more my carb intake?

    Thank you and I appreciate you take time out of your busy schedule to answer all the

    • Jacqueline,
      I thought I said that >5.6% was considered insulin resistance. If you heard or I said 5.0%, I apologize. Your numbers are perfect!! Keep up the great work!!
      Adam Nally, D.O.

  4. We don’t have a LDL-P test here in Malaysia. Will the Apo-A and Apo-B test be sufficient to conclude that we have large fluffy LDL?

    • Yes, Alex. App B, Non-HDL cholesterol, triglycerides and and HS-CRP are some simple tests that can tell you if your cholesterol is shifting the right direction.

      • Thank you for your quick response. I will look into getting the Apo-B done and report back here when I get the results.

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