Low-fat diets raise triglycerides

Martin, a hospital employee, knowing that I fuss a great deal with lipids and lipoproteins, showed me his lipid panel because the result triggered a "panic value" for triglycerides at 267 mg/dl. He asked if he should go on a serious low-fat diet.

I asked Martin what he had for breakfast: a whole wheat bagel with no-added-sugar jam. Lunch: a turkey sub on whole grain bread, no mayonnaise. Snacks: baked chips, pretzels ("a low-fat snack!").

In years past, if person developed high triglycerides levels, a very low-fat diet was prescribed. Someone would come to the hospital, for instance, with abdominal pain from pancreatitis (an inflamed pancreas)due to the damaging effects of triglyceride levels >1000 mg/dl. For this reason, many people still believe that all instances of elevated triglycerides should be treated with a reduction in fat intake.

This is absolutely wrong. While a fat restriction may reduce triglycerides in genetically-programmed responses when triglycerides are >1000 mg/dl, lesser levels of high triglycerides of, say 250 or 300 mg/dl, do not respond to dietary fat restrictions as a sole strategy.

Yes, a reduction in unhealthy fats (saturated, trans, polyunsaturated) helps. But a reduction in fats of all sorts is not necessary and can, in fact, worsen the problem. We learned this lesson years ago with the Ornish diet and similar ultra low-fat approaches. When you reduce fat intake significantly to <10% of calories, triglycerides go way up. In those days, it wasn't uncommon to see triglycerides skyrocket past 200 or 300 mg/dl on these diets.

Why are triglycerides important? Triglycerides are an ingredient in creating the lipoproteins VLDL, IDL, small LDL. Elevated triglycerides trigger a drop in HDL, a shift towards small, ineffective HDL, and contribute to heightened inflammation. Higher triglycerides also tend to go hand in hand with lipoproteins that persist for extended periods (12-24 hours or longer) in the blood after a meal.

Triglycerides respond very nicely to a dramatic reduction in processed carbohydrates, especially wheat and corn. Of course, wheat is the bulk of the problem, since it has grown to occupy an enormous role in many people's diet, not uncommonly eaten 3,4, or 5 times per day in various forms, as it has in Martin's diet. Eliminating all sources of high-fructose corn syrup is also helpful, since high-fructose corn syrup shoots triglycerides way up. (Recall that high-fructose corn syrup is everywhere: ketchup, beer, low-fat or non-fat salad dressings, breads, fruit drinks, sports drinks, breakfast cereals, etc.)

Curiously, it is a fat that also powerfully reduces triglycerides in the form of fish oil. In the Track Your Plaque program, fish oil, taken at truly effective doses of 4000 mg per day or more (to provide at least 1200 mg EPA+DHA), is our number one choice after reduction of processed carbohydrates for reduction of high triglycerides.

Comments (4) -

  • Bruce K

    6/10/2008 7:42:00 PM |

    _I asked Martin what he had for breakfast: a whole wheat bagel with no-added-sugar jam. Lunch: a turkey sub on whole grain bread, no mayonnaise. Snacks: baked chips, pretzels ("a low-fat snack!")._

    What do you think of Joel Fuhrman's approach? He would not allow people to eat bagels, jam, bread, chips, and pretzels. The base of his diet is veggies (half raw, half-cooked), then fruits, beans, potatoes, raw nuts, and raw seeds. Grains are at the top of Fuhrman's food pyramid.

    http://www.nutritionforwellness.org/img/food_pyramid.gif

    Also, when he says "whole grains", he means unbroken grains like brown rice, oatmeal, etc. Not flours, or pastas, or breads made with flour. The only breads he would allow are things like sprouted grain breads, made without any flour.

    Most people who eat a low-fat diet eat bad foods. They don't eat high quality foods. Dr. Fuhrman claims to lower triglycerides and improve all other health markers, because he stricly limits foods like flour, fruit juice, vegetable oils, sugar, etc. Maybe a low-fat diet based on grains (esp flours) will raise the triglycerides, but a low-fat diet based on vegetables, fruits, beans, nuts, and seeds (Fuhrman's) wont.

    Fuhrman emphasizes nutrient-density far more than people like Dr. Dean Ornish. Whole grain flours are very perishable and quickly turn rancid. Weston Price pointed this out, but most people didn't bother to listen and still don't. Here's an article about how whole grain flours cause sterility if they are stored for as little as 15 days, while flour and bread that is fresh-ground doesn't. How many are eating fresh flour? I would say <1%, maybe zero.

    http://eap.mcgill.ca/Publications/EAP35.htm

  • Anonymous

    7/1/2009 11:14:32 AM |

    Just a small correction - Dr Fuhrman's diet is not really low fat like Ornish/McDougall, the only similarity to those diets is the predominance of plant based foods.

    It eliminates/restricts saturated fat and plant oils but he is VERY pro 'good' fat in it's natural packaging i.e. nuts, seeds, avocado and fish oil in some cases (he prefers DHA from algae due to mercury in fish for most people and esp pregnant/lactating/babies but for high doses still recommends high quality fish oil especially for autoimmune patients). Re the nuts/seeds/avocado - in his weight loss strategy he does limit them but a minimum level is compulsory on a daily basis and he actively encourages people to have them while maintaining ideal weight i.e. can go very high if very skinny, lower if overweight but cannot eliminate them.

  • buy jeans

    11/3/2010 6:41:31 PM |

    Yes, a reduction in unhealthy fats (saturated, trans, polyunsaturated) helps. But a reduction in fats of all sorts is not necessary and can, in fact, worsen the problem. We learned this lesson years ago with the Ornish diet and similar ultra low-fat approaches. When you reduce fat intake significantly to <10% of calories, triglycerides go way up. In those days, it wasn't uncommon to see triglycerides skyrocket past 200 or 300 mg/dl on these diets.

  • jim

    8/26/2011 4:23:10 PM |

    Do saturated fats elevate triglyceride levels in the body?  Jim

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Dr. William Blanchet: A voice of reason

Dr. William Blanchet: A voice of reason

I don't mean to beat this discussion to a pulp, but looking back over the comments posted on www.theHeart.org forum, I am so deeply impressed with Dr. William Blanchet's grasp of the issues, that I posted his articulate and knowledgeable comments again.

Here is one post in which Dr. Blanchet, in response to accusations of trying to profit from heart scans, provides a wonderful summary of the logic and evidence behind the use of heart scans as the basis for heart disease prevention.


Yes, I have seen a dramatic reduction in coronary events.

Of 6,000 active patients, 48% being Medicare age and over, I have seen 4 heart attacks over the last 3+ years. 2 in 85 year old diabetics undergoing cancer surgery, one in a 90 year old with known disease and one in a 69 year old with no risk factors, who was healthy, and had never benefited from a heart scan.

The problem with coronary disease is that we rely on risk factors. Khot et al in JAMA 2003 showed that of 87,000 men with heart attacks, 62% had 0 or 1 major risk factor prior to their MI. According to ATP-III, almost everyone with 0-1 risk factors is low risk and most do not qualify for preventive treatment. EBT calcium imaging could identify 98% of these individuals as being at risk before their heart attack and treatment could be initiated to prevent their MI.

Treating to NCEP cholesterol goals prevents 30-40% of heart attacks. Treating to a goal of coronary calcium stability prevents 90% of heart attacks. Where I went to school, a 40% was an F. Why are we defending this result instead of striving to improve upon it? I am not making this up, look at Raggi's study in Arteriosclerosis, Thrombosis, and Vascular Biology 2004;24:1272, or Budoff Am J Card.[I believe it's the study Dr. Blanchet was referring to.]

I strongly disagree with the assertion that the stress test is a great risk stratifier. Laukkanen et al JACC 2001 studied 1,769 asymptomatic men with stress tests. Although failing the stress test resulted in an increased risk of future heart attack, 83% of the total heart attacks over the next 10 years occurred in those men who passed the stress test. Falk E, Shah PK, Fuster V Circulation 1995;92:657-671 demonstrated that 86% of heart attacks occur in vessels with less than 70% as the maximum obstruction. A vast majority of
patients with less than 70% vessel obstruction will pass their stress test.

Regarding [the] question of owning or referring for EBT imaging, I would be amused if it were not insulting. The mistake that is often made is that EBT imaging is a wildly profitable technology. It is not nearly as profitable as nuclear stress imaging. Indeed there are few EBT centers in the country that are as profitable as any random cardiologist's stress lab.

How can we justify not screening asymptomatic patients? Most heart attacks occur in patients with no prior symptoms and according to Steve Nissen, 150,000 Americans die each year from their first symptom of heart disease. My daughter is at this moment visiting with a friend who lost her father a few years ago to his first symptom of heart disease when she was 8 years old. That is not OK! We screen asymptomatic women for breast cancer risk. Women are 8 times more likely to die from heart disease than breast cancer. We do mass screening for colon cancer and we are over 10 times more likely to die from heart attacks than colon cancer. An EBT heart scan costs 1/8th the cost of a colonoscopy.

So what say we drop the sarcasm and look at this technology objectively. Read the literature, not just the editorial comments. This really does provide incredibly valuable information that saves lives.

Yes, a 90% reduction in heart attacks in my patients compared to the care I could provide 5 years ago when I was doing a lot of stress testing and referring for revascularization. Much better statistics than expected national or regional norms. I welcome your scrutiny.



That's probably the best, most concise summary of why heart scanning makes sense that I've ever heard. And it comes from a primary care physician in the trenches. With just a few paragraphs, Dr. Blanchet, in my view, handily trumps the arguments of my colleagues arguing to maintain the status quo of cholesterol testing, stress tests, and hospital procedures.


Note:
Dr. Blanchett talks openly about his affiliation with an imaging center in Boulder, Colorado, Front Range Preventive Imaging. I'm no stranger to the accusations Dr. Blanchet receives about trying to profit from the heart scan phenomenon. Ironically, heart scanning loses money. It is a preventive test, not a therapeutic, hospital-based procedure. Free-standing heart scan centers that do little else (perhaps virtual colonoscopies) usually manage to pay their bills but make little profit. Hospitals that offer heart scans usually do so as a "loss-leader," i.e., an inexpensive test that brings you in the door in the hopes that you will require more testing.

Accusations of profiteering off heart scans are, to those in the know, ridiculous and baseless. On the contrary, heart scans are both cost-saving and life-saving.

Comments (21) -

  • wccaguy

    11/24/2007 6:19:00 PM |

    I had an opportunity to speak with Dr. Blanchet for a few minutes recently.  A great doctor and a nice guy.

    He's in Boulder, Colorado.  Here's the web site link I was able to contact him through.  (I've separated out the link onto two lines to ensure that the complete link appears in comments.  You'll need to put the two lines together as a single URL to paste into your browser.)

    http://www.bch.org/caregiver/
    physiciandetail.cfm/184

    If I lived close to Boulder, Colorado, I'd be working to make him my primary care physician.

  • Rich

    11/24/2007 8:13:00 PM |

    Dr. Davis:

    Thank you!

    About profitability: My calcium scan in California cost $500. The new-ish GE scanner that was used costs $1.8 million. I estimate that the $500 fee can only yield about $100 gross margin under high-patient-volume circumstances.

    -Rich

  • Dr. Davis

    11/24/2007 8:33:00 PM |

    I am not one to moan about the costs of running a scan center, since I've never had any financial interest in a scan center (despite numerous accusations of "secret arrangements," etc.), but costs of running a center also include:

    1) $12,000 or so a month upkeep. No kidding. The GE's of the world, though they do great engineering work, make many times their investment back just from the rich  maintenance contracts. I've seen these maintenance contracts break the back of many independent scan centers.

    2) Because physicians are so hard to educate on the value of heart scans, scan centers by necessity rely on advertising, which is very costly.

    3) Paying physicians to read scans. I can tell you from personal experience, since I do read scans and receive a small fee for each reading, that the reading fee is paltry. If I were doing this for money, I wouldn't waste my time. But it's not about money. It's about providing a necessary and important service.

    This is why independent scan centers have struggled across the country. It is getting better, but mostly because of the adoption of the new CT technologies by hospitals.

  • TedHutchinson

    11/25/2007 10:36:00 AM |

    Here are the actual prices those lucky enough to live in USA can get a Coronary Artery Scan ("heart scan") — EBT examination of heart with calculation of coronary calcium score. Includes all interpretations and comprehensive report. Radiologist examination of chest images. Report sent to patient and physician if requested. (For repeat scans, calcium volume scoring and notation of rate of progression or reversal)
    If claim is submitted to the insurance company and it is denied because it is considered "Not a Covered Benefit" $440
    35% Discount if paid at the time of service (Patient waives the rights to receive Health Insurance Claim Form) $395
    Anyone who thinks those prices are unreasonably high should see prices in the UK where Coronary Artery Scans cost £525.
    However, as it costs me about that to get my car serviced in the UK and there's no guarantee the work won't be done by an untrained lad on a job creation scheme, it's still good value.

  • Paul Kelly - 95.1 WAYV

    11/26/2007 1:28:00 PM |

    Is an EBT scan the same as a CT scan? My understanding is that it's the same thing...only faster. True? Are the levels of radiation the same?

    Thanks!

    Paul

  • G

    11/26/2007 11:16:00 PM |

    Has any had a scan in the Bay Area? I know that Walnut Creek and San Jose offer sites...  Any recommendations?  I'm thinking about getting my dad and husband xmas gifts...  I thought the price was bout $199 but I guess prices are higher now...inflation? being Calif?

    THANKS in advance!

    What is it with all you William/ Bill cardiologists...  all achieving medical miracles in a world of super-sized ego's and Pharma-driven gimmicks...

  • G

    11/27/2007 12:07:00 AM |

    Dr. Davis, You mentioned that for patients with Type 2 diabetes in your book (yes, finally got my hands on a copy! -- will need to order FAR in advance for Xmas gifts this yr! I'm giving the 'gift of life'!!) that reversal is rare?

    Now with so many tools (and the ability for you to post and share your progress) it seems like that is no longer true? Would you say so in your practice? and to what degree at this current time? what if pts are really really extremely aggressive with carbs, exercise and dramatic wt loss?

    BTW, the patient we discussed earlier (it's been about 1 mon now)is now doing substantially better.  He's exerting without angina! THANK YOU SO SO MUCH!! We actually stopped Actos and I think that made a huge difference also. (When combined with insulin, there appears to be a large increase in CHF (although person had no edema, PND or other signs), just shortness of breath with any exertion.)
    We're normalizing the Vit D and I think that has made the h-u-g-e-s-t difference (besides possibly the Actos -- no echo so don't know?). I haven't had a chance to start as many as the other interventions yet but will. He's doing a lot more raw nuts as well (and no wheat). DO you think the omega-6's are bad -- found in wheat, corn products? (I don't recall reading that here yet?) Especially for certain subpops? like high Lp(a) like my friend?

    Other labs have come back. I was wondering if I could get your thoughts briefly?
    CRP 0.5 (yes couldn't BELIEVE it!)
    DHEA-S 275 ug/dL
    TESTOST 440 ng/dL
    lipoprotein(a) 110 (wow)
    PTH 23
    Fructosamine 300 (we're getting there)
    Home glucose averages now 140s (1hour postprandially -- getting better! my goal normal < 120-130)

    Specifically, is there room to go with DHEA (for the Lp(a))? alpha-lipoic acid (not mentioned in book or blog? any experience yet?)  

    (L-carnitine and the Heart Bar are scheduled for his next visit)
    I am so grateful for all your commentary and advice...

  • Dr. Davis

    11/27/2007 12:30:00 AM |

    Thanks, G.

    I don't know much about the San Jose center, but I do know that the Walnut Creek scanner is an EBT device. They are also very interested in prevention/reversal there.

  • Dr. Davis

    11/27/2007 12:37:00 AM |

    The entire vitamin D concept is new since I wrote Track Your Plaque in 2003. Since then, I have seen type II diabetics drop their heart scan scores with addition/correction of vitamin D blood levels.

    For Lp(a), I nearly always try niacin first, then DHEA and/or testosterone as adjuncts. However, there may be little room for much testosterone supplementation, given a "middling" testosterone level. DHEA works better in females, but can still exert some effect in males (using doses of 25-50 mg per day in males). I've been disappointed with l-carnitine's effect, for the most part.

    I've not systematically used lipoic acid. I'm presuming you mean to enhance insulin responsiveness. When I have tried it, the results were small, but only in a few patients.

    Wheat avoidance, vitamin D, and exercise exert enormous effects, as you are witnessing. Keep up the great work with your people!

  • G

    11/27/2007 1:00:00 AM |

    Hi! Thank you for responding! I'm so relieved that your seeing the same progress in Type 2 DM's (and Dr. Blanchet as well)!
    I had thought as much...  I know when you published the book, it was already 'out-dated' by 12-18months, right? Your frustration is palpable but you are so correct, I certainly would not be of such enormous help to the individuals I work with if I hadn't come across your information 6-8wks ago (to share the hopefulness of actual CAD secondary and primary reversal)! Keep up the strong work!
    Regarding lipoic acid, it has been mentioned by people studying longevity (many of course support the same lifestyle changes as you -- the CRON-ers, Bruce N. Ames, etc). It is usually mentioned in conjunction with L-carnitine for mitonchondrial rejuvenation.

    I appreciate the info on the Walnut Creek site! We'll be checking it out! Take care, G

  • larry

    11/27/2007 6:45:00 AM |

    I get more impressed every time I read this blog!

    I am thinking about firing my Cardiologist and would like to know about Heart Scan Centers in Portland, OR as well as a Cardiologist to refer.

    Briefly, my medical history is that I have survived a Stroke in May 2004.

    In 2006, I didn't feel well and went to my Primary Doctor. He did a Nuclear Stress Test in his office. I was advised to not take my Beta Blockers for the test. I experienced a life threatening arrhythmia during the test. I went home and was advised to take my Beta Blocker for another test the next day. This time I was told things were fine.

    Three months later I had chest discomfort which brought me to the ER. No heart attack but sent to a Cardiologist for more testing. Again, round two of the Nuclear Stress Test and was advised not to take my Beta Blockers. I voiced my hesitation. Not being a Cardologist, I proceded to take the test. This time I had V-Tach.

    I have had a triple bypass on my left Coronary Artery and a stent the size of Rhode Island in my right Coronary Artery. Surprizing, no MI at any time.

    I have lost close to 35 pounds since surgery and am an avid bicycler. I have pedalled close to 600 miles during the month of August during lond distance events.

    The more I read about diets and heart disease, it appears to me that the AHA Cardiac Diet is a waste of time.

    Help me, Doc! Point me in the right direction!

  • Dr. Davis

    11/27/2007 12:01:00 PM |

    Hi, Larry--

    For the closest scan center, see our Scan Center listings on the www.trackyourplaque.com website. However, be warned that we rely on people like you to update us and thus the listing is neither complete or up-to-date. (As we grow, we clearly need to hire somebody just to keep this service updated.)

    I would invite you to look at our membership website, www.trackyourplaque.com. At your stage of the game, while a heart scan may or may not be possible anymore, the principles of the program still apply. I would suggest to you that, given what you've told me, the causes of your heart disease have yet to be uncovered. This will be crucial for long-term prevention/slowing/reversal of your disease.

    We are only starting to develop a listing of interested physicians. However, a lipidologist might be someone to look for in your area.

  • larry

    11/27/2007 4:49:00 PM |

    My heart disease was caused by smoking. I stopped smoking in 1993 after a lifetime of abuse. High blood prsseure was the cause of the stroke. My carotid arteries are clear.

    My LDL was 29 after surgery and my HDL was 65. I believe that exercise is key to me, but I must 'feed the machine' that propels me on my bike.

    Thanks for the imput, I will look into it..

  • Dr. Davis

    11/27/2007 10:52:00 PM |

    Don't forget about lipoprotein(a), a very important pattern that is hugely ignited by smoking.

  • Paul Kelly - 95.1 WAYV

    11/29/2007 7:42:00 PM |

    Hi Dr, Davis,

    You wouldn't believe the trouble i'm having trying to get someone to give me a CT Heart Scan without trying to talk me into a Coronary CTA. Every facility I've talked to keeps harping on the issue that calcium scoring only shows "hard" plaque...and not soft. I also had a nurse today tell me that 30% of the people that end up needing a coronary catheterization had calcium scores of ZERO. That doesn't sound right to me. What determines whether or not someone needs a coronary catheterization anyway?

    As always - thanks in sdvance for your response!

    Paul

  • Dr. Davis

    11/29/2007 11:56:00 PM |

    Paul-

    Please see an upcoming Heart Scan Blog on this question. I am embarassed and angered that scan centers dispense such information.

  • Dr. Davis

    12/6/2007 2:21:00 AM |

    Paul--

    A full length report on this topic is on the Track Your Plaque website. I would invite you to take a look. Both devices are reasonable choices for a heart scan, though EBT has less than half the radiation exposure of a 64-slice device.

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    That's probably the best, most concise summary of why heart scanning makes sense that I've ever heard. And it comes from a primary care physician in the trenches. With just a few paragraphs, Dr. Blanchet, in my view, handily trumps the arguments of my colleagues arguing to maintain the status quo of cholesterol testing, stress tests, and hospital procedures.

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