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Paradox of hypercholesterolaemia in highly trained, keto-adapted athletes
  1. Brent C Creighton1,
  2. Parker Neil Hyde2,
  3. Carl M Maresh2,
  4. William J Kraemer2,
  5. Stephen D Phinney1,
  6. Jeff S Volek2
  1. 1 Virta Health, San Francisco, California, USA
  2. 2 Department of Human Sciences, The Ohio State University, Columbus, Ohio, USA
  1. Correspondence to Dr Jeff S Volek; jvolek7{at}


Objective A growing number of ultra-endurance athletes have switched to a very low-carbohydrate/high-fat eating pattern. We compared markers of cholesterol and the lipoprotein profile in a group of elite ultra-runners consuming a high-carbohydrate (HC) or low-carbohydrate (LC) diet.

Methods Fasting blood was obtained from competitive male ultra-endurance runners habitually consuming a very low-carbohydrate (LC; n=10) or high-carbohydrate (HC; n=10) diet to determine blood cholesterol profile, lipoprotein particle distribution and sterol biomarkers of cholesterol balance.

Results Plasma total cholesterol, low-density lipoprotein (LDL-C) and high-density lipoprotein (HDL-C) cholesterol were all significantly greater (p<0.000) in the LC group (65%, 83% and 60%, respectively). There were also significant differences in lipoprotein particle distribution as evidenced by a greater size and concentration of large HDL and LDL particles, and total LDL particle concentration was significantly greater in the LC group, but they had significantly fewer small LDL particles.

Conclusion Ultra-endurance athletes habitually consuming a very low-carbohydrate/high-fat diet for over a year showed unique cholesterol profiles characterised by consistently higher plasma LDL-C and HDL-C, less small LDL particles, and lipoprotein profiles consistent with higher insulin sensitivity. There may be a functional purpose to the expansion of the circulating cholesterol pool to meet the heightened demand for lipid transport in highly trained, keto-adapted athletes.

  • low carb high fat
  • lipoprotein metabolism
  • cholesterol balance

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  • Contributors JSV, WJK, CMM and SDP were involved in the conception and design of the study. All authors made contributions to interpretation of data and drafting the manuscript or revising it critically for important intellectual content.

  • Funding This work was supported by contributions from Quest Nutrition and The Robert C and Veronica Atkins Foundation.

  • Competing interests JSV and SDP receive royalties from books on nutrition and exercise. JSV and SDP are founders of Virta Health and have equity positions; BCC is an employee at Virta Health.

  • Patient consent Obtained.

  • Ethics approval The study was approved by The Ohio State University Biomedical IRB.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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