LDL-P Drops by 27nmol/L With Every 1% Reduction in Trans Fat Intake. Plus: "Trans-Fat Free" Does Not Mean Risk Free!

In contrast to the message "trans fats = bad". The information that cookies and bakery, not cooking oil, margarine, chips & co are the main trans fat offenders in our diet has reached only a very small group of people.

There are only few 'nutritional wisdoms' out there that are actually 'wise'. One of them is the notion that "trans-fats are bad for you". By now that's something every fifthgrader knows. What most people don't know, though, is how bad "bad" actually is and whether the small amounts of trans fatty acids, the industry is cleverly hiding in their products by downsizing them in a way that "one serving"contains less than 0.5g of transfats - that's the magic loophole in the FDA regulations according to which transfats don't have to appear on the label, as long as the total amount per serving is less than 0.5g.

The question I would like you to remember, when you read more about the most recent strudy from the Preventive Cardiology Program at the Columbia University Medical Center/New York-Presbyterian Hospital in 2013 is: 

Do those 0.5g/serving the FDA is turning a blind eye on matter?

Within the past decades, the ill health effects of transfats have been addressed by countless studies. The study at hand, however, is the first one to directly assess and quantify the influence of transfats on LDL particle number (LDL-P = particle number, not LDL-C = LDL content!).

This is not about CLA & Co: Most of you will be aware that the "bad" trans-fat this article is not about CLA, but about the trans-fats from partially hydrogenated vegetable oils and other industrially processed fats and oils. If you want to know how much trans-fats (in % of total fat) the french fries and chicken nuggets at "your" Mc Donald's or KFC contain, just take a look at the table on the left (data from Stender. 2006)

As Garshik et al. point out, compared to the standard measure LDL-C the exact number of LDL particles, i.e. LDL-P, has been found to be a superior indicator of heart disease risk compared.

"Studies have suggested that increased LDL-P leads to progression of CVD and that the predictive value of LDL-P for future CVD events is equal to or greater than more traditional lipid measurements such as LDL-C." (Garshik. 2013)

That alone is a huge plus, but guess what: M. Garshick, H. Mochari-Greenberger and L. Mosca have been working with real patients - no rodents.. ah pardon, strings attached ;-)

This is not just another rodent study

Having the advantage of actually working in a hospital, not a sterile lab setting, the researchers picked participants from the Family Intervention Trial for Heart Health (FIT Heart), a National Heart Lung and Blood Institute (NHLBI) sponsored randomized controlled clinical trial that enrolled 501 family members of patients who were admitted to the cardiovascular service of the New York Presbyterian/Columbia University Medical Center, as their subjects. In the course of a previous study, the subjects had been assigned to two different groups:

• 

  Table 1: Subject characteristics at baseline (Garshik. 2013)

  An intervention group, the members of which were invormed about the CVD risk factor screening results and education about diet and physicalactivity to prevent CVD, with regular contact and feedback by a health educator for up to 1-year, and
• A control group, that did not receive the information about their own CVD risk factor and was not part of the organized education program that did obviously include the advise to reduce your trans-fat intake as much as possible

In the course of this study the control group made similar lifestyle changes as the intervention group - despite a lack of formal information / education (Moska. 2008). The reduction in trans-fat intake, in particular, was virtually identical. Therefore, the scientists could pick any of the men and women from the original cohort, as long as there was no lack of information or implausible dietary data for the 1 year study period.

Is it bad, if you get 2.5% of your daily energy intake from trans-fats?

When all was said and done, M. Garshick, H. Mochari-Greenberger and L. Mosca ended up with a "participant pool" the characteristics of which you I've summarized in Table 1. If you stop gazing at Table 1 and take a look that the data in Table 2, you will see that the average subject consumed approximately 2.5% of his or her daily energy intake from trans-fats.

Table 2: Dietary intake (% of kcal/day) and corresponding serum lipid measures in the subjects of the Garshick study.

"Is 2.5% much?" I guess it depends on what you take as a reference. If your reference is the "average" European in the TRANSFAIR study from 1999, this is much. Only the Icelanders, who have the highest trans-fat consumption of all Europeans (2.1% of total calories) come remotely close.

The Greeks on the other hand, live up to their reputation as the fathers of the often-hailed Mediterranean Diet: With a mean trans-fat intake of 0.5% and 0.8% in men and women, respectively, they are compliant with the recommended maximal daily allowance (RDA) of 2.2g trans-fats per day (this statement is based on the assumption that their average caloric intake was 2,000kcal).

You don't have to move to Greece though, to reduce your personal trans-fat intake even further. It is, after all, another flawed urban nutrition myth that you could produce trans-fatty acids in your kitchen by heating whatever type of oil / fat you use to cook (if you never change the oil you use to fry at very high temperatures, things look different, though). Industrially produced junk... ah, pardon "food" - specifically cakes, cookies, etc. - is thus your most if not only significant source of dietary trans-fats. Eliminate those and you are good to go.

Remember: Higher baseline intake = greater relative effect size!

Figure 1: Linear associations between baseline dietary composition and LDL particle number (top) and between change in dietary trans-fat intake and LDL particle number in the course of 1-year (bottom); data based on Garshik, 2013.

Assuming that you are not the cookie monster and consume mostly fresh foods, your transfat exposure is probably much lower than 2.5% of your total calorie intake. The average reduction in LDL particle count per for each 1% of trans-fats you cut from your diet is thus most likely less pronounced than it was in the study at hand.

If we discard the effect size and focus on the general trend, the results of the Garshik study are still highly relevant for all of us; and what's more, most of us will have friends or relatives with similar transfat intakes, a low activity level, a low MUFA and omega-3 intake and way too little protein in their diets - and as Figure 1 can tell you, MUFAs, n-3s, protein and obviously exercise / physical activity are all factors that have been found to be associated with low(er) LDL particle counts and a correspondingly increased risk of arteriosclerosis and heart disease in the Garshik study (see Rosenson. 2002 & 2010; Prado. 2011 for the link between LDL-P and heart health).

Eggs are trans-fat free and heart-healthy | learn why.

So! How dangerous are those 0.5g of trans-fat in "trans-fat free" foods? If we consult the results of a 2011 study by Prado et al., symptom-free individuals with LDL-P levels in the 1953–3560 nmol/L tertile are 3.7x more likely to exhibit coronary artery calcification than those in the 620-1530 nmol/L tertile and take into consideration that the RDA for trans-fats is < 2.2g/day, it should be obvious that those 0.5g of trans-fats, i.e. ~25% of the your maximal daily allowance, are a problem we must not ignore.

If we assume that there is a linear relationship between LDL-P and trans-fat intake (obviously this is a gross simplification) and make a rough and scientifically highly questionable estimate of the consequences, we will find that those unlabeled 0.5g of transfats could boost your LDL levels from the first into the third tertile of LDL-P values in the Prado study (+by 675nmol/L).... that this would also mean that a daily dose of only 0.5g of hidden trans-fats could triple your likelihood of arteriosclerotic plaque should be obvious, right?

References: 

• Cromwell WC, Otvos JD, Keyes MJ, Pencina MJ, Sullivan L, Vasan RS, et al. LDL particle number and risk of future cardiovascular disease in the Framingham offspring study-implications for LDL management. J Clin Lipidol 2007 Dec;1(6):583-92. 
• Cromwell WC, Otvos JD. Low-density lipoprotein particle number and risk for cardiovascular disease. Curr Atheroscler. Rep 2004 Sep;6(5):381-7.
• Garshick M, Mochari-Greenberger H, Mosca L. Reduction in dietary trans fat intake is associated with decreased LDL particle number in a primary prevention population. Nutr Metab Cardiovasc Dis. 2013 Oct 4.
• Hulshof KF, van Erp-Baart MA, Anttolainen M, Becker W, Church SM, Couet C, Hermann-Kunz E, Kesteloot H, Leth T, Martins I, Moreiras O, Moschandreas J, Pizzoferrato L, Rimestad AH, Thorgeirsdottir H, van Amelsvoort JM, Aro A, Kafatos AG, Lanzmann-Petithory D, van Poppel G. Intake of fatty acids in western Europe with emphasis on trans fatty acids: the TRANSFAIR Study. Eur J Clin Nutr. 1999 Feb;53(2):143-57. Review.
• Mora S. Advanced lipoprotein testing and subfractionation are not (yet) ready for routine clinical use. Circulation 2009 May 5; 119(17):2396-404. 
• Mosca L, Mochari H, Liao M, Christian AH, Edelman DJ, Aggarwal B, et al. A novel family-based intervention trial to improve heart health: FIT Heart: results of a randomized
  controlled trial. Circ Cardiovasc Qual Outcomes 2008 Nov; 1(2):98-106.
• Prado KB, Shugg S, Backstrand JR. Low-density lipoprotein particle number predicts coronary artery calcification in asymptomatic adults at intermediate risk of cardiovascular disease. J Clin Lipidol 2011 SepeOct;5(5):408-13.
• Rosenson RS, Otvos JD, Freedman DS. Relations of lipoprotein subclass levels and low-density lipoprotein size to progression of coronary artery disease in the Pravastatin Limitation of Atherosclerosis in the Coronary Arteries (PLAC-I) trial. Am J Cardiol 2002 Jul 15;90(2):89.94.
• Rosenson RS, Davidson MH, Pourfarzib R. Underappreciated opportunities for low-density lipoprotein management in patients with cardiometabolic residual risk. Atherosclerosis 2010 Nov; 213(1):1-7. 
• Stender S, Dyerberg J, Astrup A. High levels of industrially produced trans fat in popular fast foods. N Engl J Med. 2006 Apr 13;354(15):1650-2.

Beyond Nitric Oxide II: Arginine & Citrulline Modulate Blood Lipids & Liver Fatty Acid Composition And Ameliorate Aortic Lipid Deposition in High Fat Fed Rats

Image 1: The mouse on the left probably
had too little arginine in its high fat diet
(just kiddin' ;-)

This is a follow up not on yesterday's third, but on the second installment of the Amino Acids for Super Humans series on Carl Lenore's Super Human Radio. In that episode I had already alluded to the metabolic benefits of arginine and citrulline supplementation, which reach far beyond their purported use as ergogenic aids and nitric oxide booster. A very recent study (El Kirsh. 2011) published a week ago ahead of print in the online issue of Cell Biochemistry & Function confirmed and expanded on the results of previous studies which showed beneficial effects on parameters of organ (specifically heart and liver) in rodent models.

6 groups of rats fed either a normal diet or the dubious "high fat" diet, scientists use to induce obesity along with the characteristic symptoms of the metabolic syndrome (insulin resistance, arteriosclerosis, etc.) were fed one of the following diets:

• group 1: normal food, no supplement
• group 2: normal food, arginine (100mg/kg; human equivalent 16mg/kg)
• group 3: normal food, citrulline (100mg/kg)
• group 4: high fat diet (HFD), no supplement
• group 5: high fat diet (HFD), arginine (100mg/kg)
• group 6: high fat diet (HFD), citrulline (100mg/kg)

Both the negative effects of the high fat diet, as well as the ameliorative effects of arginine and citrulline on serum transaminase levels (indicators of liver "activity" /high levels are mostly interpreted as signs of liver damage), triglycerides, cholesterol levels and indices of atherosclerosis were profound:

HFD feeding increased significantly serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT) activities, urea and all lipid profiles and decreased significantly serum high-density lipoprotein-cholesterol (HDL-c) and non significantly serum nitric oxide levels. L-arginine or L-citrulline administration reversed the increase in serum AST and ALT activities, urea and all lipid profiles.

As it can be seen in figure 1, the positive effects of arginine and citrulline even went beyond the mere amelioration of the detrimental effects of the high fat diet by increasing HDL-c and nitric oxide levels, decreasing the count of dangerous V-LDL particles even compared to normal diet and modulating the relative percentages of 18 : 0, 20 : 0 and 22 : 6 to 16 : 0 fatty acids in the livers of the rats on the high fat diet.

Figure 1: Triglyceride and cholesterol levels of rats fed normal chow (control) and rats on a high fat diet (HFD) supplemented with either arginine (HFD+Arg) or citrulline (HFD+Cit) (data adapted from El Kirsh. 2011)

Moreover, the beneficial effects on heart health that are generally ascribed to such improvement in blood and tissue markers could actually be confirmed by light and transmission electron microscopic images of the thoracic aorta. While the HFD group that did not receive supplemental arginine or citrulline "demonstrated structural changes in the endothelial cells of the intimal layer, medial smooth muscle cells as well as in the adventitial layer", there was only "little structural alterations in animals supplemented with L-arginine or L-citrulline along with HFC feeding".

Taken together, these and the results I reported in the aforementioned episode of Amino Acids for Super Humans should well be able to change your perspective on your favorite pre-workout product forever - even if it does not give you the pump the fancy ad you saw when you bought it promised, it may well save your organs from the consequences of one or another dietary faux pas. I hope, I do not have to tell you, though, that it would border on or rather be plain nutritional idiocy, if you used arginine and citrulline to make up for the consumption of the famous westernized high fat, high carb, low protein fast food diet (which would be similar to the HFD the rats consumes)!

Too Much of a Good(?) Thing: When Fish Oil Starts Clogging Your Arteries and Fattening Up Your Liver.

If you are no regular visitor of the SuppVersity, I guess, you are religiously taking your (high dose?) fish oil, day in day out. So what? It probably lowers your total and low density cholesterol (LDL-C; it may reduce your triglycerides and thus improve your insulin sensitivity. Yet, in doing all those "great" things, the unmetabolized and peroxidized remainder of everyone's favorite wonder-supplement begin to clog your arteries and liver - at least, if you believe in the validity of that kind of rodent studies which suggested the usefulness of fish oil, in the first place.

Image 1: Micrograph of non-alcoholic fatty liver disease, caused by the same kind of lipid accumulations
Shirazi et al. observed in the rats receiving fish oil treatment (image by Nephron)

Shirazi et al. (Shirazi. 2011) recently published a paper reporting exactly that: "Fish oil increases atherosclerosis and hepatic steatosis, although decreases serum cholesterol in Wistar rat" - The scientists had fed two groups of pregnant rats (and, after birth, their offspring) with either a fish oil containing or a standard, soy oil based diet. Both diets had the same overall fat content of 70 g/kg (according to standard AIN93-G recommended by American Institute of Nutrition). In terms of total calories, the diets thus contained 15.9% of the total energy in form of either fish or soy oil. The overall omega-3 to omega-6 ratios of the diets were 6:10 for the fish oil and 1.1:10 for the soy bean oil groups; where omega-3 in fish oil came from EPA and DHA, while the omega-3 content in the soy bean oil diet came from alpha-linoleic acid (ALA).

Image 2: In the aorta of rats on a diet rich in fish oil, fatty streaks like that
formed in the aortae (image source www.heartsite.com)

After 70 days the rats were killed and hepatic and aortic specimen were analyzed. The results are unsettling:

[...] fatty streak in fish oil fed pups were significantly more than that in the other group. [... liver] ductular cell hyperplasia in pups fed with fish oil was significantly more than that in animals fed with standard diet. There was a positive relationship between fatty streak in aorta and ductular hyperplasia in liver (r = 0.470 and p= 0.037)

Although the animals had free access to food (ad-libitum feeding) the pathological changes cannot be a consequence of differing calorie intakes. Both groups consumed roughly 16g of the respective diet. According to Shirazi et al., a feasible explanation for these observations and their inconsistency with previous studies by Saraswathi et al. (Saraswathi. 2009), Bringhenti et al. (Bringhenti. 2010), Zampolli et al. (Zampolli. 2006),and Casós et al. (Casos. 2008) would be the lower total amount of dietary fish oil, different (more varied) overall fat compositions of the diets and shorter study periods, respectively:

One possible explanation for this discrepancy is that in our study animals faced higher amounts of dietary fish oil; Saraswathi et al. used 209 g/kg of mixed oils (including coconut oil, olive oil, corn oil and soy bean oil) plus 60 g/kg fish oil, while we used 70 g/kg fish oil which was the only dietary fat source. The dosage of fish oil used in Zampolli et al. and Casós et al. studies were 1% and 5%, respectively, which was lower than 15.9% used in the present study. In the study performed by Bringhenti et al. animals were fed with fish oil containing diet from weaning till puberty which is a shorter period comparing to ours.

On the other hand, the results of this study stand in line with those of Ritskes-Hoitinga et al. (Ritskes-Hoitinga. 1998), Verschuren et al. (Verschuren. 1998) and Brenner et al. (Brenner. 1990), which, in parts (e.g. Ritskes-Hoitinga) observed even more severe  aortic atherosclerosis and hepatic steatosis than Shirazi and his colleagues. [ Something to think about: Isn't it telling that all those studies have been published before the fish oil craze? And before GlaxoSmithKline started making big bucks by selling is "pharmaceutical grade fish oil" Lovaza. Add to that the fact that Shirazi et al. obviously did not find an American publisher for their study and make up your own thoughts. ]

So what? In essence these results only confirm what I have been saying before. Supplementation with reasonable amounts of fish oil (~2g) may make sense, especially if your diet is naturally low in omega-3 fatty acids in general and DHA, in particular. Mega-dosing on the other hand, or trying to compensate for fatphobia by overconsumption of fish oil, i.e. consuming a low- to no-fat diet, while supplementing huge amounts of fish oil >5g), falsely believing that you would do your body a favor by providing him exclusively with the "good essential fatty acids", will do more harm than good. After all, the "best" (do we really think low total cholesterol is good) serum cholesterol and triglyceride levels are useless, if you die from clogged arteries and a liver defect.