Harvard strikes again.
The February 2008 issue of the Harvard Heart Letter (subscription only) contains an article titled Triglycerides: A Big Fat Problem. The article discusses the correlation of elevated triglyceride levels with the development of coronary artery disease, then lists eight methods for reducing elevated triglyceride levels. It’s this list I want to discuss, but first let’s consider what triglycerides are and what they do.
Triglycerides are storage fats composed of three fatty acid chains hooked onto a glycerol (a 3-carbon carbohydrate) molecule. Fats travel in the blood as triglycerides and are stored in the cells as triglycerides. Each time a triglyceride moves into or out of a cell, the three fatty acids must first be removed from the glycerol backbone. After the fatty acids move across the cell membrane into or out of the cell, the fatty acids are then reattached in a process called esterification. (The particular bond between the fatty acids and the glycerol molecule is called an ester bond.)
There is undoubtedly a correlation between elevated levels of triglycerides in a fasting blood sample and the risk for heart disease. But, remember, although correlation implies causation it doesn’t really prove causation. As far as I can tell there is no firm data showing precisely how elevated levels of triglycerides actually drive the development of heart disease, but there is a considerable body of data demonstrating a strong correlation between elevated triglycdride levels and heart disease. My opinion, for what it’s worth, is that elevated levels of triglycerides in fasting blood are a marker for heart disease, meaning that whatever really causes heart disease also causes an elevation of triglycerides. A ridiculous example of this would be large belt sizes and obesity. Obese people wear large belts, but the belts don’t cause the obesity.
If this is the case, then simply lowering triglycerides won’t really reduce the risk of heart disease unless however you reduce triglycerides also reduces the real risk. Focusing on reducing triglycerides only would be comparable to an obese person buying a smaller belt in an effort to reduce his bulk because, after all, non-obese people have smaller belts.
We know that chronically elevated blood sugar, even if it is within what is considered the normal range, is a risk factor for heart disease. (Despite the focus over the past several decades on cholesterol in it’s many forms being a risk factor, this has never been conclusively shown to be true. The correlation between elevated blood sugar and heart disease, although dismissed or ignored by lipid-hypothesis promoters is much more closely associated in a dose response manner by the data than is cholesterol. See this old post for an explanation.)
After years of low-carb dieting myself and of taking care of thousands of patients on low-carb diets, I can tell you one thing with pretty much certainty: Low-carb diets reduce triglyceride levels markedly. And I can tell you that low-carb diets reduce blood sugar levels as well. Most of the patients with the highest fasting triglyceride levels also have elevated fasting blood sugars. On a low-carb diet, these patients drop their triglyceride levels like a rock.
Now, having this history, let’s take a look at the eight methods the Harvard Heart Letter recommends to help people reduce their triglycerides.
1. Beware of bad fats. Cut back on saturated fat (found in red meat and full-fat dairy foods) and trans fat (in some fried and commercially prepared foods).
Always the first recommendation by those in the grip of saturated fat hysteria. In their minds, no matter what the problem, cutting saturated fat makes it better. You can eat saturated fat to your heart’s content and still markedly reduce your triglyceride levels as long as you rigidly reduce your carbs. Same with trans fat. Needless to say, I’m not a fan of trans fat, but many patients have brought about tremendous reduction of their triglyceride levels while eating a lot of processed food by simply restricting their carbs. This isn’t the ideal situation, but it does give the lie to the idea that simply reducing trans fat will reduce triglyceride levels.
2. Go for good carbs. Eat whole grains and cut back on sugary drinks and foods.
Cutting back on sugary drinks and foods is sound advice. But they have to be virtually eliminated, not just cut back on if you expect much triglyceride lowering. Unfortunately, ‘good’ carbs elevate triglycrides as much as ‘bad’ carbs. And here they go again with the whole grains nonsense. Do these people not realize that we humans can’t eat whole grains. If you don’t believe me, go get some wheat grains and try to eat them. These grains are in a protective shell that we can’t break through to get at the starch within. In order to make the much-beloved whole grains edible, they have to be processed. What these people mean by whole grains are grains that have been processed up to the very last stage that removes all the brown husks from the flour. Whole grains, as these people mean them, are processed grains. You can go out and increase your consumption of five-grain, whole-wheat bread out the wazoo and watch your triglycerides rise. I can tell you categorically that eating whole grains as intended by these people will absolutely not lower your triglycerides. Eating real whole grains probably wouldn’t have much impact because they would pass through undigested.
3. Check your alcohol. Moderate drinking is good for the heart, unless you are a “responder” in whom alcohol dramatically boosts triglycerides. To determine if you’re a responder, avoid alcohol for three weeks and have your triglycerides tested.
The responder business counts only if there is actual demonstrated causation between elevated triglycerides and heart disease, which there isn’t. I suspect something else is going on here, but in all honesty, if I were a ‘responder’ I would probably cut back on my alcohol consumption until I figured out what is really going on. Thank God I’m not.
4. Go fish. Omega-3 fats in some fish lower triglycerides. Have fish twice a week.
Omage-3s do indeed work to lower triglycerides and are protective against heart attack. But I would have fish twice per week only if I wanted to increase my mercury levels along with my omega-3s. A much better way is by taking mercury-free fish oil and/or krill oil in supplement form. If you insist upon eating fish, go for sardines. They are small, low on the food chain and haven’t had time to concentrate much mercury.
5. Aim for a healthy weight. If you are overweight, aim to lose at least 5% to 10% of your weight to lower triglycerides.
Weight loss will really help to lower your triglycerides if you accomplish it via a low-carb diet. In fact, if you go on a rigid low-carb diet, you will lower your triglycerides dramatically long before you lose much weight.
6. Get moving. Exercise lowers triglycerides and boosts HDL.
I don’t have a problem with this recommendation, although you can lower triglycerides and raise HDL levels much more quickly with diet than you can with exercise.
7. Stop smoking. Smoking isn’t good for triglyceride levels (or anything else).
From the data I’ve read on smoking, that habit seems to drive the forces of insulin resistance and the metabolic syndrome. I’m pretty sure that insulin resistance and hyperinsulinemia are the driving forces behind elevated triglycerides so anything you can do to reduce these underlying problems will reduce your triglycerides. Having said that, however, I’ve had a number of patients who smoked, refused to quit despite my nagging, and still lowered their triglycerides by eating low-carb. But don’t get me wrong – I believe everyone who smokes should quit.
8. Get help from a medication. Niacin, fibrates, fish oil, and cholesterol-lowering statins have all been shown to lower triglycerides.
Readers of this blog can, I’m sure, imagine my response to this recommendation.
If you want to lower your triglycerides, lower your carbs. It’s as simple as that. But you’ve got to really lower your carbs, not just make a half-hearted stab at a low-carb diet. If your idea of lowering your carbs is avoiding a dessert from time to time, but continuing to chow down on ‘good’ carbs all day long, you’re going to be disappointed. But if you eat a lot of meat, even red meat, accompanied by green and colorful vegetables and low-carb fruits, you should be rewarded with triglycerides that are almost always below the 150 mg/dl limit of what’s considered ‘normal,’ and you will more than likely find yourself with fasting triglycerides below 100 mg/dl, which is a very good place to have them.
On another note, I’m traveling today, so probably won’t be able to get comments posted until late tonight. I’m planning a post on the vitamin D situation that so many people have written questions about, and you won’t believe the latest from Anthony Colpo. All to come this week.
Dr. Mike,
You mention in this article that “if you go on a rigid low-carb diet, you will lower your triglycerides dramatically long before you lose much weight.” How quickly does human physiology react to the low carb diet in respect to triglyerides? And what do you consider at dramatic change.
Best wishes!
I checked one patient – a 55 year old male advertising exectutive – who had a trigylceride level of 1500 mg/dl that he lowered to under 100 mg/dl in 11 days. I’ve never checked anyone in under 11 days, but I have seen many, many patients who dropped their levels dramatically within six weeks, which is the typical length of time I wait before rechecking.
Sir Hola…am working my way through GTaubes opus and wondered if you had anything to say about the overfeeding/paradox part of the book..of course not the oer feeding of crabohydrates(for once an intentional typo)..but that of fat and protein and the resultant levels of energy with all that confers.
Am interested in this as if i want to lean-out i have to literally eat 2500/3000 cals (protein/fat) or more and the paradox seems to be is that cos protein satiates one so well/fully (no pun) it’s easy to eat far less, be thus satiated and then not eat enought to allow/facilitate(whatever the word) the bod to hook into its reserves.
Anybody else know owt about this, care to comment..anything.
Thanks much.
Sinc.
Simon (Fellows)
supachramp at yahoo dot com
I have lowered my Triglycerides from 2.4 = 212 to 1.2 = 106 in six days, it is keeping it of that does not work, when I introduce the correct calories back with in a matter of a few days I am back where I started, I follow 80/10/10, I have kept a daily record of food intake and readings for three weeks
Dr. Mike, Your wrote that smoking:
“seems to drive the forces of insulin resistance and the metabolic syndrome”
I am wondering by what mechinism this happens? The reason I ask is because I wonder if a prescription stimulant, taken as directed could / would be likely to cause the same problems with insulin resistance and the metabolic syndrome? (or perhaps smoking causes the problem by some action entirely other than via dopamine manipulation)
Since I don’t smoke and encourage every one I know to quit, I haven’t really delved into all the mechanisms involved. I have read countless papers showing that smoking increases insulin resistance and hyperinsulinemia. I think it is a different mechanism than via dopamine.
Excellent post Dr. Mike. Thanks again and safe travels.
Best,
W
Dr. Mike.
I read a copy of the article in the Harvard Heart Letter. I love the chart at the bottom of the article that shows that Drugs and fish oil both are equally effective in the treatment of triglycerides.
Jamie
Bacon, eggs used to be full of omega-3s too.
Dr Mike,
Are triglycerides usually composed of sat fatty acids or can they be MUFA, PUFA? I recall from PPLP that the body can exchange acid types as needed? Does Jane Brody’s comment, “The body needs absolutely NO saturated fats. Feel free to eliminate them from your diet” make her All Wet or just Damp?
Triglycerides can be made of any fatty acids MUFA, PUFA and sat fats.
Dr. Mike,
Barb’s comment on how quickly going low-carb can lower triglycerides hit home with me. On December 5, 2007, I started to eat a very low-carb diet (after years of a low-glycemic diet). My previous lipid panel on August 6, 2007, showed that my triglyceride level was 109 (and my HDL was 40). Then, on January 8, my triglyceride level was tested at 47 (and my HDL — the good cholesterol — had risen above 40 for the first time in my life, to 68). So, Barb, yes, it is fast — and dramatic.
David Mendosa
Most health newsletters are just lists of old wife’s tales. They contain lots of rumor and innuendo and little actual scientific facts. Unfortunately, the public, in general, believes all information contained in them is factual.
The last time I had my blood checked, I had cholesterol of 128 and triglycerides of 13. I just want to say that I whole-heartedly agree with you on the carbohydrate restriction. I cut out carbs much before I read your book, but the results were quite dramatic. I just wish I could explain to other people about carbohydrate restriction without getting a look of cognitive dissonance from them. They just don’t comprehend the notion that grains aren’t all that healthy.
Doc, you mentioned somewhere that trigs are a much better indicator of CHD risk than any type of cholesterol modality. How much better? Is it virtually impossible to have very good trigs and get a heart attack or is it twice as good as cholesterol measurement? It would be very useful to know since I’m fighting my inlaws who want me to stop eating more that 7 eggs per week because of the cholesterol content. Like eggs could raise serum cholesterol… (I’m also a woman of 38 with no risk factors of CHD whatsoever, but that doesn’t seem to sink in with them.)
It’s not known for sure whether triglycerides are a risk factor of if they are merely related to heart disease, so there is no way to quantify their risk level. A few people have tried to quantify the triglyceride/HDL levels in terms of risk, and it appears that those who have a TGL/HDL level below 3 have fewer heart attacks than those with higher levels. In practice I found that patients on low-carb diets tend to run TGL/HDL ratios at around 1 or even less.
Dear Dr. Mike,
Thought you might appreciate this article regarding gout & sugar/fructose:
http://www.telegraph.co.uk/global/main.jhtml?xml=/global/2008/02/01/noindex/ngout101.xml
Regards,
Laurel
Thanks for the link. I’ll have to pull this paper. I’ve found the same thing in years of practice.
Cheers–
MRE
Dr. Eades (and other readers),
I have enjoyed your books and your blog, and I have an off-topic question for you. You, as I do, believe that our ancestors evolved to eat a diet that included very little carbohydrate and that “excessive” carb consumption can lead to obesity and many other problems. But what about the possibility that our body’s response to carbs could also be an evolved response? Could it be that our ancestors gorged on fruits and berries in the late summer and fall, thus gaining some body fat that could be beneficial in making it through the winter (in colder climes, obviously)? And could it be that those that did not gain fat on this diet were more likely to die in the winter and not reproduce? I am sure I am not the first to wonder about this.
Nope, you’re not the first person to have wondered. Since all animals get fatter in the fall in preparation for winter, it would seem likely that they had been selected by the forces of natural selection to do so. The enzymatic machinery that converts fructose to fat would appear to be proof. In a native diet, fructose wouldn’t be found in very high concentrations until the fall when fruits ripened, which corresponds to the time when animals need to fatten the most. Now we eat fructose all the time and wonder why we all get fat.
Cheers–
MRE
Dr. Mike:
Instead of proving the low carb diet with Colpo, how about asking him to prove any long term sustained weight loss from calorie counting? Sure, there was that wierd experiment that Newburgh cited in 1948, who was unique in the annals of obesity literature, but there are no studies that prove cutting calories works. They’ve tried it with marathons and every other type of exercise imaginable but it’s consistently shown not to work in laboratory studies. It has been proven over and over again that fat people eat no more than lean persons. They may underestimate what they eat, but the fact remains that they really eat no more than the lean. Every creature on the planet only fattens with a purpose. Those that fatten for no reason can blame diet and with it comes all the diseases of civilization.
There’s a NY Times article ( http://www.nytimes.com/2008/02/07/health/07diabetes.html?_r=1&hp=&oref=slogin&pagewanted=all )that should be of interest to everyone regarding diabetes and heart disease. It may be surprising to mainstream docs but not to those who’ve read and understood the carbohydrate hypothesis and the diabetes chapters in Gary Taubes’ book. Hopefully, Taubes will right another opinion piece on the subject and get in published in the NY Times just like what he did with regards to the Vytorin disaster.
Doc, I didn’t mean risk factor per se, I just wondered wether nearly all people who suffer heart attacks also have high trigs. Or is it more like cholesterol where some people with quite low cholesterol of all shapes and sizes still have heart attacks? Is there any statistics on this anywhere?
I don’t know this for an absolute fact, but I would bet that many more have elevated triglycerides than have elevated cholesterol.
On another note, this article in a Swedish daily paper says that Frank Hu at Harvard School of Public Health says they have managed to get some data out of Nurse’s health study that says that High-GI carbs will increase risk of diabetes and heart disease. Low-GI carbs like full grain pasta and brown rice does not, and it also says low-carb does not increase risk, rather it diminishes the risk of getting sick *under the condition that you choose fats of plant origin – canola, olive oil and nuts*. Does it say that, or is that their interpretation or do they just assume it?
Who knows what the Nurses’ Health Study says? This is regarded as a terrible study by most legit epidemiologists. Knowing the people involved, I suspect they interpret it that way because they can’t bring themselves to face the facts they would have to face were they to interpret it correctly.
Cheers–
MRE
Hi
I have very low triglycerides, very high hdl, and eat almost vegetarian. Very high carb. Total cholesterol over 460. Any comment?
No manipulation, although I have begun using salmon oil in the past six months. If I remember.
I wouldn’t know without checking of course, but if you’re on high-carb diet you could easily have the small, dense LDL particle type, although your low triglycerides militates against it. Might want to get it checked. Might want to try a different diet.
In Sept. 2016 my total chol= 218, trigl=55, HDL 102, LDL105, CHOL/HDL 2.1 Glucose 101
In 1216 total 258, trigl-58, HDL 113, LDL133 CH/HDL 2.3 Glu. 94
For other health issues,(past ca, plus PD)went on a low carb with occasional sweets (2Xmo.) almost no white carbs, high fat (all kinds) and an egg most days. Quit my dailt oatmeal breakfast. Almost no grains.
In June 2017 t CHL 246, trigl 179, HDL 60, LDL150 ratio4.1 glucose 87
Does this make sense??
If you’re really on a low-carb diet, the triglycerides do not make sense. Nor does the fall off in HDL.