It is arguably the biggest medical U-turn in history. For decades, mainstream healthy eating advice has been that to keep weight off, we should avoid fatty food.
But a radically different approach, of limiting carbohydrates and filling up instead on fat and protein, has been getting increasing support – and is now even recommended for weight loss and type 2 diabetes by various NHS bodies.
Yet in a few people, this approach – known as low-carbing, or the keto or Atkins diet – seems to raise cholesterol levels, usually seen as bad for the heart.
One such person is Dr Jen Unwin, 62, who has been low-carbing for 14 years. “Nobody has ever seen a cholesterol as high as mine. My GP nearly had a nervous breakdown trying to refer me to a high cholesterol clinic.”
At the last test, Unwin’s total cholesterol was 19 millimoles per litre (mmol/L). NHS advice is that it should be below 5 mmol/L. But she is not worried.
That’s because she has had another kind of medical check, a scan of the heart’s arteries, which shows if they are furring up. And in stark contrast to her cholesterol test, Unwin’s arteries got the best result possible – they were completely free of plaque.
“It was all clear,” said Unwin. “And all my other markers are good. So I’m not concerned.”
So, how does Unwin justify going against NHS advice on cholesterol – and what do doctors say about it?
How cholesterol can cause heart attacks
The mainstream view that fatty foods cause weight gain stems from the fact that fat has more calories per gram than protein and carbs.
People are supposed to especially avoid animal fats, such as those found in red meat and dairy, because they raise blood cholesterol levels, leading to plaque buildup in arteries. When these plaques rupture, it can trigger heart attacks and strokes.
Low-carbing adherents say that while fat is more calorific, it is also better at satisfying hunger. And so the best way to lose weight is to fill up on fat and protein and minimise carbohydrates, including both sugary and starchy foods.
Trials show low-carbing does work for weight loss, as long as you can put up with cutting out starchy staples like bread, pasta and rice.
Diabetes experts also became interested in low-carbing because this way of eating lowers blood sugar levels, which is helpful in type 2 diabetes.
While low-carbing was initially dismissed as a crank diet, today, NHS bodies and other medical groups worldwide recommend it as a valid option for type 2 diabetes or weight loss, alongside the more traditional option of low-fat diets.
In fact, Unwin’s husband, Dr David Unwin, a Southport GP and the Royal College of General Practitioners’ clinical expert for diabetes, has spearheaded the adoption of low-carbing for diabetes and obesity in the NHS.
The U-turn happened because randomised trials showed that most people on low-carb diets do not see worsening in their cholesterol levels or in other health tests, like for blood sugar and blood pressure, at least in the short term, over one to two years.
But what about those people who do get higher cholesterol?
Curry with cauliflower instead of rice
Unwin, a clinical psychologist, had tried many different diets before, but nothing had worked long-term. Low-carbing, however, led over time to a weight loss of four stone. She also now runs and weight trains.
Her typical meals include bacon and eggs, chicken curry with cauliflower as a side, lamb and green beans and roast pork and fried cabbage.
According to low-carb communities, it could raise cholesterol because the body starts using it as fuel instead of carbs, so it needs to transport it around the body. “It makes sense that the numbers go up,” said Unwin.
Plaques can rupture and trigger blood clots, leading to heart attacks (Photo: Sebastian Kaulitzki/ Science Photo Library)Her heart scans are what have really reassured her, though. These measure the amount of calcium in arteries that supply the heart, as calcium builds up in plaques.
“I had a zero score, which means zero calcium buildup in the coronary arteries. So that was reassuring,” says Unwin, whose story is featured in a recent Amazon Prime documentary, The Cholesterol Code, made through crowd-funding by the US low-carbing community. Five years later, she had a second one that gave the same result.
Heart arteries not the whole story
But some doctors have said ignoring high cholesterol levels is potentially dangerous.
Dr Joseph Cheriyan, a heart researcher at the University of Cambridge, said even if scans show the heart arteries are healthy, arteries in other parts of the body, such as the brain or legs, could have plaque building up. “Plaques can occur anywhere,” he said.
Another controversial move by Unwin is that she does not take cholesterol-lowering medicines called statins. “I haven’t got any coronary plaque, which is the thing that they would help with,” she said. “And I’m aware of potential side effects like muscle soreness and weakness.”
Professor Colin Baigent, a statin researcher at the University of Oxford, said: “Patients who develop high cholesterol when they’re taking a keto diet should consider aggressive cholesterol reduction using tools we already have, like statins [and other drugs],” he said. “I would definitely not want to be exposed to high cholesterol for years or decades.”
Baigent pointed out that trials have shown some people with a rare genetic cause of high cholesterol tend to die from heart attacks relatively early in life, but taking statins and other drugs has given them a much higher life expectancy.
Unwin is aware that most doctors would advise changing her diet or, at least, taking statins. But she has had her scans reviewed by an NHS cardiologist, who agreed she is probably at very low risk. “We will kind of keep an eye on it,” she said. “But I’ve weighed up the pros and cons.”
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