Try This – My Thoughts on High Cholesterol, Heart Disease, and A Groundbreaking Study

Here’s the truth, as someone who has a history of high LDL and high ApoB, I get nervous about high fat and keto diets. 

My cholesterol has always been a little high (genetically I’m a hyper-absorber of cholesterol), and when I started to eat lower carb and higher fat, my cholesterol went up even more!

So, what gives? Is this something I have to be worried about?

I know many of you can relate because you also have been doing everything “right” – eating low carb, eating healthy fats, and for some reason your LDL won’t budge or it's getting worse. 

Today, I’m going to talk about all of this: what I did about my high LDL and apoB and groundbreaking research that might give us a better understanding of the role of these markers in heart disease.

If you can relate to my story, you have high cholesterol, or your family and friends are struggling with high cholesterol, you’re going to want to keep reading. 

Let’s get into it… 

A Groundbreaking Study Shatters Conventional Thinking About Cholesterol 

In the past few weeks I got a chance to sit down with two researchers, David Feldman and Nick Norowitz, PhD to talk about their fascinating new study looking at the effects of high ApoB and “sky-high” LDL cholesterol on otherwise healthy individuals following a ketogenic diet to see if they had clogged arteries. 

These otherwise healthy individuals (like myself) are known as Lean Mass Hyper-Responders (LMHR). These are folks who go on a carb restricted diet, stay metabolically healthy, and yet their LDL cholesterol shoots up to levels most doctors would consider dangerously high—we’re talking 200 to 600 mg/dL. 

Wild, right?

But here’s the kicker: this study followed 100 of these individuals, all of them lean (average BMI: 22.5), on keto diets with sky-high cholesterol. The researchers used high-resolution coronary CT scans to track plaque in their arteries over one year. And what did they find?

➡️ Most participants showed no or minimal progression of plaque.
➡️ Some even saw a reduction in plaque.
➡️ And most importantly: neither LDL cholesterol nor ApoB predicted who developed more plaque.

That’s right…

The number one predictor of plaque progression wasn’t cholesterol – it was whether participants already had plaque in their arteries at the start.

As David and Nick told me “plaque begets plaque.”

Why This Matters

This turns the “cholesterol = plaque = heart disease” story on its head… at least for this specific population. 

These weren’t people with obesity, diabetes, or metabolic dysfunction. They were lean, insulin-sensitive, and had low triglycerides and high HDL (the good cholesterol). Their high LDL wasn’t due to a genetic disorder—it was a metabolic response to carbohydrate restriction.

Now, does this mean LDL and apoB don’t matter? Not exactly. The study authors were clear: these markers are still risk factors for heart disease in the general population. But context is everything.

In this study, high LDL didn’t predict artery plaque buildup. That suggests that in a metabolically healthy body, LDL might not behave the same way. This is what researchers mean by context-dependent risk.

So, if you’re one of those people who went low-carb, saw your cholesterol spike, and immediately worried you were heading toward a heart attack—this data might offer some reassurance, especially if you’re metabolically healthy and your other markers look great.

Try This: A Smarter Way to Approach High Cholesterol 

If you’re doing low-carb or keto and your cholesterol is high, here’s how to assess your real risk:

1. Don’t panic—get a heart scan. Ask your doctor about a Coronary Artery Calcium (CAC) score or ideally a coronary CT angiography (CCTA) like a Cleerly scan, which looks at both hard and soft plaque, to see if you actually have any plaque. Elevated cholesterol alone doesn’t equal plaque. This is what I did and it gave me some reassurance that what I was doing was working since my scans looked GREAT; in fact, my CCTA scan showed that I had virtually no plaque in my arteries. (More on this here where I interview my doctor Michael Twyman, M.D. about these tests and my results.)

   Additionally, I've encouraged friends who have high LDL and ApoB to do a Cleerly scan, and their results were more worrisome. In some cases, they chose to take more aggressive measures with their cardiologist, including avoiding high levels of saturated fat in the diet and even taking medications to prevent further plaque build up.

2. Zoom out. Look at the full picture—your HDL, triglycerides, insulin, waist size, blood sugar, inflammation markers (basically, your total metabolic health). If everything else looks good, you may be in the LMHR camp.

3. Work with a doctor who understands metabolic health. Most docs weren’t trained in nutrition-forward, context-rich approaches to lipids. Find one who is. Again, I’ve been working with Dr. Michael Twyman M.D. who ordered my scan and laid out all of my options.

   Ultimately, since my metabolic health is in good shape, I haven’t changed my pretty low carb diet, but I did add in Ezetimibe, a cholesterol absorption inhibitor to support my body in lowering LDL and apoB. Who knows if I'll decide to stay on the drug long-term, but personally when I decided to start the drug, I wasn't comfortable with living another 60 years+ with high levels of LDL and apoB.

   You can read about my experience with this medication and what else I’ve been doing to protect my heart here.

4. Finally, Take action. If you have plaque build up, now is the time to act. Start with what we know could potentially reduce plaque build up or aggravate it further – i.e. changing your diet and look into things like aged garlic extract and HIIT training. I’ve written about the role of these two things in reducing plaque. You can find it here and here. Work with a practitioner to consider lifestyle overhaul, medication, and a protocol to prevent clogged arteries from getting worse. 

Concluding thoughts: 

First, I want to congratulate Nick Norowitz PhD, David Feldman, and Adrian Soto-Mota, MD, PhD – it’s a huge feat to get a study like this done.

I do want to acknowledge that there has been some respectful criticism of the study, including the fact that one year is too short of a year to monitor plaque progression. 

Adrian Soto-Mota, MD, the primary investigator of the study, discusses this criticism and the limitations of the study at length on this X thread. I highly recommend checking it out.

Here’s what I’m taking away from the study: if you’re healthy, your high cholesterol alone might not be a red flag (and yes, more research is needed)— we have to consider our full picture of health, other risk factors, and work with someone who can speak to our unique bodies and needs. 

Here’s to your health, 

Dhru Purohit