The neovascularization mechanism sounds similar to that what causes age related macular degeneration. Carbohydrates from Basmati Rice (especially if refrigerated before eating), Corn, New Potatoes (especially if refrigerated before eating), Sweet potatoes, Beans, Whole fruits etc do not increase the risk factor for coronary heart disease. Wow Nigel, you’re like an argumentative gopher, popping up all over the place, I have to be alert to attend to all your queries – but I do enjoy them immensely! If fasting insulin level is a major causative factor for atherosclerosis, the best plan of action is to reduce it, amirite? You could also direct treatment to lower ApoB specifically with a low fat diet or a statin while ignoring the high insulin level. A bit of cognitive dissonance going on here, by recommending a low carb high fat diet to raise LDL-P, and then giving a stain to counter the rising LDL-P.
I think that we are all heading in the right direction here, but online, most feel the need to draw lines in the sand.
I’m concerned about people (I know of two) eating humongous amounts of butter and encouraging others to do so, glossing-over any adverse effects. A bit of cognitive dissonance going on here, when a low carb high fat diet will raise LDL-P, yet giving a stain to counter the rising LDL-P certainly confuses the brain (at least mine).
We’re mulling over a hypothesis that may very well encompass all of your points and more Charles – watch this space!
Or do we assume the low serum level is better, because we have no way of testing the tissue level? For example, there’s a fascinating use, in the works of Dr Joseph Kraft, of tinnitus as a sign of hyperinsulinaemia. Also, past generations eating dripping and flour had lower rates of metabolic disease than today, with oil and more sugar, but some individuals were susceptible to the starch plus fat combo. Indians eating ghee at 20%E SFA had low rates of DM2 and CVD, but they didn’t eat beef. You might be interested in the posts labelled NASH 1-5 where I started (from a position of some scepticism) to see a role for dietary cholesterol in disease.
How else can you explain your co-worker chomping on a low-fat neon pink cloud of cotton candy and sucking down a Coke while exclaiming, “Don’t you know avocados are high in fat?” as you’re eating your chicken, spinach, and avocado salad with olive oil dressing.
I’m not advocating bacon and salami with two slabs of lard, but rather good sources of fat, such as avocados, walnuts, coconuts, olive, and fatty fish like salmon. I thought we’d gotten over this nonsense of avoiding fat, but lately I’ve seemed to be surrounded by anti-fat proponents.
A few years ago there was a paper published that compared five different studies to figure out what we really know about low-fat and low carbohydrate diets (1). Most studies of low-fat diets allowed up to 30% of daily calories to come from fat, with one study having a very low-fat diet (<10% daily calories from fat).
After comparing and summarizing five studies with 447 dieters, the conclusion was that low-carbohydrate, non-energy-restricted diets are at least as effective as low-fat energy-restricted diets after 1 year. Translation: If you eat vastly fewer carbs, you don’t have to pay all that much attention to your total calories to lose as much weight as you would if you counted your calories and your fat.
This week I review a brand new study that compared low-carbohydrate and low-fat diets for two years.
Half the volunteers were assigned to the low-fat diet (154 volunteers) and half were on a low-carbohydrate diet (153 volunteers). Volunteers in the low-carbohydrate diet group were told to eat 20 grams of carbohydrate (which is 80 calories) a day, all from low-glycemic index vegatables. No fruits, no breads, no pasta, no high glycemic vegetables (carrots, corn, potatoes, squash, sweet potato) were permitted, but there was no focus on reducing calories. Female volunteers were told to eat between 1200-1500 calories a day, while the men were to eat 1500-1800 calories a day. Most diet studies don’t have any exercise in them, so you end up getting people losing 10 pounds (about 5 kg) in a year.
In this study, the volunteers did some exercise that started in week 4 with 4 sessions per week. There were check-ins 3 months, 6 months, a year and two years into the diets to check body composition (percent bodyfat), blood work, blood pressure and overall weight. During these get-togethers the group talked about behavioural treatments like self-montoring, what to do when you slip up, and how to deal with temptation.
From 6 months onward, there was no real difference in body weight lost between the two diets. In the first 6 months, the low-carb dieters had decreased cardiovascular disease risk with lower triglycerides, VLDL, and higher HDL, with the only increase risk factor being increased LDL. Meanwhile, the low fat dieters didn’t see as many improvements in triglyceride nor VLDL. After a year, though, triglycerides and LDL were the same for both groups, and by 2 years VLDL was the same for both groups. Hmm, so after 2 years on low-carb or low-fat diet the groups had the same weight loss, triglyceride, VLDL and LDL improvements, so it’s a tie! Well, after 2 years the low-carb diets had higher HDL, which means that the low-carbohydrate diet in this study was marginally better in decreasing cardiovascular disease risk. Sometimes if you’re going to do a two year study you throw in a few more tests just because… well, it’s two years and you might as well get as much info as you can.
There was no difference in hip bone and spine density between dieters, and the exercise program didn’t improve densities after 2 years either. The diastolic (the second lower number from your doctor) in the low-carb dieters was lower than in the low-fat dieters after the 2 years. Two years is a long time to be in a study and even if you’re not in a study, it’s important that people stay on a diet to be successful. Even though many critics of a low carb diet say that people can’t stay on it long term, in this two year study there was no difference in how many people dropped out between diet groups.
The next argument was that any weight loss from low-carb diets would be loss of muscle and liver carbohydrate (glycogen) and water, so there was no long term weight loss. Yet another argument against low-carb diets was that people couldn’t stay on them long term because they were too restrictive, but in this study there was not much difference in dropout rates between low-fat and low-carb dieters.
The last cry from the experts was that low-carb diets wouldn’t improve cardiovascular disease risk factors, like LDL cholesterol, HDL cholesterol and triglycerides. Both diets end up pretty much the same in terms of weight loss and health, with one exception: HDL cholesterol.
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Whenever you hear someone talk about cholesterol, it's always about the "good" high density lipoprotein (HDL) and the "bad" low density lipoprotein (LDL) types. While HDL and LDL are still lipids that your health professional will continue to monitor, scientists now understand that those two major lipoprotein measurements can be broken down into many smaller measurements. You probably already know that it's good to have high levels of HDL cholesterol in your blood, because it helps transport LDL cholesterol out of your body.
Those with a "3" in their name are very small particles, while those with a "2" are larger and full of cholesterol. You can find out your cholesterol subgroup numbers through a simple blood test, though not all doctors regularly include this screening. Although I can think of many more entertaining hobbies it is fascinating to watch Ivor use his engineering skills, calculating his way through piles of evidence to solve the nutrition, cholesterol and health equation.
To date ONLY a nutritional approach, specifically a well formulated low carb high fat (LCHF) diet reduces risk by raising HDL-C, and lowering triglyceride, consistent with the favorable markers observed in the original Framingham study.
Mainstream needs to better understand nutrition including whole foods diets and how to critically look at the evidence (or lack of it). Neovascularization of the coronary tunica intima, diffuse intimal thickening (DIT) is an interesting mechanism describing further insult to the blood vessel. Increasing sugars % (also possibly amylopectin & maltodextrin %) increases the % of pattern B LDL which, by implication, increases the risk factor for coronary heart disease. It’s impossible to tell on the above graph, but I think that the risk of heart disease after 4 years increases by the same proportion with increasing LDL, whatever the HDL level.
Jeff Volek plotted all the data sans logs and it was very informative in this format, and communicable to the moderately technical audience – and indeed I borrowed his summary for the talk. Unfortunately this is what most of my doctor colleagues frequently do because insulin is usually not in their radar zone unless a sky high blood sugar is staring in their face. Dayspring promotes low carb there are some he also recommends cholesterol lowering therapy if the LDL-P goes way up. Dayspring likes low-carb, low-fat to address LDL-P, makes more sense, however he understands high-fat.
Maybe it is the nature of the beast, however I do not have this luxury when it comes to seeing patients. Dayspring promotes low carb in some, he recommends cholesterol lowering therapy if the LDL-P goes way up.
I agree that statins have been show to reduce risk (mild at best for primary prevention) so could it be that low carb high fat diets and statins operate via mechanisms independent of cholesterol? You may have less in your serum (at about 7%E PUFA, once LDL-R increases) but you will have more in your body. I guess everyone has an optimal carb intake that they need to work out for themselves, using TG-HDL ratio as a proxy for IR seems useful, but most people with IR will have other symptoms to judge by.
Weight and metabolic outcomes after 2 years on a low-carbohydrate versus low-fat diet: a randomized trial. Asparagus, broccoli, Brussel sprouts, spinach and celery are low glycemic index vegatables (under 20). Both groups slowly regained weight to end up with a total of 7 kg (15.4 lb) lost after 2 years in both groups. And low-carb dieters had lower systolic blood pressure (the first bigger number from your doctor) in the first 3 months. Low-carb and low-fat groups had a 42% and 32% drop out rate (though different, not enough to be considered statistically different). In this study, when volunteers were eating the least amount of carbohydrates (the first 3 months) they had the lowest levels of VLDL cholesterol and triglycerides, while having increases in HDL cholesterol — all of which reduce cardiovascular disease risk. HDL cholesterol was higher in the low-carbohydrate group, so you have a good argument to go a low-carb diet to improve your blood lipid profile.
Effects of low-carbohydrate vs low-fat diets on weight loss and cardiovascular risk factors: a meta-analysis of randomized controlled trials.
And it's those subgroups that now provide a far more accurate picture of your cardiovascular disease risk. But you probably don't know that 14 different subgroups of HDL have been identified with names like HDL 2a, HDL 2b, HDL 3a, and so on. These larger ones, especially the 2b, are intriguing because they appear to be responsible for ridding your body of 80 percent of its LDL cholesterol. Those labeled I, IIa, and IIb don't appear to be much of a concern because they're very big particles and can't fit into crevices in arteries, and thus lead to an increased risk of cardiovascular disease. However, keep in mind that specific treatments for improving your subgroup numbers don't yet exist beyond what you already can do to raise total HDL and lower total LDL. He says that there is a discordant relationship between inflammation (use of NSAIDS) and atherosclerosis.
If insulin remains low <12 then ApoB concentrations again become mostly irrelevant, quite similar to the relationship between LDL and HDL. However, addressing lower insulin levels yields a much greater global benefit including CV risk reduction, improving diabetes, obesity, etc… I choose to focus on insulin levels.
It may be that factors producing MetSyn create a scenario in which dietary cholesterol is mismanaged, and the results are seen in amounts and behaviours of tissue cholesterol, not necessarily serum lipids. Do you think blood lipoprotien measurement can provide clues as to what is going on in the cells?
Sigurdsson MD 80 Comments I find it extraordinary how carbohydrate restriction is repeatedly rejected by the medical community as an alternative approach for obesity, the metabolic syndrome and type 2 diabetes.Obesity has reached epidemic proportions in many countries around the world. As yet there are no set guidelines for ideal levels of HDL 2b, however, studies suggest there are cardiovascular benefits when blood levels of HDL 2b comprise at least 20 percent of total HDL in men and at least 30 percent in women. However those labeled IIIa, IIIb, IVa, and IVb are much smaller and can fit into tiny crevices, possibly increasing the risk of cardiovascular disease. Trade in unhealthy saturated and hydrogenated fats found in butter, stick margarine and animal fat for healthy unsaturated and omega-3 fats found in canola oil, olive oil, nuts and salmon. Glad to have all the engineers (Nigel and Ivor) commenting, just to verify the statistical trickery. As the lower plots are actually rising at a similar rate to the upper plots, the risk of heart disease after 4 years would become significant at higher LDL values. Daysping believes that too much cholesterol is dangerous regardless of diet, including LCHF. I have even heard Peter speak at our physician obesity conference last year and the offspring cohort chart was in his PowerPoint.
Diabetes and other obesity related disorders have become increasingly common.Public health organizations and medical societies usually advocate a low-fat, high-carbohydrate, energy-deficient diet to manage weight. Scientists are not yet able to specify a lipoprotein level of these subclasses that would be considered harmful.
NSAIDS do increase the risk for cardiovascular events, but then maybe all inflammatory pathways are not the same. Everyone is different and we track progress using the tools available today in clinical medicine. Although we do not have a baseline LDL-P or apoB, how can one go from a perfect lipid profile to a seeming very high risk one in a very short period of time?
Nonetheless, clinical experience and scientific studies indicate that other approaches may be more effective.The main argument against carbohydrate-restricted, high-fat diets are concerns regarding their long-term safety. I don’t try to force the issues, but try to keep all well informed and make decisions together based on what info is available today.
I don’t try to force the issues, but try to keep all well informed and make decisions together.
Most such diets encourage increased consumption of animal products and therefore they often contain high amounts of saturated fat and cholesterol. Dr Dayspring summarizes it well in the last paragraph from the link you provided, that there is still much unknown!
It has been suggested that this may cause unfavorable changes in blood lipids and thereby increase the risk of heart disease.
It has been reported for years that diets high in saturated fat raise TC and LDL-C and diets with reduced saturated fat lowers them (Evidence Level IA in NCEP ATP-III). High intake of protein can result in large amounts of calcium in the urine, and loss of bone mass. Of course we now know what any therapy does to CV outcomes likely has little if any relationship to what that therapy does to HDL-C but the story that raising LDL-C is associated with or causal of atherosclerosis is widely accepted. In fact, low carbohydrate diets have demonstrated their therapeutic value in numerous studies, and often outperform other diets when comparisons are made. Some diabetic associations have accepted moderate carbohydrate restriction as an alternative approach for weight loss in type 2 diabetes.Doctors, cardiologists included, commonly recommend low-fat, high-carbohydrate diets to patients with heart disease, as well as for cardiovascular prevention.
The low-fat, low saturated fat, low cholesterol, high-carbohydrate approach is recommended for all. Extensive research indicates that this diet lowers blood pressure and cholesterol, and is associated with lower risk of several diseases, including heart disease. Furthermore, it was recently suggested that the DASH diet may be used for weight loss as well. For years I have struggled with the low-fat, high-carbohydrate, energy-deficient dietary approach to manage these conditions. Often weight loss is limited and not sustained, and there are very limited improvements in metabolic function. However, I might admit the lack of result is more often due to lack of compliance than something else. However, I will try to convince you that the available data does not support the conclusion that low-carbohydrate diets are less safe than other dietary approaches for people who are obese, overweight or suffer from the metabolic syndrome.The initial recommendations to avoid saturated fat and cholesterol were based on observations from epidemiological research. In fact, replacement of saturated fats with refined carbohydrate can worsen blood lipids when insulin resistance is present, by increasing triglycerides, the number of small LDL particles, and by decreasing HDL-cholesterol.
In this large prospective observational study, no trend towards higher cardiovascular event risk for women or men with higher total or saturated fat intakes, was observed.
Furthermore, negative effects on blood lipids with low-carbohydrate diets were not observed in these studies and markers of the metabolic syndrome were generally improved.Most of these randomized trials are short term studies. However, they did not find an association between low-carb diets and the incidence of, and mortality from cardiovascular disease. The authors acknowledge that their analysis is based on limited observational studies, and that large-scale trials on the complex interactions between low-carbohydrate diets and long-term outcomes are needed.
It is also necessary to point out that there was a substantial difference between studies, regarding both study design and definitions.
Such heterogeneity may make meta-analysis problematic.A Few Final WordsThere are many different versions of low-carbohydrate, high-fat diets.
For a patient with heart disease or someone with elevated cholesterol, I usually recommend monounsaturated fat and polyunsaturated fats rich in omega-3. The medical community, which I am a part of, accepts that drugs that lower cholesterol, and slightly reduce the risk of heart disease (although having considerable side effects, among them increased risk of diabetes) are given to 25 percent of adults in many countries around the world.
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