In this slide deck I demonstrate the effects of carbohydrate restriction on different lipoproteins such as HDL, LDL, non-HDL-cholesterol and apolipoprotein B (apoB). The effect of butter and saturated fat as such are compared to unsaturated fat and especially to canola oil. Meta-analysis by Mensink et al. 2003 is the primary reference for the analysis.

1. 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, MBA
Reijo Laatikainen
www.twitter.com/pronutritionist
Page 1

2. Is butter really healthy for your heart?
2

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?
3

4. Source
Meta-analysis of 60 randomized
studies in weight stable situation
by Mensink et al 2003
4

5. Lipoprotein changes when 1% of daily
energy from carbs is replaced by fats
5
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

6. Part 1, summary
6

7. 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
7
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

8. Part 2, practical example
Potatoes (200 kcal) → Butter (200 kcal)
or
Potatoes (200 kcal) → Canola oil (200 kcal)
8

9. Effects of replacing potatoes by butter
or canola oil in an isocaloric situation
9
?

10. -9.3 %
-0.7 %
0.4 %
2.8 %
6.8 %
-12.0 %
-10.0 %
-8.0 %
-6.0 %
-4.0 %
-2.0 %
0.0 %
2.0 %
4.0 %
6.0 %
8.0 %
Carbohydrate Protein* PUFA MUFA SFA
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
10
*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
11
-9.3 %
-0.7 %
2.8 %
6.4 %
0.7 %
-12.0 %
-10.0 %
-8.0 %
-6.0 %
-4.0 %
-2.0 %
0.0 %
2.0 %
4.0 %
6.0 %
8.0 %
Carbohydrate Protein PUFA MUFA SFA
Change in macronutrient intake when 10% of daily energy as carbs
(boiled potatoes) is replaced by canola oil

12. Change in LDL
12
0.1808
-0.0883
-0.15
-0.1
-0.05
0
0.05
0.1
0.15
0.2
Carbs replaced by butter Carbs replaced by canola oil
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
13
0.087
0.0694
0
0.01
0.02
0.03
0.04
0.05
0.06
0.07
0.08
0.09
0.1
Carbs replaced by butter Carbs replaced by canola oil
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
14
-0.0545
-0.2403
-0.3
-0.25
-0.2
-0.15
-0.1
-0.05
0
Carbs replaced by butter Carbs replaced by canola oil
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
15
0.1272
-0.1426
-0.2
-0.15
-0.1
-0.05
0
0.05
0.1
0.15
Carbs replaced by butter Carbs replaced by canola oil
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
16
2.88
-48
-60
-50
-40
-30
-20
-10
0
10
Carbs replaced by butter Carbs replaced by canola oil
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)

17. Part 2
17
125 grams (25 E%) of carbs → SFA
or
125 grams (25 E%) of carbs → MUFA
or
125 grams (25 E%) of carbs → PUFA

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.
18

19. 19
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 scenarios
in weight stable situation
1
2
3
?
?
?

20. Change in HDL
20
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)
0.25
0.20
0.15
0.00
0.05
0.10
0.15
0.20
0.25
0.30
by SFA by MUFA by PUFA
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
21
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)
65.00
-120.00
-192.50
-250.00
-200.00
-150.00
-100.00
-50.00
0.00
50.00
100.00
by SFA by MUFA by PUFA
Change in Apo-B (mg/L) when 25 % of energy from
carbs is replaced by different fatty acid classesmg/L

22. Change in non-HDL-cholesterol
22
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)
0.65
-0.35
-0.68-0.80
-0.60
-0.40
-0.20
0.00
0.20
0.40
0.60
0.80
by SFA by MUFA by PUFA
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)

23. Change in total cholesterol:HDL -ratio
23
0.075
-0.65
-0.80-0.900
-0.800
-0.700
-0.600
-0.500
-0.400
-0.300
-0.200
-0.100
0.000
0.100
0.200
by SFA by MUFA by PUFA
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
24
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)
0.80
-0.23
-0.48-0.60
-0.40
-0.20
0.00
0.20
0.40
0.60
0.80
1.00
by SFA by MUFA by PUFA
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)
25
No data available in
Mensink’s meta-analysis or in
any other currently available
meta-analysis

26. 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”
26

27. Healthy switch
27

28. Unhealthy switch
28

29. 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
29

30. What about morbidity and
mortality trials and prospective
cohorts?
Visit my other slide deck on butter
http://www.slideshare.net/pronutritionist/margi
ne-or-butter
30

31. What about LDL-particle size or
LDL-P?
Visit my upcoming slide deck (due before
September 2014)
31

32. Wellcome aboard!
http://twitter.com/pronutritionist
http://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.
Page 32

33. Back up slides
Calculations behind the substitutions

34. Change in LDL when canola oil
replaces potatoes
34
0.016
-0.0549
-0.0494
-0.0883
-0.1
-0.08
-0.06
-0.04
-0.02
0
0.02
0.04
POtatoes replaced by SFA
(0.5 E%)
Carbs replaced by MUFA
(6.1 E%)
Carbs replaced by PUFA
(2.6 E%)
Net change (sum)
Change in LDL cholesterol (mmol/L)

35. Change in HDL when canola oil
replaces potatoes
35
0.005
0.0488
0.0156
0.0694
0
0.01
0.02
0.03
0.04
0.05
0.06
0.07
0.08
Carbs replaced by SFA (0.5
E%)
Carbs replaced by MUFA
(6.1 E%)
Carbs replaced by PUFA
(2.6 E%)
Net change (sum)
Change in HDL cholesterol (mmol/L)

36. Change in total cholesterol:HDL –ratio
when canola oil replaces potatoes
36
0.0015
-0.1586
-0.0832
-0.2403
-0.3
-0.25
-0.2
-0.15
-0.1
-0.05
0
0.05
Carbs replaced by SFA (0.5 E%) Carbs replaced by MUFA (6.1
E%)
Carbs replaced by PUFA (2.6
E%)
Net change (sum)
Change in Tot Chol:HDL -ratio

37. Change in non-HDL-cholesterol when
canola oil replaces potatoes
37
0.013
-0.0854
-0.0702
-0.1426
-0.16
-0.14
-0.12
-0.1
-0.08
-0.06
-0.04
-0.02
0
0.02
0.04
Carbs replaced by SFA (0.5
E%)
Carbs replaced by MUFA
(6.1 E%)
Carbs replaced by PUFA
(2.6 E%)
Net change (sum)
Change in non-HDL-Cholesterol

38. Change in apoB when canola oil
replaces potatoes
38
1.3
-29.28
-20.02
-48.00
-60
-50
-40
-30
-20
-10
0
10
Carbs replaced by SFA (0.5
E%)
Carbs replaced by MUFA
(6.1 E%)
Carbs replaced by PUFA
(2.6 E%)
Net change (sum)
Change in Apo B (mg/L)

39. Change in LDL when butter replaces
potatoes
39
0.208
-0,0234 -0,0038
0.1808
-0.05
0
0.05
0.1
0.15
0.2
0.25
Carbs replaced by SFA
(6.5 E%)
Carbs replaced by MUFA
(2.6 E%)
Carbs replaced by PUFA
(0.2 E%)
Net change (sum)
Change in LDL cholesterol (mmol/L)

40. Change in HDL when butter replaces
potatoes
40
0.065
0.0208
0.0012
0.087
0
0.01
0.02
0.03
0.04
0.05
0.06
0.07
0.08
0.09
0.1
Carbs replaced by
SFA (6.5 E%)
Carbs replaced by
MUFA (2.6 E%)
Carbs replaced by
PUFA (0.2 E%)
Net change (sum)
Change in HDL cholesterol (mmol/L)

41. Change in total cholesterol:HDL –ratio
when butter replaces potatoes
41
0.0195
-0.0676
-0.0064
-0.0545
-0.08
-0.07
-0.06
-0.05
-0.04
-0.03
-0.02
-0.01
0
0.01
0.02
0.03
Carbs replaced by SFA (6.5
E%)
Carbs replaced by MUFA
(2.6 E%)
Carbs replaced by PUFA
(0.2 E%)
Net change (sum)
Change in Tot Chol:HDL -ratio

42. Change in non-HDL-cholesterol when
butter replaces potatoes
42
0.169
-0.0364
.-0,0054
0.1272
-0.05
0
0.05
0.1
0.15
0.2
Carbs replaced by SFA (6.5
E%)
Carbs replaced by MUFA
(2.6 E%)
Carbs replaced by PUFA
(0.2 E%)
Net change (sum)
Change in non-HDL-Cholesterol

43. Change in apoB when butter replaces
potatoes
43
16.9
-12.48
-1.54
2.88
-15
-10
-5
0
5
10
15
20
Carbs replaced by SFA (6.5
E%)
Carbs replaced by MUFA
(2.6 E%)
Carbs replaced by PUFA
(0.2 E%)
Net change (sum)
Change in Apo B (mg/L)