Wednesday, December 23, 2009

Half-hearted Atkins diet and cardiovascular disease

I would like to comment on a recent article comparing the Atkins, Ornish and South Beach diets (Miller et al., 2009; full reference at the end of this posting), which has been causing quite a lot of commotion among bloggers recently. Especially low carb. bloggers.

An excellent post by Michael Eades clarifies a number of issues with the study, including what one could argue is the study's main flaw. Apparently the study compared a half-hearted Atkins diet, with probably equally half-hearted Ornish and South Beach diets.

I refer to the study's Atkins diet as half-hearted because it seems to rely on a daily consumption of between 120 and 180 grams of carbohydrates. This is unlikely to lead to ketosis, the cornerstone of the Atkins diet, where the body uses ketone bodies (made from dietary as well as body fat) as a source of energy.

As I see it, the main findings of the study were that the participants in the half-hearted Atkins diet, after a period of 4 weeks on the diet, and when compared with the participants in the other diets, had: (a) greater levels of total cholesterol and LDL cholesterol, with only a small improvement in their HDL cholesterol and triglycerides levels; and (b) greater levels of markers for inflammation (e.g., C-reactive protein).

The participants were young and healthy. Their average age was 30.6 years, and their average body mass index was 22.6. On average, their total cholesterol was 184.9 mg/dL, triglycerides were 78.1 mg/dL, LDL cholesterol was 107.2 mg/dL, and HDL cholesterol was 62.2 mg/dL. These are arguably fairly healthy numbers; although quite a few doctors might want to put most of these folks preventively on statins because of their LDL being greater than 100.

What I find interesting about this study, and consistent with both my own experience and also a theory that I have, is that it suggests that a low carb. diet has to really be low carb. in order to bring about the benefits that one normally sees as a result of a diet that induces ketosis. A diet with, say, > 150 g of refined grains per day, is not really a low carb. diet.

Again, in my experience, and that of many other people, a truly low carb. diet (very low in, if not devoid of, refined carbs and sugars), will lead to an impressive increase in HDL cholesterol (especially for those who have low HDL to start with), an equally impressive decrease in triglycerides, increased insulin sensitivity, and possibly a decrease in LDL.

However, a half-hearted Atkins diet may actually lead to elevated LDL (of the small-dense type), and more inflammation, just like this study suggests it does, without the benefits regarding HDL and trigs. The reason is that the still relatively high level of carbohydrate intake, especially if it comes in the form of refined carbs. and sugars, will lead to higher levels of insulin being secreted into the bloodstream. This will promote increased body fat deposition. The extra saturated fat being consumed will be turned into body fat, and not used as energy, starving the cells and leading to increased hunger.

A diet rich in saturated fat may indeed be bad when it is also a diet even moderately rich in insulin-boosting, easily digestible carbs. This may be one of the main reasons why there have been so many studies in the past showing a correlation between saturated fat consumption and heart disease; studies that typically did not control for carbohydrate consumption.

In a recent interview on the Livin' La Vida Low-Carb Blog, Dr. John Salerno goes into more detail regarding this issue, recommending a much more rigid adoption of the Atkins diet than many think is okay. (In fact, I often talk to people who think that if they cut a very high carb. intake in half - e.g., from 400 to 200 grams per day - replacing the carbs with fat, they will be halfway into a full blown Atkins diet.) Dr. Salerno has worked in the past with Dr. Atkins. He calls his diet the Silver Cloud Diet. I am not sure I agree with all that Dr. Salerno had to say, but his argument in favor of a diet very low in carbs. does make sense to me.

Finally, I think that it is dangerous to extrapolate the results of any study, no matter how comprehensive, to the population in general. Each individual is unique in terms of his or her genetic makeup and life history; the latter also influences metabolic patterns. (Even identical twins raised together may display different metabolic patterns, because of their different life histories.)  So, while a low carb. diet may work well for a lot of people, it may have very negative effects on a few. Increases in inflammation markers and adverse effects on LDL cholesterol (especially when LDL is measured directly, accounting for particle numbers and sizes) are warning signs that any low carb. dieter should pay attention to.

Reference:

Miller, M. et al. (2009). Comparative effects of three popular diets on lipids, endothelial function, and c-reactive protein during weight maintenance. Journal of the American Dietetic Association, 109, 713-717.

Tuesday, December 22, 2009

Guest Commentary: Where are Nurse Practitioners in Health Care Reform?

Theresa Pluth Yeo, PhD, MPH, MSN, CRNP, AOCNP
Coordinator, Advanced Practice Oncology Nursing Program
Assistant Professor, Jefferson Schools of Nursing and Population Health
(Former President of the Nurse Practitioner Association of Maryland)

Cortese and Korsmo, in their September 23, 2009 article in the NEJM, observed that, “Americans do not consistently receive high-value health care. Collectively, our country spends more on health care than any other nation, but our people do not receive the best outcomes, safety, service, or access (to health care) in return.”

Our health care system is largely dominated by a plethora of specialists but deficient in primary care physicians. At a time when only 247 residency positions in primary care are available for graduating medical students per year (down 328 residency positions since 1999), over 6,000 nurse practitioners (NPs) are educated each year at more than 325 colleges and universities. Most of these NPs choose primary care or family practice settings for employment. (For the uninitiated, NPs are fully-trained and licensed registered nurses who complete a Master’s or doctoral degree as an advanced practice nurse and pass a certifying examination administered by a national board, which allows them to be licensed by state boards of nursing as a NP).

NP educational programs provide training in the diagnosis and treatment of acute minor illnesses, disease prevention, and management of stable chronic conditions. Nurse practitioners are part of the solution in health care reform and fill an important niche in providing access to a qualified health care provider for millions of Americans. NPs are a win-win for patients – NPs bring their education, compassion and experience as RNs to bear on patient care, yet they are paid less than physicians. An ever growing body of evidence points to comparable quality care – and often higher patient satisfaction – with NPs as primary health care providers. Currently there are 139,000 NPs practicing in the US.

So why is the AMA threatened by NPs? In October 2009 the AMA launched an offensive, targeting NP practice in a document entitled: AMA Scope of Practice Data Series – Nurse practitioners. The document states in part that: “The physician is responsible for the supervision of nurse practitioners and other advanced practice nurses in all settings and that the physician is responsible for managing the health care of patients in all practice settings.” This is blatantly untrue. Nursing has been a self-regulating and self-licensing profession for as long as medicine has. Why has the leadership of the AMA decided that physicians and only physicians have the “right” to assess, diagnose and treat ill persons and that all “non-physician providers” should be supervised by a physician?

The American Nurses’ Association recently issued a response to this AMA document, voicing its objection to the AMA’s attempts to change the public’s perception of NP practice as anything other than fully qualified professionals working within a legally established scope of practice. As America struggles to reconstruct its health care delivery “system,” it is unproductive for one profession to attempt to marginalize another. NPs stand ready to help meet the nation’s health care needs as collaborating partners, not as physician supervised providers. Health care reformers look our way!

Saturday, December 19, 2009

Total cholesterol and cardiovascular disease: A U-curve relationship

The hypothesis that blood cholesterol levels are positively correlated with heart disease (the lipid hypothesis) dates back to Rudolph Virchow in the mid-1800s.

One famous study that supported this hypothesis was Ancel Keys's Seven Countries Study, conducted between the 1950s and 1970s. This study eventually served as the foundation on which much of the advice that we receive today from doctors is based, even though several other studies have been published since that provide little support for the lipid hypothesis.

The graph below (source: canibaisereis.com, with many thanks to O Primitivo) shows the results of one study, involving many more countries than Key's Seven Countries Study, that actually suggests a NEGATIVE linear correlation between total cholesterol and cardiovascular disease.


Now, most relationships in nature are nonlinear, with quite a few following a pattern that looks like a U-curve (plain or inverted); sometimes called a J-curve pattern. The graph below (source also: canibaisereis.com) shows the U-curve relationship between total cholesterol and mortality, with cardiovascular disease mortality indicated through a dotted red line at the bottom.

This graph has been obtained through a nonlinear analysis, and I think it provides a better picture of the relationship between total cholesterol (TC) and mortality. Based on this graph, the best range of TC that one can be at is somewhere between 210, where cardiovascular disease mortality is minimized; and 220, where total mortality is minimized.

The total mortality curve is the one indicated through the full blue line at the top. In fact, it suggests that mortality increases sharply as TC decreases below 200.

Now, these graphs relate TC with disease and mortality, and say nothing about LDL cholesterol (LDL). In my own experience, and that of many people I know, a TC of about 200 will typically be associated with a slightly elevated LDL (e.g., 110 to 150), even if one has a high HDL cholesterol (i.e., greater than 60).

Yet, most people who have a LDL greater than 100 will be told by their doctors, usually with the best of the intentions, to take statins, so that they can "keep their LDL under control". (LDL levels are usually calculated, not measured directly, which itself creates a whole new set of problems.)

Alas, reducing LDL to 100 or less will typically reduce TC below 200. If we go by the graphs above, especially the one showing the U-curves, these folks' risk for cardiovascular disease and mortality will go up - exactly the opposite effect that they and their doctors expected. And that will cost them financially as well, as statin drugs are expensive, in part to pay for all those TV ads.

Friday, December 18, 2009

Stop Measuring and Start Thinking


Stop Measuring and Start Thinking

I recently wrote a paper suggesting that the arts might just offer us the most potent means of questioning the grotesque market-driven society that we live in, a society that insists on measuring everything in terms of cost-benefit-analysis.

In this paper that will be published shortly, I suggested that the arts not only offer us a means of questioning the world, and imposing some sort of order on the chaos that surrounds us; but that popular culture too, offers a potent part to play in the arts/health agenda. For those of you interested in popular culture and public health I’d like to recommend the writing of Mark Burns and his Sex and Drugs and Rock and Health, which can be found at www.sexanddrugsandrockandhealth.com

Since the global downturn, lots of economists have been talking of creative approaches to their work; whatever that might mean. To be honest; it makes me slightly nervous. Consumerism, to which we’re all in some way addicted, has infected all aspects of society. In the art world itself, the hyper-inflated egos and prices associated particularly with ‘Brit Art’ reflects elitism, consumerism and our obsession with celebrity culture.

Over the past thirty years, market forces have been the governing philosophy of how we live our lives, and over the last 12 months we’ve seen how imposing market values on all elements of human life has terrible consequences. The impact of mental illness in dominant, unequal societies offer some stark financial facts, with doctors in England in 2005 writing 29 million prescriptions for anti-depressant drugs, costing over £400 million to the NHS 1 and in 2003, the USA spent more than $100 billion on mental health treatments. 2

Across the North West I’ve experienced some amazing practice in the arts and seen the impact participating can have on people and yet I’m constantly asked for hard unequivocal evidence as to its value. In his Reith Lectures for the BBC this year Michael Sandel, Harvard Professor of Government, invites us to think of ourselves, less as consumers and more as citizens, and argues for politics of the common good where commodities of community, solidarity and trust are not commodities that deplete with use, like our finite environmental or economic resources, but are more like muscles, that grow stronger with exercise. These wonderful and relevant lectures can be listened to at www.bbc.co.uk/programmes/b00kt7sh

So, do we really need to weigh, measure and count everything we do to justify the arts?

After recently giving the paper in which I expanded on these themes, there followed a discussion that turned to the work I’m supporting around a National Forum for Arts and Health. This was about ‘strategy’ and ‘manifestos’ and I could feel the delegates’ eyes beginning to glaze.

Whatever statements and strategies we develop around the arts in relation to society and well-being, they’re going to date and stagnate on a thousand groaning shelves.

As a student, I always loved the pompous and extreme nature of artists’ manifestos (think Marinetti)…we have been discussing right up to the limits of logic and scrawling the paper with demented writing.’3

Perhaps when we look to manifestos and pamphleteering, we should take a slightly more provocative stance. I’d like to recommend two pieces of art that I put forward as manifestos in their own right.

The first is Jonathon Swift and his Modest Proposal,4 written in 1729. This was a stinging satire in the form of a pamphlet. In the guise of a well-intentioned economist, Swift proposed a solution to the poverty and inequity of the time, by suggesting the rich purchase and eat the children of the poor. Monstrous and politically loaded, this is as biting and as powerful as the written word gets. A manifesto? Perhaps not, but an artist at the height of his powers exploiting popular culture (pamphleteering) to attack and question the norms.

As a counter-blast to Swift’s, Modest Proposal, I’d like to offer Sam Taylor-Wood’s, Still Life5 , a 3 minute 44 second film. This film of a bowl of fruit slowly decomposing is very much in the lines of an elegant still life typical of 16th and 17th century painting of the Netherlands. As the fruit slowly transforms to a mass, a cheap and throwaway, plastic ballpoint pen in the foreground, remains static and unchanged

I urge you to try and see this work. There are 6 of them out there including one at Tate Modern. Of course youtube have a few, but they don’t do it justice. I shall leave you to form your own opinion of what the work’s about and what relevance it might have to our practice and the issues facing society. For me, this work speaks far more loudly than any strategy or conscious manifesto.


1. Hansard. Written answers to questions, (2005) 439:22 Nov. 2005: Column 1798w

2. Mark, T.L et al. Mental Health Treatment Expenditure Trends, 1986 – 2003, Psychiatric Services (2007) 58 (8): 1041 – 8.

3. F.T. Marinetti, The Futurist Manifesto, 1909

4. A Modest Proposal: For Preventing the Children of Poor People in Ireland from Being a Burden to Their Parents or Country, and for Making Them Beneficial to the Publick.

5. Sam Taylor-Wood, Still Life, 2001, Edition of 6, 35 mm Film/DVD

Monday, December 14, 2009

City Police Put the Squeeze on Lemonade Stand







Congrats to the entire JSPH team for our efforts to raise money for Alex's Lemonade Stand!! Together, we raised over $1,500 through today's bake sale and online donations.
Our web page remains open for JSPH members, friends, and family, who care to make a donation: http://www.alexslemonade.org/stands/20326
As you can see from the pics above, we had a little run-in with the good officers of this city who pointed out, rightly, that we did not have the requisite city permit required to peddle home baked goods outdoors to the public. As good stewards of population health, we removed the home baked stuff but continued to sell pre-packaged items and a variety of beverages.
Thanks to all who stopped by our table to make donations for a very worthy cause - we appreciate your tremendous enthusiasm and generosity!!

Friday, December 11, 2009

Guest Commentary: Healthcare Reform is Fiscal Reform

Eric Jutkowitz
Post-Baccalaureate Fellow
Jefferson School of Population Health

In last week’s New York Times opinion page, Paul Krugman wrote an excellent piece on the relationship between healthcare reform and budget reform. Although I agree with his analysis and opinion, he seems to be misunderstood by many in the media and politics.
His main thesis is that to reform healthcare is to reform the deficit problem.

Skyrocketing costs of healthcare services and the aging population are threatening not only the viability of Medicare but also the Federal budget. It may seem counterintuitive that passing health reform, which will insure more individuals and provide greater access to care, will actually help reduce the deficit. However, along with increasing access to care, the Senate healthcare proposal will enact cost-cutting measures to save money. Krugman and many other economists and health policy experts adamantly believe that the cost to insure the uninsured, coupled with cost savings, will result in a net savings to the system.

If these experts are right, that healthcare reform will reduce the budget deficit, then two key questions arise:
1) How are costs going to be cut? and
2) Why is this not being used as the primary selling point of health reform?

Cost will be controlled primarily through cuts to Medicare. From my understanding of the Senate health bill, this cost cutting will not be blind. Rather, the government will cut inefficient or ineffective programs and fund those interventions which are proven to work.

In theory, this is a good idea. However, for many health conditions and medical procedures, we don’t have all the answers as to what is the most efficient care. The government has started to fund projects which help to answer these questions, but much more research is required. Nevertheless, The Congressional Budget Office found that the proposed cost-cutting measures will result in a net savings to the healthcare system.

Why does a bill that increases access to healthcare for the uninsured, eliminates wasteful spending, and reduces the budget deficit, not easily pass through Congress? For one, there is considerable uncertainty about the types of cuts that will be made to Medicare. Aside from general fear of the unknown this has become, as Krugman points out, a key weapon of opposition and an easy way to stir up fear. However, I also believe that the President has done a poor job of making the connection between healthcare reform and the budget deficit. In every speech he gives, he should be talking about the looming budget deficit and how health care reform = budget reform. Not till this connection is made will Americans realize that healthcare reform is more than just increasing the number of insured.

Thursday, December 10, 2009

JSPH is Making Lemonade



Since the launch of our new School, we have been working hard to spread the word about the need to focus on population health. We’ve decided that there couldn’t be a better way to celebrate the holiday season than by supporting a true population health effort through hosting Alex’s Lemonade Stand.

Alexandra “Alex” Scott was just about one when she was diagnosed with neuroblastoma, a childhood cancer. Alex received treatment locally, close to her home near Philadelphia. She was determined, courageous and confident. Alex was a big dreamer, which was evident in her request to hold a lemonade stand to raise money to help her doctors find a cure for her cancer. Close to 4,500 lemonade stands have been held around the country and internationally to honor Alex and support her cause, raising over 7 million dollars.

On December 14th, JSPH will join the cause and host a lemonade stand at 11th and Walnut in front of Jefferson Foerderer Pavilion on Thomas Jefferson University’s campus. The stand will be open from 8am to 3pm, serving lemonade, hot chocolate, and sweet treats. We hope you will support our efforts by stopping by!

JSPH hosts: Alex’s Lemonade Stand

When: December 14, 2009 8am – 3pm

Where: 11th & Walnut (in front of Jefferson Foerderer Pavilion)

Wednesday, December 9, 2009

JSPH Health Policy Forum: Cultural Competency

Cultural Competency: Using A Case-Based Approach for Teaching and Learning was the title of today’s Health Policy Forum. The presenters, Lisa Hark, PhD, RD, Project Manager for Online Medical Education at Wills Eye Institute and Horace M. DeLisser, MD, Associate Dean, Spirituality and Cultural Competency at the University of Pennsylvania, used compelling real-life scenarios to illustrate cross-cultural issues that arise in clinical encounters. They discussed communication strategies for handling difficult situations and challenged the audience to examine their own perceptions.

Some Questions to Consider:

What does cultural competency mean to you and your work ?

What kinds of experiences have you had providing care to populations that you were unfamiliar with? How did you approach this? What kind of assistance did you need?

As a provider or patient do you feel that you had a negative interaction in a health care setting as a result of your culture, race, gender, language, age, sexual orientation, appearance, etc? How did you handle this?

Have you heard of any interesting programs or resources related to cultural competency?

Share your thoughts and keep the conversation going!

Tuesday, December 8, 2009

Guest Commentary: President Obama visits Pennsylvania


Photograph and Blog entry by
Patrick Monaghan
Director of Communications
Jefferson School of Population Health


There we sat, maybe a thousand of us, gathered in a small gymnasium on the campus of Lehigh Carbon Community College, nestled into a bucolic setting just outside of Allentown, Pa. The Pledge of Allegiance had been recited; the Star Spangled Banner sung. The Presidential Seal had been secured to the podium. An air of anticipation hung in the rafters that I have perhaps felt a handful of times.

Ticket holders had waited outside well over an hour, patiently filing through security as if boarding a flight home.

“Ladies and gentlemen, the President of the United States of America.” A modest roar and raucous applause from the crowd. Cameras flashing. I don’t recall hearing “Hail to the Chief,” but there he was, Barack Obama, probably the most recognizable person on the planet, walking to the stage. As he prepared to begin his remarks, he stood just a long jump shot from my seat in the bleachers.

I certainly didn’t expect to be here. Did anyone? An e-mail had been circulated earlier in the week notifying me and my colleagues at the Jefferson School of Population Health that there was an opportunity to see the President speak in our area. Six tickets – first come, first served. By the time I retrieved the message, an hour had passed. Opportunity missed, I thought.

I called anyway, and here I was, face-to-face with my first Presidential address. Regardless of your political leanings, it’s one of those events that makes you feel more connected to the Democratic Process. I’m a bit of a news junkie, and you didn’t have to be Walter Cronkite to know that this was going to make a few headlines. Welcome signs hung from businesses and schools leading to the college. Protestors at the entrance; “Don’t Tread on Me” flags; rows of news vans sprouting a small forest of satellite uplinks.

Given the setting, I had a feeling the President would focus his comments on jobs and the economy. As a JSPH staffer, I had come in hope of hearing some inside information on the health care bill. Would it come to a vote soon? Is the public option a deal breaker? What’s the story with Joe Lieberman?

As those of us vested in the health care debate understand, our nation’s fragile economy will only truly flourish when our dysfunctional health care system is mended. Health care expenses are bleeding our country dry – medical care now absorbs 18 percent of every dollar we earn.

It’s a connection that is not lost on Mr. Obama.

“What has happened is a lot of the debate in Washington has been around health care, so people think, well, I guess they must not be working on jobs,” Mr. Obama said. “No, we’ve been working on jobs the whole time. Health care is part and parcel with where we need to take our economy.”

The President began his remarks just before noon. His oratory skills are on full display in a live setting, but I was somewhat surprised by his reliance on a TelePrompTer for his formal comments. It forces him to look side-to-side (to the prompter panels) instead of straight ahead. Before concluding, he took a few questions from the audience, and it was during this unscripted segment that he seemed most at ease.

He worked the crowd on the way out, shaking hands and posing for the obligatory photo-with-a-baby. By 1 p.m. he had left the building.

We remained somewhat sequestered, momentarily suspended behind closed doors, presumably until the motorcade was out of sight. By the time we emerged from the gym, there was barely a trace he had been there.

Except for the protestors.

Refined carbs, sugar, and cholesterol: My own experience

A few years ago I went to the doctor for a routine appointment, and I was told that my LDL cholesterol was elevated. I was in my early 40s. My lipid profile was the following - LDL: 156, HDL: 38, triglycerides: 188. The LDL was calculated. I was weighing about 210 lbs, which was too high for my height (5 ft 8 in). My blood pressure was low, as it has always been - systolic: 109, diastolic: 68.

My doctor gave me the standard advice in these cases: exercise, lose weight, and, most importantly, reduce your intake of saturated fat. I was also told that I would probably have to take statins, as my high LDL likely had something to do with my genetic makeup. Again, this is quite standard, and we see it all over the place, particularly in commercials for statins.

I told my doctor that I would do some research on the topic, which I am going to save for other posts. Let me get to the point, by telling you what my lipid profile is today - LDL: 123, HDL: 66, triglycerides: 46. Again, the LDL value is calculated. I am weighing about 152 lbs now, with about 13 percent of body fat.

The HDL and triglycerides numbers above are shown in bold font because my research convinced me that these two numbers are the ones most people should really worry about when trying to address what is known as dyslipidemia. Here I am assuming that only standard lipid profiles are available; there are better alternatives, such as particle type analyses, which are not yet standard.

Many people who suffer from cardiovascular disease have low LDL cholesterol, but very few of those have high HDL cholesterol, which is one of the best predictors of cardiovascular disease among lipids. More specifically, if you have an HDL higher than 60, you have a very small chance of developing cardiovascular disease. (It can happen, but it is very unlikely, with a percentage chance in the single digits.)

Interestingly, low HDL cholesterol is also associated with the metabolic syndrome. This syndrome is characterized by the following:

- High fasting serum glucose (hyperglycemia), which is one of many signs of insulin resistance, a precursor to diabetes type 2;
- High blood pressure;
- Abdominal obesity (also known as pot or beer belly);
- Low HDL cholesterol; and
- Elevated triglycerides.

Now, you may ask, how did you increase your HDL? Well, I tried a number of things - diet and lifestyle changes - and had a blood test every 3 months. After a while I was able to put all of the measures in a spreadsheet table, and correlate them using a statistical software that I developed, to give me an idea of what was going on.

Weight was a big factor on LDL, and I was able to bring my weight down to 150 lbs and my LDL to below 100 at some point. For me, and many other people, body weight and LDL cholesterol are strongly and positively correlated (the higher the weight, the higher the LDL cholesterol - actually body fat seems to be the real culprit). Moreover, my LDL seemed to decrease more markedly when my weight was on the way down, and not as much when it was stable, even if low.

But the HDL would only increase if I increased my saturated fat intake. The problem is that every time I increased my saturated fat intake my LDL would go up; it reached 162 at one point, when my HDL went up to a modest but encouraging 47. That was my highest HDL until I eliminated refined carbs and sugars (e.g., bread, pasta, cereals, doughnuts, bagels, regular sodas) from my diet.

When I brought my intake of refined carbs and sugars down to zero, my intake of protein and saturated fat went up. Either that would happen, or I would starve, because you have to eat something. (I figured that I would not die by doing a low carb/high fat-protein experiment for 3 months to see what happened.) Also, I dramatically increased my dietary cholesterol - two to four eggs per day, organ meats, and seafood.

That is when my HDL shot up, to 66, and my LDL went down. Yes, my LDL levels seem to be negatively correlated with dietary saturated fat and cholesterol amounts, as long as I do not consume refined carbs and sugars. Moreover, it is very likely that my LDL particle size increased, and large LDL particles DO NOT cause atherosclerosis because they cannot penetrate the artery walls.

So, the bottom line is that, at least for me, an INCREASE in saturated fat and a DECREASE in refined carbs and sugars, happening together, seem to have taken me out of my previous path toward the metabolic syndrome.

Moreover, I feel a lot more energetic than before, my immune system seems to have gotten better at fighting disease, and even my pollen allergies are not as bad as they were before. Admittedly, these benefits may be strongly associated with the weight loss and the related reduction in body fat percentage.

I hope this post is helpful to others. The standard advice that people with high LDL cholesterol receive, which usually focuses on reducing saturated fat intake, has a big problem. When you reduce your intake of a type of food, you usually increase your intake of other types of food. Most people who try to reduce their saturated fat intake invariably increase their carb intake, usually with the wrong types of carb-rich foods (the man-made ones), simply because they go hungry.