Part 2.2 Fats - Triglycerides and Essential Fatty Acids

From the previous blog post, you're familiar with saturated and unsaturated fatty acids. Now we’ll look at how we obtain and use fats (synonyms: fatty acids, triglycerides. lipids), how much we need/don’t need, and why.

Triglycerides (TG): You’ve seen this term on every blood panel your doctor has ever ordered, but what does it mean and why should we care? Fasting blood-borne TG levels higher than 150 mg/dL correlate with increased risk for heart disease, fatty liver disorder, early onset type II diabetes, kidney disorders and pancreatitis (Article). Usually the effects are asymptomatic until something alarming happens and we find a doctor. TG blood screens are recommended yearly to identify high levels before they cause problems.

Triglyceride with 1) Palmitic acid, 2) Oleic acid and 3) Linoleic acids hitched on. Notice different saturation.

We get fats from two different sources: 1) our diet, 2) our liver synthesizes them from other molecules in our bodies including glucose. Yes, when you eat excess sugar, your liver uses it to make fat. (Bummer). In plants and animals, fatty acids tend to travel in threes hitched to a glycerol molecule. The glycerol carrier molecule isn’t choosy about who hooks into those three sites, so one glycerol ‘car’ can have three different fatty acid ‘riders’ varying in length or saturation-style (see image). If only one FA is hooked up, it’s a mono-glyceride, if two, a di-glyceride, and three, a tri-glyceride. This latter form is how fats mostly occur in our bodies. TGs are very large energy-dense molecules, and a lean adult has enough TG stored in them (about 15 kg or 33 pounds) to survive for more than 2 months.

For us to access the energy in dietary fats, our digestive process performs a multi-step process to break TGs down into molecules small enough to cross the intestinal lining.

Feasting: When we eat, 1) we break large fat particles into smaller ones by chewing and stomach churn. 2) most TG disassembly happens in the small intestine where enzymes rip two fatty acids off the glycerol triple-carrier to liberate free fatty acids and mono-glycerides. 3) These smaller molecules are emulsified further by the addition of bile, and are finally able to cross the microvilli membrane into the intestinal cells. 4) Once inside the intestinal cells, the TGs are reassembled into their prior triplet form, and packaged with other goodies like cholesterol and fat-soluble vitamins (A,D,E), into shipping containers called chylomicrons. 5) The chylomicron containers are shipped into the intestinal lymph system and thence into the bloodstream to deliver TGs, vitamins and cholesterol to the tissues. If cells don’t need the energy, excess TGs are instead delivered to our storage units - adipose tissue for later use. Chylomicrons decrease in size as they deliver their load to the periphery and then the empty containers return for recycling in the liver.

Fasting: When we are not eating, 1) “Need Fuel!” signals are released by cells when their energy supplies run low. These signals hit two targets. 2) Our storage units (adipose tissue) react by breaking stored TGs into free fatty acids (mono-glycerides). The mono-glycerides diffuse into the blood, and head off to the cells that need energy, for example, your leg muscle cells if you are going for a walk. 3) The liver responds by constructing new TG’s from the free fatty acids floating in the blood stream plus glucose (we use sugar to make fat!! Bummer again.) 4) The liver packages the TG and some cholesterol and protein into VLDL (very low density lipoprotein) shipping containers and sends them out in the blood. The name very low density means they contain more TG than the accompanying heavier protein and cholesterol. As the traveling VLDL shipping containers drop their TG cargo into energy-requiring cells, they become LDLs, (low density lipoproteins - relatively more protein and cholesterol-laden, see previous post on cholesterol), then IDLs (intermediate density lipoproteins), and then finally HDLs (high density lipoproteins) mostly empty protein vehicles which scavenge cholesterol and return to the liver for recycling and disposal.

TLDR-version: After a meal: blood TG levels spike because chylomicrons are clearing fat from the intestine. Fasting blood TG levels respond to energy requirements via free fatty acids from adipose tissue, and VLDLs from liver.

If the system is working well, TGs disappear into their destinations efficiently, and blood TG levels lower to normal. If the system is consistently overloaded with dietary fats, or confused by lots of sugar-induced insulin, TG blood levels respond by remained elevated and cause trouble in heart and blood vessels, liver, pancreas, kidney and more. How to decrease Triglycerides in your body to optimum levels (less than 150 mg/dL)? There are lots of ways, but the simplest and cheapest are lifestyle choices.

1) Exercise: This burns up extra TG’s floating around and decreases excess levels stored in your adipose tissue.

2) Cooking and eating: Many flavor molecules are fat-soluble which are lost in “fat-free” foods. To makeup for the lack of flavor, processed fat-free foods have sugar added to them to make them more palatable. It’s best to avoid these processed hidden-sugar-laden foods, because type 2 diabetes is risky. Instead, get more creative in the kitchen. Select recipes that are more veggie-forward, discover more pungent and umami-rich ingredients like fermented foods, spices, herbs, mushrooms etc. Instead of frying foods, roast, bake or slow-cook. It’s definitely a life-style change, but one that will benefit your health-span.

3) Drinking and smoking; Decrease alcohol intake and eliminate smoking - both are correlated with increased TGs, metabolic syndrome and morbidity from many causes.

4) Medication or supplementation: Fibrates, Niacin (prescriptions needed) and Essential Fatty Acids somewhat decrease levels of blood TGs.

Essential Fatty Acids (EFA’s) Also called Omega-3s and 6s, these are fats that we get from our diet, most notably fish oils from fish that need insulation in cold water, salmon, sardines, mackerel, steel head trout, cod, (yes, there was a reason for cod liver oil...) as well as flax, walnuts, and leafy green vegetables. The omega nomenclature (biblical reference here, science is not without a sense of humor) tells you how far from the end of the molecule the unsaturated kink is (see the final fatty acid ‘rider’ in the image above). We cannot make these EFA’s in our body and we’ll die without them, hence: essential. They are an important part of cardiac health, vision, inflammation regulation and other important functions. This is why nutritionists are always all over you to eat fatty fish like salmon. If you take the skin off your salmon before you eat it, you are losing much of the oil, so eat the skin! (Salmon skin hint: Grilling makes it even more delicious.) Include these foods in your weekly intake; walnuts, flax, chia seeds, salmon, herring, sardines, oysters, dark leafy greens, pine nuts, Brazil nuts, sunflower seeds/oil, pecans.

Overall takeaway: Balance your fat (triglyeride) intake with lots of healthy food choices, move around to burn off excess energy, eat fish and other delicious foods with EFA’s, and you’ll have solved the fat conundrum, plus you’ll enjoy the wonderful benefits of a healthy heart, liver, pancreas, kidneys and long healthspan.

What Are You Eating?! Part 1: Macromolecules and micromolecules

A healthy diet includes the appropriate amounts of 6 things:

Carbohydrates, fats, proteins, vitamins, minerals and water. A teenage athlete, a pregnant woman, and a sedentary senior all require exactly the same nutrients, but in different proportions based on their activity level and stage of life.

Macromolecules (fats, carbs, proteins) are called such because they are big polymeric (chains of repeating units) molecules, and we need a large quantity of them, usually daily. They supply energy for all activities and building material for tissue repair. We require constant bodily housekeeping to stay healthy. Micromolecules (vitamins and minerals) are small molecules and we don’t require a large quantity, but they are absolutely essential to our existence. For example, sailors who didn’t get enough vitamin C on ocean voyages suffered from scurvy. Vitamin D insufficiency causes bone fragility, Vitamin E deficiency is associated with neurologic issues, and so on.

Nutrition is a complex scientific field involving molecular biology, physiology, neurology, and chemistry, but still bumps up against the mundane everyday need of preparing and eating food. This interface of ever-evolving science vs shopping for groceries can cause consternation among regular folks who don’t have PhDs in the aforementioned subjects. And it opens the door for money-grabs by those taking advantage of the confusion with fad diets and false supplements. Add in factors like health problems caused by psychological issues, Big-Ag pesticides and pharmaceuticals, food inequity due to social injustice and climate change, dearth of scientific education… and the whole thing starts to get overwhelming. One just starts to flounder with the simple question of “What am I eating?!”

Let’s zoom out a little. The reason for much of the confusion is because nutrition is basically biology, so a lot of answers start with “It depends…”. New discoveries are being made all the time. It seems like the federal nutrition guidelines change every few years. They have to because they are based on ever-new research uncovering more facts. Can you imagine that doctors once told their patients to eat margarine??? Now, the dangers of trans-hydrogenated fats to the cardiac system are well-documented.

An aside: During a recent visit to a health professional, a dear friend with cholesterol issues was asked if they were willing to switch from butter to margarine. I almost fell off my snowshoes when he told me this story. After about 60 seconds of apoplectic sputtering and almost having a cardiac event myself, I regained coherence and wondered aloud about the nutrition education of health professionals. Alas, nutrition is quite neglected in most physician’s education.

I believe that food and movement are the underpinnings of health, and these are some of the few things we can control for our entire lives.

SO. For the next few blogs, I will focus on one nutrient at a time and give a basic overview of what, why and how much we need according to recent research. The hope is to improve your ability to winnow bunk from truth, make better choices, and empower you to ask questions about food/supplements claims, whether they come from advertising, your friend’s friend, or your doctor.

Next week: FATS. Why we need them, what they do in our bodies, best sources, amounts, the bigger picture from the inner workings of the cells, to outer effects of our choices on the environment.

Cholesterol levels; Statins and Exercise

Is one better than the other? Are they interchangeable? How do they interact? Is a multiple approach the answer? As with anything to do with biology, the answer is “it’s complex”.

Statins have been one of the most prescribed drugs to lower high cholesterol in the US since their introduction in the early 1990s. Let’s start with understanding cholesterol , why should it be lower in many people, and ways to approach it.

Our livers make a daily genetically-determined amount of cholesterol. It is necessary as a cell membrane stabilizer, a precursor of sex hormones, vitamin D and bile, and as part of the fatty-acid transport system in our blood. Animal foods add a dietary source of cholesterol, but whether dietary cholesterol is actually worrisome has been debated for years (current thoughts -> less problematic, but stay tuned...) We manage cholesterol levels internally with a recycling mechanism that recaptures some, and we also lose some through our gut. The liver uses cholesterol to create bile acids which are secreted into the intestine to facilitate absorption of dietary fats. Some of these bile acids are lost in the feces.

Handy food tips: eating high fiber foods causes more bile to be swept out of the intestine, indirectly lowering your cholesterol. Certain plant foods, (avocado, flax, peanuts) contain phytosterols, which compete with cholesterol for reabsorption sites in the intestine, thus increasing cholesterol elimination. Take home tip: eat higher fiber foods like apples, oats, beans, lentils, leafy greens and consider including avocado, flax and peanuts.

It gets a bit more complicated because you’ll hear about more than one type of cholesterol (total cholesterol reflects the sum of LDL and HDL in lipid profile blood work). Vastly simplified, LDL is a blood-borne vehicle which carries lipids and cholesterol (sloppily) out to the perifery for use in cellular metabolism and repair. The HDL vehicle returns to the liver picking up scraps of cholesterol stuck to the insides of blood vessel walls on the way. Higher HDL levels are good, because it correlates with decreased heart disease risk (you’ll want it high, remember H for high HDL). If one’s levels of LDL creeps up, this is concerning because more cholesterol and fatty acids could get dropped in the blood vessels. Narrowing and hardening of arteries due to plaques, drive up blood pressure and risk of atherosclerotic events such as heart attack and stroke. (So you want it low: remember L for low LDL). Make sure that you know your ratio of HDL to LDL (different for men vs women, but around 3.5 is good). Total cholesterol is a less precise number.

There are a number of tactics to decrease risk of atherosclerosis and improve one’s health span. The simplest one is to go on statins, also known by the following terms: atorvastatin (Lipitor), fluvastatin (Lescol XL), lovastatin (Altoprev), pitavastatin (Livalo), pravastatin, rosuvastatin (Crestor) and simvastatin (Zocor). Statins are a class of pharmaceuticals that block the creation of cholesterol in the liver, thus decreasing their overall level in the blood. They have been researched to be effective in their short-term goal of cholesterol reduction, but they are a life-long commitment of medication. Many question their side effects (myalgia, or muscle pain for some, low tolerance in others) contraindication in pregnancy, and a possible blinding effect to more overarching issues like poor nutrition or a sedentary lifestyle.

If the simplicity of taking a drug can distract us from making decisions that lead to longer term health, what happens when we choose not to use it any more? What habits are we grooming? Perhaps different lifestyle choices can be used collaboratively with statin drugs, to reduce dependence on Big Pharma and turn our attention back to creating our own healthy lifestyle. Enter: Exercise. Free, no negative side effects and many additional benefits.

Exercise and effects on Cholesterol:

We have a love-hate relationship with exercise (OMG why?!) More on this in another post, but for now let’s look at how exercise affects cholesterol levels. I’ll define exercise here as “movement to increase heart rate and respiration to meet increased activity-induced metabolic demands”.

Mechanisms are a bit murky, but it seems that exercise changes the size of LDL to make them less likely to stick on vessel walls, and increases transportation of LDL to the liver, expediting elimination. A metastudy suggests protective results of exercise are seen when folks exercise for at least 150 min/week, 5 X a week. This is a bare minimum. I suggest at least double that. Sitting is the new smoking - actually, don’t do either, they are both associated with increased risk of atherosclerosis.. (I recognize the irony of sitting to type this, I am looking forward to getting off my butt and going cross country skiing). Also, more intense exercise is more health-protective than moderate intensity, and both aerobic and resistance training are effective modalities in changing cholesterol levels.

“But I don’t have time to exercise…”

Actually, No - you don’t have time to be sick.

Though it’s much easier to take a pill than change your lifestyle and priorities, statins have a long list of inconvenient side effects (common ones are headache, muscle ache, flushing, drowsiness, dizziness, GI upset, rashes, and less common ones include hair loss, inflammation and sexual dysfunction). Plus there’s cost, medical appointments and insurance involved. Increased activity is free, available to everyone, and have very convenient side effects such as improved sleep, muscle tone, mood, bone mass, resilience, immunity, lower weight, blood pressure and stress levels, among many others. Reprioritizing to include more vigorous activity in your life is a choice that will have many long-lasting positive effects on your health.

From where I stand, if you are dealing with a diagnosis of dangerous cholesterol levels, statins are an effective and safe-enough-for-most quick fix. But it’s not the best long-term choice. Updating priorities and habits to add vigorous enjoyable movement to your life will have effects above and beyond cholesterol levels. And this is only one side of the coin - healthy food choices (a few quick tips above) are also very important.

Brainstorm about how to add more enjoyable vigorous playtime to your life to create your own joyful healthy lifestyle, minimize dependance on pharmaceuticals, and enjoy energetic spill-over of all the healthspan benefits statins cannot offer.