The dreaded niacin "flush"

As most anybody who takes niacin knows, it can cause a hot flushed feeling over the chest and face that is generally harmless, though quite annoying.

Many doctors are frightened by this response and will warn patients off from niacin. Some people who take niacin are so annoyed that they find it intolerable.

However, a very simple maneuver can relieve the hot flush in over 90% of instances: Drink water. Let me explain.

I usually instruct patients to take niacin at dinnertime. That way, food slows absorption modestly. I also ask them to drink water with dinner. If the flush occurs after dinner (usually 30-60 minutes later), then drinking two 8-12 oz glasses of water immediately breaks the flush within 3 minutes in the great majority of people. It's quite dramatic.

Doing this around dinner (lunch works just as well) allows sufficient time to clear the excess water from your body before bedtime and spare you the aggravation of disrupted sleep to urinate. Drinking plenty of water works most of the time. Only an occasional person will need to take a 325 mg uncoated aspirin to more fully break the flush. I generally suggest that patients keep the uncoated aspirin in reserve if the water doesn't provide relief within a few minutes.

Thankfully, the intensity of the niacin flush lessens, often disappears, with chronic use.

Why do some people develop the flush and other don't? It is believed that some people metabolize niacin more rapidly to a compound called nicotinuric acid, a niacin metabolite that causes dilation (relaxation) of skin capillaries--thus the flush. The rapidity of converting niacin to nicotinuric acid is determined genetically.

An occasional person really struggles with niacin to the point of intolerance. However, on the positive side, these people may also be "hyper-responders" to niacin, i.e., they show exagerated benefits in raising HDL, reducing small LDL, etc., from small doses such as 250 mg per day.

If you experience the hot flush of niacin, think water to put out the fire.

An extraordinary thing happened about 2 1/2 years ago.

While we have been following the Track Your Plaque program for coronary plaque regression for nearly 10 years, about 2 1/2 years ago we witnessed an extraordinary surge in success--bigger, faster, and more frequent drops in heart scan scores.

Up until then, we did witness significant reversal of coronary plaque by heart scan scores. We were planning to publish the data to validate this approach, but then . . .

Heart scan scores starting dropping not just 2%, or 8% . . . but 24%, 30%, 50% and more. Why? I attribute the surge in success to the addition of vitamin D.

Unfortunately, it also meant that the preceding 8 or so years of data lacked experience with supplementing vitamin D. The hundreds of participants in the Track Your Plaque program had not, until then, included vitamin D in their program.

So I decided to start from scratch (from the standpoint of data collection, not for the participants). That also meant that the preceding years of experience went unreported, though even that data far exceeded the results of what is achieved in conventional heart disease prevention.

Thus, the data I presented at the Experimental Biology Proceedings (FASEB 2008) in San Diego this week included only experiences in the group of participants that included vitamin D in their program, with data collected until mid-2007. The number of experiences is therefore modest.

However, the Track Your Plaque experience, as reported, far exceeds any prior experience in coronary plaque regression.

The full abstract will be published in the Track Your Plaque website.

Copyright 2008 William Davis, MD

Many people complain about the size of fish oil capsules. Let's face it: They're usually big and kind of smelly.

Women in particular struggle with big capsules. This becomes a real problem when somebody requires high-dose fish oil for treatment of post-prandial (after-eating) abnormalities, high triglycerides, or lipoprotein(a), when 6 or more--occasionally up to the equivalent of 20--standard fish oil capsules are required.

I came across a small capsule alternative for people who struggle with the big capsules. It's a product called Learn from PharmaOmega, a source of super purified fish oil.

The Learn product is actually made for children, since omega-3 fatty acid supplementation has been linked with improved intellectual performance. But the small capsule size is convenient for women and other people who would like to avoid the big standard-sized capsules.

Each capsule is about 60% of the size of a standard fish oil capsule (the smaller capsule in the photo, next to a standard size fish oil capsule), yet contains 375 mg EPA + DHA per capsule, 25% more than standard capsules (which contain 300 mg per capsule). The ratio of of EPA:DHA is a little more heavily weighted towards EPA with a 5:2 ration, compared to 3:1 of standard capsules. The capsules are also faintly orange flavored and non-fishy.

Disclosure: I receive no compensation for discussing or promoting this product.

Copyright 2008 William Davis, MD

Jenny provided permission to reprint her very excellent introduction to low-carbohydrate eating for people with diabetes. You can also view the original version on her Diabetes 101 website.

Jenny is a stickler for monitoring the effects of blood sugar. We might take some lessons from her experiences for improving management of people with metabolic syndrome or borderline blood sugars. In other words, monitoring the blood sugar-raising effects of various foods and food portions can provide great feedback on what foods are preferable, what undesirable, given your physiology.

Even if you are not a diabetic, Jenny's discussion is must reading to gain a better understanding of food choices, particularly carbohydrates. Along with seizing control of health, she has also gained deep wisdom in how to best manage this disease and its physiology.

Introduction to low-carb nutrition for diabetics

It's carbohydrates that raise blood sugar.

Sugars and starches, not the fats that dietitians have been warning you about for so long. If you've been testing your blood sugar after meals, you've probably noticed that already and you are starting to understand why a healthy diabetes diet will have to be one that limits carbohydrates to an amount that doesn't push your blood sugar up over the level where you are damaging your body.

But if your previous experience with restricting carbohydrates involved doing a weight loss diet like Atkins or Protein Power, which worked well for you until you crashed off it entirely and gained back all the weight you'd lost, you may be hesitant to embark on another course of dieting that requires some carb restriction.

I've been there myself. I've done the extremely low carb diet Dr. Richard Bernstein recommends for months on end. I did Protein Power for 3 years. And I've gone on the "Eat all the carbs you didn't eat over the past three years all at once" diet, too. The following observations grew out of my 8 years of experience with learning how to make carb restriction work long-term.

Unlike much of what you've read before, there are no scholarly references for this section. It's based entirely on my own observations and the experience of many dozens of people who have participated in online discussion groups devoted to low carb dieting and diabetes.

Weight Loss Diets Usually Fail but Diabetes Diets Can't Afford To Fail

People who adopt a low carb diet to lose weight tend to start out with great enthusiasm, adapt extreme dieting strategies, swear they will never eat another piece of bread or french fry for the rest of their lives, lose some weight, stall out, burn out, and slink back to their old diets, where they gain back all the weight they lost and more.

This is not a surprise. People on any diet, including low calorie and low fat, do the same thing. The body is very resistant to weight loss and deeply buried instincts in our brains do everything they can to maintain our weights, no matter how unhealthy they might be.

But while this pattern of dieting may be tolerable for those who are dieting to shed a few pounds before their class reunion, it spells disaster for those who must change their diet in order to prevent the high blood sugars that result in amputation, blindness, kidney failure and heart attack death.

Low carbing for diabetes means low carbing for life, long after the thrill has worn off of eating that runny brie and steak. Despite the hype in the diet books, it is not easy, simple, and fun. I know only a handful of people who have been able to sustain a low carb lifestyle for more than five years. And that is after years of online participation in low carb groups.

What you'll find below is what I've found works for me. I used a low carb diet to control my blood sugar for more than five years and have gone through the whole cycle, from enthusiasm, to boredom, to burnout, to saying "To hell with it, we've all got to die some time!" to starting all over again determined to avoid the mistakes that sent me round the bend the first time.

How Many Grams of Carbs to Eat? As Many as Allow You to Reach Your Blood Sugar Targets

When people think about adopting a lower carb diet, their first question is almost always, "How many grams of carbs can I eat at each meal?" Most of the diet books will answer that question with a hard and fast number. Atkins, for example, tells you to start out with 20 grams a day. Protein Power starts you at 30 grams. And Dr. Bernstein suggests 6 grams for breakfast and snacks and 12 grams at lunch and dinner.

Adopting these very low carbohydrate limits will control your blood sugar very nicely. But over time, many people find that sticking to a diet this low in carbohydrate becomes impossible. That's why I'm going to ask you to throw away all those diet books and try a new approach to restricting carbs.

What you will do is to try the strategy used by the people from the alt.support-diabetes newsgroup who informally call themselves "The 5% Club" because their A1c test results fall in the 5% range which doctors consider normal: use your blood sugar meter after each meal to determine how many grams of carbs you can eat and still meet a healthy blood sugar target.

You will start out by measuring your blood sugar one and two hours after each meal. Write down what you ate and observe what it did to your blood sugar. If a meal allows you to reach your blood sugar targets, try eating it again on a different day and test it test again, possibly at a later time, to make sure that your good numbers weren't just a result of slow digestion.

If you end up too high after a meal, the next time you eat it, cut back on the portion size of the carbohydrate elements in the meal and test again. Do this until you can hit your targets, or flag the carbohydrate-containing foods in that meal as ones your body can't handle.

What you're doing here is creating what newsgroup activist Alan S. calls, "a low spike diet" rather than a low carb diet. He can achieve normal post meal blood sugars by eating as many as 30 or 40 grams of carbohydrates at a meal. Others will find that they need to eat a lot less than that amount to hit safe post-meal blood sugar targets.

Usually how much carbohydrate you can manage has something to do with your body size. The more you weigh, the less each gram of carbohydrate you eat will raise your blood sugar. Those of us whose weight is less than 150 lbs often find that we can eat between 12 and 20 grams of carbohydrate and still reach normal blood sugar targets without the help of medications, and that we can add perhaps another 10 or 20 grams more, with medications. People who are much heavier can often eat 30 or 40 grams per meal and still reach their blood sugar targets. In general, men can eat more carbohydrates and still reach their targets than can women, again, because of their larger body size.

How to Learn How Much Carbohydrate is in Your Food

To make this system work, it helps if you start to learn how many grams of carbohydrate are in the foods you eat. That way you won't have to test hundreds of foods once you've learned how a representative sample affect you.

The best way to learn how many grams of carbohydrates are in the different foods you eat is to read food labels carefully, invest in a nutritional guide like one of Connie Netzer's books of nutritional information, download nutrition software like LifeForm (http://www.lifeform.com) or use online calculators like Fit Day (http://www.fitday.com). Software and online sites will compute the amount of carbohydrates and other nutrients in your meal for you as long as you know the portion size.

Learn about Portion Sizes!
This brings up an important point: When you estimate how many grams of carbohydrate there are in a portion of food, it is very important to find out if the amount of food on your plate corresponds to the amount in the "one serving" listed on a label, in a book, or in your software.

The best way to do this is to invest in an electronic food scale and to weigh your foods for a few weeks until you get the hang of estimating portion size. You can get a good food scale at a gourmet kitchen shop for $25 to $40 dollars. This food scale may be the best nutritional investment you'll ever make.

Once you start using your scale, you will find that the muffin you bought at the coffee shop weighs 8 ounces, which is fully four times the 2 ounces that most food databases give as "one serving" of a muffin. When you read that a mythical 2 ounce portion of muffin contains 27 grams of carbohydrate you will realize why that 8 ounce coffee shop muffin with its 108 grams of carbohydrates sends your blood sugar into the psycho zone!

With ice cream, when you weigh your ice cream on a food scale, you'll quickly see that the "one portion" listed on the package turns out to be only a few teaspoons' worth. That bowl you've been considering as one portion of ice cream weighs in as four servings or 72 grams of carbohydrate and 600 calories, which may explain its damaging effect on both your blood sugar and your waistline.

This may sound like a lot of work, and when you first start, it is. But after you do it for a few weeks you'll find you have memorized the carbohydrate gram counts and the portion sizes for the foods you usually eat, and once you have tested your blood after eating these portion sizes, you won't have to test every time you eat a favorite meal, because you will know what it is going to do to your blood sugar.

Eating Away from Home

The biggest challenge you'll encounter as you start learning what you can eat will be eating away from home. You aren't going to be able to weigh restaurant foods nor can you look up the nutritional values of many restaurant offerings--though many of the common fast food outlets do provide nutritional information online--though often without listing portion sizes.

That makes it a very good idea to avoid starchy or sugary restaurant foods or, if you do eat them, to eat only a small portion of what you are offered. Measure your blood sugar an hour or two hours after eating if you aren't sure about how a restaurant food will affect you.

Fat and Carbs Eaten Together will Digest Slowly

Foods with a lot of fat in them take longer to digest than those without a lot of fat. This is why pizza and ice cream often give deceptively good readings on your meter. If you test a meal and see a reading that is too good to be true, be sure you test at 3 or four hours after eating.

The Truth About Pasta

Pasta was long recommended to people with diabetes as a food that would not raise blood sugar and you will still see it starring in many cookbooks and magazines intended for people with diabetes.

However, if you test pasta 4 or 5 hours after eating, you may get an unpleasant surprise. This is true with the so-called "low carb" pastas, too. These foods give you excellent readings at one and two hours because they are resistant to digestion so they don't turn into glucose right away. But five hours later, they do break down into glucose and when they do, the 52 grams of carbohydrates found in each 2 ounce serving of pasta will hit your blood stream with a nasty wallop. (Not to mention that you almost need a microscope to see a 2 ounce portion of pasta. Most people's idea of a portion of pasta is closer to 6 ounces--and 156 grams of carbohydrate!)

If you have pasta for dinner and don't see a peak 3 hours later, be sure to check your fasting blood sugar the next morning. You may see the blood sugar rise there, too.

Sugar Alcohol and "Sugar Free" Foods

The sugar alcohol used in so-called "sugar free" foods can also show up in your blood sugar an hour or two after you'd expect to see them, especially the maltitol used in "sugar-free" candy. At least half of the sugar in Maltitol does turn into glucose in your blood stream and it can raise your blood sugar, but the rise is delayed so you may miss it on testing. So if a "sugar free" food seems to be kind to your blood sugar, try testing it an hour or two after your first tests. Erythritol is the one sugar alcohol that usually does not show up in your blood sugar.

Dealing with Limited Blood Testing Supplies

In in ideal world, we'd all have all the testing supplies we needed to control our blood sugar, but in real life blood sugar test strips are very expensive and many insurers sharply limit the number of strips people with Type 2 diabetes can get each month.

Here are some strategies that can help you if your access to strips is limited.

If you only have 50 strips to get you through a month, plan out what you are going to test ahead of time. Pick one of your favorite meals, and test at 1 hour after eating the first time you eat it and 2 hours after eating the second. Do this with a couple different meals and see if there's a pattern as to when you see the highest reading--whether it is at one hour or two. Then choose another meal and test it at the time when you saw the highest reading in the earlier meal. If you ever get a surprisingly low reading, try testing an hour later or earlier, to make sure you aren't missing the peak.

Make the goal of your testing be learning how many grams of carbs you can tolerate in one meal. If you learn that 30 grams is your upper limit, use software and your scale to find portions of other foods that will also clock in at 30 grams or less. Test one or two of these, and if you see the result you expect, you don't have to test every time you eat these foods again.

Wal-mart sells a cheap and effective blood sugar meter with strips that cost one half as much as other vendors. Some drug stores also sell store brand meters with cheaper strips. If you need more strips, consider the $50 you pay for another 100 strips an investment in your health. It's far better to spend that $50 now, than to spend it on expensive doctor bills caused by complications you don't need to develop!

Keep the focus on Achieving your Blood Sugar Goals

By testing after meals, you'll learn how many grams of carbohydrate your own, unique, body can handle. And more importantly, you'll also be able to decide if you are going to be able to control through diet alone, of whether it is time to talk to your doctor about supplementing dietary control with drugs.

Many people are so excited to learn that they can achieve normal blood sugars by cutting way back on carbohydrates that they become zealots for low carb dieting. I've been there and I've done that. But it's important not to get too carried away with a "Carbs are Evil" mentality which makes it a matter of religious zeal never to let evil carbs cross your lips again. Like all conversions this one tends to fade out in time. And as we said at the start of this chapter, your ultimate goal is to maintain your blood sugar targets for the rest of your life. So the safest approach is to get the most blood sugar benefit you can out of restricting carbohydrates, but restrict them to a level you can maintain year in and year out.

Most importantly, I have learned it is best to treat carb restriction as a strategy, one of many, which used in combination with other strategies including medications if needed, can give you normal blood sugars, rather than the One and Only True Way. If you can be flexible and find more than one tool to help you meet your blood sugar targets, you are more likely to be able to maintain those excellent blood sugars for years to come.

Eliminate "Habit Carbs" and Concentrate on "Value Carbs"
When people think about restricting their carb intake they assume this means never eating any of their favorite foods again.

But for many of us, this doesn't have to be true. Why? Because a quick look at your daily carb intake will often reveal that the bulk of the carbohydrates you are eating are what I call "habit carbs." These are the carbs you eat without a second thought because they are there. Not because they taste good. Not because you couldn't live without them. Just because you're in the habit of eating them.

Here is a list of some prime "habit carbs."

Steam table mashed potatoes

Limp french fries

Squashy hamburger buns

Cardboard toast

Cold home fries

Stale boxed cookies

How many of these flavorless, starchy foods are you consuming everyday just because they're there? Probably more than you realize. So before you lift that fork-full to your mouth, ask yourself, "Is this food thrilling me?" If not, put it down. This should go a long way towards getting your carb intake down.

What I'd call "value carbs" are those carb-rich foods that really do mean something to you. I'm not going to lie to you. You are not going to be able to make them the mainstays of your diabetes diet. But by using the strategies describe below, you should be able to eat enough of these foods to keep yourself from feeling deprived--without destroying your health.

Don't Create "Forbidden Foods!"

If you are one of those people who could live happily on Purina People Chow, you can skip what follows. But if food has been important to you, and if you have hitherto had a long and emotionally satisfying relationship with food, or if, like me, baking from scratch was one of your favorite ways to show love and express creativity, restricting your carbohydrate input will mean that a whole lot of what you've been eating (and baking) up until now is suddenly, completely, off limits. I can't eat cake and get a healthy blood sugar level. Even with two different diabetes drugs in my system. I can't eat cake even with an insulin shot before I eat it. I love cake but there is no way I can eat more than a bite or two without seeing very high blood sugars and there is no way I can eat two bites of cake and be happy. The same goes for french fries and Thai noodles.

During the first enthusiastic weeks of exploring carb restriction most people deal with this kind of discovery by coming up with new recipes and finding new, delicious and healthy things they can substitute for old, high carb standards. They appreciate the way cutting way back on carbohydrates curbs their hunger and makes food much more manageable. This is good and it is why long term low carbing is possible. But our old favorite foods do not go away that easily.

If you decide that some food you have been eating and enjoying all your life will never again cross your lips, it is almost 100% guaranteed that you'll end up pigging out on that very same food at some time in the future, hating yourself, and even beginning a binge that can throw you completely off your diet for months.

It might not happen the first month you are restricting your carb intake or even the first year. It took me three years of low carbing to get to where I crashed off my stringent low carb diet. But eventually it happens, and because after almost a decade of counting my carbs I've learned that I will never lose my love for certain foods that don't love me, I've put a lot of time into finding a way of restricting my carbohydrate intake in a way that avoids the buildup those feelings of deprivation that eventually lead to long periods of unwise eating.

The key, for me, is to build safety valves into my diet. I don't call them "cheats" or "bad foods" for reasons I'll get into later. I call them "off plan" foods because they are not food I can make an ongoing part of my daily food plan. Because my goal is life-long blood sugar control, I accept that I will occasional eat "off plan" and that this is okay as long as I am meeting my blood sugar targets most of the time. "Good enough" control that I can adhere to year in and year out beats a few months of perfection followed by crashing off the diet entirely and ruining my health. Here is one way to approach doing this:

Do the Diet Straight for a Month or Two Before You Try Off-Plan Goodies

As you learn what foods raise your blood sugar and what foods don't, you will almost certainly find that there are a lot of foods you used to love that don't work for you anymore. Waffles for breakfast, coffee cake at coffee break, three slices of pizza with crust, a burger with a bun and a side of fries are just a few of the foods that it is almost certain will not allow you to meet your post-meal blood sugar targets.

As you keep using your meter to test what you eat, if you are like most people with diabetes you'll also learn that some of the so-called "low glycemic" foods and the supposedly "healthy" whole grains that nutritionists recommend for people with diabetes won't work either. Oatmeal and whole wheat bagels raise my blood sugar far too high, so does cracked whole wheat, whole wheat bread, and brown rice.

If the dietician tells you a food is good for you, but your meter tells you it is raising your blood sugar to a level that is high enough to cause complications, you will have to listen to your meter. Your meter will tell you what is safe to eat and for the first couple of months while you are learning how to get your blood sugar under control and how bring those high blood sugars down to normal levels you will have to accept that you can only eat those foods that don't cause spikes.

If you attempt to add in off-plan foods before you are solidly on-plan you may never really get into the swing of eating a diet that controls your blood sugars and you may not get to where your body learns to enjoy the lower carb foods that don't give you blood sugar swings.

But after you've gotten your blood sugar under control, nothing horrible will happen if you make room for a small portion of some high carb treat every now and then.

How to Add Off-Plan Foods to the Plan

If you've avoided bread for a couple months, the humble roll in that restaurant bread basket may start to call out to you with an irresistible siren song. If you give in and eat it, with each bite you may find yourself feeling as if you are doing something incredibly sinful--the way you might have felt if you had eaten a whole box of chocolates in the past.

That feeling is the sign that you're heading for trouble. You've created a "forbidden fruit" and sooner or later that forbidden fruit is going to get you. You may find yourself thinking about that roll, craving another, sneaking off to eat one where nobody knows you, or, alternatively, you may declare that you will never again eat a roll ever--and then ruin your Thanksgiving holiday when you go to Aunt Glenda's and refuse to eat even a single one of those wonderful rolls of hers you've eaten every year of your life which say, "This is the family Thanksgiving" to you.

It is far better to make a bit of room in your diet for high carb treats so that they don't build up a charge. If you do this, you'll find that they almost never taste as good as you remembered, and you'll be able to leave them behind without turning them into an object of obsession.

Just knowing that you can eat some specific off-plan food at some future time, when it is scheduled, makes it that much easier to say, "No thanks" to it, and maintain your healthy blood sugar the rest of the time.

How Often Can You Eat Off-Plan?
How often you have an off-plan food depends a lot on your dietary goals, how high your blood sugar is before you eat carbs, and whether you are willing to exercise after eating. It also depends greatly on what medications you are taking for your diabetes. Whatever I eat, I try to keep my blood sugar below 120 mg/dl (6.7 mmol/l) at 2 hours after any meal.

Forty minutes of cardiovascular exercise will burn off a lot of extra carbs, so if you exercise regularly, try to eat your high carb treat before you head for the gym.

If you're trying to lose weight, you may have to keep off plan treats few and far between. When I was actively losing weight on a low carb diet without medications I ate one off-plan meal about once every two weeks.

Once I reached my weight loss goal I loosened up a bit but I found it best to cycle between weeks of eating a strict very low carb diet, and then a week of eating slightly more carbs--but I tried very hard not to ever anything that would cause my blood sugar to be over 120 mg/dl (6.7 mmol/L) at 2 hours after a meal because doing so makes me feel rotten.

Throw Away the Vocabulary of Self-Destructive Dieting

When you eat something with carbs in it, don't think of it as a "cheat." Cheating is what you do when faced with an authority figure--your 9th grade math teacher or the IRS. But you are the one in control of what you eat. So when you eat something that is off-plan, you should stop thinking of it as "getting away with something" and treat it instead as something you've decided to do--for a reason that should be clear to you while you do it.

If you keep eating things that were not what you had intended, rather than beating yourself up, it's time to reconsider your food plan and figure out why it isn't working. Are you having trouble finding foods in restaurants that don't raise your blood sugar? Maybe it's time to bring your lunch along to work for a while, or to find new place to dine.

Are you bored with what you have been eating? Google for good low carb recipes you can try at home. There are thousands of them. If you use the Google Groups search and look for messages in alt.support.diet.low-carb that start with "REC" you'll find a treasure trove of ideas to try.

Keep the vocabulary of sin and guilt for the confessional. You're going to eat a lot of things in the years to come that will mess up your blood sugar. But if you are kind to yourself and dust yourself off after you mess up and keep on going, doing the best you can to hit your blood sugar targets, you may very well end up healthier than many people who do not have diabetes. The important thing is to keep at it, doing the best you can and forgiving yourself when the best you can do isn't as good as you wish it was.

Know Your Limits
I've learned the hard way I can't eat half a blueberry muffin, so I don't even try portion control for that particular food. I know blueberry muffins are trouble and I also know that I will eventually eat one. That's just how it is, so every blue moon or so I eat a blueberry muffin, experience the miserable high blood sugars that follow, and then remember why I don't eat muffins every day any more. What I don't do is fool myself that I can buy a muffin and only eat half. Everyone has a few foods that fall into this category. Treat them with caution!

Eat Off-Plan Foods Out of the House
I've learned the hard way that if a big box of something full of carbs is in the fridge, bad things are going to happen. So I try to eat my off-plan foods away from home. I eat my muffins or cookies at a coffee house. I have a slice of pizza at a pizzeria. I don't buy a box of muffins or a whole pizza and bring them home.

Getting this strategy to work requires that your whole family understand what's at stake. It took me a couple years of harping on what "complications" means, but by now, my family understands that if my blood sugar is too high, I'm damaging my body. They want to keep me around for a while, so they understand that there are some foods that shouldn't be brought into the house--ever.

When other family members want to have treats at home, they are kind enough to buy things I don't like. For example, if someone wants Ben & Jerry's they buy the Chunky Monkey flavor that I find revolting, not the New York Fudge. By the same token, when my kids lived at home, I didn't buy them the brands of cookies I can't resist. There are plenty of others cookies they liked that don't tempt me at all, and those were the ones in the cupboard.

Over the years the nondiabetic members of my family learned that no one is doing themselves a favor scarfing down 300 grams of fast acting carbohydrate every day--particularly not people with a family history of diabetes and heart disease!

Medications Can Help

I'm not a big fan of medications because I've learned the hard way that drug companies lie about side effects and some of these side effects are permanent and can ruin your life. But I learned the hard way, too, that some of us (like, say me) can't get normal blood sugars no matter how low our carb intake. For us, adding a diabetic drug or two to our daily regimen may be the only way we can get normal blood sugars without a life of tormenting self-denial.

Drugs I have found useful over the years include metformin, precose, and post-meal insulin shots. The new incretin drugs, Januvia and Byetta help some people make dramatic improvements in their blood sugar, but the way that they work makes it necessary to eat a slightly higher amount of carbohydrates with them because they only work when your blood sugar rises over a certain threshold. Even with these drugs (including Januvia) I've never been able to eat more than 120 grams of carbohydrates a day, but after many years of eating an extremely low carb diet--which was the only diet that would control my blood sugars--120 grams of carbs a day feels like a completely normal diet!

Be Aware of Rising Insulin Resistance

Some people may find that eating a low carb diet is not enough to control their blood sugar because they are very insulin resistant. Perhaps they have been diagnosed with PCOS, or have to take a drug, like Prednisone that increases insulin resistance. The book, Dr. Bernstein's Diabetes Solution by Dr. Richard K. Bernstein, the distinguished diabetes doctor, recommends Metformin as an appropriate drug for patients on a low carb diet whose blood sugars are still not completely controlled. It isn't a cure by any means, just one more tool you can use to keep blood sugars under control, and if you limit your insulin resistance you may solve both weight and hunger problems that otherwise can derail your diet.

You can read more about the different drugs available to help control blood sugars HERE. Just remember that all these diabetes drugs work best when you combine them with some level of carbohydrate restriction. How much restriction? Test your meals one and two hours after eating, and your blood sugar meter will tell you exactly how much.

Top Medical Journal Publishes Landmark Study Showing Very Low Carb Diet Most Effective and Safest for Lipids etc.

In case you are still being given out-of-date medical or nutritional advice by people who tell you that a low carb/high fat diet will give you a heart attack, take a look at this recently published study, which appeared in the Journal of the American Medical Association.

This study found that an Atkins style low carb diet not only caused double the weight loss of the low fat diet at the end of one year, but it did not adversely affect cholesterol levels.

This finding, added to the Women's Health Initiative finding (after $40 million dollars of research) that low fat dieting does NOT prevent heart disease, should lay to rest any last fears you might have about the impact of cutting carbs on your health.

The findings of this study, are not news to anyone who has tried a low carb diet and stuck with it for any period of time, but they appear to amaze the entire medical community who continue to cling to their to the "Fat is Bad" religious belief long no matter what evidenced-based medical studies might come up with.

Bottom line: You can cut your carbs way down, replace carbs with fat, and await the better health this kind of eating will provide.

Comparison of the Atkins, Zone, Ornish, and LEARN Diets for Change in Weight and Related Risk Factors Among Overweight Premenopausal Women: The A TO Z Weight Loss Study: A Randomized Trial.Christopher D. Gardner, PhD; Alexandre Kiazand, MD; Sofiya Alhassan, PhD; Soowon Kim, PhD; Randall S. Stafford, MD, PhD; Raymond R. Balise, PhD; Helena C. Kraemer, PhD; Abby C. King, PhD

Here's the summary of the WHI findings:

NIH News: News from the Women?s Health Initiative: Reducing Total Fat Intake May Have Small Effect on Risk of Breast Cancer, No Effect on Risk of Colorectal Cancer, Heart Disease, or Stroke

Here's a study that documents the effectiveness of lowering carbs and increasing fat and protein consumption for the control of blood sugar in the absense of weight loss:

Control of blood glucose in type 2 diabetes without weight loss by modification of diet composition. Nutrition & Metabolism 2006, 3:16.

To Get More Help with Making a Low Carbohydrate Diet Work

My "Low Carb Facts and Figures" site, which now shares this server, has more information I collected back in the days when I used a low carb diet for both weight loss and blood sugar control.

You'll find articles there that address a few of the issues people run into while eating a very low carb diet,which are not answered in a completely honest fashion by the people who sell diet books promising you can lose weight easily while gorging on all your favorite foods--which, sadly, is 99% of all authors writing diet books.

I stumbled onto Jenny Ruhl's Diabetes Update blog after I received several very insightful comments to this blog whenever I posted a discussion on diabetes or pre-diabetes/metabolic syndrome.

Who the heck was this commenter who clearly had deep insight into diabetic issues?

It turned out to be Jenny Ruhl, a woman who learned her lessons the hard way: by receiving a belated diagnosis of (an unusual form of) diabetes, then receiving plenty of mis-guided advice from physicians on diet and treatment. Reading her many blog posts and websites, you get the clear sense of how hard this individual worked to gain the depth of knowledge she's acquired, on a par or superior to most diabetes specialists.

And she minces no words in expressing her heartfelt and carefully considered opinions. But that's what I look for: people who are unafraid to voice opinions that may not be consistent with the flow of conventional thought, but ring true and prove effective.

Dr. Davis: From your blog and websites on diabetes, it is clear that you exceptionally knowledgeable in the world of diabetes, metabolic syndrome, and related disorders. Can you give us a little background on how you came to this quest?

Jenny: Though I was told I was a "classic type 2" [diabetic] by my doctors, nothing I read about diabetes corresponded to my own experience. I knew my diabetes had not been caused by obesity because I'd been a normal weight all my life until my blood sugars went out of control at which point I developed ravenous hunger and gained a lot of weight very quickly.

I also wondered at the huge gap between what Dr. Bernstein said was a normal blood sugar and what my doctors told me was a safe blood sugar for a person with diabetes. The people I met who followed Bernstein's very low carb diet had much better blood sugars and far fewer complications, but my doctors dismissed this as irrelevant. So I decided to do some research to find out who to believe. I plunged into the medical journal articles that had recently been made available on the web to see if I could answer two questions: What causes diabetes? and "What does science actually know about what blood sugar levels damage organs?"

The result was the information that became the basis for the Blood Sugar 101 site. Initially, I attempted to sell it as a book, but editors told me that though what I'd learned was "fascinating" it would be "over the head" of the typical health book buyer who wanted simple explanations and if possible, a simplistic slant towards "cure." Fortunately, the very strong response and high traffic volume to the web site proved that, as I had thought, there are a lot of people who do want more than an oversimplified overview and who, given the information they needed, were able to make huge positive changes in their health.

Dr. Davis: What do you think your life would be like if you hadn't pursued this unique course?

Jenny: Possibly a lot shorter.

People in my family die of heart attacks in their 50s, probably from undiagnosed high blood sugars. The pattern of the type of diabetes I have is to have a normal fasting blood sugar and an extremely high post-meal blood sugar after consuming very few grams of carbohydrate. When doctors diagnose using only the fasting blood test, they miss those highs, which research is now finding to be a primary cause of heart disease.

I also would have been a lot fatter. My doctors told me that I was packing on 20 lbs a year due to "normal menopausal changes" and that there was nothing I could do about it. Lowering my carbs significantly dropped all the weight I had gained and I still weigh a lot less now than I did in 1998.

Dr. Davis: You've been a keen observer of the diabetes scene for some years. Have you discerned any important trends in both the public's perception of diabetes as well as how diabetes is managed in the conventional world?

Jenny: The huge difference I see is that, over the last decade, the online diabetes community has learned the value of cutting back on carbohydrates and shooting for truly normal blood sugar levels. So people who put some time into researching diabetes online and talking with those of us who have succeeded in avoiding complications will learn that they do not have to settle for very high blood sugars and deterioration their doctors think inevitable.

Unfortunately, the media have put most of their energy into promoting the discredited idea that diabetes is caused by gluttony and sloth and to promoting the equally discredited idea that people with diabetes should eat a high carbohydrate diet and avoid fat.

So for now there is a huge divide in the quality of life of those people with diabetes who educated enough to go out on the web and educate themselves and those who get their diabetes information from doctors. Sadly most doctors still encourage patients to eat low fat/ high carb diets, and counter the very high blood sugars this diet produces with oral drugs of questionable efficacy, while assuring patients they will be safe if they maintain blood sugar levels that meet the American Diabetes Association's recommendations, though a mass of research shows these are high enough to produce every single diabetic complication possible.

Dr. Davis: I understand that you've released a new book, Blood Sugar 101. How is your book unique in the world of diabetes books? Who should read Blood Sugar 101?

Jenny: Blood Sugar 101: What They Don't Tell You About Diabetes differs from other books in that it gives the reader a much deeper understanding of what is really going on in their bodies as their blood sugar control breaks down and what sciences knows about how abnormal blood sugars cause complications. Then it gives the reader the tools they need to find what diet and/or drug regimen will brings their own, unique, blood sugars down to a truly safe level.

Unlike some books, this one does not present a one-size-fits-all solution, but recognizes that Type 2 diabetes is really a catch-all diagnosis that covers a lot of disorders that behave quite differently. That is why what works for one person with diabetes may not work for another.

Because this book provides details available nowhere else about the physiology of diabetes and the drugs available to treat it, readers will find the information they need to work with their doctors to craft a regimen that brings their blood sugar into the range that preserves and improves their health.

Dr. Davis: Before we close, tell us a little about yourself outside of your diabetes advocate role.

Jenny: I live in rural New England and am a passionate gardener. I've been online since 1980 when I was part of the team at IBM that developed the first commercial email program, PROFS. I got involved in online discussion groups in 1987 and have been messaging on bulletin boards ever since.

I was a professional singer/songwriter in Nashville in my youth and spent my middle years as a bestselling author of books about consulting. Right now a lot of my energy goes into managing the financial and software side of a family business that makes hand made pocket tools for collectors.

Dr. Davis: Thank you for your great insights, Jenny!

True to form, Dr. John Cannell has published yet another wonderfully insightful Vitamin D Newsletter.

One item caught my eye, a response to a question about the Marshall Protocol. I, like Dr. Cannell, was inundated with questions about this so-called protocol, which amounts to little more than the unfounded speculations of a non-physician, actually someone not even involved in health care.

In all honesty, I blew the whole issue off after I read Dr. Marshall's rants. They smack of pure quackery, though from somebody who clearly has a command of scientific lingo. To Dr. Cannell's credit, he took the time and effort to construct a rational response in the latest issue of the newsletter. I reproduce his response here:

Dear Dr. Cannell:

I understand Dr. Marshall conducted a study and found vitamin D is bad for you. What kind of study did he do?

Mary, Minneapolis, Minnesota

Dear Mary:

I have been inundated with letters asking about Professor Marshall's recent "discovery." Some have written that to say they have stopped their vitamin D and are going to avoid the sun in order to begin the "Marshall protocol." The immediate cause of this angst is two publications, a press article in Science Daily about Professor Marshall's "study" (which is no study but simply an opinion) in BioEssays. Dr. Trevor Marshall has two degrees, both in electrical engineering. Before I begin, I want to again remind you that I am a psychiatrist who works at a state mental hospital. In my duty to full disclosure, I must say that I have known a lot of psychiatrists in my life and a few electrical engineers. If I knew nothing else of a disagreement between two people but their professions, I would believe the electrical engineer, not the psychiatrist.

In reading his two articles, Dr. Marshall's main hypotheses are simple. (1) Vitamin D from sunlight is different than vitamin D from supplements. (2) Vitamin D is immunosuppressive and the low blood levels of vitamin D found in many chronic diseases are the result of the disease and not the cause. (3) Taking vitamin D will harm you, that is, vitamin D will make many diseases worse, not better. If you read his blog, you discover that the essence of the Marshall protocol is: "An angiotensin II receptor blocker medication, Benicar, is taken, and sunlight, bright lights and foods and supplements with vitamin D are diligently avoided. This enables the body's immune system, with the help of small doses of antibiotics, to destroy the intracellular bacteria. It can take approximately one to three years to destroy all the bacteria." That is, Dr. Marshall has his "patients" become very vitamin D deficient.

Again, Dr. Marshall conducted no experiment and published no study. He wrote an essay. He presented no evidence for his first hypothesis (sunlight's vitamin D is different than supplements). From all that we know, cholecalciferol is cholecalciferol, regardless if it is made in the skin or put in the mouth. His second hypothesis is certainly possible and that is why all scientists who do association studies warn readers that they don't know what is causing what. Certainly, when low levels of vitamin D are found in certain disease states, it is possible that the low levels are the result, and not the cause, of the disease. Take patients with severe dementia bedridden in a nursing home. At least some of their low 25(OH)D levels are likely the result of confinement and lack of outdoor activity. However, did dementia cause the low vitamin D levels or did low 25 (OH)D contribute to the dementia? One way to look at that question is to look at early dementia, before the patient is placed in a nursing home. On the first day an older patient walks into a neurology clinic, before being confined to a nursing home, what is the relationship between vitamin D levels and dementia? The answer is clear, the lower your 25(OH)D levels the worse your cognition.

Wilkins CH, Sheline YI, Roe CM, Birge SJ, Morris JC. Vitamin D deficiency is associated with low mood and worse cognitive performance in older adults. Am J Geriatr Psychiatry. 2006 Dec;14(12):1032-40.

Przybelski RJ, Binkley NC. Is vitamin D important for preserving cognition? A positive correlation of serum 25-hydroxyvitamin D concentration with cognitive function. Arch Biochem Biophys. 2007 Apr 15;460(2):202-5. Epub 2007 Jan 8.

These studies suggest that the low 25(OH)D levels are contributing to the dementia but do not prove it. Only a randomized controlled trial will definitively answer the question, a trial that has not been done. So you will have to decide if vitamin D is good for your brain or not. Dr. Marshall seems to be saying demented patients should lower their 25(OH)D levels. Keep in mind, an entire chapter in Feldman's textbook is devoted to the ill effects low vitamin D levels have on brain function.

Brachet P, et al. Vitamin D, a neuroactive hormone: from brain development to pathological disorders. In Feldman D., Pike JW, Glorieux FH, eds. Vitamin D. San Diego : Elsevier, 2005.

It is true that in some diseases, high doses of vitamin D may be harmful. For example, in the early part of last century, the AMA specifically excluded pulmonary TB from the list of TB infections that ultraviolet light helps. They did so because many of the early pioneers of solariums reported that acutely high doses of sunlight caused some patients with severe pulmonary TB to bleed to death. Thus, these pioneers developed very conservative sun exposure regimes for pulmonary TB patients in which small areas of the skin were progressively exposed to longer and longer periods of sunlight. Using this method, sunlight helped pulmonary TB, often to the point of a cure. Furthermore, it is well known that sunlight can cause high blood calcium in patients with sarcoidosis. In fact, sarcoidosis is one of several granulomatous diseases with vitamin D hypersensitivity where the body loses its ability to regulate activated vitamin D production, causing hypercalcemia.

Cronin CC, et al. Precipitation of hypercalcaemia in sarcoidosis by foreign sun holidays: report of four cases. Postgrad Med J. 1990 Apr;66(774):307-9.

Furthermore, although medical science is not yet convinced, some common autoimmune diseases may have an infectious etiology. I recently spoke at length with a rheumatologist who suffers from swollen and painful joints whenever he sunbathes or takes high doses of vitamin D. As long as he limits his vitamin D input his joints are better. To the extent vitamin D upregulates naturally occurring antibiotics of innate immunity, sunlight or vitamin D supplements may cause the battlefield (the joints) to become hot spots. I know of no evidence this is the case but it is certainly possible.

However, If Dr. Marshall's principal hypothesis is correct, that low vitamin D levels are the result of disease, then he is saying that cancer causes low vitamin D levels, not the other way around. The problem is that Professor Joanne Lappe directly disproved that theory in a randomized controlled trial when she found that baseline vitamin D levels were strong and independent predictors of who would get cancer in the future. The lower your levels, the higher the risk. Furthermore, increasing baseline levels from 31 to 38 ng/ml reduced incident cancers by more than 60% over a four year period. Therefore, advising patients to become vitamin D deficient, as the Marshall protocol clearly does, will cause some patients to die from cancer.

Lappe JM, Travers-Gustafson D, Davies KM, Recker RR, Heaney RP. Vitamin D and calcium supplementation reduces cancer risk: results of a randomized trial. Am J Clin Nutr. 2007 Jun;85(6):1586-91.

I will not write again about Dr. Marshall's theories. No one in the vitamin D field takes him seriously. Personally, I admire anyone willing to swim against the tide and raise alternative theories. I have done the same with influenza and autism. However, I agree with the New York Times, An Oldie Vies for Nutrient of the Decade and Jane Brody's conclusion, "In the end, you will have to decide for yourself how much of this vital nutrient to consume each and every day and how to obtain it." I agree. You will have to decide for yourself.

John Cannell, MD
The Vitamin D Council

The American Heart Association (AHA) was kind enough to send me an e-mail headlining the breaking news from the American College of Cardiology (ACC) meetings underway in Chicago:

ISAR-REACT 3
A Randomized, Double-Blind, Active-Controlled, Multi-Center Trial (ISAR-REACT 3) of Bivalirudin Versus Unfractionated Heparin in Troponin-Negative Patients Undergoing Percutaneous Coronary Interventions After Pre-Treatment With 600 mg of Clopidogrel

TRITON - TIMI 38 Stent Analysis
Prasugrel Compared to Clopidogrel in Patients With Acute Coronary Syndromes Undergoing PCI With Stenting: The TRITON - TIMI 38 Stent Analysis

Percutaneous Coronary Interventions in Facilities without On-Site Cardiac Surgery (NCDR)

(And four other similar reports)

Let's meld the ACC headlines with the financial headlines:

July 2, 2007
The Medicines Company announces reacquisition of all marketing rights to bivalirudin, anticoagulant growing in use for coronary angioplasty and related procedures. 2008 sales anticipated to be in the $15-20 million range, to grow to $90-110 million, a growth rate of 50% per year.

November 20, 2007
Drug manufacturing giant, Eli Lilly, vies for a portion of the $5 billion (annual revenues) oral anti-platelet market, now occupied by Plavix, with its newer, but questionably better, agent, prasugrel.

Growth of the coronary angioplasty (percutaneous coronary intervention, or PCI) doesn't ordinarily make headlines, but the performance of specific companies within the industry does. Angioplasty and cardiac device maker (inc. the drug-coated stent, Taxus), Boston Scientific, for instance, announced record sales of $8.537 billion for 2007, an increase of $536 million. How to grow this market? We could always hope for more people with heart attacks or other unstable symptoms. Or, we could . . . increase the number of hospitals capable of PCI! Brilliant.

The money behind this push for procedures is staggering. It drives enormous marketing efforts, pays Washington lobbyists, pays for many nice dinners and trips for doctors who engage in the system, and pays for very costly research.

And the AHA and ACC are kind enough to let us know about these great pieces of news.

Have you ever wondered to what degree health care is driven by a profit motive?

A doctor advises you to undergo a procedure. Is that advice motivated solely by concern for your health and welfare? Or, does the generous financial compensation peculiar to procedures bias your doctor’s decision?

The billboard on the highway advertises a hospital heart program. Is it meant to raise awareness of lifesaving services? Or, is it the same as an ad for a casino or hotel chain, a marketing tool for generating business?

At one time or another, we’ve probably all shared a suspicion that healthcare is occasionally motivated by money: over-priced prescription drugs, hospitals charging higher prices to the uninsured, the three-minute doctor’s visit for $200.

Direct-to-consumer drug advertising has brought aggressive drug sales tactics front and center to the public’s attention. “Ask your doctor about . . .” is the mantra of countless 30-second spots appearing several times an hour on national television. Direct-to-consumer drug advertising has provided the American public with a $4.5 billion reminder that there’s money to be made in the world of prescription drugs (U.S. Government Accountability Office). And there’s certainly a load of money to be made. A 2003 Harvard and Massachusetts Institute of Technology study showed that, of every dollar spent on consumer drug advertising, $4.20 was recovered through increased sales (Impact of Direct-to-Consumer Advertising on Prescription Drug Spending; Henry J Kaiser Family Foundation). A $53,000 ad run three times during the Oprah Winfrey Show is money well invested for a drug manufacturer.

The knotty issue of medical errors has recently captured attention. Unintentional medical errors—-nurses administering the wrong medication, doctor misdiagnoses or amputating the wrong leg, unrecognized medication interactions—-are an estimated $29 billion headache. Former Secretary of Health and Human Services, Tommy Thompson, reported that up to 98,000 lives are lost every year as a result of errors in healthcare delivery.

No doubt, these are all enormous problems that plague our healthcare system.

But I am going to make the case for a much larger problem. The magnitude of this problem dwarfs that of medical errors. It’s not an issue of neglect, nor is it committed in error. It is built on intentionally committed acts, systematically conducted on a massive scale, and sustained by the participation of many. It is a plague of unprecedented proportions on the health care system. It requires the willing participation of parties at multiple levels, from lone medical practitioners, to hospitals, to multi-billion dollar medical device and drug manufacturers, even to institutions like the FDA and American Heart Association.

The problem is the bizarre situation that has evolved in health care for the heart. I specify health care for the heart, not heart disease, because actual disease is not always part of the equation. Astonishingly, much of the inflated cost of heart care is based on the feared specter of heart disease, the implied threat of heart disease, the possibility, sometimes vanishingly remote, of heart disease based on some harbinger of risk. Sometimes the disease itself is nowhere in sight.

The system thrives on a culture of fear, an open ticket to over-testing and profligate spending. Ads cleverly admonish you to “Do it for your family”. Nuclear stress testing alone generates $18 billion of costs. Yet this test is normal in 80% of people tested. Worse, the 20% of “abnormal” stress test results are not always indicative of genuine disease, they are “false positive,” and are a big part of the reason that 30% of heart catheterizations fail to show disease. “My arteries checked out okay!” relieved patients will declare?-but there may have been no reason to have pursued a costly test like catheterization in the first place. But the system makes far better sense when you understand that nuclear stress tests and heart catheterizations are the bread and butter of cardiologists and hospitals, and the ticket to more financially rewarding procedures.

This approach evolved in the 1960s, when coronary heart disease itself was impossibly difficult to diagnose until a catastrophe like heart attack declared itself. But in the 21st century, coronary heart disease is easily, inexpensively, and safely detectable, decades before heart attack risk looms over your life. Yet murky, risk-based tests like stress tests and cholesterol testing continue to dominate the practice of “heart disease detection” in real-life practice.

Make no mistake: This problem is huge. The cardiovascular health care system has mushroomed into a gargantuan profit-generating mechanism, far larger than is required to deliver essential heart care. In 2003, over $431.8 billion was spent in the U.S. on cardiovascular health care, $151.6 of this on coronary disease alone (American Heart Association, Heart Disease and Stroke Statistics—2007 Update). The U.S. Department of Health and Human Services projects that total health care spending will double to $3.6 trillion by 2014, consuming 18.7 percent of the nation's economy, much of the increase due to expanding cardiovascular costs.

Most tragically, the system has grown through the exploitation of trust. The faith we have in doctors, hospitals, and the institutions and people associated with healthcare has been subverted into the service of profit. Many practitioners and institutions have chosen to operate under the guise of doing good but instead capitalize on the public’s willingness to accept as fact the need for a major heart procedure and all its associated costly trappings.

Copyright 2008 William Davis, MD

The New England Journal of Medicine just published a new analysis of the Multi-Ethnic Study of Atherosclerosis (MESA) database authored by Dr. Robert Detrano of University of California-Irvine.

As we would expect, the study confirmed the ability of heart scans and coronary calcium scoring to predict heart attack. This study is unique, hovever, in including Hispanics, Chinese Americans, and African Americans in its 6722 participants.

The analysis confirmed that coronary calcium scores yielded similar information, regardless of race. It confirmed that people with a zero heart scan score had a nearly zero risk of cardiovascular events; it also confirmed that higher scores (e.g., >300) yielded much greater risk over the 4 years of observation: 7.73-fold greater risk for people with scores 101-300; 9.67-fold greater for scores >300.

One of the media reports on the study can be viewed on HeartWire

Bill Sardi's Knowledge of Health website and blog also has an insightful commentary.

To those of us who have used heart scans in thousands of people, the MESA results come as no surprise, having seen these phenomena played out every day in real life. Although similar results have been previously shown in a number of other smaller studies, Detrano's analysis of MESA does serve to further validate these concepts. It also serves to deliver the message more broadly into the mainstream media message.

No surprise whatsoever: Coronary calcium scores obtained through heart scans represent a measure of the disease--coronary atherosclerosis--itself. It is not a risk factor that may or may not be associated with development of coronary atherosclerosis. Thus, when heart scan scores are held up in comparison the cholesterol, LDL cholesterol, c-reactive protein, or any other risk measure, heart scan scores outshine all these measures by enormous margins as predictors of your future.

Want to know what your uncorrected heart disease future could be? Consult your heart scan score. Not your cholesterol panel.

Copyright 2008 William Davis, MD

Ideally, you get a heart scan and your doctor sits down with you and provides a rational, insightful discussion on what the results mean.

Is heart attack in your future? If so, when? Are blockages present? What is the role of other tests like stress tests and heart catheterizations? Do CT coronary angiograms add any important information? What is the role of cholesterol? Can diet or nutritional supplements impact on heart scan score?

But what happens if you are unable to get the answers you desire? What if you get brusque responses, or your doctor just doesn't know? Or what if there is a clear conflict of interest or the possibility of financially-tainted advice? ("You need a heart catheterization right away or you'll die of a heart attack!")

One example of this process was posted by a frustrated Member of Track Your Plaque who found that answers were virtually unobtainable from his/her doctors:

I underwent a heart scan a few weeks ago, based on a recommendation from a doctor. I assumed that, since I was paying for it, and I requested it, the results would be fully explained to me.

Late on a Friday afternoon, the radiologist who intrepreted it called me and said I would be receiving a report, and so would the doctor. I asked that she explain them to me. She said their policy was to give the report to the doctor and let him explain them. She did say I was in the 90th percentile for my age--and that 10% had a worse score. I asked where do we go from here, and she said, if you're not having symptoms, maybe lifestyle changes, but YOUR DOCTOR will let you know. I asked for a copy of the films and reports, and was told YOUR DOCTOR can request them. I called back a little later and she was gone. It was starting to sink in that I must have a terrible score. In the meantime, I did what I should have done before I went for the scan---looked up information on the internet, and read about calcium scoring. This website [Track Your Plaque] hadn't showed up in my Google search, so a lot of the information was useless.

I did manage to get the score of 186, with the breakdown per artery from someone at the clinic, but only after I insisted I paid for the test, I have a right to the information. 'Course having a score per artery didn't really help---what did it mean? ie: if a 72, how did that correlate to any blockages? Was it a big lump...or spread along the wall throughout the artery.

I had an appt. the following Tuesday with THE DOCTOR---a very busy doctor. After an hour and 1/2 wait in a crowded waiting room, I got to see him. We discussed briefly another issue, and he started walking out. I followed him out and said I wanted my full l5 minutes of time allotted in their scheduling, which seemed to irritate him.

I followed him into his office and said, WHAT ABOUT THE HEART SCAN? What do the numbers mean? He responded that he didn't know, he'd have to see the films, but don't worry--you're probably ok, and I should get a thallium stress test anyway. He said he couldn't intrepret the numbers, or give an opinion on where the plaque was or how it was configured.

I then went to the interventional cardiologist that afternoon and the thallium stress test was scheduled. I asked about the HEART SCAN, and again, no acknowledgment. I asked if he would get the films and explain the results, and again no acknowledment as he was walking out the door.

After this lengthy saga.....MY QUESTION IS....since this is a test you can order yourself (literature at center made mention of the tests you can get without a doctors request)......WHO IS THEIR FIDUCIARY RESPONSIBILITY TO WHEN IT COMES TO EXPLAINING THE RESULTS?

I learned more on this website [Track Your Plaque], and the emailed book then I did dealing with two doctors and the center itself. Thinking back, there was nothing but a brochure on the test at the center. No "Track your Plaque" stuff.

Day 2
I called the scanning center and relayed my dilemma. I was put in touch with another radiologist--a very informative one, who appeared passionate about heart scans as a preventive test. He compared them to mammograms. He hadn't heard about the "Track Your Plaque" program but was going to check it out. He said people varied in their responses to the test results, as well as doctors/cardiologists as to the next step. (ie: lifestyle changes..the next test, etc). He seemed to feel blockages of more than 50% for many cardiologists would indicated angioplasty and stenting.

I'm going back to review the films with him later this week. He wasn't that concerned with the 101 reading on the right artery. The 72 on the left he had concerns with and indicated the CAT test [CT angiography] would offer more as far as how much was there, and approx. blockage, and could be a baseline to compare to in the future. He said some cardiologists would go right to angioplasty...some to a CAT which is more conservative...some might watch and encourage lifestyle changes. He said the Heart Scan doesn't show soft plaque. He also said the internist who referred me was one of only a few in the city that felt strongly about the heart scan---and probably used it to take further action via a referral, and just didn't have time to discuss it, with the way medicine is run these days.

This Member's frustrated post pretty much sums it up:

1) Doctors don't seem to have the time nor motivation to be bothered about offering advice that leads to prevention of disease.

2) The tendency is to always ask, "Are heart procedures necessary?", not "How did this happen?" or "What can we do about this to keep it from getting worse?" How about diet, supplements, and other tools to use at home?

The obvious uneasiness of the radiologist, the last physician this Member spoke with, can just as easily lead to boneheaded advice: Maybe getting a stent isn't such a bad idea. Maybe a CT angiogram is an absolute necessity.

I hear comments like this every day. It is the reason why I continue to plug away at this program and try to set things straight.

By the way, subscribers to our Track Your Plaque Newsletter just heard about our latest success story, Roy, who dropped his heart scan score over 500 points. If you are yet not a newsletter subscriber, click here.

Copyright 2008 William Davis, MD

In January, 2007, $11.6 billion (2006 net sales) cereal manufacturing giant General Mills rolled out three million boxes of Wheat Chex and Multi-Bran Chex, each boasting a picture of cardiologist, Dr. Nieca Goldberg's face on the box.

Dr. Goldberg has been a frequent national spokeswoman for the American Heart Association (AHA). In a media interview, American Heart Association President, Dr. Alice Jacobs, stated that she supports Dr. Goldberg's work with the General Mills’ products. "The AHA is always in favor of educating the public on how to make heart-healthy lifestyle choices." Dr. Jacobs added that the AHA doesn't consider Goldberg's appearance on the cereal boxes ‘an endorsement’ of the products. "The content on the box is basic heart health information," she said.

Putting images of someone like Dr. Goldberg on cereal boxes appeals to a certain audience, mothers worried about health in this instance. Manufacturers recognize that the perceptions of their food need to be created and nurtured.

Eerily reminiscent of tobacco company tactics of the 20th century? Recall the Brown and Williamson claim that Kool cigarettes keep the head clear and provide extra protection against colds? Lucky Strike, Chesterfield, and Camels all promoted the health benefits of cigarettes, including prominent endorsements by physicians.

How about Philip Morris’ ads for Virginia Slims cigarettes: "You've come a long way, baby"? Interestingly, food manufacturing behemoths Kraft and Nabisco were both majority-owned by Philip Morris, now renamed Altria.

Take a look at the composition of these two "heart healthy" breakfast cereals endorsed by Dr. Nieca Goldberg and the American Heart Association:

Products like this:

--Make people fat--abdominal fat (wheat belly)
--Reduce HDL cholesterol
--Raise triglycerides
--Dramatically increase small LDL
--Increase inflammatory responses
--Increase blood pressure
--Increase likelihood of diabetes

These products are sugar and sugar-equivalents with a little fiber thrown in and a lot of marketing propaganda, aided and abetted by the misguided antics of the American Heart Association and Dr. Goldberg. It's hard to believe that Dr. Goldberg would sell her soul on something so knuckleheaded for a moment of notoriety.

As I've often said, if a product bears the AHA Check Mark of approval, be sure not to buy it.

Anne
5/18/2007 3:17:00 AM |

I had a severe reaction to my first dose of niacin - wish I could remember what dose was prescribed. I not only had a flush, but I itched all over and my face and mouth swelled up. Was that an allergy or can the niacin flush get that bad.

Dr. Davis
5/18/2007 11:29:00 AM |

Hi,Anne--
Your reaction is a rare variety that I've seen only a handful of times. There's no such thing as allergy to niacin itself, though someone rarely can be allergic to another component in the capsule. It is possible to take niacin after such a reaction, but you need to work with your doctor. I've re-introduced niacin after such reactions at very small doses of, say, 50 mg (immediate-release) and built up very slowly over months, even years. This has worked out well.

Anne
5/19/2007 10:08:00 PM |

Thank you for your answer. The niacin I was prescribed was Niaspan. I can ask my cardiologist if there is a gentler brand and a lower dose.

Kathy and Wes
7/26/2007 10:42:00 PM |

My reaction to 500mg of niaspan was burning from head to foot 2 1/2 hours after taking it. In addition, my heart was beating so fast I couldn't believe it. If felt like I was being burned with a curling iron all over my body. The only thing I could do to relieve it was to splash cold water all over me. My Dr. wants me to try it again. taking a baby aspirin an hour before hand. I only had this twice out of four times. But I am very afraid to try it. It lasts almost an hour.

Kathy and Wes
7/26/2007 10:48:00 PM |

My Dr. put me on 500mg of Niaspan. I have taken it 4 times and twice had the worst reaction. I became beat red from head to toe, and my skin felt like I was being burned with a curling iron. The only relief I could get was to splash water on my skin. This lasted almost an hour. My heart was also pounding at an excelerated pace. My physician would like me to try it one more time with a baby aspirin, which I did once. Are you sure that it is safe with a reaction like that?

Thanks

Kathy

Dr. Davis
7/27/2007 12:05:00 AM |

Plenty of water--meaning 16-24 oz, if okay with your doctor--with your niacin can be very helpful in the beginning. In my experience, people who live with chronic dehydration (there's lots) struggle the most with niacin.

Dr. Davis
7/27/2007 12:07:00 AM |

Kathy--

I can NEVER offer medical advice online.

I can only tell you that I've had many people navigate through these feelings just by paying attention to hydration. Only an occasional person is truly unable to tolerate it.

Another option I use in my patients is to induce "tolerance" by accepting a small dose, e.g., 250 mg SloNiacin (Upsher Smith) for several months, and increase it very slowly. But you need to discuss this with your doctor.

Doris
7/28/2008 3:50:00 PM |

I have taken Niacin for over two years. By brother-in-law was in the emergency room with flushing. The doctor had given him Niacin and told him to take a big dose daily. I can't remember if it was 2000mg for sure, but I think it was. I began at 100 mg and on the fifth day went to 200 mg. After taking that for 4 days I upped it to 300 mg. You get the pattern. I eventually made it up to 3000 mg. I buy it at the health food store in the mall because the Niacin in the discount stores tend to be nonflushing. I still flush occasionally, but not severely. I enjoy the flush as I know, or pretend,that is where the little niacin crumbles are eating up the cholesterol. Ha. Good luck. I found this suggestion online posted by a doctor.
btw, I have itched a bunch for maybe 10 minutes while it flushed. My flushes are not too severe to continue. I did go off Niacin and am restarting because I looked online for Niacin overdoses and I had some of the symptoms. I decided I had got too high on dosing.

Jenn
8/22/2008 1:31:00 PM |

Why is Niaspan considered a better medication (at least by my doctor) than over the counter niacin, when it causes so much more flushing? On regular Niaspan, I don't flush every day, but if I do, it's anywhere from 2-18 hours after I take it. My doctor started me on the Niaspan-Crestor combination, and I can set my watch by it- 8 hours after I take it, every day.
It's hard to get ready for work, when my face is blotchy and puffy and it hurts to apply makeup or comb my hair. Is flushing connected to diet and exercise? That is, is it supposed to make you flush if you eat the wrong things or don't exercise? I can't understand why my doctor would insist on my using Niaspan unless he's trying to use the flushing as a behavior modification program.

Anonymous
9/1/2008 9:22:00 PM |

I had an odd reaction to Niacin. After eight wonderful days of taking it, I woke up one evening with a feeling that my body was on fire from head to toe. Remembering that I needed to take an aspirin when flushing had occurred, I went to the kitchen where I had a series of seizures. Upon eliminating everything in me, we called an ambulance.
The ER physician said it was a normal reaction and to continue to take the medication as prescribed. I called my family doctor the next morning and he said I did have a reaction, which I stopped at that moment.
So, did I have an allergic reaction to the medication or just a seizure out of no where?

Thanks,
Tina

Murf from WA
10/13/2008 8:20:00 PM |

this doc is cool but u guys are all a bunch of little whiners! Niacin flush is such a rush I can literally feel all the toxins leaving my body and it feels GREAT. so quit complaining. this "flush" is doing you good. I assure you. The whole point is to flush. calling the ER because you are flushing may be a sign that you are a hypochondriac. maybe u should see a therapist?

Anonymous
10/18/2008 2:56:00 PM |

I agree w/"murph" but not so aggressively--the flush is good, good, good. You are just freaking out a little but because it's odd and unusual to you, at first. You should be flushing, it's increased blood flow that is getting all the nasty stuff out of your system and after the pinkness subsides I have been asked about what I'm doing with my skin because it's glowing! I swear my skin looks clearer and more youthful. I take it when I wake up, before breakfast & a shower and by the time I get to work my pink is gone, I'm more awake & my skin is glowing. LOVE IT, DON'T FEAR IT.

PinkyTink
10/30/2008 4:37:00 PM |

I used to work in a pharmaceutical - packaging niacin. I would have my hands gloved, my arms covered, my hair in a net and wearing scrubs with a lab coat over them - just inhaling the niacin while working with it in raw form left me very sensitized to niacin reactions, which I attribute more to a feeling of a bad sunburn for about an hour. I too have had difficulty breathing and swelling of my esophagus during a reaction after higher doses or inhalation during the time I worked in the lab.
I do not feel those who are speaking here are hypochondriacs and unless you've gone through something, you should really not judge others their symptoms - clearly the seizure person would argue you that their issue was not in her mind, do you not agree?
I personally just find the reaction plain annoying, but have had to adhere to my doctor's warning of being wary of certain forms and doses of niacin due to my persistent reaction post-contact... those who do not understand this, i have no worries; nor am I whining or complaining - facts are facts - they are what they are - I make no apologies for stating them. Enjoy your day

New to Niacin
11/6/2008 2:45:00 AM |

I agree with PinkyTink that the feeling most like a niacin flush is like a sunburn. Here's my account for those interested in case studies. I tried niacin (250mg) for the first time two days ago and thought "well, this feels nice; it's kind of hot and tingly as if I were blushing over my entire body." If some is good, more is better, right? Wrong! Yesterday I tried 500mg, encouraged by the fact that the recommended dose is 1-2 grams, and determined to fix my cholesterol problem all in 1 day. Nope. I spent about 3 hours with what felt like the worst sunburn that I've ever had (and being a native to SoCal, I've had a few). The burn started on my face, which was fine since it doesn't touch anything. It then included my face, shoulders and upper torso, which was moderately annoying but I was able to continue working. At the 1 hour mark or so, the fire had engulfed my lower torso and my buttocks as well so I kneeled in front of my computer (the prickling and burning too intense to put pressure on) to work. About a half an hour after that, my entire body was on fire and I just gave up and paced around until the intensity was bearable at about the 2.5 hour mark. It was incredibly itchy from the 1.5-2.5 hour mark, and I did rub and put an ice pack on excessively itchy spots occasionally, which relieved a bit of the discomfort. (I didn't know about the dehydration fix, so I'll try that next time.) I am planning on continuing with niacin, but with a slower increase to get my tolerance up, YMMV. To those who don't think the flush is a big deal or pretty debilitating, we may be describing different levels of intensity.

headlightsonthehighway
11/28/2008 6:28:00 AM |

I've taken half of a 100mg dose and it usually causes just a bit of flushing for around 15 minutes. But tonight I decided to take the whole 100mg and my face not only felt like it was on fire, it went to my hands, then arms, neck, shoulders, then my legs. My face (mostly my nose and upper lip) swelled up and I looked like I had fallen asleep at the beach for 8 hours. My heart raced and I was afraid that maybe I was having an allergic reaction, but after about an hour, it subsided. I will only take the smaller doses from now on. The flushing isn't so bad, but the swelling scared me a little.

Anonymous
3/17/2009 12:03:00 PM |

I had an intense, long-lasting niacin flush similar to the worst mentioned on here. I also have some menopausal flushing (even with estrogen), rosacea, and migraines. People with any of those conditions should be careful about niacin. I don't think it is all that rare to have a very bad reaction to it, because there are a lot of people who have one or more of these conditions.

Kaylin
5/1/2009 4:25:00 AM |

I took 500mg of niacin today and had quite a flush! It was a very good thing that I happened to be at my parents' house with my three young children instead of driving, because after my skin felt sunburn-hot and turned beet-red all over, everything started looking very bright and I would have passed out if my mom hadn't led me to a bed to lay down. I am so thankful she was there because she had to take care of my kids while I laid on the bed for a couple of hours recovering. Almost passing out is not a hypochondriac invention, people! I thank the good doctor for his information as I am encouraged to continue taking niacin, but at much smaller doses until my body gets used to it.

Michele
5/18/2009 3:03:00 PM |

Hi. I was doing fine on 500 mg of time-released niacin twice a day for five months with only minor flushes. Yesterday, about four hours after taking the first 500 mg pill, my face flushed beet red and got very hot. Ditto for my upper back. Can this be due to the niacin, even though I didn't just start taking it and the flush occurred hours after I took one?

Anonymous
5/29/2009 11:09:11 PM |

I just bought a new multivitamin at a health store and didn't notice it's huge level of niacin and I had a severe reaction like some of you described...full body sunburn, itching, rash, burning, and swelling of upper lip. My heart raced. I had to run home from work and take a Clonidine that I had for rosacea flushes and a benedryl (probably a bad idea, but I was desperate for relief) and am still waiting for some relief. I would beware of the flushes...those of us with rosacea know, with every flush comes inflammation and capillary damage which can age you and ruin your complexion.

Cookie
6/12/2009 2:43:40 AM |

Be careful advising people that there is no such thing as a niacin allergy. I cannot even tolerate 2 bites of food that has been supplemented with it, without my lips swelling and burning and itching starting. I first discovered my allergy to it by taking it as a supplement by itself. I broke out in hives and itched terribly for a few days. I didn't want to believe it, so I took it again a month later. Repeat, only worse this time. I can't even take it in any form, energy drinks, cereal bars or B100. I drink 2 quarts of water daily, and as much as I can more,
when I realize I have eaten it in something by accident. This is the most serious itching and welts I have ever experienced. Hoping this helps someone else, Laura

Dr. William Davis
6/12/2009 7:37:47 PM |

Cookie--

You do NOT have a niacin allergy. If you did, you would not be alive. Niacin is required for human life.

What you have is an unusual idiosyncratic reaction. This does not mean that niacin is safe. It means that you are among the rare exceptions in tolerance to greater than pellagra-preventing doses of this B vitamin.

Cookie
6/20/2009 3:57:39 PM |

Hi Dr Davis,
I do believe you may be right that the allergy is not just Niacin alone. I have found I have severe reactions to Niacinamide, but not Niacin alone. I looked up the difference on Wikipedia and they are very close in their chemical makeup and definition. But, they are not the same. http://en.wikipedia.org/wiki/Niacinamide
The bond is N,O,NH2

Whereas, the bond for Niacin is N,O,OH.
http://en.wikipedia.org/wiki/Niacin
I am no scientist, but my body certainly knows the difference.
I hope this helps someone else.

Anonymous
7/26/2009 3:54:52 AM |

A doctor told me to take a baby asprin and 500 mg of niacin for one week then increase it to 1000 mg. Presently, I am on my third day of 500 mg, here is my experience with flushing. The first day was no problem. I took one baby asprin before my meal and the 500 mg of niacin after my meal. I felt like I had a bad sunburn, but everything was fine. I noticed I didn't turn red where I was sitting, but everywhere my skin was exposed was red and hot. Day 2 - I took 2 baby asprins before my meal and 500 mg of niacin after my meal. The flushing was almost unbearable. Quite different from day 1. I stripped my clothes off because I couldn't stand anything on my skin, stood in front of a fan, and iced my body. Then I remembered about yesterday the parts of my body that were covered did not have a bad sensation, so I put clothes back on and jumped in bed with covers. That did help relieve the symptoms. Today is day 3. I was scared because I didn't want a repeat of yesterday. I thought about reducing my dose, but I had a plan. I took 2 baby asprins before my meal and 2 motrin and 500 mg of niacin after my meal. I put on long pants and a long sleeve turtleneck sweater, and had an ice pack ready for my face and hands. The flushing episode went really well. I didn't even have a bad sunburn feeling. It was just slight. I don't know if this will work for anyone else or on day 4.

Anonymous
7/27/2009 1:54:58 AM |

Day 4 - I did the same thing as day 3. I took 2 baby asprins before my meal and 2 motrin and 500 mg of niacin after my meal. I put on long pants and a long sleeve turtleneck sweater. I had very slight hotness in my hands and face. That is it. I didn't need an ice pack today. I don't know why this method works, but if it will help anyone else I'm glad I posted my comments.

Laxana's World
8/7/2009 3:28:40 AM |

I had never been told about any reaction to Niacin...I took it before dinner and thought I was on fire...I found this site and drank water and took aspirin...it helped, but a cool water bath w/ baking soda and time finally made it better (it's been three hours and my skin is still extremely sensitive and somewhat flushed)...this has been one of the more unpleasant side effects to any medication. I want to continue to lower my cholesterol, and already take red rice yeast and fish oil...I don't know if I can continue the niacin...no fun.

Phil5115
8/22/2009 9:55:04 AM |

I get the itching and burning as well, but the worst is a swelling sensation in my ears. Not pleasant, but my triglycerides are improving.

Anonymous
8/31/2009 6:56:12 PM |

Being flushed is nothing. I took an over the counter niacin tablet and besides turning as red as a lobster (no exaggeration--I was the color of a stop sign) my blood pressure fell fast and I landed on the floor unconscious. There are those of us with a severe reaction to niacin supplements; it is not trivial and it is well worth thinking about. Having such a precipitous drop in pressure is dangerous.

robert
9/2/2009 11:08:39 PM |

Hmmm...I take niacin like this - 0500- 500mg SloNiacin; 0900- 500 mg Miacin; 1200- 500 mg Niacin; 1600- 500mg Niacin: I rarely flush and when I do, it is extremely mild and does not even register. I don't know what all the fuss is about. Maybe I am taking it incorrectly?

Kris
10/17/2009 12:59:22 AM |

The only time I get a flush is when I have eaten garlic and then taken the niacin. It is not pleasant and scared me very badly the first time. I do not know why this happens. Has anyone else had a similar experience?

Anonymous
10/26/2009 7:26:52 PM |

My experience was extreme. I have been taking the Niacin with Crestor for 3 days. When I sat down to lunch today I suddenly felt warm and took off my sweater. within 2 minutes I was burning in agony from head to foot and my body was shaking. I was itching, shaking and burning while my heart was racing. I was beyond beat red and it was far more painful than any sunburn I had ever experienced. I was in tears and scared witless. I am a 40 year old ex football player. I am not afraid of a little pain, this was torture! I felt like someone was burning every inch of skin from my body all at once and I could do nothing but lie down and scream. My Wife called the doctor who said it was normal and would pass. My triglycerides were about 108 but my doctor wants to see them at 80. For those who think it's just whining, I hope you never have to experience what I have just gone through! I wouldn't put that on anyone no matter how cluless they were. Until you've experienced a severe reaction, do not even try to minimize the pain. It is beyond belief. That was 4 hours ago and I am still itching.

Doug
11/17/2009 7:24:50 PM |

I have used Efudex and fluoruracil for treatment of Actinic Keratosis with the last treatment 2 years ago. Since then, my arms barely show any signs of damage, but my legs still showed the damage which would be more prevalent when I got hot and sweaty. I took my first 500 mg dose of Niacin 4 days ago at night. I only felt a little flushing and tingling, and didn't think it was bad at all. The next day, my legs looked as bad as they did after using the fluoruracil for 4 weeks. I have not taken another dose of Niacin and my skin has not improved at all. I think the Niacin is telling me that the Actinic Keratosis was not destroyed on my legs. Do dermatoligists use Niacin to make AK's more pronounced so that they can find them? Will my current condition get better?

John
12/20/2009 2:18:28 AM |

Hello, all! I have been taking Niacin daily for more than 30 years. I don't take it for cholesterol but rather as a treatment for Meniere's Disease but that's another story entirely. I believe because of the length of time that I've been a Niacin user that I have more experience with it than perhaps anyone, anywhere. I can go months without a flush and then I can experience a mild flush eveery day for a week. I flush much more with non-timed release forms than with timed release forms. Some times I experience a really bad flush. I mean REALLY bad. Not just the feeling that's akin to the worst sunburn that I've ever experienced but the feeling that the skin on my face weighs many pounds more than it possibly could and if it gets REALLY bad, my stomach tightens up as though it wants to screw itself into a tiny, tiny ball, nearly doubling me over. Twicee in my life I have come perilously close to passing out during a flush. Once while driving and the second just about an hour ago tonight. Tonight's was the worst that I have ever experinced by far. It got so bad that I actually feared that I was on the verge of dying. This flush lasted far longer than any before it. Usually they pass in 15-20 minutes for me but tonight's effects have drawn out for more than an hour. As I type this post, my hands are still shaking as I am "coming down" from the flush. The thing of it is though that I knew it was going to be bad tonight, just not this bad. You see, I usually take my Niacin in the form of a timed-release caplet (Slo Niacin) early in the morning and if I forget to take it early in the day, the likelihood of a bad flush increases the later that I take it. Yesterday I realized at 3PM that I hadn't taken my Niacin so, fearing the severee flush, I simply didn't take it at all. Today, I once again forgot to take it early and risked taking it at 4PM. The flush didn't hit me until 7 but when it did, it grew slowly and to a height I had never experienced. WOW!I'm just about back to normal after an hour and a quarter!!! I just read the advice about taking an aspirin and I will keep some on hand in case it gets this bad again. I also think I'll make a SERIOUS effort to remember to take it first thing in the morning from now on!

Bram
1/26/2010 1:50:43 AM |

Hi,

I really had to post a comment too.
After reading John's post I felt a lot better. I also had the worst flush ever today. Normally i take 1000 Mg Niacin twice a week, but last week I skipped my doses, just to give my body a little time for itself. Normally the flush starts after 1-1.5 hours and than slowly my body starts to feel a little bit hot from top down, not too bad, kind of nice even. Today after 20 minutes or so, in one second my head became SUPERHOT, my lips and my facial muscles felled paralized, my heart started racing (maybe because of the new strange experience) I looked in the mirror and my complete face was hanging down. I've never seen this before so my heart started beating faster and I started hyperventilating. At that moment I really thought it was the end of my life. It was really bad. But now I know I'm not alone so we'll see what happens next time;
Maybe a smaller dose, this was really scary.

Anonymous
1/30/2010 9:07:17 PM |

I started taking niacin yesterday (250 pil per day), no flush, but today I experienced it. Ears got hot, then face then upper body. Slight itching. it lasted about 30 minutes. Nice.
I wonder if it is ok to have a glass of wine while taking niacin pills?
thanks

Anonymous
2/17/2010 3:48:50 AM |

Anonymous don't drink wine. I had the swelling of the lips, face, I looked like my face was about to explode, it was tightened and my face looked like a 20 year olds skin, I itched for 2 hours scratching my arms raw. I laugh about it now when I read your post, but I was scared.

Barbara
3/28/2010 10:05:40 AM |

So my cardiolgist told me to take 1 325 mg aspirin 30 minues before bed & 2 Niaspan at bed time. twice now I have been up for 3-5 hours with the flushing reaction from hell. The thing is I get hives when I get hot. The itching from the flush coupled with the itching from the hives caused by the heat is unbearable. I burn from head to toe & even went outside to cool off, in just a tank top, in Colorado, with a foot of snow on the ground. Still burning. The water does seem to be helping. From now on I'll eat at bedtime & dring 24 oz of water to help. I have to work 7 hours today with no sleep. This stinks.

Anonymous
7/4/2010 10:40:02 PM |

Hey, I have no problem with the niacin flush (actually feels good -- and I feel great afterwards). However, I stupidly tried the non-flush niacin (because the pharmacist recommended it) which also contained inositol... I had an allergic reaction for the first time in my life (lasted six hours). Had to go to the hospital. Never touching no-flush or inositol supplements again. Real niacin only (you have to ask for it over the counter here).

Anonymous
7/4/2010 10:47:47 PM |

To continue previous post: I would avoid Niaspan or extended-release niacin or inositol if you have the allergic reactions as posted above (unbearable hives, itching and heat). Real niacin effects lasts about a half an hour and feel good -- and if you don't like that feeling just use an aspirin half an hour before taking it. The actual allergic reaction I experienced with inositol or "no-flush" niacin (as others above obviously have) is hell. Besides, scientifically, only real niacin works for cholesterol or depression (no-flush and time-release are an upselling marketing scam). There is a HUGE difference between the allergic reaction (to inositol, no-flush, and time release) and the normal real niacin flush.

Anonymous
7/4/2010 10:56:53 PM |

Addendum to previous two posts: the allergic reaction I had started a few hours after I too the no-flush/inositol. The redness and hives covered my entire upper torso, the unbearable itching appearing in random places. The hives and itching became so bad I jumped in a cool shower for over 2.5 HOURS because I was worried that just scratching myself would leave scars. I finally went to the hospital and was given benadryl. Took another hour to go away. Avoid no-flush or inositol or time-release if you have the allergic reactions.

Anonymous
7/20/2010 9:32:53 PM |

I was taking a rather small dose, a 100mg mega B vitamin. I got the flushing red response, but then my breathing got rather weak and I had to lie down. I tried another pill a week later and exactly the same thing happened. I got really light headed and was forced to lie down.

Allergy? I see you guys trying 1000mg... how can I react so strongly to 100?

Newton Kinglsley IV
9/29/2010 3:39:50 PM |

You're probably right about that water. I took 200 mg today with breakfast, a dose that usually doesn't cause me grief. But damn was I baked today. Felt like I was being burned alive and my skin filleted off with razor sharp steel wool dipped in acid.

But I drank 16 oz of water and that sure seemed to help. Usually I drink a few glasses of water but today I didn't and I bet that's what did it.

I also took some asa but there's no way that was absorbed quite so quickly. The worst of the flushing stopped in 5 minutes. It's still present, but tolerable.

Venkat
10/1/2010 10:21:57 PM |

I had been asked to have 500mg Niacin with 350mg asprin first once a day for 2 weeks then twice a day. I never felt much other than a stuffy nose which I didn't know was related but then one night I woke up feeling hot and uncomfortable. Drank water and had an asprin and slept. I stopped taking it after that. My doctor recommended I continue so I started today by having the slow release Niacin in the morning around 10am after breakfast. At 2:30pm while I was driving suddenly I felt hot in the face, hands, body and legs. I realized I was having the flush but didn't know how to control it hence I looked up online and I am glad I stumbled on to this blog. Can't believe that it is just a vitamin causing all this. Side effects seem to be worse than most drugs.

Anonymous
10/22/2010 12:18:26 PM |

Thanks folks...I have been taking Niaspam for a while now...6 months...working up to 1500 mg a day (taken at night with aspirin). What's funny is in general I tolerate it okay, with only minor flushing, but today I had an ATTACK like many of you describe that was so debilitating I felt like jumping out the window to get our of my own skin. Even getting the water into my system wasn't so easy because I was so uncomfortable. Between the water and aspirin, I'm back to the managable "light sunburn" itch level. I think 1500 mg may just be too large a dose for me and I may need to cut back to 1000 mg. Also, I do occassionally drink, and since I know the reaction between alcohol and niacin is bad, I don't take it on nights where I've had a couple. Anyway, it's some relief to know that the reaction I had today isn't that uncommon, miserable as it is. I appreciate the tips on dealing with this strange medication and will continue to follow posts here...

Anonymous
10/28/2010 4:51:40 AM |

Great article Doc, thanks. I just flushed now, felt like a bad sunburn, and your water trick helped!

I have been on Niaspan for a while, usually avoiding the flush with some tips from my heart Dr. He recommended two things that help me: take at bedtime, so if the flushing happens I am probably asleep, and also take my daily aspiring about 30 minutes before the Niaspan, which he says helps avoid the flush.

Problem is, I usually end up taking the aspirin at the same time as the Niaspan for convenience, and that might not give thye aspirin enough time to help. Tonight, I took the pills at bedtime as usual, but ended up staying up later.

One time when first on Niaspan, my heart raced like crazy with the flush, like another writer had. Anyway, thanks for great info.

Lemia
12/20/2010 10:12:47 PM |

Dr. Davis,
Po"tay"to, Po"tah"to, with regards to allergy or sensitivity. Particulary with lay people, if it causes an anaphalactic reaction (or even Hives, for that matter), might as well call it an allergy. People also naturally need iodine in their bodies, and while "technically" you would say I have an iodine "sensitivity", that does not (and did not) stop me (nor many of my patients in the Cath Lab) from having an allergic reaction to IV iodine (and forget about topical betadine!)

To argue with someone about whether it is called an allergy or not, may give a non-medical person the idea that a sensitivity to something naturally occurring is therefore nothing to worry about. In my case, and many others, it would mean death. I think the nomenclature should be changed personally - if something can end up causing an anaphalactic reaction it SHOULD be called an allergy.

Lemia
12/20/2010 10:14:34 PM |

Correction: I meant to say "Anaphalactic reaction" and not "Allergic reaction"

Lemia
12/20/2010 10:25:59 PM |

As a side note: I recently had what would be seen as a typical "allergic" reaction after taking just 250 Niacin - (this was Slo-Niacin) which I have been taking for years - as a matter of fact, I have gone down from 500mg. Never had a problem with it before today. Throat, tongue and lip swelling, wheezing, hives and a raised rash over full head and torso, front and back.

My curiousity is over whether high levels of HDL itself may be a factor in such a severe reaction. I already have an extremely high HDL and wondering if increasing an already high HDL was the culprit. I would like to hear your thoughts on that and if you know of any such studies. My own physician would like me on a statin, which besides giving me many side effects (all of them), I am doubtful as to their need with a normal ratio. Despite having a high total cholesterol (ranging any given time from 275 to 325) , my ratio is absolutely fine. Again, I am interested in hearing your thoughts on the subject.
Thanks greatly.

Anonymous
2/3/2011 3:49:55 AM |

I am so relieved to read about others' experiences. I have been taking Niaspan 500mg for about 6 months with fairly mild flushing. Last night I had a severe reaction. I turned bright red, rapid heart rate, shortness of breath. I was burning up from the top of my head to the top of my thighs ( my legs were fine ). I am a RN and worked ER for 20 years and never knew that these symptoms could occur after many months of the same dosage. It was a relief to hear that it was not just me! I will continue to take the Niaspan but am taking the night off tonight!

Elizabeth Dugan
2/27/2011 3:44:45 AM |

I took Niacin (500mg) for a couple of days and am going insane with the itching. I haven't taken it for 2 days now but I am still itching. Does anyone know how long the Niacin stays in one's system? Thank you.

Anonymous
3/15/2011 4:25:50 AM |

im twelve and my dad made me eat a little..now i feel like im right in front of a 450 degree oven and i also feel like theres spikes protruding out of my body and my heart is beating like 5 time per secend

Anonymous
3/30/2011 8:06:04 PM |

The first time I took straight Niacin, not in a B-Complex, I got the flush severely. It actually started INSIDE my chest, it suddenly felt like there was cold water suddenly inside of my lungs, and I burst into a coughing fit. From there it spread. If it had stayed on my skin, it would have been fine. But it was inside my ears, and my whole sinuses puffed up so much I could barely breathe. I got VERY dizzy. I was on my way to the gym, and walked up 3 flights of stairs. By the time I got to the top of the stairs, my blood pressure had dropped so much I didn't make sense when talking, and then I promptly passed out. An ambulance was called, and after I came to and threw up, my BP was at some ridiculously low rate, like 55/40 or somewhere around there. VERY bad reaction, will not be taking again.

And for those of you dismissing extreme reactors as "hypochondriacs", the flush is subjective, and how is passing out hypochondria?

Anonymous
4/8/2011 12:26:17 AM |

I have been taking niacin for years...I have found it to be the cure to brain farts...you know when you brain goes on vacation for like 3 seconds. I can't have that, I play bullet chess for several hours on end. That is where the whole game is played in a minute or less. Three seconds is an eternity. Anyway, I just had a massive flush; it happens once a year or so.  What usually triggers it for me is eating something with white bread.  They add niacin to it.  It is just enough to push me over the edge and instant beet.  You have to wait a few hours before having any white bread after taking niacin. Burger buns and pizza crust are the worst. It was Pizza this time. Intense exercise can also trigger it. But burger buns that is the biggie. I don't drink, so I have no familiarity with that interaction.
One thing I did not see here is that afterword for a few days I feel really run down.  I either get the flush or not and when I do it is head to toe fire and itch, and I need several aspirin (I am 290 lb with a good deal of muscle)and lots of water and like three or more hours before it goes down.  I don't get a racing heart rate though. I don't want to cast any aspersions, but that sounds like panic ;). Oh, and scratching makes it worse for me, when it starts. I avoid that. I also sit down and do some mental relaxation exercises. I get dizzy if I stand up so I don't ;) I also think the shivering is just from having so much blood at the surface...it just pulls the heat from the core. I only shiver if I sit in front of a fan...still...I prefer the fan and shivers to fiery skin. But when I have not had access to a fan or cold water, I haven't had a shiver. I am not suggesting people take a lot of aspirin that is just me.
Hmm, I like the dehydration explanation. When I exercise I do so intensely and for at least an hour...I suppose dehydration could be the reason exercise can trigger it in me.  I'll have to try extra water an hour before exercise. I may have been a little dehydrated this morning too as I awoke with both arms asleep and I was not sleeping on them. When that happens or if I have cramps when sleeping or on getting up, I have made the connection that I am generally dehydrated.

Anonymous
4/9/2011 4:52:51 AM |

I have been taking Niaspan for about 4 months. At first I had anxiety and flushing. Now I just have the flushing and not daily. My doctor recommended that I take it with applesauce or apricots. Pharmacist told my to take it with a low dose aspirin. Spicey food also seems to cause a reaction. I don't always get a flush and it only lasts about 20 minutes. My doctor also suggested I not use the aspirin because I won't get the full benefits. I am being monitored with blood tests and cholesterol is better. I also take Crestor. I am a 51 year old post menopausal female with a family history of heart problems which I would like to avoid

Robin Ireland
3/14/2012 3:34:40 PM |

I stumbled upon a cure for the flush a few years ago. I was searching online and wound up at a drug reps site. Apparently one of their companies was doing a study on the Polyphenol Quercetin, and its natural ability to stop flushing. There were talks of combining Niacin with Quercetin to prevent it. So, being that it is a Polyphenol, and good for you, I thought I''d try it. It worked the very first time, and has worked for years since. I''ve been on up to 2G of Niaspan a day, and I take 2.5 G of Quercetin about 20 minutes beforehand and I almost never flush at all. If I do I just take a couple 500mg capsules of Quercetin and it goes away within 20 minutes. So, while I get a great dose of healthy Polyphenols I fight the flush too. I wish more people knew about this. Just a word of wisdom though. Get the Quercetin alone. Some brands package it with Bromelain, which I found to upset my stomach over time.

Dr. William Davis
3/16/2012 12:32:57 AM |

Excellent find, Robin!

You sure you need that much niacin, however?

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