Risks for coronary disease 2008 31. December 2007 William Davis (27) According to conventional thinking, there are identifiable risks for coronary disease and heart attack. These risk factors are: * smoking * high blood pressure * high blood cholesterol and excessive saturated fat intake * diabetes * being overweight or obese * physical inactivityI'd agree with all the factors listed (though I would argue about the importance of high blood cholesterol and saturated fat; they are not as important as commonly made to be.)Is the list complete? From the unique perspectives gained in the Track Your Plaque program, I'd offer a significantly different list. Trying to stop or reduce coronary atherosclerotic plaque and heart scan scores makes you a whole lot smarter about what works and what doesn't work. So, in addition to the risk factors listed above, I would add: * Small LDL particles--Lots of small LDL particles is MORE important than high LDL. * High blood pressure with exercise * Excessive wheat intake and other processed carbohydrates--An issue of explosive importance today. Wheat creates large numbers of small LDL particles, among other adverse effects. * Vitamin D deficiency--Among the most powerful risks I know of. It belongs at the top of the list. * Vitamin K2 deficiency * Low HDL cholesterol * Blood sugar >100 mg/dl * High triglycerides--While some argue about whether triglycerides are a risk that behaves independently of patterns like low HDL, they are neglecting the potent force of this risk. Sure, it occurs in tandem with low HDL (usually, though not always), but it is a factor that can leave you with risk even when HDL is raised to healthy levels. * Lipoprotein(a)--It is eminently, positively crystal clear that lipoprotein(a) is a powerful risk for heart disease. The lack of a profitable treatment keeps it hidden in the shadows. * Pessimism--Be happy, do better. Be a constantly angry, frustrated, complaining sourpuss and you are more likely to succumb to heart disease, cancer, or other undesirable fate. These are the risk factors that we address through the Track Your Plaque program, a list that yields a far more powerful and comprehensive approach to control over coronary plaque/atherosclerosis, sufficient to achieve reversal in many (though not in all) instances. I view the list of conventional risk factors as a "no brainer" list. Sure, smoking is a risk factor. But there are virtually no smokers in the Track Your Plaque program. If you smoke, you clearly don't care enough to engage in a high-intensity prevention program like this. Saturated fat? Perhaps, but the battlefield of heart disease is riddled with the bodies of those who employed this as their sole strategy and failed catastrophically. Diabetes, hypertension, and overweight all represent a continuum of risk; the solutions offered in the conventional scheme (i.e., low-fat diet, etc.) make these patterns worse, not better.The conventional response to heart disease risk is trapped somewhere in 1973 and has not changed in over 30 years. Heart disease continues to be a growth industry for hospitals and the pharmaceutical and medical device industries. The "official" organizations continue to deliver an antiquated, outdated message. If you want heart disease, follow the American Heart Association diet. If you want established heart disease to get worse, follow the American Heart Association diet. If you want diabetes or, if you already have diabetes or pre-diabetes, if you want it to worsen and develop organ damage (eyes, kidneys, nervous system, etc.), then follow the American Diabetes Association diet. USDA food pyramid? Loosen your belt!The list of conventional risk factors for heart disease is woefully inadequate. If that is as far as your prevention program takes you, heart disease will not be controlled or prevented. At best, it might be slowed; at worst--and more likely--it might be accelerated.
Food sources of vitamin K2 27. December 2007 William Davis (46) Vitamin K2 is emerging as an exciting player in the control and possible regression of coronary atherosclerotic plaque. Only about 10% of dietary vitamin K intake is in the K2 form, the other 90% being the more common K1. The ideal source of K2 is natto, the unpalatable, gooey, slimy mass of fermented soybeans that Japanese eat and has been held responsible for substantial decreases in osteoporosis and bone fractures of aging. Natto has an ammonia-like bouquet, in addition to its phlegmy consistency that makes it virtually inedible to anyone but native Japanese. I say that the conversation on vitamin K2 is emerging because of a number of uncertainties: What form of vitamin K2 is best (so-called MK-4 vs. MK7 vs. MK-9, all of which vary in structure and duration of action in human blood)? What dose is required for bone benefits vs. other benefits outside of bone health? Why would humans have developed a need for a nutrient that is created through fermentation with only small quantities in meats and other non-fermented foods? Much of the developing research on vit K2 is coming from the laboratories of Drs. Vermeer, Geleijnse, and Schurgers at the University of Maastricht in the Netherlands, along with several laboratories in Japan, the champions of K2.MK-7 and MK-8,9,10 come from bacterial fermentation, whether in natto, cheese, or in your intestinal tract; MK-4 is naturally synthesized by animals from vitamin K1. While natto is the richest source of the MK-7 form, egg yolks and fermented cheeses are the richest sources of the MK-4 form. Chicken contains about 8 mcg MK-4 per 3 1/2 oz serving; beef contains about 1 mcg. Egg yolks contain 31 mcg MK-4 per 3 1/2 oz serving (app. 6 raw yolks). Hard cheeses contain about 5 mcg MK-4 per 3 1/2 oz serving, about 70 mcg of MK-8,9; soft cheeses contain about 30% less. Natto contains about 1000 mcg of MK-7, 84 mcg MK-8, and no MK-4 per 3 1/2 oz serving. Feta cheese Thanks to the research efforts of the Dutch and Japanese groups, several phenomena surrounding vitamin K2 are clear, even well-established fact: --Vitamin K2 supplementation (via frequent natto consumption or pharmaceutical doses of K2) substantially improves bone health. While K2 by itself exerts significant bone density/strength increasing properties in dozens of studies, when combined with other bone health-promoting agents (e.g., vitamin D3, prescription drugs like Fosamax and calcitonin), an exaggerated synergy of bone health-promoting effects develop. --The MK-4 form of vitamin K2 is short-lived, lasting only 3-4 hours in the body. The MK-7 form, in contrast, the form in natto, lasts several days. MK-7 and MK-8-10 are extremely well absorbed, virtually complete. --Bone health benefits have been shown for both the MK-7 and MK-4 forms. --Coumadin (warfarin) blocks all forms of vitamin K. Interestingly, farm-raised meats and eggs do not differ from factory farm-raised foods in K2 content. (But please do not regard this as an endorsement of factory farm foods.) Another interesting fact: Since mammals synthesize a small quantity of Vit K2 forms from vitamin K1, then eating lots of green vegetables should provide substrate for some quantity of K2 conversion. However, work by Schurgers et al have shown that K1 absorption is poor, no more than 10%, but increases significantly when vegetables are eaten in the presence of oils. (Thus arguing that oils are meant to be part of the human diet. Does your olive oil or oil-based salad dressing represent fulfillment of some subconscious biologic imperative?) If we believe the data of the Rotterdam Heart Study, then a threshold of 32.7 micrograms of K2 from cheese yields the reduction in cardiovascular events and aortic calcification.It's all very, very interesting. My prediction is that abnormal (pathologic) calcium deposition will prove to be a basic process that parallels atherosclerotic plaque growth, and that manipulation of phenomena that impact on calcium depostion also impact on atherosclerotic plaque growth. Vitamins D3 and K2 provide potential potent means of at least partially normalizing these processes. As the data matures, I am going to enjoy my gouda, Emmenthaler, Gruyere, and feta cheeses, along with a few egg yolks. I'm going to be certain to include healthy oils like olive and canola with my vegetables. All images courtesy Wikipedia. Copyright 2007 William Davis, MD
Track Your Plaque: Naughty or nice? 24. December 2007 William Davis (6) Among the many wonderful surprises we've had at Track Your Plaque this holiday season was a letter from Santa Claus himself!It seems that Santa, like the rest of us, has been busy surfing the web for useful health information the last few months. He was struck with this curious discussion we've been having about "wheat belly" and all the unhealthy consequences of wheat products in our diet. He writes:"I wouldn't have believed it myself, except that my waist size has grown four inches in as many years. Sure, I'm known for my healthy girth, but now even Mrs. Claus calls me fat!"I was open to new ideas when I came across this crazy discussion about eliminating wheat from your diet. So I said, "What have I got to lose?" Well, four weeks later and 12 lbs lighter, I'm convinced. Now comes the tough part: I've got to deliver all the toys and resist all those cookies the children put out for me. I wonder if wheat makes reindeer fat, too?"Anyway, thanks to your program I'm back to my old weight again. Doc says my blood sugar and blood pressure are also back down to normal. Thanks, Track Your Plaque! (You'll find something extra special under the tree this year.)"And so it goes. I'm tempted to put Santa's testimonial on our homepage, but I think that may be tooting our own horn a bit too much. Have a wonderful holiday!
Vitamin D: Treatment for metabolic syndrome? 21. December 2007 William Davis (44) Metabolic syndrome is that increasingly common collection of low HDL cholesterol, high triglycerides, high blood sugar, and high pressure that now afflicts nearly 1 in 4 adults, rapidly gaining ground to 1 in 3. Beyond these surface factors, metabolic syndrome also creates small LDL particles, VLDL, intermediate-density lipoproteins (IDL), increased imperceptible inflammation measured as higher c-reactive protein, and greater blood clotting tendencies. Metabolic syndrome is usually, though not always, associated with a big tummy ("beer belly," though I call it "wheat belly"). In short, metabolic syndrome creates a metabolic mess that leads to dramatic increases in heart disease, vascular disease and stroke, and cancer. The medical community has been paying increasingly greater attention to this condition because of its booming prevalence and because of the big bucks invested in "education" by the manufacturers of the diabetes and pre-diabetes drugs, particularly makers of Actos and Avandia. But here's a curious observation: Replacement of vitamin D to healthy levels (we aim for 50-60 ng/ml, or 125-150 nmol/l) yields:--Higher HDL--Lower triglycerides--Lower blood sugar--Reduced c-reactive protein--Reduced blood pressure--Reduced small LDL--Enhanced sensitivity to insulin(Whether blood clotting and effects on IDL should be added to this list is uncertain.) It's obvious: Vitamin D is proving to be a very important and powerful corrective influence on many of the facets of the metabolic syndrome. In fact, I would go as far as saying that, side by side, vitamin D yields nearly the same effect as prescription drugs Actos and Avandia--without the extravagant cost (nearly $200 per month), leg swelling, congestive heart failure and heightened heart attack risk (with Avandia), and average 8 lb weight gain. Of course, vitamin D also provides benefits beyond metabolic syndrome like facilitation of coronary plaque regression, increased bone density, reduced arthritis, and reduced risk of several cancers. You'd think that agencies like the American Diabetes Association (ADA) would be all over vitamin D like white on rice. Yet they remain curiously quiet about the entire issue. (That should come as no surprise to anyone familiar with the behavior and politics of this organization, the same outfit that has widely propagated the ADA diet, a program that accelerates diabetes and its complications. In my view, the ADA is an embarassment.) For a really great story and video on vitamin D that includes a terrific interview with vitamin D guru and Track Your Plaque friend, California psychiatrist Dr. John Cannell, go to What's the Real Story on Vitamin D?. While the video will yield little new to readers of The Heart Scan Blog or Track Your Plaque members, it just feels really good to see a well-made, high-class video production echoing many of the things we've been talking about these past two years.
Appetite stimulants 20. December 2007 William Davis (17) Ever have days when you just can't seem to get enough to eat, your stomach gnawing just a hour after a meal? We all get them, some more than others. Other days, you can be content with a few simple foods and hunger is subdued, temptation easy to control.Why such contrasts on different days?A major part of the reason can be the presence of appetite stimulants, factors that trigger appetite beyond rational control. The list of common appetite stimulants includes:--Sleep deprivation--A very important factor. Lack of sleep drives tremendous appetite, and often for the wrong foods (processed carbohydrates). I personally have experienced my most shamefully indulgent days when sleep-deprived. The solution is obvious: Sleep. Another factor that is based purely on personal observation is that of waking mid-phase. In other words, waking up while you're still enjoying the deeper phases of sleep (e.g., phase 3,4, or REM). This can oddly disrupt your day and your impulse control. I usually try and time sleep to increments of 90 minutes to coincide with the average duration of the full cycle of sleep. For example, 7 1/2 hours is better than 8 hours, since the extra half hour puts your square into a deeper sleep cycle.--Excessive caffeine--Caffeine stimulates stomach acid. This triggers the impulse to eat . . . and eat and eat. Image courtesy Wikipedia--Aspirin and other anti-inflammatory agents--If you take aspirin (as many of our Track Your Plaquers do), then beware of the gastritis that can develop. Like excessive caffeine, it also triggers the impulse to eat, likely a protective mechanism, since food sops up excess acid. I ask patients to take periodic breaks from aspirin, e.g., a week off every two or three months, to allow the stomach to heal. Alternatively, an occasional dose of acid-suppressing medication is a safe practice, e.g., Pepcid AC 10-20 mg; Prilosec 10-20 mg.--Wheat-containing foods--Followers of The Heart Scan Blog know my feelings on this. Wheat is a potent appetite stimulant: Eat something containing wheat like a pretzel or whole wheat bagel, and you want more. You may want more immediately, or a little later when your blood sugar plunges after the wheat-driven insulin surge. Solution: Dump the wheat, one of the most unhealthy food groups around.--Alcohol--Though perhaps not a direct appetite-stimulating effect, the loss of impulse-control with alcoholic drinks can lead to overindulgence, often in the worst foods. Just beware.--Hanging around with heavy people. Remember peer pressure? It can be subliminal. People with poor eating habits provide the silent message that it's okay to yield to impulse, overeat, overindulge, and choose the wrong foods.--Stress--Whether through cortisol stimulation or other means, stress triggers appetite in some people. If you experience this and must give in, reach for raw nuts or nuts, rather than wheat snacks or chips. The effect will be minimal, perhaps even beneficial, rather than the bloating, appetite-stimulating, fattening effect of crackers, chips, or pretzels. This may be the same phenomenon as taking prescription steroids like prednisone.--Short dark days, long nights--In other words, winter. Though just an anecdotal observation, I am convinced that vitamin D supplementation is an effective antidote to this effect. The short, dark days just don't bother you as much, perhaps not at all, and there's no impulse for comfort foods. How about appetite suppressants? In this list I would include 1) raw nuts--especially almonds, walnuts, pecans, and pistachios, the sort with a fibrous covering and rich in monounsaturates, 2) other sources of plentiful healthy oils, e.g, use more olive oil in your salad or add it to hummus for your veggie dip, 3) space-occupying fibers such as glucomannan, inulin (such as in Fiber Choice), and psyllium seed products. Counteracting the above appetite stimulants like sleep deprivation is, of course, important.The coming wheat frenzy, otherwise known as the holidays, is an especially important time to be aware of these effects. Eat, drink, and be merry--but with rational impulse control not driven by subconscious appetite stimulants.
"Heart scans are experimental" 18. December 2007 William Davis (25) Let me warn you: This is a rant. It is prompted by a 44-year old woman. She has a very serious lipoprotein disorder. Her family experiences heart attacks in their 40s and 50s. I asked for a heart scan. Her insurance companied denied it. This is nothing new: heart scans, like mammograms, have not enjoyed reimbursement from most insurers despite the wealth of data and growing acceptance of this "mammogram" of the heart. However, 10 minutes on the phone, and the "physician" (what well-meaning physician can do this kind of work for an insurance company is beyond me) advised me that, while CT heart scans for coronary calcium scoring are not covered, CT coronary angiograms are. Now, I've been witnessing this trend ever since the big players in CT got involved in the game, namely Philips, Siemens, Toshiba, and GE. These are enormous companies with hundreds of billions of dollars in combined annual revenues. They, along with the lobbying power of cardiology organizations like the American College of Cardiology, have gotten behind CT coronary angiograms. This is most likely the explanation of why CT coronary angiograms have rather handily obtaining insurance reimbursement. Interestingly, the insurance company I was speaking to is known (notorious?) for very poor reimbursement practices. A CT heart scan, when properly used, generates little revenue, a few hundred dollars to a scan center, barely enough to pay for a device that costs up to $2 million. However, CT coronary angiograms, in contrast, yield around $2000 per test. More importantly, they yield downstream revenues, since CT angiograms are performed as preludes to conventional heart catheterizations, angioplasty, stents, bypass surgery, etc. Now we're talking tens or hundreds of thousands of dollars revenue per test. What puzzles me is that much of that increased cost comes out of the insurance company. Why would they support such tests if it exposes them to more costs? I'm not certain. It could be the greater pressures exerted by the big CT companies and powerful physician organizations. I seriously doubt that the insurance companies truly believe that heart scans for coronary calcium scoring are "experimental" while CT coronary angiograms are "proven." If all we did was compare the number of clinical studies that validate both tests, we'd find that the number of studies validating heart scans eclipses that of coronary angiograms several fold. Experimental? Hardly. The smell of money by physicians eager to jump on the bandwagon of a new revenue-producing procedure is probably enough to have them lobby insurers successfully. In contrast, plain old heart scans just never garnered the kind of vigorous and vocal support, since nobody gets rich off of them. If CT coronary angiograms are sufficiently revenue producing that my colleagues and the CT scanner manufacturers have managed to successfully lobby the health insurers, even one as financially "tight" as the one I spoke to today, well then I take that as testimony that money drives testing, as it does the behavior of hospitals, many of my colleagues, and can even force the hand of insurers.
When meat is not just meat 18. December 2007 William Davis (7) The edgy nutrition advocate, Mike Adams, over at NewsTarget.com came up with this scary photo tour of a processed meat product from Oscar Mayer: Mystery Meat Macrophotography: A NewsTarget PhotoTour by Mike Adams Along with increasingly close-up photographs of this meat-product, Adams lists the ingredients in Oscar Mayer's Cotto Salami: Beef hearts PorkWaterCorn syrupBeefContains less than 2% of:SaltSodium lactateFlavorSodium phosphatesSodium diacetateSodium erythorbate DextroseSodium nitriteSoy lecithinPotassium phosphatePotassium chlorideSugarAs I reconsider the role of saturated fat in diet, given the startlingly insightful discussion by Gary Taubes of Good Calories, Bad Calories, I am reminded that not all meat is meat, not all saturated fat sources are equal. I am concerned in particular about sodium nitrite content, a color-fixer added to cured meats that caused a stir in the 1970s when data suggesting a carcinogenic effect surfaced. The public's effort to remove sodium nitrite from the food supply was vigorously opposed by the meat council and it remains in cured meats like sausage, hot dogs, and processed meats like Cotto Salami. A 2006 meta-analysis (combined analysis of studies) of 63 studies did indeed suggest that sodium nitrite was related to increased risk of gastric cancer. This argument is plausible from animal models of cancer risk, as 40 animal models have likewise suggested the same carcinogenic association. Also, fructose? This is most likely added for sweetness. Recall that fructose heightens appetite and raises triglycerides substantially. I personally have a natural aversion to meat. I don't like the taste, the look, smell, and the thought of what the animal went through to make it to the supermarket. But, considered from the cold, carnivorous viewpoint of the question, "Is meat okay to eat?", among the issues to consider is whether the meat has been cured or processed, and does that process include addition of sodium nitrite. Cotto Salami and similar products are not, of course, what carnivorous humans in the wild ate. This is a processed, modified product created from factory farm animals raised in cramped conditions and fed corn and other cheap, available foods. It is not created from free-ranging animals wandering their pastures or pens, eating diets nature intended. This results in modified fat composition, not to mention hormones and antibiotics added. These are not listed on the ingredients. Wild meat does not contain fructose or color-fixers, either. So don't mistake "meat" in your grocery store for meat. It might look and smell the same--until you look a little closer. Copyright 2007 William Davis, MD
Don't lament no OTC mevacor Cureality | Real People Seeking Real Cures Toggle navigation Home Blog Home Archive Join Now Log in Dr. William Blanchet: A voice of reason 24. November 2007 William Davis (21) I don't mean to beat this discussion to a pulp, but looking back over the comments posted on www.theHeart.org forum, I am so deeply impressed with Dr. William Blanchet's grasp of the issues, that I posted his articulate and knowledgeable comments again. Here is one post in which Dr. Blanchet, in response to accusations of trying to profit from heart scans, provides a wonderful summary of the logic and evidence behind the use of heart scans as the basis for heart disease prevention. Yes, I have seen a dramatic reduction in coronary events. Of 6,000 active patients, 48% being Medicare age and over, I have seen 4 heart attacks over the last 3+ years. 2 in 85 year old diabetics undergoing cancer surgery, one in a 90 year old with known disease and one in a 69 year old with no risk factors, who was healthy, and had never benefited from a heart scan.The problem with coronary disease is that we rely on risk factors. Khot et al in JAMA 2003 showed that of 87,000 men with heart attacks, 62% had 0 or 1 major risk factor prior to their MI. According to ATP-III, almost everyone with 0-1 risk factors is low risk and most do not qualify for preventive treatment. EBT calcium imaging could identify 98% of these individuals as being at risk before their heart attack and treatment could be initiated to prevent their MI.Treating to NCEP cholesterol goals prevents 30-40% of heart attacks. Treating to a goal of coronary calcium stability prevents 90% of heart attacks. Where I went to school, a 40% was an F. Why are we defending this result instead of striving to improve upon it? I am not making this up, look at Raggi's study in Arteriosclerosis, Thrombosis, and Vascular Biology 2004;24:1272, or Budoff Am J Card.[I believe it's the study Dr. Blanchet was referring to.] I strongly disagree with the assertion that the stress test is a great risk stratifier. Laukkanen et al JACC 2001 studied 1,769 asymptomatic men with stress tests. Although failing the stress test resulted in an increased risk of future heart attack, 83% of the total heart attacks over the next 10 years occurred in those men who passed the stress test. Falk E, Shah PK, Fuster V Circulation 1995;92:657-671 demonstrated that 86% of heart attacks occur in vessels with less than 70% as the maximum obstruction. A vast majority ofpatients with less than 70% vessel obstruction will pass their stress test.Regarding [the] question of owning or referring for EBT imaging, I would be amused if it were not insulting. The mistake that is often made is that EBT imaging is a wildly profitable technology. It is not nearly as profitable as nuclear stress imaging. Indeed there are few EBT centers in the country that are as profitable as any random cardiologist's stress lab.How can we justify not screening asymptomatic patients? Most heart attacks occur in patients with no prior symptoms and according to Steve Nissen, 150,000 Americans die each year from their first symptom of heart disease. My daughter is at this moment visiting with a friend who lost her father a few years ago to his first symptom of heart disease when she was 8 years old. That is not OK! We screen asymptomatic women for breast cancer risk. Women are 8 times more likely to die from heart disease than breast cancer. We do mass screening for colon cancer and we are over 10 times more likely to die from heart attacks than colon cancer. An EBT heart scan costs 1/8th the cost of a colonoscopy.So what say we drop the sarcasm and look at this technology objectively. Read the literature, not just the editorial comments. This really does provide incredibly valuable information that saves lives.Yes, a 90% reduction in heart attacks in my patients compared to the care I could provide 5 years ago when I was doing a lot of stress testing and referring for revascularization. Much better statistics than expected national or regional norms. I welcome your scrutiny.That's probably the best, most concise summary of why heart scanning makes sense that I've ever heard. And it comes from a primary care physician in the trenches. With just a few paragraphs, Dr. Blanchet, in my view, handily trumps the arguments of my colleagues arguing to maintain the status quo of cholesterol testing, stress tests, and hospital procedures. Note:Dr. Blanchett talks openly about his affiliation with an imaging center in Boulder, Colorado, Front Range Preventive Imaging. I'm no stranger to the accusations Dr. Blanchet receives about trying to profit from the heart scan phenomenon. Ironically, heart scanning loses money. It is a preventive test, not a therapeutic, hospital-based procedure. Free-standing heart scan centers that do little else (perhaps virtual colonoscopies) usually manage to pay their bills but make little profit. Hospitals that offer heart scans usually do so as a "loss-leader," i.e., an inexpensive test that brings you in the door in the hopes that you will require more testing.Accusations of profiteering off heart scans are, to those in the know, ridiculous and baseless. On the contrary, heart scans are both cost-saving and life-saving. Vitamin D2 rip-offs 23. November 2007 William Davis (21) Here's a sampling of prescription vitamin D2/ergocalciferol products available:Prescription ergocalciferol (vitamin D2) (Drisdol brand), 50 caps for $130.84. Alfcip brand of erogocalciferol (vitamin D), 30 capsules for $28.20. Ergocalciferol (vitamin D2) as Drisdol oral solution, 1 bottle $146.26.How about vitamin D3/cholecalciferol?Carlson's brand cholecalciferol (vitamin D3), 120 capsules $5.09. Cholecalciferol, vitamin D3, is far less expensive than ergocalciferol, vitamin D2. Cholecalciferol is available as a supplement without prescription. Ergocalciferol is available only by prescription. The price difference must mean that the plant-based form, ergocalciferol, must be far superior to the naturally-occurring human form, vitamin D3. Of course, that's not true. Dr. Robert Heaney's study is just one of several documenting the inferiority of D2/ergocalciferol, Vitamin D2 Is Much Less Effective than Vitamin D3 in Humans. D2 exerted less than a third of the effect of D3. In my experience, D2/ergocalciferol often exerts no effect whatsoever. One woman I consulted on came into the office having been prescribed Drisdol capsules, 50,000 units every day for the past 18 months (by mistake by her physician). Blood level of active 25-OH-vitamin D3: Zero. But the pharmacy and drug manufacturer collected $1413 for her 18-month course. Cost for a 4000 unit per day dose of D3/cholecalciferol: $45--and it would have actually worked. In my view, prescription vitamin D2 is yet another example of drug manufacturer scams, a product that provides no advantages, costs more, but yields bigger profits. Yet this wonderful supplement called cholecalciferol, among which Carlson's is an excellent choice, is available to you inexpensively, without prescription, and actually provides the benefits you desire. Stenosis detection vs. plaque detection 22. November 2007 William Davis (5) One of the most common misunderstandings encountered by both physicians and the public is that, to create an effective heart disease prevention program, we need tools for atherosclerotic plaque detection. What we do not need is a tool for stenosis detection. (Stenosis means percent blockage. A 50% stenosis means 50% of the diameter of an artery is reduced by atherosclerosis.)This issue came to mind recently with the ongoing conversation at Heart.org forum, in which the conversation predictably degenerated into a "what good are heart scans when there are better tests to detect blockage" sort of mentality. They are right: There are better tests to detect stenoses or blockages, such as stress tests, heart catheterization, and CT coronary angiography. If someone is having chest pain or breathlessness, these tests are useful to help understand why. These tests are preludes to stents, bypass surgery, and the like. They are the popular tools in hospitals, the ones that provide entry into the revenue-yielding world of heart disease procedures. Plaque detection, on the other hand, is principally a tool for the person without symptoms. In this regard, it is more like cholesterol testing. I doubt my colleagues would bash cholesterol because it doesn't reveal blockages. Plaque detection identifies the person who has already started developing atherosclerosis. Dr. William Blanchett of Colorado articulates this idea well: EBT calcium imaging not only identifies the vast majority of individuals at risk, it also identifies individuals with minimal risk. In other words, it distinguishes those who are likely to benefit from treatment . . .and it identifies those unlikely to benefit from treatment. Furthermore, the greatest value of EBT calcium imaging is that with serial imaging you can determine who is and who is not responding to treatment. Those patients not responding to the initial treatment are identified by progression of their calcified plaque on a subsequent scan are then placed on additional therapies. The net result is a remarkable reduction in heart attack rates.Ahh, the voice of reason. Plaque detection empowers you in your prevention program. If you know how much plaque your begin with, you can track that value to know whether you have having a full effect or not. Stenosis detection, on the other hand, empowers your doctor and provides the irresistible impulse to stent. Another common objection raised to plaque detection is "why bother if you're going to give everybody a statin anyway?" We know the origins of that argument, don't we? If the only strategy known to your doctor is cholesterol reduction with statin drugs, then perhaps that's right. But, with awareness of all the things that go beyond statin drugs, often make them unnecessary, then knowledge of who should engage in an intensive program of prevention or not is enabled by plaque detection. Is an increase in heart scan score GOOD? 20. November 2007 William Davis (30) In response to an earlier Heart Scan Blog post, I don't care about hard plaque!, reader Dave responded:Hello Dr Davis,Interesting post about hard and soft plaque. I recently had a discussion with my GP regarding my serious increase in scan score (Jan 2006 = 235, Nov 2007 = 419).After the first scan we started aggressively going after my LDL, HDL and Trig...196,59,221And have them down to 103, 65, 92 - we still have a way to go to 60/60/60 [The Track Your Plaque target values]-So the increase is a surprise, but my doctor said that the increase could in part be cause some of the soft plaque had been converted to hard plaque and the scan would show that conversion. Dave's doctor then responded to him with this comment:"Remember that although your coronary calcium score has gone up, this does not mean that you are at greater risk than you were a year ago. Remember that the most dangerous plaque is the not-yet calcified soft plaque, which will not show up on an EBT [i.e., calcium score]. It is only the safe, calcified plaque that can be measured with the EBT. [Emphasis mine.] For your score to go up like it did, while your lipids came down so much, what had to happen was that lots of dangerous unstable plaque was converted to stable, calcified plaque. There are no accepted guidelines for interpreting changes in calcium scores over time, because the scores tend to go up as treatment converts dangerous plaque to safer plaque. We do know that aggressively lowering LDL reduces both unstable and stable plaque, and we know that risk can be further lowered by adjuvant therapy such as I listed above."Huh?This bit of conventional "wisdom" is something I've heard repeated many times. Is it true? It is absolutely NOT true. In fact, the opposite is true: Dave's substantial increase in heart scan score from 235 to 419 over 22 months, representing a 78% increase, or an annualized rate of increase of 37%. This suggests a large increase in his risk for heart attack, not a decrease. Big difference!Dr. Paulo Raggi's 2004 study, Progression of coronary artery calci
Dr. William Blanchet: A voice of reason 24. November 2007 William Davis (21) I don't mean to beat this discussion to a pulp, but looking back over the comments posted on www.theHeart.org forum, I am so deeply impressed with Dr. William Blanchet's grasp of the issues, that I posted his articulate and knowledgeable comments again. Here is one post in which Dr. Blanchet, in response to accusations of trying to profit from heart scans, provides a wonderful summary of the logic and evidence behind the use of heart scans as the basis for heart disease prevention. Yes, I have seen a dramatic reduction in coronary events. Of 6,000 active patients, 48% being Medicare age and over, I have seen 4 heart attacks over the last 3+ years. 2 in 85 year old diabetics undergoing cancer surgery, one in a 90 year old with known disease and one in a 69 year old with no risk factors, who was healthy, and had never benefited from a heart scan.The problem with coronary disease is that we rely on risk factors. Khot et al in JAMA 2003 showed that of 87,000 men with heart attacks, 62% had 0 or 1 major risk factor prior to their MI. According to ATP-III, almost everyone with 0-1 risk factors is low risk and most do not qualify for preventive treatment. EBT calcium imaging could identify 98% of these individuals as being at risk before their heart attack and treatment could be initiated to prevent their MI.Treating to NCEP cholesterol goals prevents 30-40% of heart attacks. Treating to a goal of coronary calcium stability prevents 90% of heart attacks. Where I went to school, a 40% was an F. Why are we defending this result instead of striving to improve upon it? I am not making this up, look at Raggi's study in Arteriosclerosis, Thrombosis, and Vascular Biology 2004;24:1272, or Budoff Am J Card.[I believe it's the study Dr. Blanchet was referring to.] I strongly disagree with the assertion that the stress test is a great risk stratifier. Laukkanen et al JACC 2001 studied 1,769 asymptomatic men with stress tests. Although failing the stress test resulted in an increased risk of future heart attack, 83% of the total heart attacks over the next 10 years occurred in those men who passed the stress test. Falk E, Shah PK, Fuster V Circulation 1995;92:657-671 demonstrated that 86% of heart attacks occur in vessels with less than 70% as the maximum obstruction. A vast majority ofpatients with less than 70% vessel obstruction will pass their stress test.Regarding [the] question of owning or referring for EBT imaging, I would be amused if it were not insulting. The mistake that is often made is that EBT imaging is a wildly profitable technology. It is not nearly as profitable as nuclear stress imaging. Indeed there are few EBT centers in the country that are as profitable as any random cardiologist's stress lab.How can we justify not screening asymptomatic patients? Most heart attacks occur in patients with no prior symptoms and according to Steve Nissen, 150,000 Americans die each year from their first symptom of heart disease. My daughter is at this moment visiting with a friend who lost her father a few years ago to his first symptom of heart disease when she was 8 years old. That is not OK! We screen asymptomatic women for breast cancer risk. Women are 8 times more likely to die from heart disease than breast cancer. We do mass screening for colon cancer and we are over 10 times more likely to die from heart attacks than colon cancer. An EBT heart scan costs 1/8th the cost of a colonoscopy.So what say we drop the sarcasm and look at this technology objectively. Read the literature, not just the editorial comments. This really does provide incredibly valuable information that saves lives.Yes, a 90% reduction in heart attacks in my patients compared to the care I could provide 5 years ago when I was doing a lot of stress testing and referring for revascularization. Much better statistics than expected national or regional norms. I welcome your scrutiny.That's probably the best, most concise summary of why heart scanning makes sense that I've ever heard. And it comes from a primary care physician in the trenches. With just a few paragraphs, Dr. Blanchet, in my view, handily trumps the arguments of my colleagues arguing to maintain the status quo of cholesterol testing, stress tests, and hospital procedures. Note:Dr. Blanchett talks openly about his affiliation with an imaging center in Boulder, Colorado, Front Range Preventive Imaging. I'm no stranger to the accusations Dr. Blanchet receives about trying to profit from the heart scan phenomenon. Ironically, heart scanning loses money. It is a preventive test, not a therapeutic, hospital-based procedure. Free-standing heart scan centers that do little else (perhaps virtual colonoscopies) usually manage to pay their bills but make little profit. Hospitals that offer heart scans usually do so as a "loss-leader," i.e., an inexpensive test that brings you in the door in the hopes that you will require more testing.Accusations of profiteering off heart scans are, to those in the know, ridiculous and baseless. On the contrary, heart scans are both cost-saving and life-saving.
Vitamin D2 rip-offs 23. November 2007 William Davis (21) Here's a sampling of prescription vitamin D2/ergocalciferol products available:Prescription ergocalciferol (vitamin D2) (Drisdol brand), 50 caps for $130.84. Alfcip brand of erogocalciferol (vitamin D), 30 capsules for $28.20. Ergocalciferol (vitamin D2) as Drisdol oral solution, 1 bottle $146.26.How about vitamin D3/cholecalciferol?Carlson's brand cholecalciferol (vitamin D3), 120 capsules $5.09. Cholecalciferol, vitamin D3, is far less expensive than ergocalciferol, vitamin D2. Cholecalciferol is available as a supplement without prescription. Ergocalciferol is available only by prescription. The price difference must mean that the plant-based form, ergocalciferol, must be far superior to the naturally-occurring human form, vitamin D3. Of course, that's not true. Dr. Robert Heaney's study is just one of several documenting the inferiority of D2/ergocalciferol, Vitamin D2 Is Much Less Effective than Vitamin D3 in Humans. D2 exerted less than a third of the effect of D3. In my experience, D2/ergocalciferol often exerts no effect whatsoever. One woman I consulted on came into the office having been prescribed Drisdol capsules, 50,000 units every day for the past 18 months (by mistake by her physician). Blood level of active 25-OH-vitamin D3: Zero. But the pharmacy and drug manufacturer collected $1413 for her 18-month course. Cost for a 4000 unit per day dose of D3/cholecalciferol: $45--and it would have actually worked. In my view, prescription vitamin D2 is yet another example of drug manufacturer scams, a product that provides no advantages, costs more, but yields bigger profits. Yet this wonderful supplement called cholecalciferol, among which Carlson's is an excellent choice, is available to you inexpensively, without prescription, and actually provides the benefits you desire.
Stenosis detection vs. plaque detection 22. November 2007 William Davis (5) One of the most common misunderstandings encountered by both physicians and the public is that, to create an effective heart disease prevention program, we need tools for atherosclerotic plaque detection. What we do not need is a tool for stenosis detection. (Stenosis means percent blockage. A 50% stenosis means 50% of the diameter of an artery is reduced by atherosclerosis.)This issue came to mind recently with the ongoing conversation at Heart.org forum, in which the conversation predictably degenerated into a "what good are heart scans when there are better tests to detect blockage" sort of mentality. They are right: There are better tests to detect stenoses or blockages, such as stress tests, heart catheterization, and CT coronary angiography. If someone is having chest pain or breathlessness, these tests are useful to help understand why. These tests are preludes to stents, bypass surgery, and the like. They are the popular tools in hospitals, the ones that provide entry into the revenue-yielding world of heart disease procedures. Plaque detection, on the other hand, is principally a tool for the person without symptoms. In this regard, it is more like cholesterol testing. I doubt my colleagues would bash cholesterol because it doesn't reveal blockages. Plaque detection identifies the person who has already started developing atherosclerosis. Dr. William Blanchett of Colorado articulates this idea well: EBT calcium imaging not only identifies the vast majority of individuals at risk, it also identifies individuals with minimal risk. In other words, it distinguishes those who are likely to benefit from treatment . . .and it identifies those unlikely to benefit from treatment. Furthermore, the greatest value of EBT calcium imaging is that with serial imaging you can determine who is and who is not responding to treatment. Those patients not responding to the initial treatment are identified by progression of their calcified plaque on a subsequent scan are then placed on additional therapies. The net result is a remarkable reduction in heart attack rates.Ahh, the voice of reason. Plaque detection empowers you in your prevention program. If you know how much plaque your begin with, you can track that value to know whether you have having a full effect or not. Stenosis detection, on the other hand, empowers your doctor and provides the irresistible impulse to stent. Another common objection raised to plaque detection is "why bother if you're going to give everybody a statin anyway?" We know the origins of that argument, don't we? If the only strategy known to your doctor is cholesterol reduction with statin drugs, then perhaps that's right. But, with awareness of all the things that go beyond statin drugs, often make them unnecessary, then knowledge of who should engage in an intensive program of prevention or not is enabled by plaque detection.
Is an increase in heart scan score GOOD? 20. November 2007 William Davis (30) In response to an earlier Heart Scan Blog post, I don't care about hard plaque!, reader Dave responded:Hello Dr Davis,Interesting post about hard and soft plaque. I recently had a discussion with my GP regarding my serious increase in scan score (Jan 2006 = 235, Nov 2007 = 419).After the first scan we started aggressively going after my LDL, HDL and Trig...196,59,221And have them down to 103, 65, 92 - we still have a way to go to 60/60/60 [The Track Your Plaque target values]-So the increase is a surprise, but my doctor said that the increase could in part be cause some of the soft plaque had been converted to hard plaque and the scan would show that conversion. Dave's doctor then responded to him with this comment:"Remember that although your coronary calcium score has gone up, this does not mean that you are at greater risk than you were a year ago. Remember that the most dangerous plaque is the not-yet calcified soft plaque, which will not show up on an EBT [i.e., calcium score]. It is only the safe, calcified plaque that can be measured with the EBT. [Emphasis mine.] For your score to go up like it did, while your lipids came down so much, what had to happen was that lots of dangerous unstable plaque was converted to stable, calcified plaque. There are no accepted guidelines for interpreting changes in calcium scores over time, because the scores tend to go up as treatment converts dangerous plaque to safer plaque. We do know that aggressively lowering LDL reduces both unstable and stable plaque, and we know that risk can be further lowered by adjuvant therapy such as I listed above."Huh?This bit of conventional "wisdom" is something I've heard repeated many times. Is it true? It is absolutely NOT true. In fact, the opposite is true: Dave's substantial increase in heart scan score from 235 to 419 over 22 months, representing a 78% increase, or an annualized rate of increase of 37%. This suggests a large increase in his risk for heart attack, not a decrease. Big difference!Dr. Paulo Raggi's 2004 study, Progression of coronary artery calci