Is a ketogenic diet appropriate for improving cardiovascular health in a healthy adult without known cardiovascular disease?

Is the Ketogenic Diet Good for Heart Health?

No, the ketogenic diet does not meet criteria for cardiovascular health and should not be recommended as a heart-healthy dietary pattern for adults without cardiovascular disease. 1

Why the Ketogenic Diet Falls Short for Cardiovascular Health

The ketogenic diet provides approximately 53% of calories from total fat and 26% from saturated fat with very low carbohydrate intake—a macronutrient distribution that explicitly does not meet established criteria for cardiovascular health. 1 This stands in stark contrast to evidence-based heart-healthy dietary patterns.

Established Heart-Healthy Dietary Patterns

The American Heart Association and American College of Cardiology strongly recommend dietary patterns that have robust evidence for cardiovascular protection: 2

• Mediterranean-style diet: High in vegetables, fruits, whole grains, fatty fish, nuts, and olive oil; moderate in total fat (32-35% of calories) with low saturated fat (9-10% of calories). This pattern reduces blood pressure by 6-7/2-3 mmHg and lowers cardiovascular disease risk. 2

• DASH dietary pattern: High in vegetables, fruits, low-fat dairy, whole grains, poultry, fish, and nuts; low in sweets. When all food is provided and weight is stable, DASH lowers blood pressure by 5-6/3 mmHg and reduces LDL cholesterol by 11 mg/dL. 2

Both patterns emphasize whole grains, vegetables, fruits, lean proteins, and limit red meat—the opposite of typical ketogenic approaches. 2

Concerning Lipid Effects of Ketogenic Diets

The most significant cardiovascular concern is the elevation of atherogenic lipoproteins. A 2024 meta-analysis of 27 randomized controlled trials found that ketogenic diet intervention increased: 3

• Total cholesterol by 0.36 mmol/L (approximately 14 mg/dL)
• LDL cholesterol by 0.35 mmol/L (approximately 13.5 mg/dL)
• These elevations occurred despite weight loss

Marked elevation of LDL cholesterol warrants immediate cessation of the ketogenic diet. 1 This is particularly concerning because LDL cholesterol elevation is a direct causal factor in atherosclerotic cardiovascular disease.

While the ketogenic diet does reduce triglycerides by 0.20 mmol/L and modestly increases HDL cholesterol by 0.16 mmol/L, these benefits do not offset the concerning rise in atherogenic lipoproteins. 3

Mixed Evidence on Cardiovascular Outcomes

The relationship between very-low-carbohydrate diets and cardiovascular mortality remains controversial: 4, 5

• Low-carbohydrate patterns (not as extreme as ketogenic) show more favorable cardiovascular mortality outcomes than very-low-carbohydrate ketogenic approaches. 4
• One subanalysis from the CARDIA study found that progression of coronary artery disease (measured by coronary artery calcium) was more pronounced in people with low-carbohydrate intake, especially when compensatory calories came from animal sources rather than plant-based sources. 5
• Animal-based ketogenic diets have been associated with increased all-cause mortality in patients who have already suffered a myocardial infarction. 5

Short-Term Metabolic Benefits Do Not Equal Long-Term Cardiovascular Health

While ketogenic diets can produce rapid short-term reductions in body weight, triglycerides, HbA1c, and blood pressure, these benefits are not sustained in long-term observations. 4 The initial improvements are largely attributable to caloric restriction and weight loss rather than the metabolic state of ketosis itself. 6

The ketogenic diet's efficacy for weight loss and metabolic improvements loses statistical significance over time, making it an unreliable long-term strategy for cardiovascular risk reduction. 4

Safety Concerns in Cardiovascular Patients

Several critical safety issues make the ketogenic diet particularly problematic for cardiovascular health management: 7, 6

• Hypotension risk: Rapid weight loss can cause substantial drops in blood pressure, precipitating symptomatic hypotension, especially in patients on antihypertensive medications. Close medical supervision is mandatory. 7

• Drug interactions: Patients taking SGLT2 inhibitors must avoid ketogenic diets due to documented risk of euglycemic diabetic ketoacidosis. 7, 6

• Nutritional deficiencies: Ketogenic diets may lead to deficiencies of thiamine, folate, iron, and magnesium, which can exacerbate cardiac and neurological complications. 7

The Evidence-Based Alternative

For cardiovascular health in adults without known cardiovascular disease, consume a dietary pattern that emphasizes vegetables, fruits, whole grains, low-fat dairy products, poultry, fish, legumes, nontropical vegetable oils, and nuts while limiting sodium, sweets, sugar-sweetened beverages, and red meats. 2 This can be achieved through the DASH dietary pattern, Mediterranean-style diet, or USDA Food Pattern. 2

These patterns have high-quality evidence (Level A) demonstrating sustained improvements in blood pressure, lipid profiles, and cardiovascular outcomes—benefits that persist as long as the pattern is consumed. 2

Common Pitfalls to Avoid

• Do not confuse short-term weight loss with cardiovascular health. The ketogenic diet may produce rapid initial weight loss, but this does not translate to long-term cardiovascular benefit and comes at the cost of elevated LDL cholesterol. 4, 3

• Do not assume all "low-carb" diets are equivalent. Moderate carbohydrate restriction (as in Mediterranean or DASH patterns) differs fundamentally from the extreme restriction of ketogenic diets. 2, 4

• Do not overlook the quality of fat sources. If someone insists on following a lower-carbohydrate approach, emphasize unsaturated fats from plant sources rather than saturated fats from animal sources. 5