Vascular Plaque Reduction with Ketogenic Diet – A Case Study

Does your diet really reverse vascular disease?  I mean, will the diet you’re following ACTUALLY reverse the plaque burden that has occurred over the years of eating the SAD diet (Standard American Diet)?

It appears that the ketogenic diet does.  At least that’s what research is showing, and that’s what I am seeing clinically.  Let me give you an example.  Reversal of vascular disease is what I saw last week in this patient case study in my office.

Meet “Mrs. Plaque” (name has been changed to protect her identity).  She is a very pleasant 78 year old female who has been seeing me as a patient for the last 10 years.  We identified worsening cholesterol and hyperinsulinemia in this patient a few years ago, and last year, she finally decided to go on a ketogenic diet after we noted slight worsening blood sugar (HbA1c increased to 6.1%), worsening cholesterol and a recent TIA (transient ischemic attack or “mini stroke”).  We identified a 44% blockage in her left internal carotid artery and a 21% blockage in the right internal carotid artery putting her at risk for further cerebral ischemic events like a stroke and/or other vascular events like a possible heart attack down the road. She refused STATIN therapy as she had previous myalgia and side effects with their use in the past.

Past Medical History:  Hyperlipidemia, Impaired Fasting Glucose (Pre-Diabetes),.Asthma, GERD, Irritable Bowel, Generalized Anxiety, Idiopathic Peripheral Neuropathy, Surgical Menopause (Hysterectomy) with Secondary Atrophic Vaginitis, Recent TIA, Cataracts, Appendectomy

Medications: Plavix 75mg one daily, Premarin Cream 0.635mg every other day, Xanax 0.5mg at bedtime for anxiety, Lyrica 50mg one nightly for neuropathy, Vitamin D 2000 IU daily , TUMS 750mg twice a day.

Her carotid ultrasound and carotid medial intimal thickness (CIMT) study completed April 1, 2015 is present below.  You can see that her intimal thickness is only slightly higher than the average female her age, however, she has notable internal carotid artery blockage in both the right and the left sides.


The “mini stroke” and the report above, convinced her that she needed to tighten up her diet.  The patient’s husband was also a diabetic and the patient had been “partially” restricting sugar in her diet up to this point in time, however, she had not fully jumped on the ketogenic band wagon.    At this point she decided to change her diet.

She was placed on a ketogenic diet, restricting her carbohydrates to no more than 20 grams per day and increasing total fat to >50-60% of her total calories.  Nothing else changed including her medications.  She followed this program for the next year and this is the blood work that she had while following this program:

4/2/2015 8/4/2015 11/6/2015 5/12/2016
HbA1c (%) 6.1 5.8 5.2
Tot Chol (mg/dL) 224 156 230 233
HDL (mg/dL) 76 76 87 96
LDL-C (mg/dL) 134 65 128 123
Small Dense LDL-P (nmol/L) 481 150 222 217
Triglycerides (mg/dL) 72 76 74 68
Fasting  Insulin (uIU/mL) 12
Glucose (mg/dL) 91 95 92 85

Because she was already partially restricting her sugar intake, her triglycerides and small dense LDL particle number was not bad, however, her average blood sugars were still significantly elevated. Weight decreased from 127 lbs to 119 lbs in August. She admits to slightly increased protein intake over the holidays and her weight increased back up to 125 lbs as of her last visit.

These labs also demonstrate that Total Cholesterol and LDL-C don’t appear to correlate with regression of plaque.

The image below is the patient’s repeat CIMT and carotid ultrasound 13 months later through the same lab.  What is dramatic is that she has had over 10% regression in the plaque in both internal carotid arteries and a return of her carotid intimal thickness to the average female in her age bracket.


This case study is consistent with the findings of Dr.Shai and his group when they did a two year comparative dietary intervention study of Low Fat – Group 1, Mediterranean Diet – Group 2, and a Ketogenic Diet – Group 3 on vessel wall volume and CIMT.


Carotid IMT changed by −1.1% from 0.816 mm at baseline to 0.808 mm after 2 years (P=0.18), with no significant difference between diet groups (P=0.91). There was a trend toward significant correlation between the 2-year changes in carotid IMT and VWV (r=0.173, P=0.056).

So, does your diet reverse vascular disease?  Evidence is pointing to the fact that the ketogenic diet does.  I return to the statement Hippocrates made over 2000 years ago, “Let food be thy medicine, and let medicine be thy food.”

Oh, and pass the bacon.

43 Comments on “Vascular Plaque Reduction with Ketogenic Diet – A Case Study

  1. Bob,
    Great question. Thank you.
    Specific effects of a ketogenic diet on ApoE 3/4 and ApoE 4/4 have not been individually studied as far as I am aware. However, clinically, I have yet to see a problem and those with specific increased risk of atherosclerosis.
    Those patients with Apo E2 and E4 alleles seem to correlate closely with increased risk of insulin resistance. The ketogenic lifestyle is dramatically helpful in these cases. However, in any case where there is question, watch your cholesterol and blood sugar closely with your doctor when you are making a dietary change.

  2. Can you show Current Medications so we can see if the diet changed what medications are required. I think this would be interesting. Also, was there any weight change for her?

  3. This is so interesting. I have been KETO 4+ years. 69-1/2. Trigs 33, HDL 165, LDL 80,
    Total CHol 248. Can’t figure why my fasting glucose average is 95. A1C 5.3
    I am considered a very fit athlete. Can’t figure why FG is so high and would think my A1C would be lower.
    I have never heard you mention supplementing creatine monohydrate and being KETO.

    • When you’ve been in ketosis for longer than 4-6 months, you start seeing physiologic glucose sparing at the muscle level that causes fasting blood sugars to stay slightly higher, 90-105 in many people. This is a normal physiologic response. Once you begin eating carbohydrates regularly again, blood sugars fasting drop to lower than 95 routinely unless you are still insulin resistant.

      • Thank you. Do you feel creatine monohydrate can benefit a Keto diet?
        Find very little research on this.

      • Karen,
        Creatine only increased water content of the myocyte (muscle cell). Because it is a protein, it does have the possibility of keeping you out of ketosis if you us too much of it. It really has no other benefit than short term muscle size increase and very mild short term strength gain while using it. Otherwise there is limited data on its use with a ketogenic diet.

      • Have been taking 5gms daily of creatine monohydrate. the last three weeks. My blood keytones are never real high…probably my age and female.. I get measures of .5 – 1.2mm. When I take KETO-OS i go up to 2.8.
        I have a feeling there will be more discussions on this in the near future.
        Always look forward to yours and Jimmy’s timelines,…
        Thanks for your quick response.
        Karen Donegan

      • Karen, how are you testing your ketone level?

        I’ve been on a low carb diet for about 2.5 years and have never actively attempted to get into or monitor for a ketogenic diet, but I’m going to start that soon. I do keep my carbs low a lot (except splurges like a trip to NYC this weekend). I also fast regularly now, which I’m sure puts me in ketosis.

        I just bought a ketone blood test meter, as I’ve read that there are multiple types of ketones, and the urinalysis and breath ketone meters rely one one type of ketone, which has a lower value once you’ve been in ketosis for a while.

        I have noticed that my fasting blood sugar is still relatively high (in the 90s), except for when I go on a long term fast (4.5 days), where I have reached 63 and 74. My HbA1c varies but the lowest I’ve gotten (same test day as the 74, done after 4.5 days of fasting) was 5.2. Like you, I keep thinking my HbA1c will be lower, but it hasn’t gotten that low.

        The machine I bought also will test for blood glucose, so I may begin testing for that too. All of the testing I related above has been tests by labs.

        By the way, an HDL of 165 is truly unbelievable. Mine (male) was below 40 for years (due to high carb diet, it turns out) and after 2.5 years of LCHF is finally above 50. While I’m not a big believer in these blood markers (I think they’re surrogates for deranged insulin and/or insulin resistance and/or something else), that’s an impressive HDL.

      • Hey Bob,
        I use the Precision Extra meter for ketones. I do compare that meter to the Contour meter. 9 times out of the the Contour will show a lower glucose reading. Sometimes as much as 10-15 numbers. I have been low carb many years. Only the last 4+ have I stayed in ketosis 98% of the time. I have always/forever been insulin resistant. Figured a lot of this on my own past 25+ years. Compliments to Dr. Atkins.
        I can put 40 miles on a road bike 3-4 time a week with some very fast sprints and never bonk. I am often told there are not many 69 year old women that the power I have on a road bike.
        Have never felt better. Hardest thing at this stage of life is I need more “down” to recoup. Will never go back.
        Hope you continue on your Keto journey.

      • Thank you, Karen. The precision extra meter is the one I purchased. The meter is inexpensive, but the ketone strips are not. I don’t plan to do too much ketone testing, as it’s relatively easy to tell if I’m in ketosis, but I like things to be more scientific if I can do that.

        I’ll probably do more glucose testing, especially since the strips are much cheaper, and I’m interested to see what my fasting and non-fasting glucose really is.

        It’s too bad there’s no test meter for insulin, as that would be a very informative test (I was eating 5+ meals as low carb, then realized that protein causes an insulin response, and then started intermittent fasting and upping my fat content to reduce insulin).

        I think if you’re 69 and riding your bike actively, you’re on the high end of the spectrum. There probably aren’t many your age doing that.

      • Bob, I buy my ketone blood testing strips fro Universal Drugs Canada. I have not found much cheaper. Jimmy Moore might be able to suggest a better link. I also have the Ketonix Blow into test tubes. Good, but does not measure blood keytones.
        I commend you on your fasts. 18 hours is my max. Probably need to try a bit harder.

        Sounds like you are doing your best to understand all this Keto “stuff”. I just love learning about all of this because it has had such a positive input on my life of struggle with weight, athletics and mood. Can’t go back but would be nice to be 30 years younger.

        Please do not hesitate to connect with me……Karen

  4. Dr. Nally, I am trying to find the information you posted on preparing for a blood draw in a previous article. Can you point me in the right direction? Thx.

  5. Can a ketogenic diet help reverse intermittent claudication in my lower legs? My most recent A1C was 5.6, HDL 100, Trig 45. I am 69, and have been Type 1 Diabetic for 42 years.

  6. From the study you referenced

    Two-year weight loss diets can induce a significant regression of measurable carotid VWV. The effect is similar in low-fat, Mediterranean, or low-carbohydrate strategies and appears to be mediated mainly by the weight loss–induced decline in blood pressure.

    The main findings in this study are as follows: (1) Diet-mediated weight loss over a 2-year period induced a significant regression of carotid VWV; (2) carotid IMT and 3DUS VWV changes are mainly predicted by diet-induced changes in blood pressure over 2 years compared with the changes in lipoprotein levels; and (3) all diets provided a similar benefit, suggesting that the low-carbohydrate diet is at least as effective as the others and may be considered an alternative to low-fat and Mediterranean diets. However, our power to detect moderate differences in the effect of the 3 diets was limited.

    SO – please explain why you consider a ketogenic diet to be SUPERIOR to the other diets used in the study??

    • For two reasons. First, I’ve never seen sustained weight loss with low fat or the Mediteranian diet in the 15 years I’ve been in practice. And, second, what I see clinically is more prominent then what was seen in the traditional low-carb arm in the Shai study. The Shai study followed the Atkins protocol with the addition of carbohydrate back into the diet over a 2 year period. Clinically, I see greater changes within a year on a truly ketogenic diet that are more prominent than the results in the study. The results were shown to be statistically significant in all diets, but
      there was 10-30mm^3 greater VWV change in the low-carb arm then the other two diets. This is what I see pretty consistently over a period of a year clinically on a ketogenic diet.

      • What rates of progression do you normally see in your practice with regard to arterial plaque?

        Have you ever seen stabilization (0% change year to year) and/or regression using this diet?

      • Are you aware of this study?

        Effect of a Combined Therapeutic Approach of Intensive Lipid Management, Omega-3 Fatty Acid Supplementation, and Increased Serum 25 (OH) Vitamin D on Coronary Calcium Scores in Asymptomatic Adults
        William Davis, MD, FACC,1* Susie Rockway, PhD, CNS,2 and Mary Kwasny, ScD3

        The impact of intensive lipid management, omega-3 fatty acid, and vitamin D3 supplementation on atherosclerotic plaque was assessed through serial computed tomography coronary calcium scoring (CCS). Low-density lipoprotein cholesterol reduction with statin therapy has not been shown to reduce or slow progression of serial CCS in several recent studies, casting doubt on the usefulness of this approach for tracking atherosclerotic progression. In an open-label study, 45 male and female subjects with CCS of ≥ 50 without symptoms of heart disease were treated with statin therapy, niacin, and omega-3 fatty acid supplementation to achieve low-density lipoprotein cholesterol and triglycerides ≤60 mg/dL; high-density lipoprotein ≥60 mg/dL; and vitamin D3 supplementation to achieve serum levels of ≥50 ng/mL 25(OH) vitamin D, in addition to diet advice. Lipid profiles of subjects were significantly changed as follows: total cholesterol −24%, low-density lipoprotein −41%; triglycerides −42%, high-density lipoprotein +19%, and mean serum 25(OH) vitamin D levels +83%. After a mean of 18 months, 20 subjects experienced decrease in CCS with mean change of −14.5% (range 0% to −64%); 22 subjects experienced no change or slow annual rate of CCS increase of +12% (range 1%-29%). Only 3 subjects experienced annual CCS progression exceeding 29% (44%-71%). Despite wide variation in response, substantial reduction of CCS was achieved in 44% of subjects and slowed plaque growth in 49% of the subjects applying a broad treatment program.

      • Any comments as to the study? After all – it used a low fat diet and statins to reverse arterial plaque.

  7. Wonderful job!!! You are amazing.
    I have APS.taking warferin 10mg.
    Been doing keto for 3 moth (felling great) is keto good for me!!!
    keep doing your great job!!

  8. Pingback: The Truth About Low Carbohydrate Diets And Hair Loss — Perfect Hair Health

  9. Hi Dr Nally,

    TG and HDL ratio is one of the best indicators of cardiovascular disease risk.

    Back a few years in 2014 when I started a low carb high fat diet, I tested my blood after 4 months.

    Heres mine:

    TG/HDL = 70.88/69.66 = 1.05

    My wife started at the same time as me, took the test too and got

    TG/HDL = 70.74/69.66 = 1.15

    These are pretty much perfect figures.

  10. Hi Doc,

    I’ve had an angioplasty to unblock plaque build up in my legs one on each leg, same place, even the consultant didn’t know why this happened apart from me been a smoker ( since quit) and I’m only 47 yr old female I’ve been prescribed crestor for the past year but hate taking it, I’ve been on keto diet for a year also, my legs feel fine now but when I ask my doc if I can come off statins they say ” no” , my cholesterol level has never been higher than 5 even when I had intermittent claudication, will my keto diet help ? Any studies I can use to show my doctor?

  11. Awaiting results on: Tumor Recrosis factor alpha
    Interleukin 1 beta, quant
    IGF binding protein
    Homocysteine, serum
    Lipid Panel. (My request)
    My Dr. Has “gone” Vegan. As I have been Keto for 5 years. LCHF I do measure blood keytones. I think he thinks I am killing myself.

    Almost afraid to see these results. Hope he is proven wrong. Or to prove, not every patient is healthy on a vegetarian/vegan diet.

    Shook him up with my previous HDL 185…..Trigs 50.

    I so look forward to your posts, thx….Karen

  12. I am 69 year old female recently admitted to the hospital as a result of confusion. They at the Chandler Regional Medical center treated me as a stroke. As it turned out there was no evidence of stroke after a CT of the head, an MRI/MRA of head, neck and brain. and heart echo. I had a aortic valve replacement in 2015. The echo was good, however they felt the vertebral arteries in the neck have atherosclerosis and needed to be treated with Plavix and a statin. My total chol was 289, LDL 193, TG 114, A1c 5.3. These were non fasting in the hospital but are similar when fasting. I have been on and off kepo for the past year and had lost 10 lbs and was happy with that. We have been in AZ on vacation the past three weeks and will be here another 2 1l/2 weeks. I have not really be totally kept but at least 50% of of the time the last month and I feel already that I have gained back a good part of the weight. My main concern now is the Plavix. I am not happy about being on it. My question for Doc Muscle is what do I do now. I am concerned about the possibly of another episode and since they have not told me exactly what my diagnosis is I am concerned. I have been told by some other professional I need to change my Ketogenic diet and I really don’t want to. I love my coffee and heavy cream in the am. I like the Keto diet and thought I was heading in the right direction but also see where I needed to do a better job of keeping my carbs lower. Most recently my carbs were running about 30-50 carbs a day. I am in Chandler AZ and wondering if there is someone here or Phoenix that I could meet with about this or if Doc Muscle can help.


    • Hello Richyne. Thank you for contacting me, however, due to the nature of medicine and without a formal face-to-face doctor patient relationship, I cannot answer any individual questions, make individual medical recommendations or give individual nutritional recommendations. To maintain the highest standards of medical compliance, clarity and accuracy for answers regarding these issues, you will need to schedule an appointment with me face-to-face in the office (623) 584-7805 or take these questions directly to your personal physician. Thank you for your understanding.

      • I’m not sure if this was clear in the article, you are saying that during intervention (whatever diet it was) people ate the same number of calories?

      • How come that people are losing weight differently then? Is the food not metabolized as efficiently? I mean, it seems to be that ingested calories are not the same as those absorbed? This would mean that the food eaten is not metabolized in the same way and definitely results in less calories used than the other intervention groups.

        From my perspective this looks like a calorie trick by exploiting human metabolic inefficiencies. Same trick is often employed on the other side of the spectrum with low-fat high starchy diets (most often vegan diets) which seem to have the same effect. People eat enormous amounts of calories of starchy, leafy, fruity vegetables and fruits and still lose more weight than other interventions and they all reportedly keep the caloric intake the same.

        It seems a bit of an observational trickery, or I just haven’t seen anywhere a mechanistic explanation of why this stuff happens.

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