butter is not a good choice for low carber

Changes in apoB, LDL, non-HDL-cholesterol, HDL and LDL particles when carbohydrates are replaced

by different fatty acids

Scientific evidence

Registered dietitian, M.Sc, MBAReijo Laatikainen

www.twitter.com/pronutritionist

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2

Is butter really healthy for your heart?

3

Why this slide deck?• It’s rather widely accepted that apoB, non-HDL-cholesterol and

total cholesterol:HDL –ratio are better predictors of coronary heart disease (CHD) risk than LDL-C alone. The importance of LDL particle number (LDL-P) and high share of small dense LDL is yet to be confirmed in meta-analyses vs apoB etc.

• Some proponents of the low carb diet maintain that saturated fat is either beneficial or neutral in regards to these risk factors and that “… saturated fat has nothing to do with heart disease”. Point seem to be that if you reduce carbohydrate intake substantially, all the key risk factors will settle within the optimal range

• In some occasions media has declared butter heart healthy

• What is actually known about lipoproteins when carbohydrates (“carbs”) are replaced by different fatty acid classes?

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Source

Meta-analysis of 60 randomized studies in weight stable situation

by Mensink et al 2003

5

Lipoprotein changes when 1% of daily energy from carbs is replaced by fats

Mensink RP, Zock PL, Kester AD, Katan MB. Effects of dietary fatty acids and carbohydrates on the ratio of serum total to HDL cholesterol and on serum lipids and apolipoproteins: a meta-analysis of 60 controlled trials. Am J Clin Nutr. 2003 May;77(5):1146-55

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Part 1, summary

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Direction of effects when only 1 E% of carbs is replaced by fatty acids

HDL LDL T-Chol:HDL-ratio

apoB Non-HDL-C

Carbs→SFA

+/- 0 +/- 0 Not calculated in the original paper. I’ve done the math (ie. red text previous slide)

Carbs→MUFA

Carbs→PUFA

Mensink RP, Zock PL, Kester AD, Katan MB. Effects of dietary fatty acids and carbohydrates on the ratio of serum total to HDL cholesterol and on serum lipids and apolipoproteins: a meta-analysis of 60 controlled trials. Am J Clin Nutr. 2003 May;77(5):1146-55

Green arrow= beneficial change in a risk factor, red/striped arrow=negative change, +/-0= not statistically significant change

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Part 2, practical example

Potatoes (200 kcal) → Butter (200 kcal)or

Potatoes (200 kcal) → Canola oil (200 kcal)

9

Effects of replacing potatoes by butter or canola oil in an isocaloric situation

?

10

Carbohydrate Protein* PUFA MUFA SFA

-12.0 %

-10.0 %

-8.0 %

-6.0 %

-4.0 %

-2.0 %

0.0 %

2.0 %

4.0 %

6.0 %

8.0 %

-9.3 %

-0.7 %0.4 %

2.8 %

6.8 %

Change in macronutrient intake when 10% of daily energy as carbs (boiled potatoes) is replaced by animal fat (butter)

Changes in macronutrient intake when butter replaces potatoes

*Protein is considered neutral in the following calculations (no data in Mensink). Therefore actual amount of carbs replaced is 9.3 E%-0.7 E%= 8.6 E%. It follows that the ‘replaceable’ fat intake is also reduced by 0.7 E%, and this reduction is splitted to all 3 fatty acid classes in the following calcutions.

11

Changes in macronutrient intake when canola oil replaces potatoes

Carbohydrate Protein PUFA MUFA SFA

-12.0 %

-10.0 %

-8.0 %

-6.0 %

-4.0 %

-2.0 %

0.0 %

2.0 %

4.0 %

6.0 %

8.0 %

-9.3 %

-0.7 %

2.8 %

6.4 %

0.7 %

Change in macronutrient intake when 10% of daily energy as carbs (boiled potatoes) is replaced by canola oil

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Change in LDL

Carbs replaced by butter Carbs replaced by canola oil

-0.15

-0.1

-0.05

0

0.05

0.1

0.15

0.20.1808

-0.0883

Change in LDL (mmol/L)mmol/L (For mg/DL multiply by 38.67)

Mensink RP, Zock PL, Kester AD, Katan MB. Effects of dietary fatty acids and carbohydrates on the ratio of serum total to HDL cholesterol and on serum lipids and apolipoproteins: a meta-analysis of 60 controlled trials. Am J Clin Nutr. 2003 May;77(5):1146-55 (calculated from Table 1)

13

Change in HDL

Carbs replaced by butter Carbs replaced by canola oil0

0.01

0.02

0.03

0.04

0.05

0.06

0.07

0.08

0.09

0.1

0.087

0.0694

Change in HDL (mmol/L)mmol/L (For mg/DL multiply by 38.67)

Mensink RP, Zock PL, Kester AD, Katan MB. Effects of dietary fatty acids and carbohydrates on the ratio of serum total to HDL cholesterol and on serum lipids and apolipoproteins: a meta-analysis of 60 controlled trials. Am J Clin Nutr. 2003 May;77(5):1146-55 (calculated from Table 1)

14

Change in total cholesterol:HDL –ratio

Carbs replaced by butter Carbs replaced by canola oil

-0.3

-0.25

-0.2

-0.15

-0.1

-0.05

0

-0.0545

-0.2403

Change in TOT CHOL:HDL -ratio

Mensink RP, Zock PL, Kester AD, Katan MB. Effects of dietary fatty acids and carbohydrates on the ratio of serum total to HDL cholesterol and on serum lipids and apolipoproteins: a meta-analysis of 60 controlled trials. Am J Clin Nutr. 2003 May;77(5):1146-55 (calculated from Table 1)

15

Change in non-HDL-cholesterol

Carbs replaced by butter Carbs replaced by canola oil

-0.2

-0.15

-0.1

-0.05

0

0.05

0.1

0.15 0.1272

-0.1426

Change in non-HDL-Cholesterol (mmol/L)mmol/L (For mg/DL multiply by 38.67)

Mensink RP, Zock PL, Kester AD, Katan MB. Effects of dietary fatty acids and carbohydrates on the ratio of serum total to HDL cholesterol and on serum lipids and apolipoproteins: a meta-analysis of 60 controlled trials. Am J Clin Nutr. 2003 May;77(5):1146-55 (calculated from Table 1)

16

Change in apoB

Carbs replaced by butter Carbs replaced by canola oil

-60

-50

-40

-30

-20

-10

0

10

2.88

-48

Change in apoB (mg/L)mg/L

Mensink RP, Zock PL, Kester AD, Katan MB. Effects of dietary fatty acids and carbohydrates on the ratio of serum total to HDL cholesterol and on serum lipids and apolipoproteins: a meta-analysis of 60 controlled trials. Am J Clin Nutr. 2003 May;77(5):1146-55 (calculated from Table 1)

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Part 2

125 grams (25 E%) of carbs → SFAor

125 grams (25 E%) of carbs → MUFAor

125 grams (25 E%) of carbs → PUFA

Page 18

The following calculations are theoretical because edible fats are

mixtures of different fatty acids. However, calculations

demonstrate the direction of the change with given fatty acids.

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25 E% of carbs

all replaced by SFA

25 E% of carbs

all replaced by MUFA

25 E% of carbs

all replaced by PUFA

3 scenariosin weight stable situation

1

2

3

?

?

?

20

Change in HDL

Mensink RP, Zock PL, Kester AD, Katan MB. Effects of dietary fatty acids and carbohydrates on the ratio of serum total to HDL cholesterol and on serum lipids and apolipoproteins: a meta-analysis of 60 controlled trials. Am J Clin Nutr. 2003 May;77(5):1146-55 (calculated from Table 1)

by SFA by MUFA by PUFA 0.00

0.05

0.10

0.15

0.20

0.25

0.30

0.25

0.20

0.15

Change in HDL (mmol/l) when 25 % of energy from carbs is replaced by different fatty acid classes

mmol/L (For mg/DL multiply by 38.67)

21

Change in apoB

Mensink RP, Zock PL, Kester AD, Katan MB. Effects of dietary fatty acids and carbohydrates on the ratio of serum total to HDL cholesterol and on serum lipids and apolipoproteins: a meta-analysis of 60 controlled trials. Am J Clin Nutr. 2003 May;77(5):1146-55 (calculated from Table 1)

by SFA by MUFA by PUFA

-250.00

-200.00

-150.00

-100.00

-50.00

0.00

50.00

100.00

65.00

-120.00

-192.50

Change in Apo-B (mg/L) when 25 % of energy from carbs is replaced by different fatty acid classes

mg/L

22

Change in non-HDL-cholesterol

Mensink RP, Zock PL, Kester AD, Katan MB. Effects of dietary fatty acids and carbohydrates on the ratio of serum total to HDL cholesterol and on serum lipids and apolipoproteins: a meta-analysis of 60 controlled trials. Am J Clin Nutr. 2003 May;77(5):1146-55 (calculated from Table 1)

by SFA by MUFA by PUFA

-0.80

-0.60

-0.40

-0.20

0.00

0.20

0.40

0.60

0.800.65

-0.35

-0.68

Change in Non-HDL (mol/L) when 25% of energy from carbs is replaced by different fatty acid classes

mmol/L (For mg/DL multiply by 38.67)

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Change in total cholesterol:HDL -ratio

by SFA by MUFA by PUFA

-1.000

-0.800

-0.600

-0.400

-0.200

0.000

0.2000.075

-0.65

-0.80

Change in Tot Cholesterol:HDL -ratio when 25% of energy from carbs is replaced by different fatty acid

classes

Mensink RP, Zock PL, Kester AD, Katan MB. Effects of dietary fatty acids and carbohydrates on the ratio of serum total to HDL cholesterol and on serum lipids and apolipoproteins: a meta-analysis of 60 controlled trials. Am J Clin Nutr. 2003 May;77(5):1146-55 (calculated from Table 1)

24

Change in LDL-C

Mensink RP, Zock PL, Kester AD, Katan MB. Effects of dietary fatty acids and carbohydrates on the ratio of serum total to HDL cholesterol and on serum lipids and apolipoproteins: a meta-analysis of 60 controlled trials. Am J Clin Nutr. 2003 May;77(5):1146-55 (calculated from Table 1)

by SFA by MUFA by PUFA

-0.60

-0.40

-0.20

0.00

0.20

0.40

0.60

0.80

1.00

0.80

-0.23

-0.48

Change in LDL (mmol/L) when 25% of energy from carbs is replaced by different fatty acid classes

mmol/L (For mg/DL multiply by 38.67)

25

Changes in LDL-particle size, LDL pattern B or number (LDL-P)

No data available in Mensink’s meta-analysis or in any other currently available meta-analysis

Conclusion • Replacing carbohydrates by PUFA/MUFA compared to SFA induces

more beneficial changes in the key CHD risk factors, ie. apoB, non-HDL-cholesterol and total cholesterol:HDL ratio, in addition to LDL-C.

• All fatty acids in place of carbohydrates increase HDL cholesterol

• When carbohydrates are replaced by SFA, apoB and total cholesterol:HDL ratio seem to change little or not at all. This may partly explain why replacing saturated fat by carbohydrates has not been associated with improved CHD outcomes in prospective cohorts (Jakobsen et al. 2009)

• Favouring food items rich in MUFA and PUFA instead of SFA is likely to be beneficial to cardiovascular health when “going low carb”

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27

Healthy switch

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Unhealthy switch

Disclaimer

This analysis focuses on lipoprotein changes only in weight stable situation.

Other diet related factors (such as protein quality, fiber, vitamins, minerals,

phytochemicals, healthy weight etc.) may also play a critical role in preserving

cardiovascular health

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Page 30

What about morbidity and mortality trials and prospective

cohorts? Visit my other slide deck on butter

http://www.slideshare.net/pronutritionist/margine-or-butter

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What about LDL-particle size or LDL-P?

Visit my upcoming slide deck (due before September 2014)

Wellcome aboard!

http://twitter.com/pronutritionisthttp://www.facebook.com/pronutritionist

http://www.pronutritionist.net

Reijo Laatikainen, RD, MBA

Images bought and licensed from BigStockPhoto. Snapshots from papers and sites referred to.

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Back up slides

Calculations behind the substitutions

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Change in LDL when canola oil replaces potatoes

POtatoes replaced by SFA (0.5 E%)

Carbs replaced by MUFA (6.1 E%)

Carbs replaced by PUFA (2.6 E%)

Net change (sum)

-0.1

-0.08

-0.06

-0.04

-0.02

0

0.02

0.04

0.016

-0.0549-0.0494

-0.0883

Change in LDL cholesterol (mmol/L)

35

Change in HDL when canola oil replaces potatoes

Carbs replaced by SFA (0.5 E%)

Carbs replaced by MUFA (6.1 E%)

Carbs replaced by PUFA (2.6 E%)

Net change (sum)0

0.01

0.02

0.03

0.04

0.05

0.06

0.07

0.08

0.005

0.0488

0.0156

0.0694

Change in HDL cholesterol (mmol/L)

36

Change in total cholesterol:HDL –ratio when canola oil replaces potatoes

Carbs replaced by SFA (0.5 E%)

Carbs replaced by MUFA (6.1 E%)

Carbs replaced by PUFA (2.6 E%)

Net change (sum)

-0.3

-0.25

-0.2

-0.15

-0.1

-0.05

0

0.05

0.0015

-0.1586

-0.0832

-0.2403

Change in Tot Chol:HDL -ratio

37

Change in non-HDL-cholesterol when canola oil replaces potatoes

Carbs replaced by SFA (0.5 E%)

Carbs replaced by MUFA (6.1 E%)

Carbs replaced by PUFA (2.6 E%)

Net change (sum)

-0.16

-0.14

-0.12

-0.1

-0.08

-0.06

-0.04

-0.02

0

0.02

0.04

0.013

-0.0854

-0.0702

-0.1426

Change in non-HDL-Cholesterol

38

Change in apoB when canola oil replaces potatoes

Carbs replaced by SFA (0.5 E%)

Carbs replaced by MUFA (6.1 E%)

Carbs replaced by PUFA (2.6 E%)

Net change (sum)

-60

-50

-40

-30

-20

-10

0

10

1.3

-29.28

-20.02

-48.00

Change in Apo B (mg/L)

39

Change in LDL when butter replaces potatoes

Carbs replaced by SFA (6.5 E%)

Carbs replaced by MUFA (2.6 E%)

Carbs replaced by PUFA (0.2 E%)

Net change (sum)

-0.05

0

0.05

0.1

0.15

0.2

0.25

0.208

-0,0234

-0,0038

0.1808

Change in LDL cholesterol (mmol/L)

40

Change in HDL when butter replaces potatoes

Carbs replaced by SFA (6.5 E%)

Carbs replaced by MUFA (2.6 E%)

Carbs replaced by PUFA (0.2 E%)

Net change (sum)0

0.01

0.02

0.03

0.04

0.05

0.06

0.07

0.08

0.09

0.1

0.065

0.0208

0.0012

0.087

Change in HDL cholesterol (mmol/L)

41

Change in total cholesterol:HDL –ratio when butter replaces potatoes

Carbs replaced by SFA (6.5 E%)

Carbs replaced by MUFA (2.6 E%)

Carbs replaced by PUFA (0.2 E%)

Net change (sum)

-0.08

-0.06

-0.04

-0.02

0

0.02

0.04

0.0195

-0.0676

-0.0064

-0.0545

Change in Tot Chol:HDL -ratio

42

Change in non-HDL-cholesterol when butter replaces potatoes

Carbs replaced by SFA (6.5 E%)

Carbs replaced by MUFA (2.6 E%)

Carbs replaced by PUFA (0.2 E%)

Net change (sum)

-0.05

0

0.05

0.1

0.15

0.2

0.169

-0.0364

.-0,0054

0.1272

Change in non-HDL-Cholesterol

43

Change in apoB when butter replaces potatoes

Carbs replaced by SFA (6.5 E%)

Carbs replaced by MUFA (2.6 E%)

Carbs replaced by PUFA (0.2 E%)

Net change (sum)

-15

-10

-5

0

5

10

15

20

16.9

-12.48

-1.54

2.88

Change in Apo B (mg/L)