So today we're going to talk about part 2
of something that's significantly more important than LDL cholesterol
we'll get into the content for today part 2 of triglyceride over HDL ratio
last week we talked about triglyceride over HDL ratio
what is it why is it important and today we're going to talk about
why it's important the optimal ratio ethnicity you know you'll hear when
people start wading into the triglyceride over HDL ratio
you'll start hearing them quote numbers about well for the Latinx community for
the African-American community for the Caucasian community I'll give you a
spoiler on that one I think that part is way overdone
there's clearly patterns that we see in these different communities but we'll
talk about why I think that's way overdone again a
little bit later in the content section probably the most important part
of this though is how to naturally lower triglyceride and raise HDL if you listen
to this channel you've heard it once you've heard it a thousand times you
can't supplement your way out of a lifestyle
problem you can't procedurize surgerize
stent bypass your way out of a lifestyle issue
and you can't prescribe your way out of a lifestyle issue in other words
how can you naturally impact this and this is
the same theme the natural ways of improving your triglyceride over HDL
ratio are the best what are those we'll talk
about and how they work and can lowering carbs
improve triglyceride HDL remnant cholesterol and cardiovascular
risk brief spoiler the answer is obviously
yes and we'll talk about how so the
triglyceride over HDL ratio is important it's an important
predictor of cardiovascular disease risk and a marker of insulin resistance
that's why when people come to me and they don't have any of the
OGTT type tests or insulin resistance tests
even with a test that they usually have and that is that old cholesterol test
I can start getting some really important information
and again it's not so much about LDL here
it's about level of insulin resistance so simply put the blood triglyceride
level over your HDL as measured by a lab test
that's what this ratio is now you go back to some of the older studies
older as in a decade ago the WISE study stands for Women's Ischemia Syndrome
Evaluation or WISE 544 women were referred to
cardiovascular disease evaluation the triglyceride over
HDL ratio ranged from 0.3 to 18.4
individuals with lower triglyceride over HDL ratio
had lower cardiovascular risk and again that was one of the studies
that really started to bring this to attention it was in the American
Heart Journal the typical triglyceride over HDL cut points that you
saw then and that you see now I think are way too high but we'll talk about
that a little bit later as well the recommendations you'll see are
less than 2 is ideal and above 4 is too high I would
clearly agree with above 4 is too high in European measurements
they're talking about less than 0.87 is ideal or 0.87
millimoles per liter corresponds to milligrams per
deciliter in the US and 1.7 millimoles per liter corresponds
to 4 milligrams per deciliter in the US
I have again a little bit stricter recommendations for what is
optimal let's talk a little bit about ethnicity so
this was in a study in the by Willey associates the Northern Manhattan study
race and ethnic differences in the relationship between lipid profile
components and risk of myocardial infarction again the
Northern Manhattan study so the triglyceride over HDL ratio
appears to vary by ethnicity Hispanic Americans 3.9
non-Hispanic black 2.9 non-Hispanic white 3.3 so therefore does
ethnicity matter should we have a different cut point
for different ethnicities I don't recommend focusing on that
there are several reasons such as the fact that ethnicities are often mixed
and maybe even unknown I've got some friends that
consider themselves a walking rainbow they've got
Hispanic they've got African-American they've got Caucasian
blood all in the same person so what is that person's ethnicity so that's one
reason but there are other reasons as well the
biggest reason is that triglyceride or HDL ratio is an indicator of the health
of insulin and glucose metabolism the lower the
better we know this is the most important thing
that's killing us and disabling us on a regular basis
so let's keep an eye on that ratio not this doesn't even mention that most
of the cut points used in research as markers for prediabetes
are too high for example ratios of 2 and 3 confer
risk no matter what your ethnicity happens to be or what mixes of ethnicity
you happen to have if your triglyceride over HDL is 3
you really need to focus on getting it down and
your goals should be 1 or less the goal should be as low as possible
I recommend that my patients target 1.5 or less
and actually 1 if you can get there and I've got plenty of patients
Chuck for example who I mentioned earlier Chuck Smith
he had that heart attack and let his Tesla drive into the hospital
he had already lost 50 pounds before he had that heart attack it was on the
low-fat diet and he checked his triglyceride over HDL
found that it was varying between 5 and 7 that same
Chuck now has his triglyceride over HDL ratios
routinely below 1 so how did he do that and how can we
do that reliably first of all lose weight second
eat fewer carbs carbs have a big impact here three exercise
number four get dietary and supplemental omega-3s
there are medications that improve the triglyceride over HDL ratio
as well statins actually do sometimes they have not the greatest impact in
some of these areas but most of the time they will have like
a 10 to 20 percent improvement on triglyceride over HDL
they can lower triglycerides by as much as 50%
but usually reliably 10 to 20 percent the major impact of triglycerides
I mean of statins on the triglyceride over HDL ratio
is its impact on the triglycerides other medications that impact that
triglyceride over HDL ratio the fibrates Lopid Fibricor Tricor
prescription-strength niacin and niacin supplements
both can decrease triglycerides but also increase HDL prescription-strength
omega-3s icosapent ethyl you've heard that recently it's the
fish oil on steroids or Vascepa Epanova Lovaza
they're all prescription forms of omega-3s
and again there's a heck of a lot of supplemental forms
of omega-3s and there's a lot of dietary forms of omega-3s
I get mine from eating salmon now can lowering carbs
improve the triglyceride over HDL ratio and what about RC
and what is RC remnant cholesterol can lowering carbs improve
triglyceride over HDL ratio the remnant cholesterol and cardiovascular risk
well these studies over on the side and that we list on this page would indicate
so and I think that there's a lot more out
there than just these studies the Abbasi study is a human clinical
trial using a crossover design people ate high carbs 60% of their
calories that was their version of high carbs
for two weeks then low carbs then 40% was their version of low carbs for two
weeks and they had a washout period of two weeks in between
the high carb diet doubled triglyceride levels
tripled remnant cholesterol and lowered HDL by 15
so as you can see that was a big impact with just a moderate
change in carbs the Wang study it was a randomized clinical trial
in mice the Volek study a meta-analysis you remember a meta-analysis is where
you're looking at multiple studies it reviewed pre-2005 studies which had
already shown that low-carb diets decreased triglycerides
and remnant cholesterol while increasing HDL the Ebbeling study
it's also a human subject's clinical trial it was done at Harvard
subjects on a low carb diet had lower triglyceride
and higher HDL how much are you going to improve that triglyceride over HDL ratio
researchers also showed that the low-carb diets were less likely to
result in weight rebound due to improved energy expenditure and
leptin now let's go back and think about why
and how why is there triglyceride in the blood
the most common reason for elevated triglycerides is
prediabetes triglycerides can also become elevated in several inherited
diseases but again the vast majority of increased
triglycerides that I see are due to prediabetes how does that
happen so here we go to how chronically high
insulin stimulates adipocytes and hormone-sensitive
lipase hormone-sensitive lipase we'll talk about that what that is in just a
second we covered that some last week and this
is repetition because it's a little bit technical and
because a lot of folks on my channel have an interest
on this molecular level and how that works
so hormone-sensitive lipase that tells the
body to start breaking up fats into fatty acids this results in release of
too many fatty acids from the fat cells these excess fatty acids
take up space in high density lipoproteins
and low density lipoproteins an enzyme called
CETP cholesterol ester transfer protein facilitates the exchange of
cholesterol in large HDL and large LDL with triglycerides so in
other words what happens is you shrink and decrease your HDL
population triglyceride-enriched HDL and LDL
in turn are metabolized by hepatic liver lipase resulting in loss
of that large HDL and we covered this last
week how you look at a fractionation this is a fractionation of the HDL and
LDL components and what you should have this
is the HDL component it should look like a bell curve
normal bell curve but you have this place over on the right hand side where
major chunk was taken out that's because of this last process
where VLDLs have a lot of triglycerides in them
they transfer that CETP cholesterol ester transferase
transfers that triglyceride into the large
HDL in exchange for cholesterol that large HDL then gets metabolized
by the liver so that's why you get that big
chunk of HDL taken out so again with these high carb diets we get
increased triglycerides and as you see decreased HDL
continue to get great feedback regarding the webinars and here's why
you know on the internet when you hear a webinar you expect for somebody to try
to sell you something we're not doing that we're trying to
tell you something people are coming in with their labs from Quest
inflammation panel OGTT insulin survey response
and then they're finding out do I have inflammation do I have
insulin resistance and where does that fit in terms of other folks
we're getting ready to start one for CIMT as well
so again people are really excited about finding out
their own status looking forward to seeing you there
thanks