Understanding Carbohydrate and Lipid Health

Do high-carb diets increase triglycerides? And are elevated triglycerides always a bad sign for cardiovascular health? We'll be answering these questions in today's episode of the Energy Balance Podcast, a podcast where we explore health and nutrition from the bioenergetic view and teach you how to maximize your cellular energy to maximize your health. In today's episode, I'll be discussing what causes increased triglycerides on a high-carb diet I'll also discuss whether the small, dense LDL particles are really the culprits behind cardiovascular disease. I'll go over how lipid values on a high-carb diet compare to a low-carb diet, including lean mass hyper-responders. I'll also discuss whether low HDL levels will increase your risk of heart disease and whether high triglyceride levels cause heart disease. As always, to check out the show notes where I'll reference the studies, articles, and anything else that I mentioned throughout this episode, head over to jfeldmanwellness.com slash podcast. And with that... let's get started. All right, so this is going to be a solo episode where I'm going to be discussing different aspects of lipid panels and different impacts on lipid values. You know, we're talking triglycerides, HDL, LDL, and some other kind of intricacies there when it comes to a high-carb diet. I'll also be comparing this to a low-carb diet and also... comparing this to a state of insulin resistance and what's going on physiologically, and then also what this all means when it comes to cardiovascular health and general metabolic health. And there's a number of reasons why I wanted to discuss this. For one, it's something that clients and members of my programs mentioned quite often, which is they see certain changes in their lipid values, sometimes increases in triglycerides, sometimes decreases in HDL, and they're normally concerned about that or different practitioners that they see are concerned about that because of the... potential implications there. So I wanted to touch on it from that standpoint. And then also because it's a concern when it comes to a high carb diet. I mean, there's a number of concerns out there considering that much of the health world is, or alternative online health world is skewed toward a low carb diet. So some of the concerns when it comes to going toward a high carb diet are things like increased triglycerides. So I wanted to discuss that and whether it's really a concern. And to start... You know, it's worth mentioning that in kind of the general Western population, high triglycerides and low HDL are typically indications of metabolic syndrome, insulin resistance, and therefore also cardiovascular disease. You know, they're indicators and markers that are associated with those different chronic health issues. And of course, those are associated with pretty much every chronic health issue, all sorts of different symptoms, you know, pretty much anything you can think of there. So generally not a good sign. And generally the reference range for triglycerides goes up to around 150 milligrams per deciliter. And most practitioners, most people, especially in the alternative health space, would like to see that value quite a bit lower than 150 milligrams per deciliter. Often they'll say below 100 and even lower, often as low as possible. And that's also something that's generally not ideal. So we can come back to that a bit later. And it's also worth mentioning when we're talking. kind of mainstream and different lipid markers, that this is also very much the case with LDL levels, where LDL levels, when they're elevated, they're typically associated with metabolic syndrome, insulin resistance, and cardiovascular disease and tons of other negative outcomes, right? Generally not something we want to see. And this holds true when people are on a kind of standard Western diet. And I see this quite a bit. If you've seen people eating a standard kind of typical Western diet. And they have elevated LDL. It is very clearly associated with worse health. This is shown very clearly in the literature. And I've seen it quite a bit in people who are not as health conscious and coming to me for help. And when we see elevated LDL, it tends to be correlating with a lot of negative health outcomes, a lot of other chronic health issues. But we discussed in a couple of episodes, which I'll link to in the show notes, regarding lean mass hyper responders and the lipid energy model. We discussed in those episodes that we have to consider the context when we're interpreting a marker like LDL. And for someone who's not on a Western diet, but instead is maybe, let's say, on a low-carb or ketogenic diet, LDL values can mean something entirely different from what they indicate in kind of a mainstream or Western average population that's not on a ketogenic diet. And that's because LDL itself is a marker. It's an indicator. And we have to interpret it. We have to understand what is actually. indicating, to be able to interpret and apply it and understand if it's actually going to mean the same thing in different circumstances. And so we're going to be doing the same thing today, but looking at some of the same markers, LDL, HDL, triglycerides, but in the context of a, I'll call healthy high carb diet, a bioenergetic diet, which it's worth mentioning when we're comparing this to a Western diet, there are a lot of differences. For one, Western diets tend to be pretty... I mean, they're kind of moderate carb, moderate fat. They're generally not at all low fat. They generally aren't even that high in carbs since so many of the standard processed foods are high in both carbs and fats. Of course, they're very much reliant on refined grains, a lot of processed food with a lot of very high PUFA foods like the seed oils that obviously are being discussed quite a bit. So. What I'm talking about here is a diet that is very different than that, of course. So with that in mind, let's dig into what actually goes on on a high carbohydrate diet in terms of the lipids, what's going on physiologically, and then what it actually indicates and whether or not it's actually a concern, whether or not it's actually a problem. So we're actually going to start here by looking at the lipid energy model. We're looking at a graphic here that We looked at in the lean mass hyper responder series, a kind of two-part series, where we're seeing what's going on physiologically that's affecting the different lipid values in the blood. And so in this graphic, we can see a couple of things. And this is a graphic, again, showing what's happening on a low-carb ketogenic diet in someone who is generally insulin sensitive and generally healthy. And we kind of have a number of steps here going in order. So the first couple steps are that there's a lack of carbohydrates, which leads to a lack of glycogen storage in the liver. It leads to generally low insulin levels and also generally high levels of stress hormones, glucagon, epinephrine or adrenaline and cortisol. Those hormones then trigger what's called hormone sensitive lipase, which causes the release of fat from the fat tissue into the blood in the form of. free fatty acids. After that, the next step is that the liver will, I mean, a lot of things will happen with the free fatty acids. They'll get picked up by different tissues and used as fuel, but they'll also be picked up by the liver and they'll then be repackaged into triglyceride form and put into lipoproteins called VLDL. And that VLDL will then be released from the liver containing a number of things, but including those triglycerides. And then when they're in the blood, uh, they... We'll get acted on by what's called lipoprotein lipase or LPL. This is inside the peripheral tissues and will basically take the triglycerides up from the VLDL. So the VLDL is basically a carrier for triglycerides, among other things, you know, cholesterol, esters and things like that. And when the peripheral tissues are using a lot of fats, they want to pick up those triglycerides from the VLDL and use them to convert to energy. And so they'll express higher levels of LPL, lipoprotein lipase, to pick up those fats from the VLDL, the triglycerides, which then converts the VLDL into LDL and HDL. And so this is what's generally responsible for the lipid values that are seen in lean mass hyper responders on a low carb diet, where you see low triglycerides because the amount of VLDL is generally low. There's not a lot of triglycerides being carried through the blood. You tend to see high LDL and high HDL as a result of having had a lot of ELDL that's been converted to LDL and HDL by dropping off the triglycerides. And yeah, you generally see those three things when we're looking at lipids, low triglycerides and high LDL and high HDL. So we discussed this in those previous episodes, but there are some potential concerns here, not necessarily just because of some correlation between LDL and cardiovascular disease. but rather because there are some negatives to the hormonal state that is responsible for this phenomenon, as well as the metabolic state that's responsible for this phenomenon. So I don't think this is necessarily ideal, but again, it's not just because of some kind of outdated assumption that any change in LDL is directly going to be correlated with change in cardiovascular risk or something like that. So if we then take this kind of same diagram, the same concept, and apply it to what's going on on a high-carb, low-fat diet, or at least lower-fat diet. And in someone who's insulin-sensitive, we see essentially the opposite going on here. So what we see is there's adequate glycogen, adequate carbohydrates, and we generally have low levels of the stress hormones, low levels of glucagon, adrenaline, and cortisol. This leads to a lack of HSL, hormone-sensitive lipase. which leads to a lack of free fatty acid release. So we generally have lower levels of free fatty acids, which leads to less uptake of those free fatty acids at the liver, which then leads to generally less VLDL secretion from the liver, or at least about the same as if you were on kind of a normal diet, but less relative to the lean mass hyper responder phenotype. Now, despite there being less LDL secreted from the liver compared to this phenotype, we also have decreased... removal of the triglycerides from the LDL. And remember, that's happening through LPL, or lipoprotein lipase. And that lipoprotein lipase is dependent on what sort of fuel the peripheral tissues are using. Are they mostly using fat or are they mostly using carbohydrates? If they're mostly using fat, they're going to want to take up a lot of that triglyceride, and so they're going to have elevated levels of LPL. In this case, when we're talking about a higher carb, lower fat diet, we're going to have decreased levels of LPL because the general peripheral tissues... are using more carbohydrates and less fat. As a result here, we see reduced triglyceride clearance from the blood, reduced triglyceride removal from VLDL, which leads to generally higher levels of VLDL and triglyceride-rich VLDL, which leads to higher levels of triglycerides in the blood. It also generally leads to lower levels of HDL and LDL because you don't have much turnover conversion from VLDL to LDL and HDL. You don't have as much transfer there. So as a result... you see basically the opposite presentation is what you see in lean mass hyper-responders, which is you tend to see higher levels of triglycerides. Again, they aren't always out of range, but generally higher and lower levels of HDL and lower levels of LDL. Now we're going to talk about the implications of this and whether or not this is actually something that's concerning, but it is worth mentioning that this is very different from what's going on with the lipids in the case of insulin resistance. In the case of insulin resistance... There are parts of both of these mechanisms, both of these pathways, both the lean mass hyper-responder phenotype, and we'll call it the high-carb, low-fat phenotype. There are aspects of both of those happening at the same time in a way that's pretty dysfunctional and leads to a similar set of lipids as you might see on the higher-carb diet in some ways, but also similar to what you're going to see on a low-carb diet in some ways. So it's a bit of a mix of both, and it really comes down to... insulin resistance issue, which is a metabolic issue going on inside the tissues where they're not using glucose well. I discussed this on quite a few prior podcast episodes, so I'll link to those. But I did want to mention before we jump into what's actually happening in the insulin resistance state, that when it comes to creating a diet to help you improve your cardiovascular health and metabolic health, there's a lot of conflicting information out there. You might have in the past been tempted to try low-carb keto. Maybe you've tried those things, as many of us have. Or maybe you're seeing a lot of other conflicting health information out there. But that's why I've created the Energy Balance Food Guide, which is going to help you determine exactly what to eat to optimally support your metabolism and help you lose weight, improve your digestion, get amazing sleep, boost your energy, improve your cardiovascular health, and so much more. It's a one-page infographic that organizes foods on a spectrum based on how effectively they support your metabolism. And it also is a separate spectrum that adjusts the scale for you in the case that you're dealing with various digestive symptoms. So, The food guide makes it extremely easy to get started with a bioenergetic approach to optimizing your health. So head over to jfeldmanwellness.com slash guide to download your free energy balance food guide. So with that, let's dig into what's going on in terms of the lipids and the underlying metabolism in a state of insulin resistance. So in a state of insulin resistance, there are there's normally adequate levels of glycogen, but because the. peripheral tissues, because generally in the body there are metabolic issues, we're not using that glucose very effectively. And as a result, we tend to see elevated levels of stress hormones, namely glucagon, adrenaline, and cortisol. Now these increase the activity of hormone-sensitive lipase and therefore increase the release of free fatty acids. So we see the same elevated free fatty acids that we would see on a low-carb diet. And also similar to a low-carb diet, Those free fatty acids are going to be taken up by the liver and packaged into triglycerides. Now, in this case, this is largely happening because there's normally metabolic dysfunction going on at the liver, and it's not properly metabolizing carbohydrates or fats, really. And as a result, again, it's packing up the free fatty acids into triglycerides. It's going to be storing some of them, which we discussed in the fatty liver series. So I'll link back to that, but it's also going to be sending those. those free fatty acids out in the form of triglycerides being carried by VLDL. So you see that same increase in VLDL and increase in triglyceride synthesis being in this state of insulin resistance. So that part again is similar to what you would see on the low carb diet in the lean mass hyper responders. You see the increased triglyceride synthesis and the increased VLDL. Now, in this case, there are going to be higher levels of lipoprotein lipase because the Peripheral tissues are generally relying on fatty acid oxidation, and that will lead to some turnover of VLDL into LDL. But there's not as much or as elevated levels of lipoprotein lipase, and that's because the peripheral tissues are generally full of fuel. They're not effectively using that fuel very well. Their metabolism is pretty deranged. And so as a result, you're not going to have enough. triglyceride uptake from the VLDL, and you're going to have a lot of triglyceride release through VLDL from the liver. And so that tends to lead to not only elevated levels of the LDL, as I just mentioned, but also elevated levels of VLDL, and as a result, also elevated levels of triglycerides. So in this case, we're seeing a combination of multiple things happening. We're seeing increased VLDL and increased LDL, and also, therefore, increased triglycerides. So we're seeing pieces of both sides here, both the high-carb side and the low-carb side. And— It's indicating something completely different because the excess triglycerides is indicating a number of things. It's indicating the excess stress that caused the increased free fatty acids. It's also, along with that, indicating the mitochondrial dysfunction going on at the liver, which is causing those free fatty acids to be converted to triglycerides and taken out as VLDL. And then we're also seeing this indicate peripheral mitochondrial dysfunction, issues with energy production throughout all the tissues, which is what's leading to basically a state of excess lipid where... And the tissues are not able to effectively use fuel. And so there's a lot of there's basically excess fuel or in a state of excess fuel because we're not effectively using it. And that's going to lead to the elevated triglycerides in the blood. And again, we're also seeing the elevated LDL in this case. Now, one thing that is not mentioned as much here, I'm just going to touch on it real briefly and we'll come back to it later. But that's going to be LDL size. So. One thing that's often discussed in especially the alternative health world is this idea of what are considered large fluffy LDL particles and small dense LDL particles. The general idea is that the small dense ones are more atherogenic, more contributory to atherosclerosis, whereas the large fluffy ones are generally benign. And we'll again, we'll come back to this later on whether that implication is actually the case. But. In general, the amount of small dense LDL particles is going to be the result of how many triglyceride rich VLDL and LDL particles there are. So when you have a lot of that VLDL staying around in the blood, you're typically going to have higher levels of the small dense LDL. And this is going to happen in the case of insulin resistance. And it also generally will happen or will trend in that direction in the case of a high carb, low fat diet. And again, we'll come back to that in a little bit. So this is so that's. kind of the overview of what's going on in this case, what's responsible for the different lipid values we might see in different metabolic states. But that leads us to the question of what does that mean? What are the implications here? Should we be concerned about cardiovascular risk or the metabolic state that's induced by a high-carb diet especially? We already talked about the lean mass hyper-responder phenotype and why the elevated LDL is so important. Low triglycerides, elevated HDL isn't something that's particularly concerning from a cardiovascular standpoint. From a metabolic standpoint, I do think there are concerns there. Again, I mentioned those in that prior episode. But in the case of the high-carb, low-fat diet or lower-fat diet, we want to consider whether the elevated triglycerides, lower HDL, and generally a bit lower LDL, at least definitely lower than on a low-carb, high-fat diet. but potentially higher amounts of the smaller dense LDL levels. We're wondering if those few things are going to be driving negative health outcomes. And again, it's going to be a situation where we need to consider the larger context and what they're actually indicating here. And we talked about this again in those prior episodes. If these markers are not just markers, if they're actual independent drivers of, let's say, cardiovascular risk, then, you know... You can be pretty confident that it's not going to be ideal to see either elevated levels of triglycerides or elevated levels of LDL. But what we discussed there is that that's not actually the case. These are just markers. They're just indicators. They have certain associations, especially in the Western world on a Western diet. But that doesn't actually mean that they're independent risk factors, so to speak. Now, hypertriglyceridemia, like excess triglycerides. is sometimes considered to be an independent risk factor for cardiovascular disease in some studies, but much like LDL, which is also considered that way in many studies, a lot of things are not adequately controlled for. And in the case of excess triglycerides, one thing that's definitely not adequately controlled for is insulin sensitivity. So we're going to dig into that now, whether the lipid values that you might see on a higher carb diet are just markers or what they actually reflect about the underlying context and whether. This is actually something we want to be concerned about in terms of cardiovascular disease risk or metabolic syndrome or anything else along those lines. And so we're going to be digging into a study here titled, An Elevation of Triglycerides Reflecting Decreased Triglyceride Clearance May Not Be Pathogenic, Relevance to High Carbohydrate Diets. So they mentioned a number of things here. We're going to start with triglycerides. So the first things that they mentioned here, or at least the first things we're going to highlight here, they state, the researchers observed that endothelium-dependent vasodilation was severely impaired relative to the control group in the hypertriglyceridemic subjects who were severely insulin resistant, but not in those who were only mildly insulin resistant. So again, to make that clear, they were looking at subjects with high levels of triglycerides. And the ones who were severely insulin resistant, the function of the endothelium of the blood vessels, essentially, was severely impaired in the people who had high triglycerides and were severely insulin resistant. The people who had high triglycerides and were mildly insulin resistant, there was no impairment in the endothelium-dependent vasodilation, or basically just the function of the blood vessels. So that's the first thing they state here. They then state, this finding supports the conclusion that insulin resistance syndrome rather than hypertriglyceridemia per se, mediates the endothelial dysfunction and increased coronary risk associated with increased triglyceride levels. So they're just touching on one study here, but again, what they're saying is that basically the high triglyceride levels are just generally an indication of insulin resistance, but if the insulin resistance is not there, and again, insulin resistance just being a global state of impaired glucose metabolism or just generally impaired metabolism, but... Glucose being the more sensitive one is really the important thing here. So with insulin resistance being a state of generally impaired glucose metabolism, that's responsible for any increase in coronary risk and endothelial dysfunction rather than the triglycerides themselves. They then state another relevant study was published by Cho Wenchik et al. These researchers assembled a group of severely hypertriglyceridemic patients with an average triglyceride level of 1914 mg per deciliter. characterized as Fredrickson type 5, in whom a marked deficit of lipoprotein lipase, or LPL, activity, rather than insulin resistance syndrome, appears to be primarily responsible for the elevation of triglycerides. So again, just to make this clear, they're talking about a group of people that have a major deficit in LPL activity, and so they have extremely high triglyceride levels. And so we know that this is a state that's, you know, you're not seeing these massive levels of triglycerides just from insulin resistance. This is due to an issue with the lipoprotein lipase. They then state, forearm blood flow responses to infusions of acetylcholine and of nitroprusside were measured in this group and in a set of normal lipidemic gender-matched controls. The responses of the two groups did not differ. So basically, if you have extremely high triglyceride levels, 1900 milligrams per deciliter, in this case, that was not due to insulin resistance, there was no difference, basically, in terms of the blood flow response in terms of circulation and endothelial function between that group and a group with normal levels of triglycerides. And again, what this indicates is that if it's not insulin resistance causing the elevated triglycerides, they themselves are not actually a concern. All they are in most cases is a marker of insulin resistance, again, a marker of poor glucose metabolism. They alone are not an independent driver of heart disease or metabolic syndrome. They then go on to talk about this in terms of the size of LDL particles. Remember I was saying that on a higher carb, lower fat diet, you might tend to see smaller, more dense LDL particles. And they state here, might it not be the case that small LDL particles are just functioning as a marker for insulin resistance syndrome, which is the real mediator of the associated risk. The prospective Quebec cardiovascular study has generated data consistent with this interpretation. Thus, when they examined individuals who had a moderate level of circulating LDL particles, LDL peak particle diameter had no influence whatever on coronary risk. So again, just to make that clear, in people who had moderate levels of circulating LDL, so they still had a decent amount of LDL, it just wasn't elevated. The diameter, the size of the LDL particles had no influence on heart disease risk. They then go on to say, in individuals with an elevated number of LDL particles and small LDL particle diameter, a six-fold increase in risk was observed. Arguably, this reflects the joint impact of down-regulated LDL receptors and insulin resistance syndrome. If small LDL particles were indeed uniquely pernicious as mediators of endotheliopathy, it is hard to see why LDL size did not matter in subjects with normal levels of LDL particles. So again, we're talking about a very parallel situation here. In insulin resistance, in most cases, you'll see elevated levels of LDL particles. And in that case, if you see elevated levels of LDL number and they're small, then there seems to be an increased coronary risk. Whereas if you have, quote, normal or moderate levels of LDL and they're small, there's no increase in risk. And if it was just the small LDL particles on their own, that was the risk factor or the driver of the state, you would see it in both cases. The higher or the smaller your LDL particles were, they increase your risk regardless of which group you were in. Now, we also know, based on what we discussed in the lean mass hyper responder phenotype episodes, that LDL particles and total LDL concentration alone are also not responsible for coronary risk and heart disease risk. They're just markers of insulin resistance in most cases for most people, but there are clearly exceptions. And so, and if you're on a very low carb, high fat diet and you're insulin sensitive, you might see elevated LDL. And again, that's a case where it's not actually associated. with anything related to heart disease. So we're seeing again, very similar thing here. And we also see something very similar when it comes to HDL. So the authors state, a low HDL is characteristic of third world societies at minimal risk for coronary disease. Evidently, a high HDL is crucially protective only in the context of risk factors that can induce endothelial dysfunction. Bernard has pointed out the fact that the total cholesterol to HDL ratio. Of the Tarahumara Indians, whose traditional diet is extremely high in carbohydrates and low in fat, is over 5, a ratio that in Western society would be associated with high coronary risk, yet coronary disease is virtually unknown among this population. So, very similar to what we're seeing with LDL and triglycerides, low HDL is evident in a number of, they say, third world societies, and we're going to talk about some of these native cultures and their lipid values and what we can take away from that. But HDL is generally... low in those cases, despite the fact that there's really no signs of cardiovascular disease. Again, we'll dig into this in more detail, but it's worth mentioning. I mean, they mentioned here that the high HDL must just be protective in the context of other risk factors. I think I would say again, that the assumption that the HDL is inherently protective is much like the assumption that LDL is inherently damaging or that triglycerides are inherently damaging. The reality being that these are really more so markers or indicators of what's going on. And there are certainly cases where low HDL is associated with really negative outcomes. Like most cases, most people in Western society especially will see that association. But that doesn't mean it's because the HDL is protective and we have a lack of HDL. Rather, it's more of an indicator of the underlying metabolic state. So let's take a look at some native cultures and their lipid values and their different dietary intake, you know, their different macronutrient breakdowns and everything. And also their cardiovascular risk as further evidence for what we're discussing here in terms of the potential lack of concern when it comes to triglyceride levels being elevated and smaller LDL and lower levels of HDL on a higher carb, low fat or lower fat diet. And so we'll start with those Tarahumaras, the Tarahumara Indians of Mexico. I'm sure they're no longer called Indians, but that's at least how they phrase it in this research, which is from a couple decades back. And this is the population that was mentioned at the end of that last study. We're going to look here at a study titled the Plasma Lipids, Lipoproteins, and Diet of the Tarahumara Indians of Mexico. So a couple of things to note here, a couple of quotes that they share. First off is looking at the macronutrient intake. So they state that the total fat intake was low, 11 to 12% of total calories. When we look at the rest of the diet, they state the Tarahumara diet was a high carbohydrate diet, 75 to 80% of the total calories, largely starch, and associated with a very high crude fiber intake of 15 to 21 grams per day. The salt intake was 5 to 8 grams per day, lower than the salt intake of most North Americans, although it's worth mentioning that it's a little higher than the sodium recommendations put out by the different associations in the Western world. Moving on here, they state the mixture of corn and beans in the diet provided a protein intake of 79 to 96 grams per day. This was ample both in amount and in protein quality. Essential amino acid requirements for human nutrition were more than adequately met by the quantities and mixture of beans and corn protein. Now, I do want to mention here, I'm not suggesting this as an optimally healthy diet. This is far from what I would recommend. Again, you can refer to the Energy Balanced Food Guide for more information there and also prior episodes that I can link back to where we've discussed. the foundations of a bioenergetic diet. I would certainly not recommend this, but it's worth noting they're on a very high carb diet, 75 to 80% of total calories, around 10 to 12% total calories from fat. And so we're looking at about 15% protein, give or take. And we can look here at table two, which is titled as the cholesterol and triglyceride content of the different lipoprotein fractions of the tarahumaras. And we see a few different things here. So when we look at the averages throughout the total sample or throughout the adults, we'll just use the total sample. We see very high or not very high, but we see elevated levels of triglycerides at 148 milligrams per deciliter. Again, this is right at the border of what's considered high. from most lab ranges. Normally they'll say 150 is really the cutoff where you're talking about high triglycerides, but we're basically right there. And many people would suggest that you don't want your triglycerides above, let's say a hundred. So their triglycerides average around 148 milligrams per deciliter. They do tend to have relatively low LDL largely due to not only the fact that their fat intake is very low, but also that their fat is very low in saturated fats. Again, not something I would generally recommend, but their LDL looks like the average is around 87 milligrams per deciliter. And their HDL is very low. So the average is 25 milligrams per deciliter of HDL. And normally that's recommended to be at least above 40. But again, many people in the alternative world want it above 50, above 60. And we'll talk about this really clear associative risk between low HDL and cardiovascular disease and vice versa. But again, we're seeing a population here that. has no signs of cardiovascular disease. By all signs, they're considered extremely healthy, and their HDL is very low, triglycerides are relatively high, and in this case, the LDL is on the lower end as well, or I guess I should say kind of moderate end. So that's the Tarahumaras, but there are a couple others that I think are worth getting into here. The next one is the Tukisenta. So we have a study here titled Epidemiological Studies in a Total Highland Population. to kisenta new guinea and this quote states a comprehensive survey of cardiovascular disease was carried out on 779 persons over 15 years of age carbohydrate provided more than 90 percent of caloric intake and the consumption of protein and salt were about 25 and 1 gram daily respectively drinking water was soft the population was lean physically fit and in good nutritional state there was no increase with age in mean blood pressure serum cholesterol fasting, blood glucose, or adiposity. Glucose tolerance was, I'll actually just pause here. So we're seeing a very high carb diet, more than 90% of total carbs, very low protein, very low salt diet. Again, definitely not something I recommend, but it's interesting to see what the outcomes are here and what the effects are on the lipids as a representation of what we discussed earlier in terms of the metabolism or the metabolic state that underlies different lipid values. And again, worth mentioning here, very healthy by all accounts, no signs of cardiovascular disease, no general increases in blood pressure, no increases in fasting glucose, no increases in adiposity, meaning no weight gain with age as well. They're generally lean, physically fit. So this is nothing like what we see in the standard Western population. Yet many people like to blame that on carbohydrates. But as we see here, it's definitely not that simple. And... It's not just due to increased activity in these populations either, which we'll get to with the last group here. But continuing on with this quote, they state glucose tolerance was high and they actually did some glucose tolerance tests with these different populations. And they're pretty profound how much better glucose tolerance they have compared to other kind of Western populations. They're extremely glucose tolerant, extremely insulin sensitive. They have very, very good glucose metabolism. So they say glucose tolerance was high. The average fasting serum triglyceride level was 142 milligrams per deciliter. Serum uric acid levels were not high. So I'll just pause here. This is something else that's often suggested in the kind of anti-low carb crowd, which is that carbohydrates will excessively increase uric acid, which has all of these downstream negative effects. We talked about this in a couple of episodes, why A, this is really not the case. And in order to create a state with elevated uric acid levels, you basically need people who are insulin resistant, who are given hundreds of grams of pure fructose in a day, who are not allowed to move or exercise a normal amount. They're forced to be sedentary. Only then do you really see increases in uric acid. And even then, it's more of a protective mechanism than anything else. Again, not something ideal, but not really something that happens other than really, really extreme states that are. Generally not seen in the vast majority of the population, maybe except for people who are dealing with type 2 diabetes, are very overweight, are very sedentary. are drinking massive amounts of soda in a day, although even then you're getting the glucose with the fructose, which helps to mitigate any increases in uric acid anyway, since many times they're endotoxin related due to having pure fructose without glucose, not absorbing it well, feeding bacteria and increasing uric acid. So in any case, we spent a couple of episodes discussing why this is really not any concern for someone eating a healthier high carb diet, even really an unhealthy one. It's, it's, uh, not driven by the carbohydrates themselves or the sugar itself. So in any case, in this population, again, super high carb diet, their glucose tolerance is high. Average fasting triglyceride level was 142 milligrams per deciliter. Ceramic acid levels were not high. Pipe smoking was common. No diabetes or gout were found. Again, things that are suggested to be caused by high carb intake. There was a low prevalence of diagnosable cardiovascular diseases, and they were looking at hypertension, valvular disease. cardiac decompensation and cerebral and peripheral vascular disease. They also state ischemic heart disease was rare, if not absent, as indicated by resting and post-exercise electrocardiograms. So by doing as many tests as they could at the time to identify their state of cardiovascular health, there was no indication of anything when it comes to a They say diagnosable cardiovascular disease, very low prevalence. And this is all compared especially to Western populations. But again, a suggestion that super high carb diet is not a concern when it comes to cardiovascular health, but also high levels of serum triglycerides. In this case, at 142 is not alone a driver of the cardiovascular disease risk. Now, the last population we're going to look at here is the Katavans. The Katavans are interesting because they are also on a very high carb diet. but they're also on a high saturated fat diet, which changes things up a little bit. So we're going to look at a study titled Determinants of Serum Triglycerides and High Density Lipoprotein Cholesterol in Traditional Trobriand Islanders, the Katava Study. So we're going to look at their diet first, where they state tubers such as yams and sweet potato are dietary staples supplemented mainly by fruit, fish, coconut, and leafy vegetables, and the intake of Western food is negligible. According to our estimates, the percentages of energy from protein, fat, and carbohydrates are 10, 21, and 69% in ketava. The estimated intakes of saturated, monounsaturated, and polyunsaturated fats in ketava are 17, 2, and 2%, respectively. So what we're looking at here is a diet containing 69% carbohydrates, 21% fat, and 10% protein. Again, this is on the... Low end of fat that I normally recommend. It's a bit low on protein for what I normally recommend, but I would say better, at least closer to what I would recommend compared to the prior two groups that we've looked at. And of the fat intake, 81% is coming from saturated fats because the total amount of fat they're getting in their diet is 21%. That includes 17% saturated fat, 2% monounsaturated and 2% PUFA. So they're on a generally very low PUFA diet and a very high saturated fat diet. And when we look at the lipids here, we see a couple of things. And we've got two tables, one looking at the lipid values in men and the other looking at women. For the men, we see total cholesterol levels averaging 181 milligrams per deciliter. We see triglycerides averaging 151 milligrams per deciliter. So elevated here, again, right at the border. We see HDL at 43, LDL at 108. We also see insulin at 4.0. So. The LDL here is clearly increased relative to the other two populations we looked at. And the HDL is also low like those prior populations. As far as the women, their cholesterol values are similar. Their total cholesterol is 224 milligrams per deciliter. Triglycerides are a little lower at 115 milligrams per deciliter. HDL is at 46. LDL is higher at 155. And insulin is at 4.8. So a couple of things that we see here in both groups, we see low levels of fasting glucose and low levels of insulin, both of which indicate very good insulin sensitivity. Again, maybe some would say despite their 69% dietary calories coming from carbohydrates, of course, and I'll link back to some episodes where we've talked about this, but high carb diets don't cause insulin resistance, as is evidenced here and by many other studies and populations. But again, we see very good. carbohydrate metabolism here, very good insulin sensitivity. But in terms of the lipoproteins, in terms of the lipids, we see elevated triglycerides more so in the men than the women, but again, relatively elevated, much like those other two populations. We see relatively low HDL and we see slightly elevated LDL, especially compared to those last two populations. And this is largely due to both slightly higher fat intake and also that fat largely coming from saturated fats. But again, like those other populations, this is a group that's in fantastic health. And they state that here in this quote, where they state, however, although the Katavans are apparently free from overweight, hypertension, hyperinsulinemia, hyperleptinemia, cardiovascular disease, and malnutrition, the population means of triglycerides and HDL cholesterol are not favorable in comparison with those of Caucasians. So again, free of overweight. high blood pressure, high insulin, which is a sign of insulin resistance, high leptin, cardiovascular disease, and malnutrition, despite having elevated triglycerides and low HDL. And they mention also, because this is something that I hear so often is, yes, carbohydrates are fine as long as you're incredibly active or if you're young. Now, in these different populations, even with age, they're still extremely healthy. So it does not support the fact that you should reduce your carbohydrate intake as you age. or you're not as carbohydrate tolerant, really, it's just a question of what's going on metabolically and what types of carbohydrates are you eating? What else are you eating? And what else are you doing in your life? But on the physical activity side, and this is the case with many of the native populations, the ketavans are not particularly active. It states the level of physical activity of ketavans was roughly estimated at 1.7 multiples of BMR of basal metabolic rate. And- This is considered to be around average for Western men and women as well, so they're not actually any more active than their Western counterparts. And then they state in conclusion, despite the fact that cardiovascular disease seems to be absent in Catawba, triglycerides were related to non-HDL cholesterol, HDL cholesterol, and ApoA1, the ApoA1 to HDL-C ratio, in an identical manner to that observed in Caucasians, while conversely, neither the level of triglycerides nor HDL cholesterol. was associated with markers of insulin sensitivity. Again, it just comes back to the central thesis we have here, which is that in the Western population in general, elevated triglycerides and low HDL is happening due to underlying insulin resistance, meaning due to underlying metabolic pathology, where our tissues are not effectively converting the food that's coming in into energy. That is not the case in these populations eating higher carb, lower fat diets. Rather, it's the result of other mechanisms like having very low stress hormones, low levels of... free fatty acids, low levels of fat utilization leading to low levels of LPL or lipoprotein lipase. And you basically have these similar markers that are even related to each other in a very similar way, yet they're not associated with insulin sensitivity and they're also not associated with cardiovascular disease risk. And that's really what the question comes down to. And again, a very, very parallel phenomenon here as to what we see in the lean mass hyper-responder phenotype. So in conclusion here, if you're shifting over to an energy balanced approach, and let's say you're coming from a low carb diet, and you're seeing that your triglycerides have come up a little bit, your HDL has come down and your LDL has come down. Is that a sign of cardiovascular disease risk? Is that a sign of metabolic syndrome? Is that a sign that you're doing something wrong? And the short answer here is no. When we look at the data, when we look at the physiology, when we look at the mechanisms, that's not what's actually going on here. Instead, it's just. The product of a shift in the metabolic state, a shift toward using more carbohydrates and less fat, shift toward downregulation of the stress hormones. And it's, in the case of insulin sensitivity, not at all associated with cardiovascular disease. Now, it's also worth mentioning the caveat. Some people are also dealing with insulin resistance, and they might start to increase their carbs and see a really significant increase in triglyceride levels. And maybe in… maybe even an increase in LDL can happen sometimes. And often those things are more of a sign of, if they're happening when adding carbs in and bringing fat down, typically, if that's the case, that's more of a sign of insulin resistance. And we would tend to see other signs as well, like weight gain and other kind of negative effects, as opposed to the effects that we're looking for, like improved energy, sleep, digestion, reduced stress, like reduced physiological stress and all of the... kind of negative symptoms that come with it. Those are the kind of things that we would want to see, but if we're not seeing those, and instead we're seeing a slightly different lipid profile with triglycerides far above 150 and LDL not really coming down or even going up, those are generally going to be signs that we're not actually properly shifting into the metabolic state where we're using carbohydrates well, and that's a very different situation, very different lipid profile, but representing a different metabolic state underneath. And that's a case where we do want to work on fixing. the underlying insulin resistance. And for that, I'll point back to a couple of podcast episodes that we did prior discussing insulin resistance. Really, when we're talking insulin resistance, we're just talking about an impaired metabolic state where the body's not effectively converting the food that's coming in into energy. And when that happens, we need to consider all the possible factors that are affecting energy production. And so you can look back at those episodes, but really throughout the entire podcast, you know, all of our episodes, we talk through different factors that affect your capacity for producing energy. We talk about endotoxin and PUFA and nutrient deficiencies and sleep issues. Tons of other factors as well, and really all of them can be culprits here. All of them are things that we want to consider. All right, so again, just to conclude here, if you're seeing an increase in triglycerides when you're raising your carbohydrate intake, especially when you're coming from a low-carb diet, that is not a sign of anything negative going on in terms of metabolic syndrome or cardiovascular disease risk, as long as, again, they're not excessively increasing, and we're confident that we're insulin sensitive, and we want to keep an eye on those markers and those indicators as well. Alright, so with that, if you enjoyed this episode, please leave a like or comment if you're watching on YouTube. And if you're listening elsewhere, please leave a review or five-star rating. All of those things do a lot to help support the podcast and are very much appreciated. As always, to check out the show notes for today's episode, where I'll link to the studies and articles and anything else that I mentioned, head over to jfeldmanwellness.com slash podcast. And if you are looking to optimally support your metabolism, improve insulin sensitivity, improve cardiovascular health, lose weight, improve your digestion, get amazing sleep, rebalance your hormones, boost your energy, and so much more with clear action steps and strategies alongside personalized guidance from me, then head over to jfeldmanwellness.com slash solution where you can find all of the information for the Energy Balance Solution program. This program includes customized health coaching. It includes a video library with videos on regulating blood sugar, restoring gut health, losing weight without destroying your metabolism, Boosting your metabolism, getting amazing restorative sleep, rebalancing your hormones, and tons more. It also includes resources like a sample meal plan and supplement guide, along with many others. And also, it includes access to a private community. So head over to jfeldmanwellness.com slash solution to check out all the details. And with that, I'll see you on the next episode.

I'll go over how lipid values on a high-carb diet compare to a low-carb diet, including lean mass hyper-responders. I'll also discuss whether low HDL levels will increase your risk of heart disease and whether high triglyceride levels cause heart disease. As always, to check out the show notes where I'll reference the studies, articles, and anything else that I mentioned throughout this episode, head over to jfeldmanwellness.com slash podcast.

And with that... let's get started. All right, so this is going to be a solo episode where I'm going to be discussing different aspects of lipid panels and different impacts on lipid values.

You know, we're talking triglycerides, HDL, LDL, and some other kind of intricacies there when it comes to a high-carb diet. I'll also be comparing this to a low-carb diet and also... comparing this to a state of insulin resistance and what's going on physiologically, and then also what this all means when it comes to cardiovascular health and general metabolic health. And there's a number of reasons why I wanted to discuss this. For one, it's something that clients and members of my programs mentioned quite often, which is they see certain changes in their lipid values, sometimes increases in triglycerides, sometimes decreases in HDL, and they're normally concerned about that or different practitioners that they see are concerned about that because of the...

potential implications there. So I wanted to touch on it from that standpoint. And then also because it's a concern when it comes to a high carb diet. I mean, there's a number of concerns out there considering that much of the health world is, or alternative online health world is skewed toward a low carb diet.

So some of the concerns when it comes to going toward a high carb diet are things like increased triglycerides. So I wanted to discuss that and whether it's really a concern. And to start...

You know, it's worth mentioning that in kind of the general Western population, high triglycerides and low HDL are typically indications of metabolic syndrome, insulin resistance, and therefore also cardiovascular disease. You know, they're indicators and markers that are associated with those different chronic health issues. And of course, those are associated with pretty much every chronic health issue, all sorts of different symptoms, you know, pretty much anything you can think of there.

So generally not a good sign. And generally the reference range for triglycerides goes up to around 150 milligrams per deciliter. And most practitioners, most people, especially in the alternative health space, would like to see that value quite a bit lower than 150 milligrams per deciliter. Often they'll say below 100 and even lower, often as low as possible.

And that's also something that's generally not ideal. So we can come back to that a bit later. And it's also worth mentioning when we're talking. kind of mainstream and different lipid markers, that this is also very much the case with LDL levels, where LDL levels, when they're elevated, they're typically associated with metabolic syndrome, insulin resistance, and cardiovascular disease and tons of other negative outcomes, right? Generally not something we want to see.

And this holds true when people are on a kind of standard Western diet. And I see this quite a bit. If you've seen people eating a standard kind of typical Western diet.

And they have elevated LDL. It is very clearly associated with worse health. This is shown very clearly in the literature. And I've seen it quite a bit in people who are not as health conscious and coming to me for help. And when we see elevated LDL, it tends to be correlating with a lot of negative health outcomes, a lot of other chronic health issues.

But we discussed in a couple of episodes, which I'll link to in the show notes, regarding lean mass hyper responders and the lipid energy model. We discussed in those episodes that we have to consider the context when we're interpreting a marker like LDL. And for someone who's not on a Western diet, but instead is maybe, let's say, on a low-carb or ketogenic diet, LDL values can mean something entirely different from what they indicate in kind of a mainstream or Western average population that's not on a ketogenic diet.

And that's because LDL itself is a marker. It's an indicator. And we have to interpret it. We have to understand what is actually. indicating, to be able to interpret and apply it and understand if it's actually going to mean the same thing in different circumstances.

And so we're going to be doing the same thing today, but looking at some of the same markers, LDL, HDL, triglycerides, but in the context of a, I'll call healthy high carb diet, a bioenergetic diet, which it's worth mentioning when we're comparing this to a Western diet, there are a lot of differences. For one, Western diets tend to be pretty... I mean, they're kind of moderate carb, moderate fat.

They're generally not at all low fat. They generally aren't even that high in carbs since so many of the standard processed foods are high in both carbs and fats. Of course, they're very much reliant on refined grains, a lot of processed food with a lot of very high PUFA foods like the seed oils that obviously are being discussed quite a bit. So.

What I'm talking about here is a diet that is very different than that, of course. So with that in mind, let's dig into what actually goes on on a high carbohydrate diet in terms of the lipids, what's going on physiologically, and then what it actually indicates and whether or not it's actually a concern, whether or not it's actually a problem. So we're actually going to start here by looking at the lipid energy model.

We're looking at a graphic here that We looked at in the lean mass hyper responder series, a kind of two-part series, where we're seeing what's going on physiologically that's affecting the different lipid values in the blood. And so in this graphic, we can see a couple of things. And this is a graphic, again, showing what's happening on a low-carb ketogenic diet in someone who is generally insulin sensitive and generally healthy.

And we kind of have a number of steps here going in order. So the first couple steps are that there's a lack of carbohydrates, which leads to a lack of glycogen storage in the liver. It leads to generally low insulin levels and also generally high levels of stress hormones, glucagon, epinephrine or adrenaline and cortisol.

Those hormones then trigger what's called hormone sensitive lipase, which causes the release of fat from the fat tissue into the blood in the form of. free fatty acids. After that, the next step is that the liver will, I mean, a lot of things will happen with the free fatty acids. They'll get picked up by different tissues and used as fuel, but they'll also be picked up by the liver and they'll then be repackaged into triglyceride form and put into lipoproteins called VLDL.

And that VLDL will then be released from the liver containing a number of things, but including those triglycerides. And then when they're in the blood, uh, they... We'll get acted on by what's called lipoprotein lipase or LPL. This is inside the peripheral tissues and will basically take the triglycerides up from the VLDL.

So the VLDL is basically a carrier for triglycerides, among other things, you know, cholesterol, esters and things like that. And when the peripheral tissues are using a lot of fats, they want to pick up those triglycerides from the VLDL and use them to convert to energy. And so they'll express higher levels of LPL, lipoprotein lipase, to pick up those fats from the VLDL, the triglycerides, which then converts the VLDL into LDL and HDL.

And so this is what's generally responsible for the lipid values that are seen in lean mass hyper responders on a low carb diet, where you see low triglycerides because the amount of VLDL is generally low. There's not a lot of triglycerides being carried through the blood. You tend to see high LDL and high HDL as a result of having had a lot of ELDL that's been converted to LDL and HDL by dropping off the triglycerides.

And yeah, you generally see those three things when we're looking at lipids, low triglycerides and high LDL and high HDL. So we discussed this in those previous episodes, but there are some potential concerns here, not necessarily just because of some correlation between LDL and cardiovascular disease. but rather because there are some negatives to the hormonal state that is responsible for this phenomenon, as well as the metabolic state that's responsible for this phenomenon. So I don't think this is necessarily ideal, but again, it's not just because of some kind of outdated assumption that any change in LDL is directly going to be correlated with change in cardiovascular risk or something like that. So if we then take this kind of same diagram, the same concept, and apply it to what's going on on a high-carb, low-fat diet, or at least lower-fat diet.

And in someone who's insulin-sensitive, we see essentially the opposite going on here. So what we see is there's adequate glycogen, adequate carbohydrates, and we generally have low levels of the stress hormones, low levels of glucagon, adrenaline, and cortisol. This leads to a lack of HSL, hormone-sensitive lipase.

which leads to a lack of free fatty acid release. So we generally have lower levels of free fatty acids, which leads to less uptake of those free fatty acids at the liver, which then leads to generally less VLDL secretion from the liver, or at least about the same as if you were on kind of a normal diet, but less relative to the lean mass hyper responder phenotype. Now, despite there being less LDL secreted from the liver compared to this phenotype, we also have decreased...

removal of the triglycerides from the LDL. And remember, that's happening through LPL, or lipoprotein lipase. And that lipoprotein lipase is dependent on what sort of fuel the peripheral tissues are using.

Are they mostly using fat or are they mostly using carbohydrates? If they're mostly using fat, they're going to want to take up a lot of that triglyceride, and so they're going to have elevated levels of LPL. In this case, when we're talking about a higher carb, lower fat diet, we're going to have decreased levels of LPL because the general peripheral tissues... are using more carbohydrates and less fat.

As a result here, we see reduced triglyceride clearance from the blood, reduced triglyceride removal from VLDL, which leads to generally higher levels of VLDL and triglyceride-rich VLDL, which leads to higher levels of triglycerides in the blood. It also generally leads to lower levels of HDL and LDL because you don't have much turnover conversion from VLDL to LDL and HDL. You don't have as much transfer there. So as a result...

you see basically the opposite presentation is what you see in lean mass hyper-responders, which is you tend to see higher levels of triglycerides. Again, they aren't always out of range, but generally higher and lower levels of HDL and lower levels of LDL. Now we're going to talk about the implications of this and whether or not this is actually something that's concerning, but it is worth mentioning that this is very different from what's going on with the lipids in the case of insulin resistance. In the case of insulin resistance...

There are parts of both of these mechanisms, both of these pathways, both the lean mass hyper-responder phenotype, and we'll call it the high-carb, low-fat phenotype. There are aspects of both of those happening at the same time in a way that's pretty dysfunctional and leads to a similar set of lipids as you might see on the higher-carb diet in some ways, but also similar to what you're going to see on a low-carb diet in some ways. So it's a bit of a mix of both, and it really comes down to...

insulin resistance issue, which is a metabolic issue going on inside the tissues where they're not using glucose well. I discussed this on quite a few prior podcast episodes, so I'll link to those. But I did want to mention before we jump into what's actually happening in the insulin resistance state, that when it comes to creating a diet to help you improve your cardiovascular health and metabolic health, there's a lot of conflicting information out there.

You might have in the past been tempted to try low-carb keto. Maybe you've tried those things, as many of us have. Or maybe you're seeing a lot of other conflicting health information out there. But that's why I've created the Energy Balance Food Guide, which is going to help you determine exactly what to eat to optimally support your metabolism and help you lose weight, improve your digestion, get amazing sleep, boost your energy, improve your cardiovascular health, and so much more. It's a one-page infographic that organizes foods on a spectrum based on how effectively they support your metabolism.

And it also is a separate spectrum that adjusts the scale for you in the case that you're dealing with various digestive symptoms. So, The food guide makes it extremely easy to get started with a bioenergetic approach to optimizing your health. So head over to jfeldmanwellness.com slash guide to download your free energy balance food guide.

So with that, let's dig into what's going on in terms of the lipids and the underlying metabolism in a state of insulin resistance. So in a state of insulin resistance, there are there's normally adequate levels of glycogen, but because the. peripheral tissues, because generally in the body there are metabolic issues, we're not using that glucose very effectively. And as a result, we tend to see elevated levels of stress hormones, namely glucagon, adrenaline, and cortisol.

Now these increase the activity of hormone-sensitive lipase and therefore increase the release of free fatty acids. So we see the same elevated free fatty acids that we would see on a low-carb diet. And also similar to a low-carb diet, Those free fatty acids are going to be taken up by the liver and packaged into triglycerides.

Now, in this case, this is largely happening because there's normally metabolic dysfunction going on at the liver, and it's not properly metabolizing carbohydrates or fats, really. And as a result, again, it's packing up the free fatty acids into triglycerides. It's going to be storing some of them, which we discussed in the fatty liver series. So I'll link back to that, but it's also going to be sending those. those free fatty acids out in the form of triglycerides being carried by VLDL.

So you see that same increase in VLDL and increase in triglyceride synthesis being in this state of insulin resistance. So that part again is similar to what you would see on the low carb diet in the lean mass hyper responders. You see the increased triglyceride synthesis and the increased VLDL.

Now, in this case, there are going to be higher levels of lipoprotein lipase because the Peripheral tissues are generally relying on fatty acid oxidation, and that will lead to some turnover of VLDL into LDL. But there's not as much or as elevated levels of lipoprotein lipase, and that's because the peripheral tissues are generally full of fuel. They're not effectively using that fuel very well.

Their metabolism is pretty deranged. And so as a result, you're not going to have enough. triglyceride uptake from the VLDL, and you're going to have a lot of triglyceride release through VLDL from the liver. And so that tends to lead to not only elevated levels of the LDL, as I just mentioned, but also elevated levels of VLDL, and as a result, also elevated levels of triglycerides.

So in this case, we're seeing a combination of multiple things happening. We're seeing increased VLDL and increased LDL, and also, therefore, increased triglycerides. So we're seeing pieces of both sides here, both the high-carb side and the low-carb side.

And— It's indicating something completely different because the excess triglycerides is indicating a number of things. It's indicating the excess stress that caused the increased free fatty acids. It's also, along with that, indicating the mitochondrial dysfunction going on at the liver, which is causing those free fatty acids to be converted to triglycerides and taken out as VLDL. And then we're also seeing this indicate peripheral mitochondrial dysfunction, issues with energy production throughout all the tissues, which is what's leading to basically a state of excess lipid where...

And the tissues are not able to effectively use fuel. And so there's a lot of there's basically excess fuel or in a state of excess fuel because we're not effectively using it. And that's going to lead to the elevated triglycerides in the blood.

And again, we're also seeing the elevated LDL in this case. Now, one thing that is not mentioned as much here, I'm just going to touch on it real briefly and we'll come back to it later. But that's going to be LDL size. So.

One thing that's often discussed in especially the alternative health world is this idea of what are considered large fluffy LDL particles and small dense LDL particles. The general idea is that the small dense ones are more atherogenic, more contributory to atherosclerosis, whereas the large fluffy ones are generally benign. And we'll again, we'll come back to this later on whether that implication is actually the case. But.

In general, the amount of small dense LDL particles is going to be the result of how many triglyceride rich VLDL and LDL particles there are. So when you have a lot of that VLDL staying around in the blood, you're typically going to have higher levels of the small dense LDL. And this is going to happen in the case of insulin resistance.

And it also generally will happen or will trend in that direction in the case of a high carb, low fat diet. And again, we'll come back to that in a little bit. So this is so that's.

kind of the overview of what's going on in this case, what's responsible for the different lipid values we might see in different metabolic states. But that leads us to the question of what does that mean? What are the implications here? Should we be concerned about cardiovascular risk or the metabolic state that's induced by a high-carb diet especially?

We already talked about the lean mass hyper-responder phenotype and why the elevated LDL is so important. Low triglycerides, elevated HDL isn't something that's particularly concerning from a cardiovascular standpoint. From a metabolic standpoint, I do think there are concerns there.

Again, I mentioned those in that prior episode. But in the case of the high-carb, low-fat diet or lower-fat diet, we want to consider whether the elevated triglycerides, lower HDL, and generally a bit lower LDL, at least definitely lower than on a low-carb, high-fat diet. but potentially higher amounts of the smaller dense LDL levels. We're wondering if those few things are going to be driving negative health outcomes. And again, it's going to be a situation where we need to consider the larger context and what they're actually indicating here.

And we talked about this again in those prior episodes. If these markers are not just markers, if they're actual independent drivers of, let's say, cardiovascular risk, then, you know... You can be pretty confident that it's not going to be ideal to see either elevated levels of triglycerides or elevated levels of LDL. But what we discussed there is that that's not actually the case. These are just markers.

They're just indicators. They have certain associations, especially in the Western world on a Western diet. But that doesn't actually mean that they're independent risk factors, so to speak. Now, hypertriglyceridemia, like excess triglycerides. is sometimes considered to be an independent risk factor for cardiovascular disease in some studies, but much like LDL, which is also considered that way in many studies, a lot of things are not adequately controlled for.

And in the case of excess triglycerides, one thing that's definitely not adequately controlled for is insulin sensitivity. So we're going to dig into that now, whether the lipid values that you might see on a higher carb diet are just markers or what they actually reflect about the underlying context and whether. This is actually something we want to be concerned about in terms of cardiovascular disease risk or metabolic syndrome or anything else along those lines. And so we're going to be digging into a study here titled, An Elevation of Triglycerides Reflecting Decreased Triglyceride Clearance May Not Be Pathogenic, Relevance to High Carbohydrate Diets.

So they mentioned a number of things here. We're going to start with triglycerides. So the first things that they mentioned here, or at least the first things we're going to highlight here, they state, the researchers observed that endothelium-dependent vasodilation was severely impaired relative to the control group in the hypertriglyceridemic subjects who were severely insulin resistant, but not in those who were only mildly insulin resistant.

So again, to make that clear, they were looking at subjects with high levels of triglycerides. And the ones who were severely insulin resistant, the function of the endothelium of the blood vessels, essentially, was severely impaired in the people who had high triglycerides and were severely insulin resistant. The people who had high triglycerides and were mildly insulin resistant, there was no impairment in the endothelium-dependent vasodilation, or basically just the function of the blood vessels.

So that's the first thing they state here. They then state, this finding supports the conclusion that insulin resistance syndrome rather than hypertriglyceridemia per se, mediates the endothelial dysfunction and increased coronary risk associated with increased triglyceride levels. So they're just touching on one study here, but again, what they're saying is that basically the high triglyceride levels are just generally an indication of insulin resistance, but if the insulin resistance is not there, and again, insulin resistance just being a global state of impaired glucose metabolism or just generally impaired metabolism, but... Glucose being the more sensitive one is really the important thing here.

So with insulin resistance being a state of generally impaired glucose metabolism, that's responsible for any increase in coronary risk and endothelial dysfunction rather than the triglycerides themselves. They then state another relevant study was published by Cho Wenchik et al. These researchers assembled a group of severely hypertriglyceridemic patients with an average triglyceride level of 1914 mg per deciliter. characterized as Fredrickson type 5, in whom a marked deficit of lipoprotein lipase, or LPL, activity, rather than insulin resistance syndrome, appears to be primarily responsible for the elevation of triglycerides. So again, just to make this clear, they're talking about a group of people that have a major deficit in LPL activity, and so they have extremely high triglyceride levels.

And so we know that this is a state that's, you know, you're not seeing these massive levels of triglycerides just from insulin resistance. This is due to an issue with the lipoprotein lipase. They then state, forearm blood flow responses to infusions of acetylcholine and of nitroprusside were measured in this group and in a set of normal lipidemic gender-matched controls. The responses of the two groups did not differ.

So basically, if you have extremely high triglyceride levels, 1900 milligrams per deciliter, in this case, that was not due to insulin resistance, there was no difference, basically, in terms of the blood flow response in terms of circulation and endothelial function between that group and a group with normal levels of triglycerides. And again, what this indicates is that if it's not insulin resistance causing the elevated triglycerides, they themselves are not actually a concern. All they are in most cases is a marker of insulin resistance, again, a marker of poor glucose metabolism. They alone are not an independent driver of heart disease or metabolic syndrome. They then go on to talk about this in terms of the size of LDL particles.

Remember I was saying that on a higher carb, lower fat diet, you might tend to see smaller, more dense LDL particles. And they state here, might it not be the case that small LDL particles are just functioning as a marker for insulin resistance syndrome, which is the real mediator of the associated risk. The prospective Quebec cardiovascular study has generated data consistent with this interpretation.

Thus, when they examined individuals who had a moderate level of circulating LDL particles, LDL peak particle diameter had no influence whatever on coronary risk. So again, just to make that clear, in people who had moderate levels of circulating LDL, so they still had a decent amount of LDL, it just wasn't elevated. The diameter, the size of the LDL particles had no influence on heart disease risk. They then go on to say, in individuals with an elevated number of LDL particles and small LDL particle diameter, a six-fold increase in risk was observed.

Arguably, this reflects the joint impact of down-regulated LDL receptors and insulin resistance syndrome. If small LDL particles were indeed uniquely pernicious as mediators of endotheliopathy, it is hard to see why LDL size did not matter in subjects with normal levels of LDL particles. So again, we're talking about a very parallel situation here. In insulin resistance, in most cases, you'll see elevated levels of LDL particles. And in that case, if you see elevated levels of LDL number and they're small, then there seems to be an increased coronary risk.

Whereas if you have, quote, normal or moderate levels of LDL and they're small, there's no increase in risk. And if it was just the small LDL particles on their own, that was the risk factor or the driver of the state, you would see it in both cases. The higher or the smaller your LDL particles were, they increase your risk regardless of which group you were in.

Now, we also know, based on what we discussed in the lean mass hyper responder phenotype episodes, that LDL particles and total LDL concentration alone are also not responsible for coronary risk and heart disease risk. They're just markers of insulin resistance in most cases for most people, but there are clearly exceptions. And so, and if you're on a very low carb, high fat diet and you're insulin sensitive, you might see elevated LDL. And again, that's a case where it's not actually associated. with anything related to heart disease.

So we're seeing again, very similar thing here. And we also see something very similar when it comes to HDL. So the authors state, a low HDL is characteristic of third world societies at minimal risk for coronary disease.

Evidently, a high HDL is crucially protective only in the context of risk factors that can induce endothelial dysfunction. Bernard has pointed out the fact that the total cholesterol to HDL ratio. Of the Tarahumara Indians, whose traditional diet is extremely high in carbohydrates and low in fat, is over 5, a ratio that in Western society would be associated with high coronary risk, yet coronary disease is virtually unknown among this population.

So, very similar to what we're seeing with LDL and triglycerides, low HDL is evident in a number of, they say, third world societies, and we're going to talk about some of these native cultures and their lipid values and what we can take away from that. But HDL is generally... low in those cases, despite the fact that there's really no signs of cardiovascular disease. Again, we'll dig into this in more detail, but it's worth mentioning. I mean, they mentioned here that the high HDL must just be protective in the context of other risk factors.

I think I would say again, that the assumption that the HDL is inherently protective is much like the assumption that LDL is inherently damaging or that triglycerides are inherently damaging. The reality being that these are really more so markers or indicators of what's going on. And there are certainly cases where low HDL is associated with really negative outcomes. Like most cases, most people in Western society especially will see that association. But that doesn't mean it's because the HDL is protective and we have a lack of HDL.

Rather, it's more of an indicator of the underlying metabolic state. So let's take a look at some native cultures and their lipid values and their different dietary intake, you know, their different macronutrient breakdowns and everything. And also their cardiovascular risk as further evidence for what we're discussing here in terms of the potential lack of concern when it comes to triglyceride levels being elevated and smaller LDL and lower levels of HDL on a higher carb, low fat or lower fat diet.

And so we'll start with those Tarahumaras, the Tarahumara Indians of Mexico. I'm sure they're no longer called Indians, but that's at least how they phrase it in this research, which is from a couple decades back. And this is the population that was mentioned at the end of that last study. We're going to look here at a study titled the Plasma Lipids, Lipoproteins, and Diet of the Tarahumara Indians of Mexico. So a couple of things to note here, a couple of quotes that they share.

First off is looking at the macronutrient intake. So they state that the total fat intake was low, 11 to 12% of total calories. When we look at the rest of the diet, they state the Tarahumara diet was a high carbohydrate diet, 75 to 80% of the total calories, largely starch, and associated with a very high crude fiber intake of 15 to 21 grams per day. The salt intake was 5 to 8 grams per day, lower than the salt intake of most North Americans, although it's worth mentioning that it's a little higher than the sodium recommendations put out by the different associations in the Western world.

Moving on here, they state the mixture of corn and beans in the diet provided a protein intake of 79 to 96 grams per day. This was ample both in amount and in protein quality. Essential amino acid requirements for human nutrition were more than adequately met by the quantities and mixture of beans and corn protein. Now, I do want to mention here, I'm not suggesting this as an optimally healthy diet.

This is far from what I would recommend. Again, you can refer to the Energy Balanced Food Guide for more information there and also prior episodes that I can link back to where we've discussed. the foundations of a bioenergetic diet. I would certainly not recommend this, but it's worth noting they're on a very high carb diet, 75 to 80% of total calories, around 10 to 12% total calories from fat. And so we're looking at about 15% protein, give or take.

And we can look here at table two, which is titled as the cholesterol and triglyceride content of the different lipoprotein fractions of the tarahumaras. And we see a few different things here. So when we look at the averages throughout the total sample or throughout the adults, we'll just use the total sample.

We see very high or not very high, but we see elevated levels of triglycerides at 148 milligrams per deciliter. Again, this is right at the border of what's considered high. from most lab ranges. Normally they'll say 150 is really the cutoff where you're talking about high triglycerides, but we're basically right there. And many people would suggest that you don't want your triglycerides above, let's say a hundred.

So their triglycerides average around 148 milligrams per deciliter. They do tend to have relatively low LDL largely due to not only the fact that their fat intake is very low, but also that their fat is very low in saturated fats. Again, not something I would generally recommend, but their LDL looks like the average is around 87 milligrams per deciliter.

And their HDL is very low. So the average is 25 milligrams per deciliter of HDL. And normally that's recommended to be at least above 40. But again, many people in the alternative world want it above 50, above 60. And we'll talk about this really clear associative risk between low HDL and cardiovascular disease and vice versa. But again, we're seeing a population here that.

has no signs of cardiovascular disease. By all signs, they're considered extremely healthy, and their HDL is very low, triglycerides are relatively high, and in this case, the LDL is on the lower end as well, or I guess I should say kind of moderate end. So that's the Tarahumaras, but there are a couple others that I think are worth getting into here.

The next one is the Tukisenta. So we have a study here titled Epidemiological Studies in a Total Highland Population. to kisenta new guinea and this quote states a comprehensive survey of cardiovascular disease was carried out on 779 persons over 15 years of age carbohydrate provided more than 90 percent of caloric intake and the consumption of protein and salt were about 25 and 1 gram daily respectively drinking water was soft the population was lean physically fit and in good nutritional state there was no increase with age in mean blood pressure serum cholesterol fasting, blood glucose, or adiposity. Glucose tolerance was, I'll actually just pause here. So we're seeing a very high carb diet, more than 90% of total carbs, very low protein, very low salt diet.

Again, definitely not something I recommend, but it's interesting to see what the outcomes are here and what the effects are on the lipids as a representation of what we discussed earlier in terms of the metabolism or the metabolic state that underlies different lipid values. And again, worth mentioning here, very healthy by all accounts, no signs of cardiovascular disease, no general increases in blood pressure, no increases in fasting glucose, no increases in adiposity, meaning no weight gain with age as well. They're generally lean, physically fit.

So this is nothing like what we see in the standard Western population. Yet many people like to blame that on carbohydrates. But as we see here, it's definitely not that simple. And... It's not just due to increased activity in these populations either, which we'll get to with the last group here.

But continuing on with this quote, they state glucose tolerance was high and they actually did some glucose tolerance tests with these different populations. And they're pretty profound how much better glucose tolerance they have compared to other kind of Western populations. They're extremely glucose tolerant, extremely insulin sensitive.

They have very, very good glucose metabolism. So they say glucose tolerance was high. The average fasting serum triglyceride level was 142 milligrams per deciliter.

Serum uric acid levels were not high. So I'll just pause here. This is something else that's often suggested in the kind of anti-low carb crowd, which is that carbohydrates will excessively increase uric acid, which has all of these downstream negative effects.

We talked about this in a couple of episodes, why A, this is really not the case. And in order to create a state with elevated uric acid levels, you basically need people who are insulin resistant, who are given hundreds of grams of pure fructose in a day, who are not allowed to move or exercise a normal amount. They're forced to be sedentary. Only then do you really see increases in uric acid. And even then, it's more of a protective mechanism than anything else.

Again, not something ideal, but not really something that happens other than really, really extreme states that are. Generally not seen in the vast majority of the population, maybe except for people who are dealing with type 2 diabetes, are very overweight, are very sedentary. are drinking massive amounts of soda in a day, although even then you're getting the glucose with the fructose, which helps to mitigate any increases in uric acid anyway, since many times they're endotoxin related due to having pure fructose without glucose, not absorbing it well, feeding bacteria and increasing uric acid. So in any case, we spent a couple of episodes discussing why this is really not any concern for someone eating a healthier high carb diet, even really an unhealthy one. It's, it's, uh, not driven by the carbohydrates themselves or the sugar itself.

So in any case, in this population, again, super high carb diet, their glucose tolerance is high. Average fasting triglyceride level was 142 milligrams per deciliter. Ceramic acid levels were not high.

Pipe smoking was common. No diabetes or gout were found. Again, things that are suggested to be caused by high carb intake. There was a low prevalence of diagnosable cardiovascular diseases, and they were looking at hypertension, valvular disease.

cardiac decompensation and cerebral and peripheral vascular disease. They also state ischemic heart disease was rare, if not absent, as indicated by resting and post-exercise electrocardiograms. So by doing as many tests as they could at the time to identify their state of cardiovascular health, there was no indication of anything when it comes to a They say diagnosable cardiovascular disease, very low prevalence. And this is all compared especially to Western populations. But again, a suggestion that super high carb diet is not a concern when it comes to cardiovascular health, but also high levels of serum triglycerides.

In this case, at 142 is not alone a driver of the cardiovascular disease risk. Now, the last population we're going to look at here is the Katavans. The Katavans are interesting because they are also on a very high carb diet. but they're also on a high saturated fat diet, which changes things up a little bit.

So we're going to look at a study titled Determinants of Serum Triglycerides and High Density Lipoprotein Cholesterol in Traditional Trobriand Islanders, the Katava Study. So we're going to look at their diet first, where they state tubers such as yams and sweet potato are dietary staples supplemented mainly by fruit, fish, coconut, and leafy vegetables, and the intake of Western food is negligible. According to our estimates, the percentages of energy from protein, fat, and carbohydrates are 10, 21, and 69% in ketava. The estimated intakes of saturated, monounsaturated, and polyunsaturated fats in ketava are 17, 2, and 2%, respectively.

So what we're looking at here is a diet containing 69% carbohydrates, 21% fat, and 10% protein. Again, this is on the... Low end of fat that I normally recommend.

It's a bit low on protein for what I normally recommend, but I would say better, at least closer to what I would recommend compared to the prior two groups that we've looked at. And of the fat intake, 81% is coming from saturated fats because the total amount of fat they're getting in their diet is 21%. That includes 17% saturated fat, 2% monounsaturated and 2% PUFA. So they're on a generally very low PUFA diet and a very high saturated fat diet. And when we look at the lipids here, we see a couple of things.

And we've got two tables, one looking at the lipid values in men and the other looking at women. For the men, we see total cholesterol levels averaging 181 milligrams per deciliter. We see triglycerides averaging 151 milligrams per deciliter. So elevated here, again, right at the border.

We see HDL at 43, LDL at 108. We also see insulin at 4.0. So. The LDL here is clearly increased relative to the other two populations we looked at. And the HDL is also low like those prior populations.

As far as the women, their cholesterol values are similar. Their total cholesterol is 224 milligrams per deciliter. Triglycerides are a little lower at 115 milligrams per deciliter. HDL is at 46. LDL is higher at 155. And insulin is at 4.8.

So a couple of things that we see here in both groups, we see low levels of fasting glucose and low levels of insulin, both of which indicate very good insulin sensitivity. Again, maybe some would say despite their 69% dietary calories coming from carbohydrates, of course, and I'll link back to some episodes where we've talked about this, but high carb diets don't cause insulin resistance, as is evidenced here and by many other studies and populations. But again, we see very good. carbohydrate metabolism here, very good insulin sensitivity.

But in terms of the lipoproteins, in terms of the lipids, we see elevated triglycerides more so in the men than the women, but again, relatively elevated, much like those other two populations. We see relatively low HDL and we see slightly elevated LDL, especially compared to those last two populations. And this is largely due to both slightly higher fat intake and also that fat largely coming from saturated fats.

But again, like those other populations, this is a group that's in fantastic health. And they state that here in this quote, where they state, however, although the Katavans are apparently free from overweight, hypertension, hyperinsulinemia, hyperleptinemia, cardiovascular disease, and malnutrition, the population means of triglycerides and HDL cholesterol are not favorable in comparison with those of Caucasians. So again, free of overweight.

high blood pressure, high insulin, which is a sign of insulin resistance, high leptin, cardiovascular disease, and malnutrition, despite having elevated triglycerides and low HDL. And they mention also, because this is something that I hear so often is, yes, carbohydrates are fine as long as you're incredibly active or if you're young. Now, in these different populations, even with age, they're still extremely healthy.

So it does not support the fact that you should reduce your carbohydrate intake as you age. or you're not as carbohydrate tolerant, really, it's just a question of what's going on metabolically and what types of carbohydrates are you eating? What else are you eating? And what else are you doing in your life? But on the physical activity side, and this is the case with many of the native populations, the ketavans are not particularly active.

It states the level of physical activity of ketavans was roughly estimated at 1.7 multiples of BMR of basal metabolic rate. And- This is considered to be around average for Western men and women as well, so they're not actually any more active than their Western counterparts. And then they state in conclusion, despite the fact that cardiovascular disease seems to be absent in Catawba, triglycerides were related to non-HDL cholesterol, HDL cholesterol, and ApoA1, the ApoA1 to HDL-C ratio, in an identical manner to that observed in Caucasians, while conversely, neither the level of triglycerides nor HDL cholesterol.

was associated with markers of insulin sensitivity. Again, it just comes back to the central thesis we have here, which is that in the Western population in general, elevated triglycerides and low HDL is happening due to underlying insulin resistance, meaning due to underlying metabolic pathology, where our tissues are not effectively converting the food that's coming in into energy. That is not the case in these populations eating higher carb, lower fat diets. Rather, it's the result of other mechanisms like having very low stress hormones, low levels of... free fatty acids, low levels of fat utilization leading to low levels of LPL or lipoprotein lipase.

And you basically have these similar markers that are even related to each other in a very similar way, yet they're not associated with insulin sensitivity and they're also not associated with cardiovascular disease risk. And that's really what the question comes down to. And again, a very, very parallel phenomenon here as to what we see in the lean mass hyper-responder phenotype. So in conclusion here, if you're shifting over to an energy balanced approach, and let's say you're coming from a low carb diet, and you're seeing that your triglycerides have come up a little bit, your HDL has come down and your LDL has come down.

Is that a sign of cardiovascular disease risk? Is that a sign of metabolic syndrome? Is that a sign that you're doing something wrong?

And the short answer here is no. When we look at the data, when we look at the physiology, when we look at the mechanisms, that's not what's actually going on here. Instead, it's just.

The product of a shift in the metabolic state, a shift toward using more carbohydrates and less fat, shift toward downregulation of the stress hormones. And it's, in the case of insulin sensitivity, not at all associated with cardiovascular disease. Now, it's also worth mentioning the caveat. Some people are also dealing with insulin resistance, and they might start to increase their carbs and see a really significant increase in triglyceride levels. And maybe in… maybe even an increase in LDL can happen sometimes.

And often those things are more of a sign of, if they're happening when adding carbs in and bringing fat down, typically, if that's the case, that's more of a sign of insulin resistance. And we would tend to see other signs as well, like weight gain and other kind of negative effects, as opposed to the effects that we're looking for, like improved energy, sleep, digestion, reduced stress, like reduced physiological stress and all of the... kind of negative symptoms that come with it.

Those are the kind of things that we would want to see, but if we're not seeing those, and instead we're seeing a slightly different lipid profile with triglycerides far above 150 and LDL not really coming down or even going up, those are generally going to be signs that we're not actually properly shifting into the metabolic state where we're using carbohydrates well, and that's a very different situation, very different lipid profile, but representing a different metabolic state underneath. And that's a case where we do want to work on fixing. the underlying insulin resistance.

And for that, I'll point back to a couple of podcast episodes that we did prior discussing insulin resistance. Really, when we're talking insulin resistance, we're just talking about an impaired metabolic state where the body's not effectively converting the food that's coming in into energy. And when that happens, we need to consider all the possible factors that are affecting energy production. And so you can look back at those episodes, but really throughout the entire podcast, you know, all of our episodes, we talk through different factors that affect your capacity for producing energy.

We talk about endotoxin and PUFA and nutrient deficiencies and sleep issues. Tons of other factors as well, and really all of them can be culprits here. All of them are things that we want to consider. All right, so again, just to conclude here, if you're seeing an increase in triglycerides when you're raising your carbohydrate intake, especially when you're coming from a low-carb diet, that is not a sign of anything negative going on in terms of metabolic syndrome or cardiovascular disease risk, as long as, again, they're not excessively increasing, and we're confident that we're insulin sensitive, and we want to keep an eye on those markers and those indicators as well.

Alright, so with that, if you enjoyed this episode, please leave a like or comment if you're watching on YouTube. And if you're listening elsewhere, please leave a review or five-star rating. All of those things do a lot to help support the podcast and are very much appreciated.

As always, to check out the show notes for today's episode, where I'll link to the studies and articles and anything else that I mentioned, head over to jfeldmanwellness.com slash podcast. And if you are looking to optimally support your metabolism, improve insulin sensitivity, improve cardiovascular health, lose weight, improve your digestion, get amazing sleep, rebalance your hormones, boost your energy, and so much more with clear action steps and strategies alongside personalized guidance from me, then head over to jfeldmanwellness.com slash solution where you can find all of the information for the Energy Balance Solution program. This program includes customized health coaching. It includes a video library with videos on regulating blood sugar, restoring gut health, losing weight without destroying your metabolism, Boosting your metabolism, getting amazing restorative sleep, rebalancing your hormones, and tons more.

It also includes resources like a sample meal plan and supplement guide, along with many others. And also, it includes access to a private community. So head over to jfeldmanwellness.com slash solution to check out all the details. And with that, I'll see you on the next episode.

Transcript for:Understanding Carbohydrate and Lipid Health

Transcript for:
Understanding Carbohydrate and Lipid Health