Tag Archive for: triglycerides

Food or Supplements? Yes!

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The results of the polyphenol study examining the impact on cardiovascular (CVD) risk factors were mixed. Here’s what the researchers found:

  • Neither the polyphenol-rich foods (berries, spices, herbs, teas, nuts, seeds, etc.) nor extracts had a significant effect on LDL- or HDL-cholesterol, fasting blood glucose, IL-6, and C-reactive protein.
  • When looking at the studies using polyphenol-rich food, there was a significant decrease in systolic and diastolic BP.
  • The polyphenol extracts had a significant effect on total cholesterol and triglycerides and had a greater reduction of waist circumference.
  • However, when both whole-food polyphenols and polyphenol extracts were used together, there was a significant reduction in systolic BP, diastolic BP, endothelial function, triglycerides, and total cholesterol.

The Upside

Polyphenols in foods and supplements were effective in reducing risk factors for CVD, both independently and when combined. This wasn’t a seminal paper that changes approaches to nutrition forever, but there were benefits. I think that’s something that was needed. It supports what my approach has always been: eat as healthy a diet as you can, and fill in the nutritional gaps with supplements.

The Problems

There were several issues. The studies included in the meta-analysis had little cohesiveness as to subjects used, sources of the foods, or the type of supplements; some used capsules while others used juices or drinks.

The issue with foods, among many, is the digestion and absorption of the active polyphenols. There’s competition with other nutrients and then the issue of the microbiome—is it functioning properly in every subject?

The issue with supplements, besides the delivery system, is whether the dose is appropriate or therapeutic. Would the amount of quercetin found in apples be the correct dose, or would you need to eat 10 apples? Would it respond the same way in the body isolated from the other polyphenols, or would another factor come into play?

The Bottom Line

In spite of its flaws, I think this study was fantastic. It demonstrated that nutrients extracted from foods can be effective in reducing CVD risk. It demonstrated that foods alone aren’t the answer and neither are supplements; it’s their use in a complementary fashion where the benefits may be found. The researchers set the stage for putting more effort into nutrition research, because there’s so much we don’t know. Yet. Until then, your best bet to support your health is to eat your vegetables and fruit, add herbs and spices, munch on seeds and nuts—and then supplement your diet with quality supplements.

What are you prepared to do today?

        Dr. Chet

Reference: https://www.sciencedirect.com/science/article/pii/S2161831323000029

It’s Still All About the Calories

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The keto vs. Mediterranean diet study was interesting for a variety of reasons. The researchers deserve a lot of credit for even attempting to try a study of this magnitude; 40 subjects may not seem like a lot, but to provide food via delivery together with instructions on preparation is very expensive and labor intensive. It should be noted that a portion of the study took place during the lockdown phase of COVID-19; that delayed some testing, but to their credit, the subjects affected continued the particular diet they were on for the two weeks until testing could be scheduled. Here are my thoughts on the results.

Blood Lipids

  • Subjects on the keto diet showed a greater decrease in triglycerides (TG) than those on the Mediterranean diet.
  • On the other hand, those on the Mediterranean showed a greater decrease in LDL-cholesterol than did the keto diet subjects.

While the researchers discussed it at length, I don’t think it was relevant. All subjects began with average fasting TG in the normal range. While both diets decreased TG, that the keto diet reduced it slightly more isn’t earth shattering when you start at a normal reading.

The same holds true for the LDL-cholesterol. Yes, the Mediterranean diet reduced it while the keto diet increased it, but the net was 6 mg/dl over the initial readings. What could have been concluded was that neither diet reduced LDL-cholesterol by an amount that was clinically meaningful.

The Microbiome

There were no tests of the changes in the microbiome under each diet reported—at least not yet. Subjects had a definite decline in fiber intake, especially when they provided their own food in the keto diet. The Mediterranean diet saw an increase in fiber intake when subjects provided their own food.

Why mention this at all? The microbiome controls the initial processing of nutrients. In addition, the immune function begins in the gut. While the keto diet may have provided some benefit related to HbA1c, at what cost? We simply don’t know. What we do know based on other research is that the lack of fiber changes the probiotic content of the microbiome.

The Bottom Line

The data showed that the subjects averaged 200 to 300 fewer calories per day regardless of diet and maintained the reduction over both diets. They ate better, they ate less, and they lost weight.

I think this study was important because it leaves us with better questions to ask in the future, such as: how would health measures be affected if subjects reduced calories another way? It also proves what I’ve been saying for years. The average weight loss after the study was 13 to 17 pounds, and that was maintained during the follow-up period. This was not a weight loss study, yet regardless of the initial diet, the subjects lost weight. I’ve said it before and I’ll say it again: regardless of the type of diet, it’s still all about the calories.

What are you prepared to do today?

        Dr. Chet

Reference: AJCN doi.org/10.1093/ajcn/nqac154

How the Quality of Your Diet Changes Your Mycobiome

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In the experiment I told you about on Tuesday, the researchers established that environment—exposure to light, temperature, and other environmental factors—affects the microbiome, including the fungi or mycobiome. The researchers then tested the changes in the mycobiome (the fungus part of the microbiome) after feeding the mice a highly processed diet compared with mice eating conventional mice chow. They also monitored changes in body composition, triglycerides, and other hormones related to obesity.

After eight weeks on the highly processed diet, there were differences in the quantity of fungi. Some groups of related organisms increased while others decreased. Because not every group has known roles in digestion and metabolism, the researchers examined metabolic changes in response to the dietary change; they found an increase in body fat and triglycerides in the male mice along with concurrent changes in hormones that signified a move toward prediabetes. (For some reason, the female mice in this species are protected from those effects.)

After examining the composition of the highly processed chow, I’d like to have seen one more group of mice in the experimental group. Because the highly processed chow had no fiber, it would have been helpful to see what would happen to the entire microbiome if the amount of fiber was the same in the processed chow as the conventional chow. Maybe it wouldn’t have impacted the fungi at all, or the change could have been significant.

The Bottom Line

What lessons can we learn from this study? We’re not mice after all. I think it means that a highly processed, highly-refined carbohydrate diet may cause undesirable changes in our microbiome, including the fungal levels as well. For example, Candida albicans is a primary fungus in our digestive system, but it can cause all kinds of problems if it gets out of control. Reducing refined carbohydrates has a beneficial impact on keeping that fungus at beneficial levels.

Regardless of your current age, a better diet is part of Aging with a Vengeance. Reducing processed food, especially carbohydrates, can benefit your microbiome and all that it impacts. Time to start now.

What are you prepared to do today?

        Dr. Chet

Reference: Comm Bio (2021).4:281 https://doi.org/10.1038/s42003-021-01820-z

Research Update on Prescription Fish Oil

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Let’s begin by taking a look at the prescription fish oil supplement medication. To review, this is a 100%-EPA fish oil that received FDA approval in December of 2019. The amount prescribed for people with high triglycerides is four grams of highly processed fish oil per day. Data from the REDUCE-IT trial suggested that there was a 25% decrease in mortality in the experimental group compared with the control group.

The current trial was called the EVAPORATE trial: Effect of Vascepa on Improving Coronary Atherosclerosis in People with High Triglycerides Taking Statin Therapy. The study began with 80 men and women, ages 30-85, with greater than 20% blockage in at least one of their coronary arteries, elevated triglycerides, and taking statin therapy; 68 subjects completed the 18-month study. The primary endpoint was to see if there was any reduction in plaque buildup in the coronary arteries.

The subjects in the prescription fish oil group saw a 17% decrease in overall arterial plaque; there was a plaque increase in the placebo group. The researchers did not track cardiovascular events or mortality in this study. We’ll take a look at the OTC fish oil supplement study on Saturday as well as determine the clinical significance of each trial.

What are you prepared to do today?

        Dr. Chet

References:
1. European Heart Journal (2020) 00, 1–8 doi:10.1093/eurheartj/ehaa652
2. https://doi.org/10.1016/j.mayocp.2020.08.034

Research Update: Fish Oil and Heart Disease

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The prescription fish oil Vascepa has been approved since December of last year. The fish oil medication was originally intended for those who had a family history of high triglycerides of 500 mg/dl or greater. In the approval process, the recommendation was lowered to those whose triglycerides were at least 150 mg/dl and who were taking a statin medication. But the research hasn’t stopped.

Research on Vascepa as well as over-the-counter (OTC) fish oil supplements continues. From the pharmaceutical perspective, more research on the use of the medication could result in an increase in the potential applications of this pharmaceutical. From the dietary supplement perspective, research may help establish the efficacy of using fish oil dietary supplements instead of the prescription medication

Last week within one day of each other, studies on prescription fish oil and fish oil supplements were published that both demonstrated significant benefits. We’ll review those studies the rest of the week and see if we can find out whether fish oil dietary supplements match up with pharmaceutical fish oil. If you want a preview of the studies, check the references below; they’re both open access.

What are you prepared to do today?

        Dr. Chet

References:
1. European Heart Journal (2020) 00, 1–8 doi:10.1093/eurheartj/ehaa652
2. https://doi.org/10.1016/j.mayocp.2020.08.034

Prescription Fish Oil: Questions Remain

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The REDUCE-IT clinical trial formed the basis for the expanded recommendations for use of Vascepa, the prescription fish-oil medication. This was an expensive trial, involving 11 countries and hundreds of medical centers with 999 physicians who recruited subjects, collected data, and kept track of the subjects for close to five years. With over 8,000 subjects, this was no easy task. As I said in Thursday’s Memo, they examined the primary and secondary prevention when the medication is taken with statins versus a placebo with statins.

While this was a tremendous effort, there are still some concerns, in my opinion.

Study Concerns

A board made up of physicians and the pharmaceutical company’s staff designed the study and helped execute it; the pharmaceutical company paid for the clinical trial, collected and managed the data, analyzed the data, and interpreted the results. Then the statistics were reviewed by an independent statistician. This creates a huge conflict of interest regardless of safeguards that may have been put in place.

When any type of study is supported by companies with vested interests in the outcome, there will always be questions. That has been true for every dietary supplement manufacturer that’s ever funded a study as well as the milk and sugar industry. It’s especially true for this study. I began by talking about a report from the financial sector. Billions of dollars are on the line. That has to be considered by the FDA before final approval is given.

I have a tendency to have faith in science, as skeptical as I may be at times. And that’s where my concerns lie; not in the financial aspect but in the study design and results.

My Concerns

As complicated as this study was, it was incomplete in my opinion. They did not collect any data on the subjects’ diet; a small change in diet could have reduced triglycerides (TG) enough to have a positive impact on secondary outcomes. The median change in TG over five years with the medication was 45 mg/dl, from about 215 down to 170 in the medication group, while it was reduced 13 mg/dl in the placebo group. We don’t know whether a group that focused on dietary changes to reduce TG would have the same reduction in CVD events; that would have been an excellent addition to the study design.

They also didn’t have a group using fish oil from dietary supplements. True, it’s not their responsibility, but we can’t know whether the same benefit might not occur if the dosing of EPA were equal:

  • Almost every study that has used fish oil to examine whether CVD outcomes could be reduced has used fish oil with 1 gram of EPA.
  • If the amount of EPA were the same, a head-to-head comparison between a supplement and medication that each had 4 grams EPA might have found a similar benefit.

The real issue is that we don’t know what makes the fish-oil medication work, just like we don’t know completely how dietary omega-3 fatty acids work. Is it just the reduction in the TG or how the oils work in the body? Are genetics involved? Diet? The microbiome? We have no idea at this time.

The Bottom Line

I’ll keep on eye on the approval process for this fish-oil pharmaceutical and let you know how it will be prescribed in the future. The decrease in TG found in the study can be done with lifestyle changes alone, so is it going to be worth the cost of a pharmaceutical for a slight reduction in CVD events? Remember the difference between medication and placebo was just 4.8%. If you fall in that category, you’ll have to decide for yourself: pharmaceutical fish oil or lifestyle change. In this case, a little work may go a long way.

What are you prepared to do today?

        Dr. Chet

P.S. This will be the last Memo until after Thanksgiving. Paula and I are doing something we haven’t done in 20 years: go on a real vacation, just us, just for fun. No work of any type. Talk to you again December 3.

Reference: N Engl J Med 2019;380:11-22. DOI: 10.1056/NEJMoa1812792.

Should You Try Prescription Fish Oil?

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The final marketing point that the prescription fish oil supplement makes is that the DHA omega-3 fatty acid found in many heart healthy fish oil blends may raise LDL-cholesterol. That’s the cholesterol, known as the lousy cholesterol, associated with an increased risk of cardiovascular disease.

Based on the studies I read, there may be a small increase in LDL-cholesterol in some studies. What they fail to mention is that there’s more than one type of LDL-cholesterol. The small, dense LDL cholesterol has been shown to be associated in CVD even when LDL-cholesterol is in the normal range; the large and fluffy LDL-cholesterol seems to have no relationship with CVD. The supplement fish oils that contain DHA seem to raise only the large LDL-cholesterol. That has led other researchers to call the effect of fish oil on LDL to be cardioprotective at best and benign at worst.

The Issues with the Marketing of Rx Fish Oil

Every company wants to put their best foot forward and prescription fish oil is no different. In reviewing the marketing materials as well as the research, here are my concerns:

  • The results of the studies they cite show a decrease in triglycerides of 33%. The mean level of triglycerides in one of the studies was about 660 mg/dl. That means it dropped the mean level to 440 mg/dl. While statistically significant, there’s no way to know whether that’s clinically significant in reducing the overall risk of CVD because the studies were so short.
  • The company clearly states that this medication is clinically relevant only to people with triglycerides greater 500 mg/dl; that’s a very small percentage of patients who may have familial high cholesterol. For the typical person with high triglycerides, this medication is not appropriate. That doesn’t mean it’s illegal to prescribe it for people with triglycerides between 250 and 500, but there’s also no evidence that it’s better than a change in diet or exercise. Will it be prescribed only for people with high triglycerides? We’ll see.
  • The company did not run comparative studies against fish oil supplements or with diet and exercise alone. Seems like that would be obvious.
  • Finally, while there are programs to get this medication for lower prices, I checked with my prescription plan and the cost would be $375 per month. For that kind of money, you can have someone prepare healthy meals specifically designed to reduce your triglycerides or take a class to learn to prepare them yourself; you could definitely join and inexpensive gym and buy more fresh fruits and vegetables.

The Bottom Line

Similar to statin medications when they were introduced decades ago, prescription fish oil should be limited to a very specific part of the population with familial high triglycerides. That’s all—no one else.

As for fish oil supplements, the issues they point out in their marketing material are not significant. You never use dietary supplements to treat any disease, but that doesn’t mean they can’t help you compensate for nutritional deficiencies. There will be a difference in the quality of any supplement so make sure you choose a quality manufacturer.

For the bulk of the population to reduce their triglycerides, reducing refined carbohydrates, saturated fats, and alcohol, increasing vegetable and fruit intake, and getting some exercise will help most. Like I always say: Eat better. Eat less. Move more.

What are you prepared to do today?

        Dr. Chet

References:
1. http://dx.doi.org/10.1016/j.atherosclerosis.2016.08.005.
2. J Clin Endocrinol Metab. 2018 Aug 1;103(8):2909-2917.
3. Am J Clin Nutr. 2004 Apr;79(4):558-63.

Fish Oil: Medication versus Supplements

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Before I address the concerns about fish oil supplements put forth by the Vascepa® prescription omega-3 website, it’s important to understand that all prescription and over-the-counter medications have been approved by the U.S. Food and Drug Administration (FDA). That means they have spent a significant amount of money—sometimes over $1 billion—to prove that the treatment claims are significant, and you can’t take that away from them. But marketing is a different story, so let’s look at what they say.

“Fish oil supplements are not FDA-approved.” True; no dietary supplement is FDA-approved, but that doesn’t mean they’re not regulated. They also can’t make claims about curing diseases.

“Daily dose could require 10 to 40 capsules to equal the prescription EPA omega-3.” That depends on the brand purchased, so that critique is weak.

“Fish oil supplements can leave a fish-y aftertaste.” Really? It’s fish oil, what would you expect? (Keeping the supplements in the refrigerator may help with that as well as taking fish oil before meals.) They suggest that the oils turn rancid and that causes the taste, but they offer no proof of that claim.

The last critique they make of fish oil supplements is that “Many contain another omega-3 fatty acid called DHA.” They say DHA can raise LDL cholesterol. I’ll address that claim and provide some concerns I have with the prescription omega-3 and how it’s being marketed on Saturday.

What are you prepared to do today?

        Dr. Chet

Treatment for High Triglycerides

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Hypertriglyceridemia, the medical term for high triglycerides, is a risk for cardiovascular disease. Recently I spotted a health headline from a medical newsletter that read “Omega-3 Fatty Acid Medications Can Boost Cardiovascular Health.” The word that caught my attention was “medications” so I checked it out.

The article described the benefits of recently approved medications based on marine omega-3 fatty acids. I checked out the latest one called Vascepa®. This is a purified form of fish oil that, according to the data on its website, can lower triglycerides up to 33%. Sounds impressive.

Back to the newsletter article: the author interviewed the lead author of a review paper that stated that prescription omega-3s are effective in lowering high triglycerides. Then she went on to say to avoid omega-3s from dietary supplements because they haven’t been proven to lower triglycerides as the prescription omega-3s have.

The website for Vascepa went a lot further in criticizing omega-3 supplements. What were their objections? Is a prescription the best way to go to treat hypertriglyceridemia? That’s what I’ll cover the rest of this week.

What are you prepared to do today?

        Dr. Chet

Reference: https://www.medicalnewstoday.com/articles/326146.php