Of the four values provided by a conventional cholesterol panel—total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides—it’s the last value, triglycerides, that provide the most useful and insightful information. The value with the least useful information? LDL cholesterol, the value your doctor obsesses over, having drunk the Kool Aid of Big Pharma.
Triglycerides are fat. Fats are triglycerides. This is true whether the fat is in the form of olive oil, butter, lard, fish oil or coconut oil. This led doctors to believe for many years that fat intake was the primary determinant of blood triglyceride levels. Dietary fat does indeed raise blood levels of triglycerides, but only to a minor degree and only during the first few hours after consuming a fatty meal. Start with a fasting triglyceride level of, say, 100 mg/dl, eat a meal of three eggs, bacon, all topped with butter—a high-fat meal–and blood triglycerides typically rise to 150-200 mg/dl. What they did not recognize until recently is that the human liver is capable of producing huge amounts of triglycerides sufficient to send blood levels into the thousands of milligrams per deciliter—values of 500, 1000, 2000 mg/dl— by converting carbohydrates and sugars into triglycerides, a process called de novo lipogenesis, or the liver conversion of sugars into fats. If you eat a meal rich in fats and carbohydrates and monitored blood levels of triglycerides every hour, you would see that there is an early rise in triglycerides during the first few hours due to fat absorption, then a much larger rise about 6 hours later due to liver de novo lipogenesis. (You can therefore appreciate how a fasting triglyceride value underestimates the behavior of blood triglycerides.)
I’ve previously discussed how you can send HDL cholesterol through the roof, signaling great changes in health and longevity. I related how I raised my HDL from 27 mg/dl to 94 mg/dl, while reducing my triglycerides from 350 mg/dl to 47 mg/dl. Plenty more people have done likewise following the Wheat Belly lifestyle. High triglycerides cause degradation of HDL cholesterol; low triglycerides thereby allow HDL cholesterol to persist and attain high levels.
A standard cholesterol panel therefore contains a snapshot of metabolic status as a triglyceride value obtained after an overnight fast. This value contains a ton of useful information. It is surprising that, given the conventional practice to focus only on total cholesterol (generally useless) or the calculated—not measured—LDL cholesterol value that is wildly inaccurate, the world of useful health information captured by the triglyceride value is typically ignored. So let’s talk about what you can learn from this value.
Among the keys to understanding triglycerides are several basic facts:
- Carbohydrates make a much larger contribution to fasting and after-meal triglycerides than fats due to the liver’s enormous capacity for de novo lipogenesis.
- Triglycerides are stored in human fat cells that are very active. Fat therefore serves as an active repository, constantly releasing triglycerides back into the bloodstream. This is part of the reason why overweight people have high triglyceride levels.
- Most triglycerides in the bloodstream are contained within particles called very low-density lipoproteins, or VLDL. Triglyceride-packed VLDL particles interact with other lipoprotein particles, especially LDL and HDL particles, contributing triglycerides to their structures. Triglyceride-enriched LDL and HDL particles go through changes that make them much smaller in size and change their behavior. Small LDL particles, in particular, are uncommonly persistent in the bloodstream (5-7 days, rather than the 24 hours of large LDL particles), are adherent to artery tissue, and more likely to provoke inflammation. Triglyceride-enriched HDL loses much of its protective capacity and is cleared from the bloodstream more quickly, resulting in a drop in total HDL cholesterol values.
- Triglycerides from de novo lipogenesis and body fat, in turn, block insulin, raising blood sugar and causing artery constriction/hypertension (“endothelial dysfunction”). This is why type 2 diabetics typically also have high triglycerides and hypertension, as well as high blood sugars.
- Triglycerides manufactured by the liver do not all leave as VLDL particles, as some stay in the liver, causing low-grade liver damage reflected in common liver tests, such as AST and ALT; this is called fatty liver. Fatty liver is therefore commonly accompanied by higher levels of blood triglycerides.
If you cut the fat in your diet while increasing grains and carbohydrates, the net effect will be a rise in triglycerides, sometimes substantial, from increased de novo lipogenesis. The increase in carbohydrate intake also grows visceral fat that, in turn, releases more triglycerides, sending them even higher. HDL levels drop, total and small LDL particle number increase and linger longer. Over time, blood sugar goes up, blood pressure goes up, fatty liver begins to show—a familiar scenario.
At what blood triglyceride level do these effects begin to kick in? 60 mg/dl. At a triglyceride level of 150 mg/dl, for instance, the level generally felt to be safe quoted in national guidelines, there is typically a substantial drop in HDL and its protective function, oodles of small LDL particles, and insulin and blood pressure effects—150 mg/dl is not ideal. It is also clear from clinical studies that cardiovascular risk begins to rise even with triglyceride levels in the 80-90 mg/dl range.
So how can you reduce triglycerides substantially, even achieving values of 40 or 50 mg/dl, as is common around here. Easy:
- Eat no wheat or other grains
- Manage carbohydrates–I advocate consuming no more than 15 grams net carbs per meal
- Supplement omega-3 fatty acids, EPA and DHA, from fish oil only–never krill, not flaxseed or chia. (Flaxseed and chia are excellent sources of the omega-3 fatty acid, linolenic acid, but not EPA or DHA.) The dose is 3600 mg EPA + DHA (total) per day, divided into two doses.
- Manage bowel flora–Feeding and cultivating bowel flora with prebiotic fibers/resistant starches drop triglycerides even further. Addressing SIBO can reduce triglycerides substantially likewise.
Do the above and visceral fat begins to shrink, also. In other words, follow the Wheat Belly lifestyle and triglycerides—as well as so many other health phenomena—all fall into place. In my many years of medical practice that include consulting on complex hyperlipidemias, I virtually never had to use any drugs to achieve triglyceride values of 60 mg/dl or less once I understood these phenomena.
And don’t forget that, in the midst of active weight loss and for several weeks afterwards, triglycerides can be higher than desirable, dropping after weight loss has subsided. This is because stored fat is composed of triglycerides; losing weight means you are mobilizing stored triglycerides, released into the bloodstream. This is normal and physiologic.