Cholesterol, Fats, Carbs, Statins and Exercise

The following random thoughts are just that - my thoughts, not facts. However, I have provided some selected cites for most of them. If you think I have been a little selective, I agree - I'm human and will spin things my way. So I've also given links to some medical search engines at the foot if you would like to do some further reading. Just one rule: papers funded by pharmaceutical companies, especially statin manufacturers, or written by authors with links to those companies have little credibility with me.

The cites are only representative of a lot of general reading. There are many more supporting papers out there. I am happy to hear from anyone with more specific papers on particular aspects - pro or con.

These thoughts are based on my own reading from many various sources over time. Lately I have found them reinforced in Taubes' book "Good Calories, Bad Calories", but most I had read before that from other sources.

1. Eating excessive carbohydrates leads to high triglycerides. The definition of "excessive" may depend on whether or not the diner has diabetes. Triglycerides are one of the three major reported components of the usual lipids panel, the other two being HDL and LDL. One that we should get but often don't is VLDL, the dangerous one; usually that is estimated by dividing the triglycerides by 5 (in mg/dl). But that estimate is very approximate.

2. LDL is considered by the mainstream medical establishment to be the bad cholesterol and most anti-cholesterol meds target that. But high triglycerides, high VLDL and low HDL are actually the ones we should be most concerned about.

3. The absolute number of our LDL is less important than the specific number of certain components of LDL; the dangerous ones are the small, dense particles. High triglycerides usually indicate high proportions of those small dense particles. Better indicators of our lipids health are VLDL and the apolipoproteins A1 and B.

4. ALL of the foods we eat affect our cholesterol levels. EXCESS of carbohydrates OR fats may lead to dyslipidemia.

5. The past research on the relationship between cholesterol and heart disease is misleading at best. There appears to be shaky support for the hypothesis that lowering cholesterol, particularly LDL, improves overall mortality and even less support for the use of statins to do that.

6. Inadequate dietary fat will lead to low HDL.

7. Exercise usually, but not always, helps increase HDL.

8. A low HDL is a better indicator of future cardiac problems than high LDL and apolipoprotein levels are a better predictor than either.

9. Diabetics should aim for a triglycerides to HDL ratio of less than 3.0 in mg/dl or 1.3 in mmol/l.

10. Cholesterol in the foods we eat such as eggs and seafood has an insignificant effect on the cholesterol in our blood stream.

11. Low LDL is also dangerous and can be related to other problems such as Parkinson's Disease, cancer and other causes of early death.

12. There is growing concern that the over-prescription of statins and limited but alarming research into their side effects needs a lot more investigation.

Putting that all together, I no longer worry about the level of fats in my diet for their affect on cholesterol. I am selective in my choices of oils, but for other reasons such as Omega 3 content or eliminating trans-fats. I also found that reducing carbohydrates reduced my triglycerides as well as my blood glucose levels. I also dropped my statin, lipitor, four years ago.

When you look back through that list, some things stand out to me. If I am going to worry about cholesterol at all, the two things that will improve it most are moderating carbohydrates for better triglycerides and increasing exercise for better HDL. It seems a happy coincidence that those are the same two things that improve my blood glucose levels most. Additionally, inclusion of some additional fats in my menu to replace those carbohydrates may also help increase HDL.

For those interested in further reading to support - or refute - my thoughts here are a few useful search engines: Google Advanced Scholar, Medline and Highwire.

Cheers, Alan

Everything in Moderation - Except Laughter.

Footnote:

Here are some additional references for you in no particular order. Most of these papers and articles apply to more than one of the points above, which is why I found it awkward to include them in the body. The titles tend to give the context.

Effects of a low-fat, high-carbohydrate diet on VLDL-triglyceride assembly, production, and clearance

Effect of Dietary Carbohydrate on Triglyceride Metabolism in Humans

Effects of a low-fat, high-carbohydrate diet on VLDL-triglyceride assembly, production, and clearance

Increased consumption of refined carbohydrates and the epidemic of type 2 diabetes in the United States: an ecologic assessmentEffect of the Magnitude of Lipid Lowering on Risk of Elevated Liver Enzymes, Rhabdomyolysis, and Cancer

Exercise Prevents the Accumulation of Triglyceride-Rich Lipoproteins and Their Remnants Seen When Changing to a High-Carbohydrate Diet

Effects of Protein, Monounsaturated Fat, and Carbohydrate Intake on Blood Pressure and Serum Lipids

Carbohydrate-Induced Hypertriglyceridemia: An Insight into the Link between Plasma Insulin and Triglyceride Concentrations

A Low-Carbohydrate, Ketogenic Diet versus a Low-Fat Diet To Treat Obesity and Hyperlipidemia

Plasma high density lipoproteins HDL2, HDL3 and postheparin plasma lipases in relation to parameters of physical fitness.

Food, Farmers and Factories

When I offer suggestions on foods for newly diagnosed type 2 diabetics on various forums such as the ADA forum or the dLife forum I am occasionally accused of concentrating far too much on blood glucose levels and ignoring other aspects of nutrition. That is not true because I am very aware that our bodies need a wide range of micronutrients, vitamins and minerals for good health. I may post at some future time on that subject in general. I mention it in passing in several past posts such as Analysis of a Day's Meals and Cinnamon, Spices, Herbs and Similar. However, I agree that to me the first priority is to get those blood glucose levels under control. After that has been achieved is the time to fine tune the resulting way of eating for other aspects of good nutrition.

Today I want to look at another aspect of the foods we eat: processing, chemicals and sources.

When they go to the market or, more likely, the supermarket to buy food and groceries most new type 2 diabetics learn fairly quickly to read the nutrition labels to check on the carbohydrate, fat, and protein content of the portions they intend eating. However, I’ve noticed that very few go beyond that label to look at the actual ingredients list.

When you start doing that, it becomes clear that many of the foods in the packets on our shelves have a lot more in them than the foods mentioned on the front of the package.

The first one that stands out to me is trans-fats. Because many countries allow manufacturers to ignore an ingredient below a minimum threshold on the nutrition table you will often find "0 gms" listed for trans-fats but “partially hydrogenated oils” listed on the ingredients list. That means the product contains trans-fats, just less than that threshold for labelling laws. So my first suggestion is to avoid all products which do that. I know of no safe minimum level for trans-fats.

On other ingredients, I have slowly formed the opinion that simpler is better. Every day we see a new scare story on a food additive that is harming us, and every other day we see a refutation of past scare stories and find that foods we thought were harmful are not. It gets confusing, doesn’t it? What is a simple guy to believe?

I am not a chemist, just a type 2 diabetic struggling to find a reasonable way of eating that not only helps manage my blood glucose levels but does not jeopardise my health in other ways. Because I am not a chemist, I err on the side of simplicity. I am a firm believer in applying KISS (keep it simple, stupid) to my food choices.

Allied to that I have absorbed some basic principles from various writers on nutrition, particularly my friend Quentin Grady who is the author of Nutrition For Blokes. Probably the most important one is that there are many different foods, especially certain vegetables, which can provide some important specific benefits; too many to list here. My way of applying that information is to include as wide a variety of fresh vegetables and protein sources in my menu as I reasonably can, with an emphasis on local seasonal produce.

When I started reading the labels on packets more closely I found that I needed a degree in Chemistry to even start to understand some of them. Here are a few examples. As a simple guy I thought the breakfast sandwich I bought on the AMTRAK from DC to NYC was a small bun, with a slice of odd-looking bacon and an egg. Later, with nothing better to do on the train, I read the fine print on the wrapper:

Bacon, Egg & Cheese On A Biscuit
INGREDIENTS:
BISCUIT:
BLEACHED ENRICHED WHEAT FLOUR (MAY CONTAIN MALTED BARLEY FLOUR AND ENZYMES, CONTAINS NIACIN, REDUCED IRON, THIAMINE MONONITRATE [VITAMIN B1], RIBOFLAVIN [VITAMIN B2], FOLIC ACID), WATER, VEGETABLE SHORTENING (PARTIALLY HYDROGENATED SOYBEAN AND/OR COTTONSEED OILS, NATURAL AND ARTIFICIAL FLAVOR, BETA CAROTENE [COLOR]), DRY BUTTERMILK, DEXTROSE, CONTAINS 2% OR LESS OF THE FOLLOWING: SODIUM BICARBONATE, SODIUM ALUMINUM PHOSPHATE, SALT, VITAL WHEAT GLUTEN, SODIUM ACID PYROPHOSPHATE, PRESERVATIVES (CALCIUM PROPIONATE, POTASSIUM SORBATE, SORBIC ACID), XANTHAN GUM.

PRECOOKED EGG PATTY:
WHOLE EGGS, WATER, SOYBEAN OIL, NONFAT DRY MILK, MODIFIED FOOD STARCH, SALT, XANTHAN GUM, NATURAL AND ARTIFICIAL BUTTER FLAVOR (BUTTER [CREAM, MILK], PARTIALLY HYDROGENATED SOYBEAN AND COTTONSEED OIL, SOYBEAN OIL, LIPOLYZED BUTTER OIL, NATURAL AND ARTIFICIAL FLAVORS), CITRIC ACID. PASTEURIZED PROCESS

AMERICAN CHEESE:
AMERICAN CHEESE (CULTURED MILK, SALT, ENZYMES, ARTIFICIAL COLOR), WATER, CREAM, SODIUM CITRATE, SALT, SODIUM PHOSPHATE, SORBIC ACID (PRESERVATIVE), LACTIC ACID, SOY LECITHIN, ARTIFICIAL COLOR.

BACON CURED WITH:
WATER, SALT, SUGAR, SMOKE FLAVORING, SODIUM PHOSPHATE, SODIUM ERYTHORBATE, SODIUM NITRITE. CONTAINS EGG, MILK, SOY AND WHEAT

How did they get all that in that little biscuit? Incidentally, the nutrition table notes 3 gms trans-fat per serve.

Or are you one of the lucky diabetics who can still eat cereal for breakfast? Special K Protein Plus looks good, right? Here is the ingredients list, from the Special K web-site:

Ingredients
WHEAT BRAN, SOY GRITS, RICE, WHEAT GLUTEN, SOYBEAN OIL, WHOLE GRAIN WHEAT, SOY PROTEIN ISOLATE, SUGAR, SALT, HIGH FRUCTOSE CORN SYRUP, MALT FLAVOR, NATURAL AND ARTIFICIAL FLAVOR, ASCORBIC ACID (VITAMIN C), SUCRALOSE, ALPHA TOCOPHEROL ACETATE (VITAMIN E), REDUCED IRON, NIACINAMIDE, PYRIDOXINE HYDROCHLORIDE (VITAMIN B6), RIBOFLAVIN (VITAMIN B2), THIAMIN HYDROCHLORIDE (VITAMIN B1), VITAMIN A PALMITATE, FOLIC ACID AND VITAMIN B12, TO MAINTAIN QUALITY, BHT HAS BEEN ADDED TO PACKAGING.

But I’m being a bit unfair, just looking at breakfasts. How about a simple, healthy, dinner from Lean Cuisine? I looked for a random example, Balsamic Glazed Chicken looked tasty:

Ingredients:
Blanched Enriched Orzo Pasta (Semolina, Niacin, Ferrous Sulfate, Thiamin Mononitrate, Riboflavin, Folic Acid), Green Beans, Cooked Chicken Tenderloin (Chicken Tenderloins, Water, Seasoning (Modified Food Starch, Sugar, Potassium Chloride, Yeast Extract, Dextrose, Spice, Onion Powder, Paprika), Isolated Soy Protein, Salt, Sodium Phosphates), Water, Spinach, Onions, Red Peppers, Yellow Peppers, Dark Sweet Cherry Juice Concentrate, Parmesan Cheese (Cultured Milk, Salt, Enzymes), Almonds, Dark Balsamic Vinegar, Modified Cornstarch, Balsamic Vinegar (Grapes, Invert Sugar), Soybean Oil, Butterfat, Sugar, Garlic Puree, Asiago Cheese (Cultured Milk, Salt, Enzymes), Salt, Brown Sugar Syrup, Enzyme Modified Parmesan Cheese (Cultured Milk, Water, Salt, Enzymes), Whey Protein Concentrate, Spices.

I am not saying any of those ingredients are bad for you. The point is that I am not qualified to know and I don’t want to discover ten years from now that I should not have been eating one of them when I get diagnosed with something nasty.

Here is just one example of late discoveries. Note in those lists that all of them include wheat and soy in one form or another. Now read Jenny Ruhl’s recent blog on that subject: Wheat May Be Sparking Autoimmune Type 1 Thanks to Soy in Our Diets

Do a little research and look up your own examples. Better still read the labels on the packets in your pantry. You will get some surprises.

Over the years I have developed a few general basic principles that I apply when choosing the foods I eat. I don’t get obsessive or religious about it, but when it is reasonably possible I apply these criteria when I am shopping:

1. I choose foods that owe more to the farmer than to the factory for their production.

2. I choose as wide a variety as I can of local seasonal vegetables, when possible, and fresh vegetables over frozen (there are exceptions).

3. I take the time (and my glasses) to read labels in detail. If I don’t know what an ingredient is, I don’t buy that product until I’ve looked it up. Usually I don’t bother to look it up, so that product isn’t bought.

4. For meat, fish and eggs, I choose range-fed over feed-lot, free-range over caged birds, wild fish over farmed.

5. I cook and eat at home more often than out.

6. When eating out I choose restaurants that cook from basics rather than restaurants that re-heat from the freezer.

Those are just the basics, obviously I include other factors such as carb content.

What criteria do you use?

Cheers, Alan
Everything in Moderation - Except Laughter.

Swine Flu, Diabetes and Good Sense

I have become increasingly concerned about the implications of the H1N1, or Swine Flu, epidemic for people with conditions such as diabetes which weaken their immune systems.

I was initially quite dismissive of the danger. I also have hypogammaglobulinemia. I travelled around the world during the SARS scare and wandered places like Cambodia, India, Egypt and Mexico last year without catching anything. Living in a small seaside village I had taken a pretty casual view of the pandemic until it hit my own family members down south in Melbourne. The good news is that they have recovered well, but that tended to grab my attention.

So I checked on some statistics. And I was shocked.

Australians are travellers, both internationally and domestically. Consequently viruses can very swiftly jump between continents and states, city and country. We started with a few minor cases despite fairly strict precautions at airports. Then we had a cruise ship infected which dropped passengers in Brisbane and Sydney. Then it hit Melbourne and spread like wild-fire; but it's not just in the big cities, we have had cases dotted all over, from the bush to the outback.

For Australia the difference between the statistics in May and today, as we passed through our winter, are quite dramatic. These are the official statistics from the Australian Government Department of Health through the Australian winter:
[note: up-dated 11th October - Alan]

_____________Cases____Deaths
17-May-09______30_______1
14-Jun-09_____1515____not given
17-Jul-09_____11962______31
12-Aug-09____28307_____100
17-Sep-09____36210_____172
09-Oct-09____36895_____185

Surprisingly those numbers have not really been making big news headlines in my town. Maybe we have become desensitised to news on subjects like this; I certainly had.

For readers outside Australia this web-site appears up to date and accurate: http://www.flucount.org/. You will notice that although the USA has the worst numbers, those in Australia and South America are disproportionately high on a population comparison. Considering that America has a population of over 300 million and Australia is a little over 21 million this list of the top three is a worry:

Most Infected Countries:
[up-dated 11th October]

United States: 44555 cases, 821 deaths
Australia: 36895 cases, 185 deaths
Mexico: 36593 cases, 248 deaths

A couple of things stand out. The higher proportional numbers south of the Equator indicate that the winter season definitely accelerates the rate of infection. A surprising point in the Northern Hemisphere statistics is the difference in death rate between European countries and North America. It looks like US medical staff would be wise to spend some time chatting to those in Germany and Greece. So would ours. Americans and Europeans should pray that the virus loses its present dramatic ability to spread before the northern winter.

The good news is that it is not as deadly as first thought in the general population; the bad news is that it is rather dangerous for those with reduced immune systems such as people with other illnesses or for pregnant women.

Getting back to diabetes, a reduced immune system can be one of the side effects of our condition. I don't suggest that we should panic but we should certainly be aware of those around us and the risks from this virus.

As a consequence of my hypogammaglobulinemia I have always taken a little extra care with my personal hygiene when travelling. I don't suggest that you need to become as obsessive as Adrian Monk, but there are times when I could be mistaken for him. For example, I never touch any exposed surface in a public lavatory or a doctor's office or reception with my bare skin; whether that is my hands or any other part of my anatomy. I have little habits I have developed for that, such as carrying my own pen for signing forms in the doctor's reception or in a pharmacy. Consider the person who touched that pen before you, and why they may have been seeing the doctor or chemist.

I can't improve much on the excellent advice in this Australian Government H1N1 page for Individuals and households. I suggest you read that and adapt it for your own situation.

Once again I don't think it is cause for panic, just for good sense and caution. It certainly won't stop me travelling. My other affliction, wanderlust, has struck again and we are off to New Caledonia for 8 days on Saturday. I've also bought the tickets to go to South America next March; provided that they'll let me in while this pandemic is happening.

Cheers, Alan
Everything in Moderation - Except Laughter.