rol is a substantially more informative predictor of IHD mortality than are total cholesterol, HDL cholesterol, or non-HDL cholesterol." 14
This is consistent with many other studies, for example this very recent analysis from the COURAGE trial 15.
High triglycerides are strongly associated with CVD
There has been drawn out controversy in the medical community as to the relationship of triglyceride levels to CVD. There are two parts to the controversy: whether or not triglycerides are an independent predictor of CVD, and whether or not triglycerides play a causative role in CVD.
In both cases, however, it doesn't matter in which way the controversy is resolved! Whether or not triglycerides independently predict CVD (and there is at least some evidence that they do), and whether or not they cause CVD, there is no controversy about whether they predict CVD. The association between triglyceride levels and CVD still holds and is strongly predictive 16, 17, 18. In fact it is so predictive that those who argue that triglyceride levels are not an independent risk factor, call it instead a “biomarker” for CVD 19. In other words, seeing high triglycerides is tantamount to seeing the progression of heart disease.
HDL-to-Triglycerides Ratio: compounding evidence
Triglycerides and HDL levels statistically interact. That means it is a mistake to treat one as redundant with respect to the other. If you do, you will miss the fact that the effect of one on your outcome of interest changes depending on the value of the other. Despite the fact that most heart disease researchers who study risk factors have not used methods tuned to find interactions between triglycerides and HDL, many studies have at least measured both. This has allowed others to do the appropriate analysis. When triglycerides and HDL have been examined with respect to each other, that is, when the effect of triglycerides is measured under the condition of low HDL, or when the effect of HDL is measured under the condition of high triglycerides, this combination of factors turns out to be even more indicative of CVD 20, 21, 22, 23.
One of the most interesting aspects of this finding from our perspective, is that the ratio of triglyceride levels to HDL is considered to be a surrogate marker of insulin resistance (See The Ketogenic Diet as a Treatment for Metabolic Syndrome.) In other words, the best lipid predictors of CVD are also those that indicate insulin resistance.
Ketogenic Diets improve risk factors for CVD
There is now ample evidence that a low carbohydrate, ketogenic diet improves lipid profiles, particularly with respect to the risk factors outlined above: triglycerides, HDL, and their ratio 24, 25, 26, 27, 28, 29, 30, 31.
Although a ketogenic diet typically raises LDL levels, which has been traditionally seen as a risk factor, it has also been shown to improve LDL particle size. In other words, although the absolute amount of LDL goes up, it is the "good" LDL that goes up, whereas the "bad" LDL goes down 31, 32. This is hardly surprising, since LDL particle size is also strongly predicted by triglycerides 33, 34, 35.
Although there have not yet been intervention studies testing the effect of a ketogenic diet on the rate of actual CVD incidents (e.g. heart attacks), the evidence about lipid profiles is strong enough to make ketogenic diets more likely to reduce heart disease than any other known intervention.
- Current medical practice uses blood lipid measurements to assess the risk of heart disease.
- Despite the continuing tradition of measuring total cholesterol and LDL, we have known for decades that triglycerides, HDL, and the ratio of the two, are much better predictors of heart disease. LDL particle size is also considered strongly predictive.
- A ketogenic diet has a very favourable impact on these risk factors, and thus should be considered the diet of choice for those at risk of CVD.
In their 2011 paper, "Low-carbohydrate diet review: shifting the paradigm", Hite et al. display the following graph (VLCKD stands for Very Low Carbohydrate Ketogenic Diet