Human Nutrition and Metabolism

A Ketogenic Diet Favorably Affects Serum Biomarkers for Cardiovascular

Disease in Normal-Weight Men1
Matthew J. Sharman, William J. Kraemer, Dawn M. Love, Neva G. Avery, Ana L. Gomez,
Timothy P. Scheett and Jeff S. Volek2
Human Performance Laboratory, Department of Kinesiology, University of Connecticut, Storrs, CT 06269-1110
ABSTRACT Very low-carbohydrate (ketogenic) diets are popular yet little is known regarding the effects on serum
biomarkers for cardiovascular disease (CVD). This study examined the effects of a 6-wk ketogenic diet on fasting
and postprandial serum biomarkers in 20 normal-weight, normolipidemic men. Twelve men switched from their
habitual diet (17% protein, 47% carbohydrate and 32% fat) to a ketogenic diet (30% protein, 8% carbohydrate and
61% fat) and eight control subjects consumed their habitual diet for 6 wk. Fasting blood lipids, insulin, LDL particle
size, oxidized LDL and postprandial triacylglycerol (TAG) and insulin responses to a fat-rich meal were determined
before and after treatment. There were significant decreases in fasting serum TAG (33%), postprandial lipemia
after a fat-rich meal (29%), and fasting serum insulin concentrations (34%) after men consumed the ketogenic
diet. Fasting serum total and LDL cholesterol and oxidized LDL were unaffected and HDL cholesterol tended to
increase with the ketogenic diet (11.5%; P 0.066). In subjects with a predominance of small LDL particles
pattern B, there were significant increases in mean and peak LDL particle diameter and the percentage of LDL-1
after the ketogenic diet. There were no significant changes in blood lipids in the control group. To our knowledge
this is the first study to document the effects of a ketogenic diet on fasting and postprandial CVD biomarkers
independent of weight loss. The results suggest that a short-term ketogenic diet does not have a deleterious effect
on CVD risk profile and may improve the lipid disorders characteristic of atherogenic dyslipidemia. J. Nutr. 132:
1879 1885, 2002.
KEY WORDS:

triglycerides

postprandial lipemia

Cardiovascular disease (CVD)3 is the leading cause of mortality in most industrialized countries including the United
States (1). Diet is a major weapon used in the fight against
CVD because of its influence on the myriad of CVD risk
factors. Current dietary recommendations call for a low-fat
(30% of energy), low saturated fat (7% total energy), low
cholesterol (300 mg/d) diet (2). However, high-carbohydrate diets are controversial (3,4), because they raise plasma
triacylglycerols (TAG) (5) and may adversely affect LDL
composition (6,7). There has been an alarming increase in the
popularity of diets with the common theme of reducing carbohydrate, prompting concern regarding their safety (8). Despite the popularity of very low-carbohydrate diets, very few
scientific studies have evaluated how these diets affect CVD
risk factors (9) and no studies have examined the effect on
recently identified CVD biomarkers (i.e., LDL particle size,
postprandial lipemia, oxidized LDL, etc).
A recent meta-analysis of prospective studies indicated that
elevated fasting TAG is an independent risk for CVD (10).

lipoprotein subclasses

The atherogenicity of TAG-rich lipoproteins in the postprandial state may play a greater role than fasting TAG, prompting
some authors to suggest that elevated postprandial lipemia is
a better predictor of CVD than fasting TAG (11,12). Abnormal postprandial lipemia precipitates production of highly
atherogenic small LDL particles and a reduction in HDL
cholesterol (12), all of which contribute to the causal role for
elevated postprandial lipemia in the pathogenesis and progression of CVD.
Individuals with a predominance of large buoyant LDL
cholesterol have been classified as pattern A, whereas those
with a predominance of small dense LDL particles are pattern
B (10). Individuals exhibiting higher levels of small dense LDL
have a greater than 3-fold risk of CVD (13,14). This is most
likely a result of the longer half-life and increased susceptibility to oxidative modification (15). The fact that LDL is extremely susceptible to oxidative damage has been known for
some time (16), with it now appearing that the oxidation of
LDL plays an important role in atherogenesis (17).
The therapeutic value of diet interventions aimed at improving CVD risk should take into account factors other than
just fasting total cholesterol, LDL cholesterol, HDL cholesterol, and TAG. In this study, we evaluated the effect of a
ketogenic diet on both fasting and postprandial lipoprotein
metabolism including measures of postprandial lipemia, LDL
size and LDL oxidation. As a first step, we studied a normal-

1
This study was supported by a grant from the Atkins Foundation, New York,
NY. Published in abstract form [Sharman, M. J., Volek, J. S., Gomez, A. L., Avery
Love, N. G., French, D. N. & Kraemer, W. J. ( 2001 ) Fasting and postprandial
lipoprotein responses to a ketogenic diet. Am. College Sports Med. 33: S213.]
2
To whom correspondence should be addressed.
E-mail: [email protected].
3
Abbreviations used: CVD, cardiovascular disease; TAG, triacylglycerol.

0022-3166/02 $3.00 2002 American Society for Nutritional Sciences.

Manuscript received 22 January 2002. Initial review completed 2 March 2002. Revision accepted 9 April 2002.
1879

SHARMAN ET AL.

1880

weight normolipidemic population to minimize the confounding effects of weight loss or metabolic abnormalities on the
dependent variables. Based on our previous work showing a
reduction in fasting TAG and postprandial lipemia after a
ketogenic diet rich in monounsaturated fat and supplemented
with (n-3) PUFA (9), we hypothesized that the ketogenic diet
used in this study would result in a similar TAG response,
which would in turn result in increased HDL cholesterol and
an increase in the average size of LDL particles.
MATERIALS AND METHODS
Subjects. Twenty healthy white men free of metabolic and
endocrine disorders volunteered to participate in this investigation.
To enhance compliance to the rigorous ketogenic dietary treatment,
we initially asked subjects if they would be willing to restrict carbohydrate to 10% of total energy for 6 wk. Twelve subjects volunteered to switch from their habitual diet to a ketogenic diet for 6 wk
(mean SD; age: 36.7 11.6 y; body mass: 79.2 8.3 kg; fat: 20.5
6.2%) and the remaining eight subjects served as controls (mean
SD; age: 35.0 13.0 y; body mass: 85.4 12.8 kg; fat: 22.2
9.0%). Subjects in the ketogenic diet group had fasting serum total
cholesterol concentrations ranging from 2.87 to 5.82 mmol/L and
TAG concentrations from 0.62 to 2.24 mmol/L. There were no
significant differences in any physical characteristics or serum lipids
concentrations between groups at the start of the study. The subjects
had not lost or gained weight in the previous year, were not adhering
to special diets or regular consumers of nutritional supplements, and
habitually consumed between 19% and 43% of energy as fat (assessed
via a 7-d food diary). All subjects were nonsmokers and were not
prescribed any medication known to affect serum lipoproteins. All
subjects were informed of the purpose and possible risks of this
investigation before signing an informed consent document approved
by an Institutional Review Board at Ball State University.
Experimental design. The study design involved normal-weight
normolipidemic men that either switched from their habitual diet
(32% fat) to a ketogenic diet (61% fat) or maintained their habitual
diet (control group) for 6 wk. Body weight was assessed and two 12-h
fasting blood samples were collected at wk 0, 3 and 6. Postprandial
TAG and insulin responses to a fat-rich test meal were measured at
wk 0 and 6 only in the ketogenic group.
Dietary intervention. The aim of the intervention diet was to
reduce carbohydrate intake to 10% of energy. The diet was designed so that fat comprised 60% of energy with no restrictions on
the type of fat from saturated and unsaturated sources or cholesterol
levels. The actual diets consumed were mainly comprised of beef
(e.g., hamburger and steak), poultry (e.g., chicken and turkey), fish,
oils, various nuts/seeds and peanut butter, moderate amounts of
vegetables, salads with low-carbohydrate dressing, moderate amounts
of cheese, eggs, protein powder, and water or low-carbohydrate diet
drinks. Foods avoided or consumed infrequently included fruits and
fruit juices, most dairy products with the exception of hard cheeses
and heavy cream, breads, cereals, beans, rice, desserts/sweets, or any
other foods containing substantial amounts of carbohydrate. A portion of the food consumed during the intervention diet (30 40%
of total energy) was provided to subjects during weekly meetings to
review compliance with the registered dietitian. These foods included
pumpkin seeds, roasted cheese, low-carbohydrate bars, shakes, and
bake mix (Atkins Nutritionals, Hauppauge, NY) and protein powders
(Super Whey Fuel and Fuel Plex Lite; Twin Laboratories, Hauppauge,
NY). Subjects were also provided with a daily multivitamin/mineral
complex (Daily One Caps With Iron; Twin Laboratories).
Each subject received individual dietary instruction weekly on
how to consume meals within the specified nutrient goals and to
assess compliance. Subjects were provided with a packet outlining
specific lists of appropriate foods, recipes and sample meal plans that
were compatible with their individual preferences and the nutrient
profile goals of the ketogenic diet. Food measuring utensils and scales
were provided to all subjects before the study to assist in the estimation of portion sizes of foods and beverages. Subjects were encouraged
to maintain adequate energy intake to maintain body weight. If body
weight changed 1 kg, dietary counseling was provided. The keto-

genic group kept records each day of the experiment (7 d during

baseline and 42 d during the ketogenic diet) and the control group
kept 7-d records during wk 1 and 6. All recorded days were analyzed
for nutrient content (Nutritionist V, Version 2.3; N-Squared Computing, First Databank Division, The Hearst Corporation, San Bruno,
CA). All intervention foods and supplements were entered into the
software database and included in the analysis of nutrient intake.
Additionally, dietary compliance was monitored using Ketostix reagent strips (Bayer Corporation, Elkhart, IN), which determine qualitatively the presence of acetoacetic acid in urine. Each subject
maintained a record of color changes on the reagent strips performed
daily at 0800.
Fasting blood collection. Fasting blood samples were obtained on
two separate days at wk 0, 3 and 6 after a 12-h overnight fast and
abstinence from alcohol and strenuous exercise for 24 h. Subjects
reported to the laboratory between 0700 and 0900 h, rested quietly
for 10 min in the supine position, and blood was obtained from an
antecubital vein with a 20-gauge needle and vacutainers.
Oral fat tolerance test. Postprandial TAG and insulin responses
to a fat challenge were assessed at wk 0 and 6 using standard
procedures in our laboratory (9). Subjects arrived at the laboratory
after a 12-h overnight fast and abstinence from alcohol and strenuous
exercise for 24 h. A flexible catheter was inserted into a forearm vein,
which was kept patent with a constant saline drip (60 mL/h). Subjects rested in a seated position for 10 min and two baseline blood
samples were obtained separated by 10 min with a 10-mL syringe. The
first 3 mL of blood withdrawn was discarded to avoid dilution of the
sample and 10 mL was subsequently withdrawn and processed. The
test meal then was consumed under supervision to ensure that the
entire meal was ingested within a 15-min period. The test meal was
designed to be rich in fat and low in carbohydrate similar to the
ketogenic diet and contained 5.44 MJ (11% carbohydrate, 2% protein, 87% fat, 52 g saturated fat, 59 g monounsaturated fat, 12 g
polyunsaturated fat, and 266 mg cholesterol). Postprandial blood
samples were obtained immediately after the meal and hourly for a
total of 8 h to assess the magnitude and time course of postprandial
lipemia. Subjects rested quietly in a seated position and consumed
exactly one liter of water only during the 8-h postprandial period. All
subjects completed the entire meal and no adverse side effects (stomach distress, nausea, etc.) were reported.
Blood analyses. Serum collected for the determination of LDL
particle size, oxidized LDL, insulin and -hydroxybutyrate were immediately stored at 80C. The remaining serum was analyzed for
glucose, total cholesterol, HDL cholesterol, and TAG using automated techniques (Roche Modular; Roche Diagnostics, Indianapolis,
IN) with calculated precision values 3%. Concentrations of LDL
and VLDL cholesterol were calculated from total cholesterol, HDL
cholesterol, and TAG (18). Fasting serum -hydroxybutyrate concentrations were enzymatically determined in duplicate using a commercially available kit (#310A; Sigma Diagnostics, St. Louis, MO)
and spectrophotometric analysis (Spectronic 601; Milton Roy, Rochester, NY). The intra-assay CV was 0.9%. Fasting serum and postprandial plasma insulin concentrations were determined in duplicate
using an ELISA kit with a sensitivity of 1.81 pmol/L (#10-1600;
Diagnostic Systems Laboratory, Webster, TX) (19). Intra- and interassay CV were 5.5% and 3.2%, respectively. Fasting oxidized LDL
were also determined in duplicate using an enzyme-linked immunosorbent assay (American Laboratory Products Company,
Windham, NH) with a solid two-site enzyme immunoassay that is
based on the direct sandwich technique in which two monoclonal
antibodies are directed against separate antigenic determinants on
the oxidized apolipoprotein B molecule. Intra-assay CV was 7.9%.
Absorbances were read on a multilabel counter (Wallac1420 Victor2;
Wallac Oy, Turku, Finland).
LDL subclasses. Separation of LDL subclasses was performed
using nongradient polyacrylamide gel electrophoresis (Lipoprint LDL
System; Quantimetrix, Redondo Beach, CA) previously described in
detail (20,21). High-resolution 3% polyacrylamide gel tubes were
used for electrophoresis. Seven bands of LDL were quantitatively
evaluated using computer software (NIH imaging software, utilizing
the Lipoprint LDL macro; Quantimetrix), which divides the scanned
gel image at designated Rf values identified by their relative mobility.

KETOGENIC DIETS AND BLOOD LIPIDS

This is based on differences in particle size (smaller particles migrate

further) and calculates the area under the curve for each fraction. We
report the relative percentage of LDL cholesterol in each band and
the mean and peak particle diameter. The peak particle diameter for
phenotype A is generally 25.5 nm, in contrast the major peak for
phenotype B is usually 25.5 nm (22). The determination of a
sample being characterized as either phenotype A or B is based on
LDL migration rates and is described in detail in Hoefner et al. (20).
Insulin sensitivity. Because high-fat diets have been associated
with insulin resistance, we estimated insulin sensitivity using the
homeostasis model analysis using fasting glucose and insulin concentrations (23). Assuming that normal-weight subjects aged 35 y have
a insulin resistance of 1, the values for a subject can be assessed from
the insulin and glucose concentrations by the formula: insulin resistance (near approximation) insulin/(22.5eln glucose).
Statistical analyses. Means and SD were calculated for all variables using conventional methods. Two fasting samples were obtained
for each blood variable and the mean of these two values used for
statistical analysis. A two-way repeated-measures ANOVA was used
to evaluate changes over time in the ketogenic and control groups.
When a significant F value was achieved, Fishers least significant
difference test was used to locate the pair-wise differences between
means. The total area (serum concentration time) under the line
connecting the postprandial TAG and insulin responses was calculated using the trapezoidal method. The change in body weight was
used as a covariate in all analyses. Relationships between variables
were examined using Pearsons product-moment correlation coefficient. A criterion -level of P 0.05 was used for all statistical
comparisons.

RESULTS
Body mass and dietary intake. All dietary nutrients were
significantly different when men consumed the ketogenic diet
compared with their habitual diet with the exception of dietary energy and alcohol consumption (Table 1). Dietary
protein, fat and cholesterol were significantly greater and
dietary carbohydrate was significantly lower (8% of total energy) during the ketogenic diet period. There were no significant changes in dietary nutrient intake in the control group
from 0 to 6 wk. There was a small but significant decrease in
body mass in the ketogenic group (2.2 1.7 kg) but not the
control group (0.4 4.1 kg).

1881

Fasting serum metabolic and insulin responses. Compared with baseline in the men who followed the ketogenic
diet, serum -hydroxybutyrate concentrations were significantly increased at wk 3 (427%) and remained significantly
elevated at wk 6 (250%; Table 2). All subjects following the
ketogenic diet had -hydroxybutyrate concentrations 0.20
mmol/L, indicating compliance with the ketogenic diet. Serum insulin concentrations were significantly reduced at 3 and
6 wk (34.2%) in the ketogenic group but unchanged in the
control group (Table 2). From 0 to 6 wk, the estimation of
insulin resistance was not affected in the ketogenic group
(0.75 0.62 3 0.52 0.35) or the control group (0.52
0.41 3 0.51 0.41).
Fasting serum lipid responses. There were significant
increases in total and LDL cholesterol that returned to values
that were not significantly different than wk 0 values at the
end of the ketogenic diet period (Table 2). Individual responses in total cholesterol were variable, decreasing in five
subjects (range: 2 to 17%) and increasing in seven subjects
(range: 1 to 60%). LDL cholesterol decreased in four subjects
(range: 4 to 11%) and increased in seven subjects (range:
2 to 70%; Fig. 1). Compared with wk 0 in the ketogenic group,
there was a significant increase in HDL cholesterol at wk 3 and
a trend (P 0.066) at wk 6. Serum HDL cholesterol decreased
in three subjects (range: 6 to 20%) and increased in nine
subjects (range: 1 to 71%; Fig. 1). There was a significant
reduction in VLDL cholesterol at wk 3 and 6 of the ketogenic
diet. Serum TAG were significantly reduced at wk 3 (30.9%)
and wk 6 (33.0%). All but one subject had a decrease in
fasting TAG (range: 1 to 50%). There were no significant
changes in serum lipids in the control group.
LDL subclass profiles. There was a significant increase in
peak particle diameter and the LDL-1 subclass distribution
after the ketogenic diet was consumed (Table 3). We also
analyzed subjects classified as pattern A or pattern B at the
start of the study. Before the diet intervention, seven subjects
were classified as pattern A and five subjects were pattern B.
Three of the five pattern B subjects switched to pattern A after
the ketogenic diet; all seven pattern A subjects remained
pattern A after the ketogenic diet. At the start of the study,

TABLE 1
Daily intake of dietary energy and nutrients in men who switched from their habitual diet to a ketogenic diet for 6 wk
and in a control group who continued to consume their habitual diet for 6 wk1

Energy, kJ
Protein, g
Protein, %2
Carbohydrate, g
Carbohydrate, %
Total fat, g
Total fat, %
Saturated fat, g
Saturated fat, %
Monounsaturated fat, g
Monounsaturated fat, %
Polyunsaturated fat, g
Polyunsaturated fat, %
Cholesterol, mg
Alcohol, %

Ketogenic diet
(wk 0)

Ketogenic diet
(wk 6)

Habitual diet
(wk 0)

Habitual diet
(wk 6)

10627 2469
113 40b
17
4b
306 100a
48 10a
91 31b
32
8b
31 12b
14
4b
27 11b
12
4b
12
6b
6
2b
332 126b
3
3

9770 1569
176 45a
30
5a
46 10b
8
3b
157 27a
61
4a
56 11a
25
2a
57 12a
25
3a
24
5a
11
2a
741 254a
1
2

8489 1962
82 16b
16
2b
287 79a
55
5a
65 18b
29
5b
21
6b
14
4b
14
5c
9
2b
9
3b
6
1b
130 14c
0
0

7594 816
70 10b
15 1b
271 47a
59 7a
50 14b
25 8b
16 6b
12 4b
12 8c
9 5b
6 3b
4 2b
118 7c
0 1

1 Values are means SD. Ketogenic diet group, n 12. Control group, n 8. Means in a row with different superscripts differ (P 0.05).
2 Percentage of total energy intake.

SHARMAN ET AL.

1882

TABLE 2
Fasting blood lipid, metabolic and insulin responses in men who switched from their habitual diet to a ketogenic diet for 6 wk and
in a control group who continued to consume their habitual diet for 6 wk1
Ketogenic group (n 12)

TC, mmol/L
TAG, mmol/L
HDL-C, mmol/L
LDL-C, mmol/L
VLDL-C, mmol/L
TC/HDL
Insulin, pmol/L
Glucose, mmol/L
-HBA, mmol/L

Control group (n 8)

Wk 0

Wk 3

Wk 6

Percent 2

Wk 0

Wk 6

Percent

4.27 0.8b
1.09 0.5a
1.22 0.2b
2.87 0.8b
0.17 0.1a
3.60 0.9
23.7 16.3a
5.00 0.4
0.08 0.1b

4.78 0.9a
0.75 0.3b
1.43 0.3a
3.22 0.9a
0.12 0.0b
3.45 0.88
19.1 12.2b
4.84 0.4
0.40 0.3a

4.47 0.81b
0.73 0.3b
1.36 0.4b
2.99 0.8b
0.12 0.0b
3.45 0.9
15.6 8.9b
4.99 0.3
0.28 0.09a

4.7%
33.0%
11.5%
4.2%
29.4%
4.2%
34.2%
0.2%
250.0%

4.24 1.0b
1.14 0.3a
1.16 0.2b
2.89 0.9b
0.18 0.0a
3.67 0.7
21.5 6.7a
5.00 0.3
0.09 0.1b

4.10 1.2b
1.08 0.7a
1.16 0.5b
2.74 1.1b
0.20 0.1a
3.59 0.8
24.3 9.9a
5.09 0.3
0.10 0.1b

3.3%
5.3%
0.0%
5.2%
11.1%
2.2%
13.0%
1.8%
11.1%

1 Values are means SD. Data were analyzed with a two-way ANOVA using body weight as a covariate. Ketogenic Diet group, n 12, Control
group, n 8. Means in a row with different superscripts differ (P 0.05). TC, total cholesterol; TAG, triacylglycerol; -HBA, -hydroxybutyrate.
2 Percent change from wk 0 to wk 6.

pattern B subjects had significantly smaller mean and peak

LDL particle diameters, a significantly greater percentage of
LDL-3 and LDL-4, and a significantly smaller percentage of
LDL-1 compared with pattern A subjects. There were no
significant changes in the percentage of any LDL subclasses or
the mean and peak particle size in pattern A subjects. There
was a significant increase in peak LDL particle diameter from
25.28 nm to 26.16 nm after the ketogenic diet in pattern B
subjects (Fig. 2), and also a significant increase in mean LDL
particle diameter. There was a significant increase in the
percentage of LDL-1 and a significant decrease in the percentages of LDL-3 and LDL-4 after the ketogenic diet in pattern B

subjects. There were no changes from 0 to 6 wk in the

concentrations of oxidized LDL in either the ketogenic group
(44.38 33.7 U/L 3 46.45 15.6 U/L) or control group
(36.49 10.9 U/L 3 39.56 16.9 U/L).
Postprandial TAG and insulin responses. Postprandial
TAG concentrations peaked 3 h after the meal and started to
decline toward fasting values 5 h after the meal (Fig. 3).
Compared with wk 0, peak postprandial TAG concentrations
were significantly lower (24%) after the ketogenic diet (2.57
1.4 to 1.96 0.7 mmol/L). The area under the postprandial
TAG curve was also significantly lower (29%) after the
ketogenic diet (17.47 9.3 to 12.39 4.2 mmol/L h).
Postprandial insulin concentrations peaked immediately after
the meal at wk 0 and 1 h after the meal at wk 6. Compared
with wk 0, the area under the postprandial insulin curve was
unaffected at wk 6 (339 168 to 283 140 pmol/L h).
DISCUSSION

FIGURE 1 Individual responses of men (n 12) in LDL-cholesterol (C; upper graph) and HDL-C (lower graph) after consuming a
ketogenic diet for 6 wk in normolipidemic, normal-weight men.

The primary objective of this study was to examine how

healthy normolipidemic, normal-weight men respond to a
ketogenic diet in terms of fasting and postprandial CVD biomarkers. Ketogenic diets have been criticized on the grounds
they jeopardize health (8); however, very few studies have
directly evaluated the effects of a ketogenic diet on fasting and
postprandial risk factors for CVD. Subjects consumed a diet
that consisted of 8% carbohydrate (50 g/d), 61% fat, and
30% protein. Adaptation to this ketogenic diet resulted in
significant reductions in fasting TAG (33%), postprandial
lipemia after a fat-rich meal (29%), and fasting insulin
concentrations (34%). There were significant increases in
LDL particle size, and no change in the oxidative LDL concentrations. There was a significant increase in HDL cholesterol at wk 3 after the ketogenic diet. Collectively, the responses in serum lipids, insulin and lipid subclasses to the
ketogenic diet were favorable in terms of overall CVD risk
profile.
Only a few studies have examined the effects of a diet with
very low amounts of carbohydrate on blood lipids (9,24). Our
laboratory recently examined the effects of a ketogenic diet
rich in monounsaturated fat and supplemented with (n-3)
PUFA on blood lipids in normolipidemic men (9). Fasting
TAG, total cholesterol, LDL cholesterol, and HDL cholesterol
changed 55%, 2%, 10%, and 10%, respectively (9).

KETOGENIC DIETS AND BLOOD LIPIDS

1883

TABLE 3
Serum LDL subclass responses in 12 men who consumed a ketogenic diet who started as either pattern A or pattern B1,2

Ketogenic group (n 12)

Wk 0
Wk 3
Wk 6
Pattern A subjects (n 7)
Wk 0
Wk 3
Wk 6
Pattern B subjects (n 5)
Wk 0
Wk 3
Wk 6

% LDL-1,
27.7 nm

% LDL-2,
26.1 nm

% LDL-3,
24.5 nm

% LDL-4,
23.0 nm

Peak LDL size,

nm

Mean LDL
size, nm

13.9 6.4b
18.4 6.8a
18.2 6.2a

16.6 5.0
19.2 5.5
19.4 5.7

6.1 5.2
5.5 3.7
4.7 3.6

2.0 3.9
0.8 1.0
0.6 1.3

26.19 10.7b
26.76 7.8a
26.71 7.8b

26.28 7.8
26.54 4.3
26.57 4.5

18.2 4.1
21.8 6.4
22.2 4.1

17.0 4.9
19.1 5.5
19.0 7.1

2.0 1.6
4.2 2.7
2.8 1.8

0.1 0.2
0.4 0.5
0.1 0.3

26.83 5.1
27.04 7.8
27.10 7.2

26.80 1.6
26.70 3.0
26.81 2.5

7.9 3.1b
13.7 4.2a
12.6 3.8a

16.0 6.1
19.2 6.1
19.9 3.7

11.7 2.3b
7.2 4.6a
7.3 4.0a

4.7 5.5a
1.3 1.2b
1.4 1.9b

25.28 9.9b
26.37 6.6a
26.16 5.1a

25.54 7.0b
26.32 5.3a
26.22 4.6a

1 Values are means SD. Means in a column within a group with different superscripts differ (P 0.05).
2 Individuals with pattern A have a predominance of large LDL particles and those with pattern B have a predominance of smaller LDL particles.

Larosa et al. (24) examined the effects of a hypocaloric ketogenic diet on blood lipids in moderately overweight normolipidemic subjects. Fasting TAG, total cholesterol, LDL cholesterol and HDL cholesterol changed 33%, 6%, 18%
and 6%, respectively. Corresponding changes in serum lipids
in this study for fasting TAG, total cholesterol, LDL cholesterol, and HDL cholesterol were 33%, 4%, 4%, and
11%, respectively. Confounding variables in these studies
include varying degrees of weight loss (2.2 to 7.7 kg) and
slight differences in the type of fat consumed. Nevertheless,
these studies collectively indicate that carbohydrate restriction
result in significant decreases in serum TAG, small increases in
total and LDL cholesterol, and moderate increases in HDL
cholesterol in normolipidemic individuals. The small but significant weight loss (2.2 kg) could have partially explained
the HDL and TAG responses in this study. A meta-analysis by
Dattilo and Kris-Etherton (25), showed that for every kilogram decrease in body weight during weight loss, HDL-C
increases 0.009 and TAG decreases 0.015 mmol/L. Using
these estimates, the 2.2 kg weight loss would have been
predicted to increase HDL by 0.198 mmol/L and decrease
TAG by 0.033 mmol/L, which amounts to only 14% and 9%
of the observed changes in these parameters. Thus, dietary
composition most likely contributed to the changes in blood
lipids in this study.

There was a significant decrease in postprandial lipemia

after the fat-rich meal (29%), which was significant but
somewhat lower than the decrease (50%) we observed in
response to a ketogenic diet rich in monounsaturated fat and
supplemented with (n-3) polyunsaturated fatty acids (9). In
contrast to our results, Miller et al. (26) reported that a low-fat
(19% of total energy)/high-carbohydrate (64% of total energy)
diet significantly reduced postprandial lipemia compared with
a diet higher in fat (41% of total energy) in normolipidemic
men. The high-fat diet in the study by Miller et al. (26) still
contained significant amounts of carbohydrate (42% of total
energy), which likely explains the conflicting results with our
postprandial TAG response in men that consumed a very low
carbohydrate (8% of total energy) diet.
The significant reduction in fasting TAG was probably due
to the combination of a reduced VLDL production rate, which
has been shown to increase on a high-carbohydrate diet (27),
and an increase in TAG removal because high-fat diets (46
65% of total energy) significantly increase postheparin plasma
LPL activity and skeletal muscle LPL activity in humans
(28 30). A greater VLDL-TAG pool size would also compete

FIGURE 2 Peak LDL particle size responses to a ketogenic diet in

normolipidemic, normal-weight men classified as pattern A (n 7) or
pattern B (n 5) at the start of the diet. Individuals with pattern A have
a predominance of large LDL particles and those with pattern B have a
predominance of smaller LDL particles. The peak particle diameter for
pattern B is usually 25.5 nm. *P 0.05 from corresponding wk 0
value.

FIGURE 3 Postprandial serum triacylglycerol (TAG) responses

(mean SD; n 12) to a fat-rich meal before (wk 0) and after (wk 6) a
ketogenic diet (n 12) in normolipidemic, normal-weight men. The area
under the postprandial TAG curve was significantly (P 0.05) lower
(29%) after the ketogenic diet (17.47 9.3 to 12.39 4.2 mmol/L
h). *P 0.05 from corresponding wk 0 value. #P 0.01 from
corresponding wk 0 value.

1884

SHARMAN ET AL.

with TAG from intestinal origin for removal during the postprandial period. Thus, elevated fasting TAG (primarily VLDLTAG) is associated with enhanced postprandial TAG (primarily chylomicron-TAG) due to competition for removal
(31). It follows then that a reduction in fasting TAG should be
directly related to a reduction in TAG responses to a fat-rich
meal, which was the case in this study (r 0.59; P 0.05).
Although the majority of studies have reported significant
correlations between changes in fasting and postprandial TAG
(9), a recent study demonstrated that a dietary regimen that
lowered fasting TAG did not result in a reduction in postprandial TAG (32), emphasizing the importance of measuring
postprandial TAG to assess overall CVD risk.
Dietary cholesterol intake increased 100% (332741
mg/d) when subjects switched to the ketogenic diet, which
would be predicted to result in significant increases in total
cholesterol and LDL cholesterol, although these were not
significantly elevated after 6 wk of the ketogenic diet. There is
great variability in the responsiveness of blood cholesterol
after increases in dietary cholesterol, which may be due to
differences in hormonal factors, obesity, and genetic predisposition (33). There were changes in the distribution of the LDL
subfractions that would be considered favorable in terms of
CVD. We observed general increases in the mean and peak
LDL particle sizes during the ketogenic diet, which were more
pronounced in subjects that exhibited a pattern B distribution
at the start of the study. Individuals with pattern B exhibit a
predominance of small dense lipoproteins and this distribution
is associated with increased risk of CVD (13,14) and was
recently shown to be the best discriminate factor for the
presence of CVD even when adjusting for other risk factors
(21). Although the characterization of pattern B is likely to
have a genetic origin (22), changes in diet are known to
influence the distribution of LDL subclasses. For example,
switching to a fat-rich diet (46% vs. 24% of total energy) was
shown to increase mean particle diameter and large LDL-1
mass and decrease small dense LDL-III cholesterol (28), while
reductions in dietary fat have the opposite effect (6,7). Despite
the changes in LDL size, we did not observe any significant
changes in oxidized LDL concentrations. Collectively these
studies indicate that when dietary fat is reduced, the distribution of LDL moves toward a smaller more dense particle and
when dietary fat is increased the distribution of LDL moves
toward a larger less dense particle. The reason some individuals are more stable in their LDL subclass distribution in
response to changes in diet is unknown but is likely to reflect
complex interactions between metabolic and genetic traits
that are influenced to varying extents depending on the level
of dietary fat (1,7).
We observed a significant decrease in fasting and postprandial insulin responses after the ketogenic diet. Decreases in
resting insulin concentrations have been reported in response
to 3 4 d of a low-carbohydrate diet high in fat (34 38). The
mechanism for such a response probably resides in the greater
reliance on fat oxidation induced by dietary carbohydrate
restriction (39) and subsequent reduced requirement for insulin to assist in glucose uptake. To our knowledge, the reduced
postprandial insulin response to a fat-rich meal observed after
a ketogenic diet has not been reported in the literature.
According to our estimate of insulin resistance using fasting
levels of glucose and insulin, subjects in this study were not
insulin resistant and there was no adverse effect of the ketogenic diet on insulin sensitivity. This is in agreement with
other studies showing no adverse effects on glucose metabolism or insulin resistance after ketogenic diets using the insulin
clamp technique (40,41).

Numerous studies now suggest that high-carbohydrate diets

can raise TAG levels, create small, dense LDL particles, and
reduce HDL cholesterol (i.e., atherogenic dyslipidemia)a
combination along with insulin resistance, that has been
termed syndrome X (42,43). Syndrome X is postulated to be
resistance to insulin-mediated glucose disposal by muscle (44),
30% of adult males and 10% to 15% of postmenopausal
women have this particular syndrome X profile, which is
associated with several-fold increase in heart disease risk.
Replacing saturated fat with carbohydrate appears to accentuate insulin concentrations and the atherogenic dyslipidemia
associated with syndrome X (44,45). The ketogenic diet in this
study resulted in favorable responses in fasting TAG, postprandial lipemia, HDL-C, LDL particle size, and insulin levels in
healthy normolipidemic men. Although the duration of the
diet was short (6 wk), these data suggest that a ketogenic
diet does not have an adverse effect on accepted biochemical risk factors for CVD and improves those associated with
syndrome X.
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