April posted this question about high triglycerides. High triglycerides are very confusing to many people, often even ignored by many of my colleagues. Because she got such lousy advice from her doctor and because the solutions are really SO simple, I thought I’d relate her story with the advice that really works.
I had blood work done last week after experiencing some edema in my feet and legs. My non-fasting triglycerides were 600 mg/dl and the doctor wants to put me on gemfibrozil and do a HbA1c to rule out diabetes. I want to try Wheat Belly first before taking the meds. Is that reasonable?
He told me I need to start the medicine right away or I am at risk of pancreatitis. I am about 100 pounds overweight, so I obviously need to make some dietary changes. This is kind of scary stuff to me. I was told other than the triglycerides my cholesterol was ‘OK.’ My vitamin D was also very low at 13 ng/ml so I was given a prescription of D3 (50,000 I.U.) for 12 weeks. I just really don’t want to start a medication like the gemfibrozil without at least giving diet a chance.
April likely has “Familial Hypertriglyceridemia,” a genetically-determined abnormality in which she is unable to clear triglycerides formed from diet. We know several things based on the facts provided by April:
1) Potential for pancreatitis really shows itself at around a triglyceride of 1000 mg/dl. This is very bad: Not only is it very painful, but it can do irreversible damage to the pancreas, both endocrine (killing off beta cells that produce insulin) and exocrine (killing off the cells that produce digestive enzymes like pancreatic lipase and trypsin). But a low-grade, imperceptible degree of beta cell damage can occur at triglyceride levels below 1000 mg/dl, sufficient to impair insulin responses and bring the prospect of irreversible type 2 diabetes closer.
2) While fats and oils are, by definition, triglycerides, a much larger contributor to blood triglycerides is the process of de novo lipogenesis: liver conversion of sugars and carbohydrates to triglyceride-containing lipoproteins. You can see this with extended monitoring of blood triglycerides: After a meal of mixed composition (fats/oils, proteins, carbohydrates, fibers), there is a modest initial rise in triglycerides at 2-4 hours, followed by a much larger rise 6-8 hours, the time lag represented by liver de novo lipogenesis from carbohydrates. High triglycerides are therefore largely caused by grains and sugars.
3) High triglycerides can be made worse by insulin resistance/pre-diabetes/diabetes. On this issue, April’s doctor was correct: Look for diabetes: Fasting glucose and HbA1c (reflecting the last 90 days of blood sugars) will almost certainly be high, given the excess weight. Conventional answer: prescribe metformin and a low-fat diet. My answer: Go berserk on diet to reduce both blood sugar (and HbA1c) and triglycerides: NO grains, NO sugars; don’t worry about fat but have MORE of it.
4) Gemfibrozil? This is a drug from the fibrate class, but similar to statin drugs in side-effects. It can reduce triglycerides 100-200 mg/dl, rarely more, so it’s not a complete answer. And it has little benefit beyond this.
5) Fish oil–If there is an agent that reduces triglycerides, it’s the omega-3 fatty acids from fish oil, EPA and DHA. However, higher doses are required, e.g., 3600 mg EPA + DHA per day, divided into two doses. Omega-3 fatty acids activate the enzyme, lipoprotein lipase, that is responsible for clearing triglyceride-containing lipoproteins from the bloodstream. Ideally, this should come in the form of liquid triglyceride fish oil, such as that from Ascenta NutraSea or Nordic Naturals, not the stuff from big box retailers that comes in capsules as the less well-absorbed ethyl ester form. It should certain NOT be the prescription form, Lovaza, as this is a big ripoff, plain and simple. (It represents a loophole in FDA regulations in that a company who can spend the money to gain FDA approval for a health indication can take something in the public domain and give it the veneer of a “drug” while charging drug-like prices for it–typical monthly cost: $300–provided physicians can be persuaded to prescribe it. There is NO analysis showing superiority over, say, Sam’s Club fish oil for $18.99 for triple-strength capsules with 900 mg omega-3s.) And it should not be krill oil, a trivial source of EPA + DHA, nor linolenic acid from flaxseed or chia. (These are fine foods, but not for reducing triglycerides.)
6) Correct vitamin D deficiency–At 13 ng/ml, April is woefully deficient. While correcting vitamin D deficiency does not reduce triglycerides per se, it can improve insulin responses and indirectly reduce triglycerides. The dose of D3 or cholecalciferol–the HUMAN form–is likely to be something like 10,000 units per day, the dose required to raise her 25-hydroxy vitamin D level to 60-70 ng/ml. (The prescription form is usually D2 or ergocalciferol, the MUSHROOM form, that is inferior in effect and duration. I don’t believe any mushrooms read this blog. There is a prescription D3, but it is not usually prescribed.)
This approach is uniformly effective. While gemfibrozil reduces triglycerides but achieves little else, the above approach also:
–Achieves weight loss–especially from visceral fat stores
–Reduces blood sugar–often sufficient to reverse diabetes
–Reduces appetite–since you lose the gliadin-derived opiates that stimulate appetite
–Reduces inflammation–because you lose the gliadin-induced abnormal intestinal permeability
–Improves gallbladder function–because you lose the lectin of wheat that blocks cholecystokinin, the hormone that stimulates the gallbladder
–Improves bowel flora–since the disruptive effects of gliadin, wheat germ agglutinin, and amylopectin A are removed.
–Improves a long list of other individual wheat-related phenomena
Target triglyceride level? I aim for 60 mg/dl or less, the level that we KNOW is associated with complete relief from abnormal triglyceride-related phenomena.