LDL cholesterol Archives - Health Tips From The Professor

What Is The Truth About Low Carb Diets?

August 30, 2022 by Dr. Steve Chaney

Why Is The Cochrane Collaboration The Gold Standard?

Author: Dr. Stephen Chaney

Atkins, South Beach, Whole30, Low Carb, high Fat, Low Carb Paleo, and Keto. Low carb diets come in many forms. But they have these general characteristics:

They restrict carbohydrate intake to <40% of calories.

They restrict grains, cereals, legumes, and other carbohydrate foods such as dairy, fruits, and some vegetables.

They replace these foods with foods higher in fat and protein such as meats, eggs, cheese, butter, cream, and oils.

When recommended for weight loss, they generally restrict calories.

What about the science? Dr. Strangelove and his friends tell you that low carb diets are better for weight loss, blood sugar control, and are more heart healthy than other diets. But these claims are controversial.

Why is that? I have discussed this in previous issues of “Health Tips From The Professor”. Here is the short version.

Most studies on the benefits of low carb diets compare them with the typical American diet.

- The typical American diet is high in fat, sugar and refined flour, and highly processed foods. Anything is better than the typical American diet.

Most low carb diets are whole food diets.

- Any time you replace sodas and highly processed foods with whole foods you will lose weight and improve your health.

Most low carb diets are highly structured. There are rules for which foods to avoid, which foods to eat, and often additional rules to follow.

- Any highly structured diet causes you to focus on what you eat. When you do that, you lose weight. When you lose weight, your health parameters improve.

- As I have noted before, short term weight loss and improvement in health parameters are virtually identical for the very low carb keto diet and the very low-fat vegan diet.

With all this uncertainty you are probably wondering, “What is the truth about low carb diets?”

A recent study by the Cochrane Collaboration (CE Naude et al, Cochrane Database of Systematic Reviews, 28 January 2022) was designed to answer this question.

The Cochrane Collaboration is considered the gold standard of evidence-based medicine. To help you understand why this is, I will repeat a summary of how the Cochrane Collaboration approaches clinical studies that I shared two weeks ago.

Why Is The Cochrane Collaboration The Gold Standard?

Who you gonna call? It’s not Ghostbusters. It’s not Dr. Strangelove’s health blog. It’s a group called the Cochrane Collaboration.

The Cochrane Collaboration consists of 30,000 volunteer scientific experts from across the globe whose sole mission is to analyze the scientific literature and publish reviews of health claims so that health professionals, patients, and policy makers can make evidence-based choices about health interventions.

In one sense, Cochrane reviews are what is called a “meta-analysis”, in which data from numerous studies are grouped together so that a statistically significant conclusion can be reached. However, Cochrane Collaboration reviews differ from most meta-analyses found in the scientific literature in a very significant way.

Many published meta-analyses simply report “statistically significant” conclusions. However, statistics can be misleading. As Mark Twain said: “There are lies. There are damn lies. And then there are statistics”.

The Cochrane Collaboration also reports statistically significant conclusions from their meta-analyses. However, they carefully consider the quality of each individual study in their analysis. They look at possible sources of bias. They look at the design and size of the studies. Finally, they ask whether the conclusions are consistent from one study to the next. They clearly define the quality of evidence that backs up each of their conclusions as follows:

High-quality evidence. Further research is unlikely to change their conclusion. This is generally reserved for conclusions backed by multiple high-quality studies that have all come to the same conclusion. These are the recommendations that are most often adopted into medical practice.

Moderate-quality evidence. This conclusion is very likely to be true, but further research could have an impact on it.

Low-quality evidence. Further research is needed and could alter the conclusion. They are not judging whether the conclusion is true or false. They are simply saying more research is needed to reach a definite conclusion.

This is why their reviews are considered the gold standard of evidence-based medicine. If you are of a certain age, you may remember that TV commercial “When EF Hutton talks, people listen.” It is the same with the Cochrane Collaboration. When they talk, health professionals listen.

How Was The Study Done?

The authors of this Cochrane Collaboration Report included 61 published clinical trials that randomized participants into two groups.

The first group was put on a low carbohydrate diet (carbohydrates = <40% of calories).

The second group was put on a “normal carbohydrate” diet (carbohydrates = 45-65% of calories, as recommended by the USDA and most health authorities).

- The normal carbohydrate diet was matched with the low carbohydrate diet in terms of caloric restriction.

- Both diets were designed by dietitians and were generally whole food diets.

The participants in these studies:

Were middle-aged.
Were overweight or obese.
Did not have diagnosed heart disease or cancer.
May have diagnosed type-2 diabetes. Some studies selected participants that had diagnosed type 2 diabetes. Other studies excluded those patients.

The studies were of 3 types:

Short-term: Participants in these studies followed their assigned diets for 3 to <12 months.

Long-term: Participants in these studies followed their assigned diets for >12 to 24 months.

Short-term with maintenance: Participants in these studies followed their assigned diets for 3 months followed by a 9-month maintenance phase.

What Is The Truth About Low Carb Diets?

All the studies included in the Cochrane Collaboration’s meta-analysis randomly assigned overweight participants to a low carbohydrate diet (carbohydrates = <40% of calories) or to a “normal carbohydrate” diet (carbohydrates = 45-65% of calories) with the same degree of caloric restriction.

If low carb diets have any benefit in terms of weight loss, improving blood sugar control, or reducing heart disease risk, these are the kind of studies that are required to validate that claim.

This is what the Cochrane Collaboration’s meta-analysis showed.

When they analyzed studies done with overweight participants without type 2 diabetes:

Weight loss was not significantly different between low carb and normal carb diets in short-term studies (3 to <12 months), long-term studies (>12 to 24 months), and short-term studies followed by a 9-month maintenance period.

There was also no significant difference in the effect of low carb and normal carb diets on the reduction in diastolic blood pressure and LDL cholesterol.

Since diabetics have trouble controlling blood sugar, you might expect that type 2 diabetics would respond better to low carb diets. However, when they analyzed studies done with overweight participants who had type 2 diabetes:

Weight loss was also not significantly different on low carb and normal carb diets.

There was no significant difference in the effect of low carb and normal carb diets on the reduction in diastolic blood pressure, LDL cholesterol, and hemoglobin A1c, a measure of blood sugar control.

Of course, the reason Cochrane Collaboration analyses are so valuable is they also analyze the strength of the studies that were included in their analysis.

You may remember in my article two weeks ago, I reported on the Cochrane Collaboration’s report supporting the claim that omega-3 supplementation reduces pre-term births. In that report they said that the studies included in their analysis were high quality. Therefore, they said their report was definitive and no more studies were needed.

This analysis was different. The authors of this Cochrane Collaboration report said that the published studies on this topic were of moderate quality. This means their conclusion is very likely to be true, but further research could have an impact on it.

What Does This Study Mean For You?

If you are a bit confused by the preceding section, I understand. That was a lot of information to take in. Let me give you the Cliff Notes version.

In short, this Cochrane Collaboration Report concluded:

Low carb diets (<40% of calories from carbohydrates) are no better than diets with normal carbohydrate content (45-65% of calories from carbohydrates) with respect to weight loss, reduction in heart disease risk factors, and blood sugar control. Dr. Strangelove has been misleading you again.

This finding is equally true for people with and without type 2 diabetes. This calls into question the claim that people with type 2 diabetes will do better on a low carb diet.

The published studies on this topic were of moderate quality. This means their conclusion is very likely to be true, but further research could have an impact on it.

If you are thinking this study can’t be true because low carb diets work for you, that is because you are comparing low carb diets to your customary diet, probably the typical American diet.

Remember that any whole food diet that eliminates sodas and processed foods and restricts the foods you eat will cause you to lose weight. Whole food keto and vegan diets work equally well short-term compared to the typical American diet.

And any diet that allows you to lose weight improves heart health parameters and blood sugar control.

If you are thinking about the blogs, books, and videos you have seen extolling the virtues of low carb diets, remember that the Dr. Strangeloves of the world only select studies comparing low carb diets to the typical American diet to support their claims.

The studies included in this Cochrane Collaboration report randomly assigned participants to the low carb and normal carb diets and followed them for 3 to 24 months.

- Both diets were whole food diets designed by dietitians.

- Both diets reduced caloric intake to the same extent.

What about the claims that low carb diets are better for your long-term health? There are very few studies on that topic. Here are two:

At the 6.4-year mark a recent study reported that the group with the lowest carbohydrate intake had an increased risk of premature death – 32% for overall mortality, 50% for cardiovascular mortality, 51% for cerebrovascular mortality, and 36% for cancer mortality. I will analyze this study in a future issue of “Health Tips From The Professor”.

At the 20-year mark a series of studies reported that:

- Women consuming a meat-based low carb diet for 20 years gained just as much weight and had just as high risk of heart disease and diabetes as women consuming a high carbohydrate, low fat diet.

- However, women consuming a plant-based low carb diet for 20 years gained less weight and had reduced risk of developing heart disease and diabetes as women consuming a high carbohydrate, low fat diet.

My recommendation is to avoid low-carb diets. They have no short-term benefits when compared to a healthy diet that does not eliminate food groups. And they may be bad for you in the long run. Your best bet is a whole food diet that includes all food groups but eliminates sodas, sweets, and processed foods.

However, if you are committed to a low carb diet, my recommendation is to choose the low-carb version of the Mediterranean diet. It is likely to be healthy long term.

The Bottom Line

The Cochrane Collaboration, the gold standard of evidence-based medicine, recently issued a report that evaluated the claims made for low carb diets.

All the studies analyzed in the Cochrane Collaboration’s report randomly assigned overweight participants to a low carbohydrate diet (carbohydrates = <40% of calories) or to a “normal carbohydrate” diet (carbohydrates = 45-65% of calories) with the same degree of caloric restriction.

If low carb diets have any benefit in terms of weight loss, improving blood sugar control, or reducing heart disease risk, these are the kind of studies that are required to validate that claim.

The Cochrane Collaboration Report concluded:

Low carb diets (<40% of calories from carbohydrates) are no better than diets with normal carbohydrate content (45-65% of calories from carbohydrates) with respect to weight loss, reduction in heart disease risk factors, and blood sugar control.

This is equally true for people with and without type 2 diabetes.

The published studies on this topic were of moderate quality. This means their conclusion is very likely to be true, but further research could have an impact on it.

My recommendation is to avoid low carb diets. They have no short-term benefits when compared to a healthy diet that does not eliminate food groups. And they may be bad for you in the long run. Your best bet is a whole food diet that includes all food groups but eliminates sodas, sweets, and processed foods.

However, if you are committed to a low carb diet, my recommendation is to choose the low carb version of the Mediterranean diet. It is likely to be healthy long term.

For more details on the study and what it means for you, read the article above.

These statements have not been evaluated by the Food and Drug Administration. This information is not intended to diagnose, treat, cure, or prevent any disease.

Is Dairy Bad For Your Heart?

December 7, 2021 by Dr. Steve Chaney

Is Dairy Right For You?

Author: Dr. Stephen Chaney

We have been told for years that dairy foods are good for us. They are part of the USDA five food groups. In fact, they are part of the dietary recommendations of every government and most health organizations across the world.

And dairy foods are nutritious. They are excellent sources of calcium, potassium, protein, and vitamins A and B12. And if they are fortified, they are also an excellent source of vitamin D. Many health experts consider them essential for healthy bones. So, you might be saying, “Case closed. We should all be eating more dairy foods”.

But, not so fast. Many dairy foods are high in saturated fats. In fact, 65% of the fat in dairy foods is saturated. We have known for years that when saturated fats replace polyunsaturated fats in the diet, LDL cholesterol levels increase. And, as I reported in a previous issue of “Health Tips From the Professor” there is excellent evidence that replacing polyunsaturated fats with saturated fats substantially increases the risk of dying from heart attack, stroke, and other forms of heart disease.

The widely accepted message from these studies is that saturated fats raise LDL cholesterol levels and increases our risk of dying from heart disease. If we accept this message, it poses a dilemma. Dairy foods are nutritious. But they are high in saturated fat. What should we do?

The answer from the American Heart Association and most other health organizations is simple. We should eat low-fat dairy foods.

But this is where it gets really confusing. Dairy foods are composed of much more than saturated fats. And you have probably seen the claims that full fat dairy foods don’t increase the risk of heart disease.

So, what is the truth about full-fat dairy foods and heart health? In this issue of “Health Tips From The Professor” I review three recent studies and the recommendations of the Heart Foundation because they shed light on this question.

Is Dairy Bad For Your Heart?

Before I answer this question, I should point out that there are two ways of looking at it.

As I said above, the studies proving that saturated fats increase the risk of heart disease, substituted saturated fats for polyunsaturated fats and controlled every other aspect of the diet. That has led the American Heart Association and other organizations to recommend that we eat low-fat dairy foods.

However, when most people hear that recommendation, they simply substitute low-fat dairy for full-fat dairy foods without changing any other aspect of their diet or lifestyle. The first two studies were designed to see if that approach was effective for reducing heart disease risk.

The first study (KA Schmidt et al, American Journal of Clinical Nutrition, 114: 882-892, 2021) was a randomized controlled trial that compared the effect of low-fat dairy foods and full-fat dairy foods on heart health parameters.

The participants in this study were:

Average age = 62
56% male
75% white
Average weight = 214 pounds
All of them were prediabetic

All participants were told to stick with their usual diets (probably typical American diets) except for the amount and type of dairy foods added to their diet. During the first four weeks they restricted dairy consumption to 3 servings of nonfat dairy/week so they would all be starting with the same amount of dairy consumption. Then they were divided into 3 groups for the 12-week study:

Group 1 continued with 3 servings of nonfat dairy/week.
Group 2 added 3 servings of low-fat dairy/day to their usual diet.
Group 3 added 3 servings of high-fat dairy/day to their usual diet.

At the beginning of the study and again at the end of the 12-week study LDL cholesterol, HDL cholesterol, triglycerides, free fatty acids, and blood pressure were measured. The results were:

There was no difference in LDL cholesterol, HDL cholesterol, triglycerides, free fatty acids, or blood pressure in the three groups at the end of 12 weeks.

There was no also significant change in LDL cholesterol, HDL cholesterol, triglycerides, free fatty acids, or blood pressure during the study in any of the three groups.

The authors concluded, “A diet rich in full-fat dairy had no effect on fasting lipid profile or blood pressure compared with diets limited in dairy or rich in low-fat dairy. Therefore, dairy fat, when consumed as part of complex whole foods does not adversely affect these classic cardiovascular disease risk factors.”

[Note: The last sentence is key. Remember the “proof” that saturated fats increase LDL levels and increase the risk of heart disease come from studies in which saturated fats were substituted for polyunsaturated fats and every other aspect of the diet was carefully controlled.

In this study, and others like it, the effects of saturated fats are studied in a complex food (dairy) in the presence of an even more complex diet containing many foods that influence the risk of heart disease.]

The second study (J Guo et al, European Journal of Epidemiology 32: 269-287, 2017) was a meta-analysis of 29 studies with 938,465 participants looking at the association of full-fat dairy consumption with the risk of dying from heart disease.

Seven of the 29 studies were conducted in the United States. Of the remaining studies 3 were from Japan and Taiwan, 2 were from Australia, and 17 were from Europe.

The results of the study were:

There was no association between full-fat dairy, low-fat dairy, and total dairy consumption and risk of dying from heart disease.

When the results were broken down into individual dairy foods.

There was no association between milk consumption and risk of dying from heart disease.

Consumption of one serving/day of fermented dairy foods was associated with a 2% decreased risk of dying from heart disease.

The authors concluded, “The current meta-analysis of 29 prospective cohort studies suggested no association of total, high and low-fat dairy and milk with risk of cardiovascular disease. In addition, a possible role of fermented dairy was found in cardiovascular disease prevention, but the result was driven by a single study.” [I would add that this effect, if confirmed by subsequent studies, is extremely small (2%).]

The first two studies do not say that full-fat dairy foods are heart healthy for everyone, as some headlines would have you believe. Instead, these studies show fairly convincingly that simply switching from full-fat to low-fat dairy foods, without changing any other aspect of your diet and lifestyle, is not as effective at decreasing your risk of heart disease as some experts would have you believe.

The third publication (WC Willett and DS Ludwig, New England Journal of Medicine 382: 644-654, 2020) was a review of the effect of dairy foods on our health. One of the authors, Walter C Willett, is one of the top experts in the field. The review covered many topics, but I will focus on the section dealing with the effect of dairy foods on heart health.

This review took a more nuanced look at full-fat dairy foods and examined the effect of substituting full-fat dairy for other protein foods.

The review concludes, “The association of milk with the risk of cardiovascular disease depends on the comparison foods. In most cohort studies [such as the studies described above], no specific comparison was made; by default, the comparison was everything else in the diet – typically large amounts of refined grains, potato products, sugar, and meat.”

The review went on to say that previous studies have shown:

“Both full-fat and low-fat dairy foods…were associated with a lower risk [of cardiovascular disease and stroke] than…the same number of servings of red meat but with a higher risk than seen with the same number of servings of fish or nuts.”

“Dairy fat…was associated with a higher risk of cardiovascular disease than was polyunsaturated or vegetable fat.”

“For persons living in low-income countries where diets are very high in starch, moderate intake of dairy foods may reduce cardiovascular disease by providing nutritional value and reducing glycemic load [the amount of easily digestible carbohydrate in the diet].”

Is Dairy Right For You?

Now I am ready to answer the question posed at the beginning of this article, “Is dairy bad for your heart?” The answer is, “It depends”.

As described above, the effect of dairy on heart health depends on our overall diet. It also depends on our lifestyle, our weight, and our health.

In addition, clinical studies report averages, and none of us are average. We all have unique diets, lifestyles, health status, and genetic makeup.

So, what does this mean for you? Perhaps it is best summed up by the recommendations of Australia’s Heart Foundation which take health status, lifestyle, and genetic differences into account:

A heart healthy diet can include dairy, but it is not essential [with careful planning and/or supplementation you can get your calcium and protein elsewhere].

Milk, yogurt, and cheese are considered neutral for heart health, meaning they neither increase nor decrease the risk of heart disease for the average person. However, the recommendations vary depending on health status, genetics, and lifestyle:

- Low-fat milk, yogurt, and cheese are recommended for people with heart disease or high cholesterol because the fat in dairy foods can raise cholesterol more for these people. [Note: If cholesterol is elevated, it usually means that individual has a hard time regulating blood cholesterol levels because of obesity, genetics, or pre-existing disease. For these individuals, diets high in saturated fat are more likely to increase LDL cholesterol and risk of heart disease.]

- Full-fat milk, yogurt, and cheese can be part of a heart healthy diet for healthy people provided most of the fat in the diet comes from fish, nuts, seeds, and healthy oils. [Note: Overall diet is important.]

Choosing unflavored milk, yogurt, and cheese helps limit the amount of sugar in your diet.

Ice cream, cream, and dairy desserts should be eaten only sometimes and in small amounts because they have more sugar and fat, and less protein, vitamins, and minerals than other dairy foods.

Butter raises LDL cholesterol levels, especially in people who already have elevated cholesterol.

- There is no evidence that butter can be part of a heart healthy diet, so you should consider healthier options such as olive oil, avocado, nut butters, and spreads made with healthier oils, such as olive oil.

The Bottom Line

However, dairy foods have been controversial in recent years. Some experts claim that only low-fat dairy products can be heart healthy. Others claim that full-fat dairy foods are just as healthy as low-fat dairy foods.

I shared three recent publications and dietary recommendations from The Heart Foundation that shed light on these controversies.

The first study found that full-fat dairy foods did not increase LDL cholesterol, triglycerides, and other heart disease risk factors.

The second study was a meta-analysis of 29 clinical studies with almost one million people. It found that full-fat dairy foods did not increase the risk of dying from heart disease.

“Case closed”, you might say. However, these studies do not say that full-fat dairy foods are heart healthy for everyone, as some headlines would have you believe. Instead, these studies show fairly convincingly that simply switching from full-fat to low-fat dairy foods, without changing any other aspect of your diet and lifestyle, is not as effective at decreasing your risk of heart disease as some experts would have you believe.

Moreover, these studies do not account for the effect of overall diet, lifestyle, health status, and genetics on the risk of heart disease.

That is why I included the third study in my review. It took the overall diet into account and concluded the effect of full-fat dairy foods on heart disease risk depends on the overall diet.

For some diets full-fat dairy increases heart disease risk.

For other diets full-fat dairy has no effect on heart disease risk.

And for some diets full-fat dairy may even decrease heart disease risk.

Finally, I included recommendations of the Australian Heart Foundation because they included the effect of health status, lifestyle, and genetics in their recommendations.

For more details on the findings of the third study and the recommendations of the Heart Foundation, read the article above.

These statements have not been evaluated by the Food and Drug Administration. This information is not intended to diagnose, treat, cure, or prevent any disease.