Accelerated Coronary Calcification with a Ketogenic Diet: A Worrisome Case Study
Following a diet very low in the percent calories from carbohydrates while driving the calories from fat very high can induce the formation of ketone bodies, the so called ketogenic or keto diet. Originally developed as a potential strategy for refractory epilepsy, it has caught on in the public sector and is followed by many individuals. There are few studies looking at cardiovascular markers on this diet and even fewer looking at cardiac events or coronary anatomy. Concern about data from epidemiologic studies reporting on diets described as low-carbohydrate has been expressed due to an association with higher mortality rates. Recently, a metabolic ward study has described a rise in the inflammatory marker hs-CRP and total and LDL cholesterol with a 4 week ketogenic diet achieving only 5% of calories form carbohydrates.
A 48 year-old male patient with a family history of heart disease was seen my clinic this week had unusual documentation of his serious entry into the ketogenic diet world and raises concerns over the unknown consequences of this dietary pattern.
The timeline below is presented.
2015: Physical exam total cholesterol 213, HDL 50, LDL 138, triglycerides 123, TSH 0.71, testosterone 348
December 2017: Adopted a strict ketogenic diet while tracking his calories to achieve ketosis and 5% calories from carbohydrates (<25 grams daily) eating meats, Bulletproof coffee, nuts, MCT oil, blue cheese dressing, avocados, salads, asparagus, and a few berries. He had no grains or dairy. He felt good and lost 45 pounds. He was working out at a CrossFit gym, running and practicing yoga beginning at this time.
June 2018: A coronary artery calcium score (CACS) was performed at the urging of his primary care physician (PCP) and returned at the 94% tile for age and gender at 130 with an artery score of 108 in his LAD, 13 in his circumflex, and 9 in his right coronary artery.
July 2018: Labs by his PCP showed a total cholesterol of 308, HDL 66, apoB 174, triglycerides of 108 and a LDL particle number >3195. He stopped Bulletproof coffee.
November 2018: Labs revealed a total cholesterol of 279, HDL 64, triglycerides 103, LDL 201, LDLp 2661, hs-CRP 0.7.
April 2019: His PCP sent him for a repeat CACS and it revealed a score of 186 (96%tile) with the LAD at 144, circumflex at 15 and the right coronary artery at 27. This was a 43% increase in 10 months. He was not on a statin at any time.
April 2019: Repeat labs revealed a total cholesterol of 287, LDL 210, HDL 70, triglycerides of 59, LDLp 2742, apoE 3/3, hs-CRP 2.4, with high cholesterol absorption markers by sterol analysis.
April 2019: He abandoned the ketogenic diet and is transitioning to a whole food plant based heart disease reversal diet and program.
This case study from my clinic this week comes on the heels of an elegant publication from the NIH lab of Kevin D. Hall, Ph.D., demonstrating that 4 weeks of a ketogenic diet in a metabolic ward setting resulted in a rise in hs-CRP and total and LDL cholesterol, similar to the patient presented. Although this patient was not a carrier of the E4 allele that might have made him more sensitive to diets high in saturated fats, he was found to be a “hyperabsorber” and it is anticipated his lipid panel will improve when it is repeated in 3 months.
Unique in this case was the availability of two CACS studies less than 10 months apart. While progression of the CACS is expected over time, often at a rate of 20% a year, the score rose over 40% in less than a year. Statin medications, which can accelerate the calcified plaque in heart arteries, were never used. He was a non-smoker, had a HgbA1C of 5.2–5.4% during this time period, and was continuously exercising with a BMI under 25 during his 17 months on the ketogenic diet. He is completely asymptomatic.
This patient did not have a coronary CT angiogram so comments on calcified versus non calcified atheroma volume is not possible. Nonetheless, the case is worrisome that others who are following the ketogenic diet are not being followed with the measurements this man had and may also be experiencing elevations of lipid fractions, inflammation, and coronary calcification.
Medical practitioners should be cautious about advising the ketogenic diet and should monitor the status of their patient’s cardiometabolic and vascular status very carefully if they are following it.