An elevation of triglycerides reflecting decreased triglyceride clearance may not be pathogenic -- relevance to high-carbohydrate diets.

The fact that carbohydrate-rich diets often increase plasma triglycerides has led some to question the wisdom of such diets. This increase is primarily attributable to a decrease in the efficiency of triglyceride clearance -- whereas the elevation of triglycerides observed in insulin-resistant subjects stems mainly from increased hepatic production of VLDL particles. There is growing reason to suspect that the increased coronary risk associated with elevated triglycerides in Western epidemiology reflects the fact that high triglycerides are a marker for insulin resistance syndrome, rather than any inherent pathogenic role of triglycerides per se. Thus, endothelial dysfunction is seen only in those hypertriglyceridemic subjects who are insulin resistant, and is absent in patients whose markedly elevated triglycerides reflect genetically defective lipoprotein lipase activity. Triglyceride levels are relatively high in certain Third World societies which are virtually immune to coronary disease so long as they persist in their traditional very-low-fat diets; in Ornish's celebrated study, a moderate rise in triglycerides coincided with a marked reduction in coronary events. Although the particle size of both LDL and HDL tends to decrease when triglyceride levels are high, it is questionable whether this effect has a major pathogenic impact. The one clear drawback of high-carbohydrate diets is a decrease in HDL particle number, resulting from decreased hepatic production of apoA-I; this effect is seen whether or not triglycerides increase. The very favorable effects of very-low-fat, whole food, quasi-vegan diets on LDL cholesterol, insulin sensitivity, and body weight appear to more than compensate for this decrease in HDL; it is notable that HDL levels tend to be quite low in Third World cultures at minimal risk for coronary disease. On the other hand, this decrease in HDL may be of more significance in the context of omnivore diets only moderately low in fat, as suggested by the fact that diets higher in unsaturated fats emerge as more protective in Western prospective epidemiology. The tendency of high-carbohydrate diets to boost triglycerides can be minimized by exercise training, supplemental fish oil, an emphasis on fiber-rich, low-glycemic-index whole foods, and the "spontaneous" weight loss often seen with ad libitum consumption of such diets -- measures which are highly recommendable whether or not triglycerides are a concern.