Prescription vitamin D

Niacin:

Over-the-counter: $2-5 per month
Prescription: $120 per month


Fish oil:


Over-the-counter: $3-6 per month
Prescription: $120 per month


Vitamin D:


Over-the-counter: $2 per month
Prescription: $70 per month



With vitamin D in particular, the prescription form is vastly inferior to the over-the-counter preparation. This is because the prescription form is ergocalciferol, or vitamin D2, not the effective human form, vitamin D3 or cholecalciferol.

When you're exposed to sun, what form of vitamin D is activated in the skin? It's all vitamin D3, no vitamin D2 whatsoever. Vitamin D3 is also far more effective than D2. People taking D3 (as long as it's oil-based) easily obtain healthy levels of vitamin D in the blood. People taking 50,000 units per day of D2 (the recommended quantity) remain miserably deficient, with minor increases in vitamin D blood levels. In short, D2 barely works at all. D3 works easily and effectively.

Moreover, D2 is the plant-based form. It is a form not found naturally in humans. D3 is the mammalian form, the same found in humans that exerts all its biologic benefits.

Then why is the prescription form of vitamin D2 (brand names Driscol and Calciferol) more expensive?

It's the same old pharmaceutical industry scam: Look for something patent protectable, regardless of whether it's superior to the non-patent protectable product, then sell it for exagerated profits. Though it is inferior and the science and clinical experience prove that it's inferior, you can still fool lots of people, including prescribing physicians. So what if you only make $50 or $100 million?

Don't fall for it. Prescription doesn't necessarily mean superior. In fact, the prescription form may be significantly inferior, as with vitamin D2. But the pharmaceutical industry carries such power and persuasion, who's going to know?

Comments (32) -

  • Anonymous

    6/23/2007 12:10:00 PM |

    I guess it could be said that a flaw some have is a willingness to take advantage of the uneducated.  

    On the niacin, my guess is that the over the counter Slo Niacin is manufactured by the same company in the same facility as the prescription form.  The machines used would be different as the FDA wants this, but the manufacturing procedures and source product would be the same.  I don't know this for a fact, but it would not surprise me if it were true.  

    For fish oil, there are only a couple facilities in the world that manufacture fish oil.  The products these facilities sell are pretty much all the same in quality.  Everyone buys from the same places.  The facilities that encapsulate pharmaceuticals often times also manufacture health foods in the same plant.  The exact machines used for encapsulating pharmaceutical fish oil and store shelf fish oil will need to be different for government purposes but basic manufacturing practices followed will be about the same.

    I was in a unique situation to witness a Germany company sell a product as a health food - and at the same time was going through the FDA drug approval process with the same exact patent protected product.  The product never did make it through testing in the end.  Phase 3 (I think that is what it is called) human studies at the Cleveland Clinic were a bust as too many people stopped taking the product. (Reportedly the product worked so well that people stopped taking it as they felt healed.)  I remember the German company planned to make “large” amounts of money off of their product if it passed testing as they would be able to charge a premium.  After testing fell through they decided to not try again.  A large American firm took on their product and placed it into every store in America, - and that was good enough for them.

  • Edward Hutchinson

    6/23/2007 1:49:00 PM |

    http://www.ajcn.org/cgi/content/abstract/84/4/694
    The case against ergocalciferol (vitamin D2) as a vitamin supplement provides more information which may interest some.
    http://www.ajcn.org/cgi/content/full/85/1/6
    Risk Assessment for Vitamin D shows that up to 10,000iu daily produces no observable adverse events but readers should note that actual harm occurs is 40,000iu are consumed daily.
    However as you body uses only 4000iu daily http://www.ajcn.org/cgi/content/full/77/1/204 there has to be good reason to take more than 4000iu daily.

  • BarbaraW

    6/23/2007 2:06:00 PM |

    Dear Dr. Davis,

    I've been reading your blog for sometime, since I found the link on Regina Wilshire's blog. I've learned a lot and want to thank you for sharing your insights and expertise with everyone. I imagine (and hope) that there are many, many more people reading it than are posting. I think what you and your colleagues are doing with Track Your Plaque is phenomenal. Interesting that there seem to be none of these services in New England, that bastion of tradition.

    I've been fascinated by your articles on Vitamin D.  In looking around at Vitamin D3 (cholecalciferol) to purchase online (I can't find gelcaps locally), I came across the "Wilderness Family Naturals" web site.  In their article on cod liver oil ( http://www.wildernessfamilynaturals.com/cod-liver-oil-health-benefits.htm ), they state:
    "Cholecalciferol is the form found in vitamin supplements and fortified dairy products and not the hormonal form of vitamin D, namely 1,25-dihydroxycholecalciferol."
    The also state: "The form of vitamin D that we get from supplements is not fully active."

    Can you talk about this for us?

    In any case, my question is: can't I just take my cod liver oil to get my Vitamin D? Do I need the gelcaps of D3 in addition?

    Thanks again,
    Barbara

  • Dr. Davis

    6/23/2007 10:04:00 PM |

    Wow! Thanks for the helpful commentary.

  • Dr. Davis

    6/23/2007 10:09:00 PM |

    Barbara-
    It's really very simple once you start checking blood levels on everybody--you quickly begin to learn what works and what doesn't.

    Vitamin D3 (cholecalciferol) is what you need. Don't be confused by the comment about the "real" form, 1,25-diOH-vitamin D3. This is a kidney metabolite. We all still need vitamin D3.

    It's best to find D3, not cod liver oil. I remain skeptical about the safety of cod liver oil due to some reports of preparations with excessive pesticide residues.

    Try www.vitaminshoppe.com or look for Carlson's preparation, both 2000 unit gelcaps of D3.

  • Cindy

    6/24/2007 9:06:00 PM |

    I take D3 and have been for at least 3 months. I've been taking 3000iu/day and just had a blood test that indicates my blood level is only 33 (22 - 67 is the reference level).

    I'm out in the sun at least 15 min a day, not including driving, walking to and from, etc.

    So...how much Vit D should I be taking? I believe you recommend a level of 50-60?

  • Dr. Davis

    6/24/2007 11:24:00 PM |

    Cindy--
    We commonly use 5000-6000 when situations like this arise and generate desirable levels. Also, the values of "normal" in the reference range you provide suggests that your laboratory also runs an outdated method of measurement. (The newer methods tend to show "references ranges" of 20-100, or something close to that range.)

  • Cindy

    6/25/2007 4:22:00 AM |

    Thanks!! I've made several changes recently thanks to your posts!!

  • Mike

    6/26/2007 6:25:00 AM |

    Hi Dr. Davis,
    I see both Vitamin D and Vitamin D3 supplements being sold:

    Vitamin D

    Do I need to assume that supplements labeled as simply Vitamin D are, in fact, D2?  Are there other forms that it could be?
    Thanks,
    Mike

  • Dr. Davis

    6/26/2007 12:33:00 PM |

    Mike-
    No, you can not assume D is D3.

    Always look for:
    1) gelcaps, not tablets
    2) D3 or cholecalciferol
    3) Never D2 or ergocalciferol.

    Those little attentions to detail will help a bunch and ensure you get the right stuff.

  • Mike

    6/26/2007 6:19:00 PM |

    Thanks!

  • Anonymous

    7/25/2007 8:32:00 AM |

    I was diagnosed with a defiency in vitamin D in january . My total level was 12ng/mL . I started taking supplementation, 800 IU daily of Vitamin D3 (cholcalciferul), and a Centrum multi-vitamin which has another 400 IU . I took that for over 6 months. I just had my level checked again . It is only 15ng/mL still !
    How much D3 should I be taking ?
    And what would be a good target for a 31 year old male ?

  • Dr. Davis

    7/25/2007 12:04:00 PM |

    There's no "one-size"fits-all" in dose for vitamin D. However:

    1) The vitamin D in multivitamins doesn't work at all.

    2) You're therefore taking 800 units per day, the dose for a small child.

    3) Most adults require 2000-6000 units per day. The D must be in capsule form, not tablet.

    4) In the Track Your Plaque program, we aim for a blood level of 50 ng/ml.

  • Anonymous

    7/26/2007 5:43:00 AM |

    Thanks, Dr.

    1) Can you expand on why that is re. multi-vitamins inefficacy of vitamin D ? Does this apply only to the vitamin D in them ?
    Are the liquid forms of multi-vitamins any better than the tablets (eg. centrum liquid) ?

    2-3) I thought according to the FDA, the recommended daily dose was 400 IU for an adult and the safe dose was 2000 IU. How did you come up with your numbers ?

    3) You guessed it - I had been taking Vitamin D in tablet form only. I can certainly believe that they were not effective given my test results. But can you explain why the tablet forms don't work ?

    Tonight I looked for vitamin D in liquid form . I had to go to 4 places - Costco, my Kaiser pharmacy, Longs, and finally Walgreen's, which had some softgels from fish oil. I bought 100 softgels of 1000 IU each for $7.99.

    The tablets I have are Nature made brand. I have about 300 left. As far as tablets go, how do you rate them ? Would you just throw them away and just take the gels ? Or take some gels and tabs ? I hate to just waste the tabs.

    4) Thanks !

  • Dr. Davis

    7/26/2007 12:30:00 PM |

    Please refer to the several previous posts under "Vitamin D" or our extensive discussion on the www.trackyourplaque.com website.

  • Dr. Davis

    7/28/2007 2:50:00 PM |

    Vitamin D should always be either "D3" or cholecalciferol, NEVER "D2" or ergocalciferol, since D2 exerts negligible benefits.

    If your preparation fails to specify which form, look for another that does.

  • Ava

    10/10/2007 8:12:00 PM |

    Hello I'm a vegan from Germany and like to respond to the argument that is circling through the web relating to D2. Since I'm vegan don't use D3 since that is produced by irridating butchers-wool with UV-light, an information that is often left out when touting this version of vitamin D as the "natural" one. Because of all the negative rap D2 has gotten, it has now in fact disappeared as a supplement in the EU, effectively starving vegans and other vegetarians of vitamin D. I was thus forced to look for alternatives to have my winter supply of vitamin D. What I do is grow my own delicatessen mushrooms right here at home and either dry them in the sun or irridate them with the Utra Vitalux 300 Watt UVB - Lightbulb after harvest which makes them a very rich source for vitamin D2.  Now here comes the interesting part. My previously utter deficient 25(OH)D below detection level, measured at the end of summer -I'm not the outside type and almost never get enough UV-exposure from sunlight- has after a year gone up to 105 nmol/L. Given that I have nowhere near enough sun exposure, and as a vegan no other dietary source of vitamin D, it is clear to me that the vitamin D2 from my sun-dried or irridated mushrooms is responsible for my recovery from hypovitaminosis D.

    Now I don't know if there's a difference of vitamin D2 in mushrooms or the pharmacological D2 in pills, all I know is that Vitamin D2 is *my* primary source of vitamin D and it's giving me excellent levels of 25(OH)D.

    What I find highly irritating is the meme like argument flying around that vitamin D3 is the one "naturally appearing in the body". Duh. Vitamin D2 is also converted into vitamin D3 so the fact that D2 is not "naturally in the human body" should be as relevant that Vitamin C is not "naturally in the human body" and has to by sourced from diet. There are many nutrients that are "not natural" in the human body and which we need to source from diet, for example the essential amino acid. Besides, since when does "natural" equate to being good? If a Uranium miner has "natural" radioactivity in his body because he is exposed to it during work, is that good? I don't think so.

    The reason I'm irritated is because the information about vitamin D2 being bad (when that is, at least in my case *not* true) has real implications and discriminatory effect on vegans and other vegetarians because not everybody of us has the patience and curiousity to produce their own Vitamin D at home, and perhaps some people don't enjoy eating mushrooms.

    There is one more point and then I'll end my rant. Every time us vegans were informed that a particular plant based nutrient like vitamin A (beta-carot.) or iron was inferior because it has a lower bio-availability, later research discovered that that lower bio-availability has actually real benefits. I wouldn't be surprised if the same appears to be true for vitamin D2. I have already come across research which noted one of the D2 metabolites to have anti cancer properties, although this study is based on non-human animals meaning it has little to no relevance to humans and is based on the exploitation and death of rats.

    For those who (despite reading this on an electronic network of computers) lay any importance on _naturality_ regarding nutrients, you may want to consider my method of just drying mushrooms in the sun. That's certainly more natural than killing sheep, stripping the hair grease of their wool and irridating that with UV-B light, which is the standard method of how vitamin D3 is produced - a byproduct of butchers waste.

  • Dr. Davis

    10/10/2007 9:40:00 PM |

    Fascinating solution!

    However, I stick by my claim that, for most people, vitamin D2 supplementation does not work. I have seen many people on as much as 50,000 units of D2 per day with zero or near zero levels of conversion to the active D3, all proven by blood levels.

    However, for a vegan, I do not have any useful non-animal solutions beyond getting sun.

  • Anonymous

    2/14/2008 8:14:00 PM |

    My Vitamin D levels, when first tested, were 12.  I have been using a Vitamin D lamp to try to raise the levels, which are now 32-33.  Initially, I took Puritan's Pride Vitamin D, which made me feel like a new person, but I quickly learned that it interfered with the efficacy of Cytomel, which I take because Synthroid interferes with yet a different medication.  Do you know of any form of Vitamin D that might not interfere with Cytomel?  

    Thank you.

  • Anonymous

    4/4/2008 5:47:00 PM |

    I just found out my vitamin D level is abysmally low from a blood test. My endocrinologist gave me a prescription for 50,000 units of vitamin D.  After reading about the subject here, I don't know whether to fill the prescription or go the the health food store and get a bottle of vitamin D3 capsules and disobey doctor's orders. We are investigating whether I have disturbances in my cortisol levels.  So far, testing has shown very low morning cortisol levels.

  • Anonymous

    5/6/2008 8:00:00 PM |

    I went from sickly to healthy from taking 50,000IU (once a week) of Calciferol, proven by my recent bloodwork.  My D level was 18 in November,  and 4 months later it was 38!!!  Taking D2 has changed my life and I continue to take it without hesitation or reservation.

    I have read that I should be taking a cal/mag supplement to increase absorbtion but I have not done so . . . your thoughts please.

  • Anonymous

    7/25/2008 6:43:00 AM |

    Maybe the lab you use for blood tests isn't DEQAS certified, and isn't accurate.  I don't know how else to explain why a recent study contradicts what you're saying about D2:

    http://jcem.endojournals.org/cgi/rapidpdf/jc.2007-2308v1.pdf

  • Anonymous

    8/5/2008 11:38:00 AM |

    Hello, can you tell me what form of D3 is best and why.

  • Anonymous

    11/7/2008 2:11:00 PM |

    Ergocalciferol (D2) has a kenetic half life of 10 days.  Calcitriol (D3) has a half life of 3 days. I am surgically hypoparathyroid and replaced 100% of that function with calcitriol or ergocalciferol for 30+ years. I find the D3 form is smoother on my body, until I forget to take my dose on any particular day. Then my mood, energy, stamina, sense of well being etc noticably deteriorate. I lived quite easily on D2 for nearly 28 years until medicare decided this life essential medication was a non life essential vitamin and forced a change to the more expensive calcitriol they would pay for. So now I painfully die in 10 days without D3 instead of 30 days if taking D2. This is germane when the price of ergocalciferol in 1991 was $1.99/100 50000IUs dose. After several years of repeated "offshore supply problems" the price is now $125/100 forn teh identical medication. Sometimes I'd drive 75 miles to another pharmacy (dealer - lol) to refill the D2 when the supply dried up. On correct fo the supply problem the price would double or triple (WTF???). Oh well - rather that a "DNR" I insist on a "JSM" (just shoot me).

  • Carminal

    11/8/2008 12:23:00 AM |

    Hi everyone,

    Firstly, I must say I agree with ava reactions being irritated above, even if not being vegan myself, but vegetarian.

    I would like also to point out that health is definitly not numbers on a paper coming from tests but is how we can feel and act.

    Good health is about feeling balanced and in a state that allows personal accomplishment. It is not, not at all, about obtaining or aiming a level of that molecule or this other one in a blood test.
    You can take two people with same amount of that molecule, or with similar tests results and having one feeling very healthy and being really so and the other one being and feeling desperetly ill. Blood tests reflect only very poorly what is really happening in the vast universe of our cells and tissues. It does not indicate at all how plenty of important biological reactions are going in us.

    It makes me smile when I read 50,000 IU of D2 did not increase D3 levels. When you place carrots in your dish, you do not have sprouts !! The purpose of taking D2 is not about raising D3 and D3 metabolites levels but D2 and D2 metabolites ones. D2 and D3 molecules react in same biological fields, and D2 is beeing used with success for decades. It is not honnest to omit that and to pretend D2 is worthless because D3 levels do not raise : it is a false demonstration.

    In my view solar exposition is the most important factor for everyone, but when not getting enough D from sun, the plant-form D (D2) is perfectly suiting. I have never read any animal study that tends to show D3 supplementation is preferable to D2; on the contrary toxicity is shown to be a lot greater with D3 hypervitaminosis than with D2 hypervitaminosis (a lot more calcifications with D3 than with D2). Plants represent the reference in food because everything we need, even B12 for example, can be found in the plant kingdom; that is not the case if the animal kingdom is taken as food. Then ask your intuition about D2 and D3 being the most desirable form of Vit. D when not receiving enough sun...

    Readers should remind that there is two different 25(OH)D : the one with D2 and the one with D3, and also two 1,25(OH)2D. Measuring the D3 forms (most commonly measured in blood tests) is meaningless if you take D2 supplements. It is NATURAL having in the blood less 25(OH)D in its D3 form during winter than during summer because at that time there is less sun activity. Correcting lowering Vitamine D activity during winter with D3 supplementation rather than with D2 is illogical and unatural.

    R. Jehl
    Naturotherapist in France

  • Anonymous

    11/30/2008 10:58:00 PM |

    Individualized Vit D supplementation is necessary. The arguments regardind D2, D3, single Hydroxy and double hydroxy depend on your body and its current disease status. For example, giving a D2 or D3 to a patient without kidney function is useless because they cannot convert it to the ACTIVE form of 1,25(0H)2D3. Kidney patients must take activated or the final form of vitamin D 1,25(0H)2D3. Liver dysfunction patients cannot convert the D3 to the single hydroxylated form, which the kidney needs in order for its metabolism. So, really, blank statements as given by the French provider indicating D2 for all is FALSE. Look up the metabolic pathway. If you are stone cold normal and only have low Vit D, then you can take either form of regular D2 or D3. If you have a disease, GI malabsorption, liver or kidney disease, granulomatous disease etc you should consult a professional to guide your dosage for proper results. I do like combining some fast acting forms with some slower acting forms to help folks feel better faster and then long term treating with slower forms if they can metabolize them. Everyone is unique and sometimes trial and error are required.

  • Anonymous

    12/22/2008 6:32:00 PM |

    I have read through these posts with interest. I am new to this site, looking for a solution to my 'no beef' diet and insufficiencies in Vitamin D (3 mostly). I am on synthroid, but never knew of the Vitamin D correlation.

    I find that in the US there appears to be NO 50,000 Vitamin D without bovine capsules. I cannot find a veggie tab surrounding even the D2.

    Can anyone advise where I might 50,000 units of Vitamin D3 with no 'cow' gelatin coating?

  • Anonymous

    2/4/2009 1:33:00 PM |

    Do you have any recommendations for those who are vitamin D deficient but cannot tolerate oil based capsules but have no problem with fortified foods?  Is the UV lamp a safe alternative?  Is there a powder form of D that is effective?

  • Anonymous

    2/6/2009 8:52:00 PM |

    I've read this discussion with a great deal of interest.  I've been supplementing with Vital Nutrients capsules which are vegetarian.  They make 2000iu capsules and 5000iu capsules. http://www.vitalnutrients.net/vnestore/detail.asp?product_id=VNVD2

  • Ava

    12/26/2009 1:17:19 AM |

    Hello this is Ava again from Germany, I posted a long rant into this thread some while ago.

    I'd just like update that I've switched from irradiated mushrooms to a vitamin D2 supplement as drops ( Sterogyl 2,000,000 ergocalciferol ) and my 25(OH)D levels are really nice in winter at 156 nmol/L or 62 ng/ml! In France it's availalbe without perscription and we've been able to get it Germany too. It's very cheap around 2 Euro for 400,000 IUs despite the name. I started out with 13 drops / 5200 IU for 14 days, then I took a single mega dose of 300,000 IUs. Since that I've been taking 70.000 IUs once a week. I'm very tall at 6' flat and this is the dose my body needs to achieve good levels.

    It's also possible to just keep on taking 3500 to 5000 every day, however it then takes much longer to reach desired serum levels.

    If you have access to this cheap product and take 5200 every day, the 2.50 Euro or so will still last you almost 3 months.

  • josephmoss

    7/24/2010 7:37:50 AM |

    Vitamin D3 Iu:

    NOW Vitamin D softgels supply this key vitamin in a highly-absorbable liquid softgel form. Vitamin D is normally obtained from the diet or produced by the skin from the ultraviolet energy of the sun. However, it is not abundant in food. As more people avoid sun exposure, Vitamin D supplementation becomes even more necessary to ensure that your body receives an adequate supply. Vitamin D3 Iu on discount at NutroVita.com.

    For more details please visit:
    http://www.nutrovita.com/32760/now-foods/vitamin-d-3-2-000-iu.htm

  • buy jeans

    11/2/2010 7:55:30 PM |

    When you're exposed to sun, what form of vitamin D is activated in the skin? It's all vitamin D3, no vitamin D2 whatsoever. Vitamin D3 is also far more effective than D2. People taking D3 (as long as it's oil-based) easily obtain healthy levels of vitamin D in the blood. People taking 50,000 units per day of D2 (the recommended quantity) remain miserably deficient, with minor increases in vitamin D blood levels. In short, D2 barely works at all. D3 works easily and effectively

Loading

Report from Washington II

Today's discussions at the Society for Cardiovascular Computed Tomography (SCCT) focused on atherosclerotic "plaque characterization".

As CT scanners get better and better at imaging the various components of plaque, some fascinating issues emerge:

--CT heart scans provide insights into what exactly is contained in an individual's atherosclerotic plaque that are not often provided even during heart catheterization. In other words, CT heart scanning is, in many instances, superior to heart catheterization, since it provides images of the artery wall, not just the internal contents.

--Progression (i.e., increase) in heart scan score is a powerful predicter of heart attack risk. Dr. Matthew Budoff of UCLA argued persuasively that the annual rate of increase in score is probably the most accurate measure of risk available, superior to cholesterol and calculated measures like the Framingham risk score.

--Coronary calcium scoring remains the best method to gauge total plaque throughout the entire coronary tree. In a person free of symptoms, the risk of a cardiac "event" (heart attack, death, procedures) is low and additional imaging (like CT angiography) is generally unnecessary.


Dr. Budoff, among the true thought leaders in CT heart scanning, also recounted his perspective on the history of heart scans. He noted that the questions asked through the years have evolved:




1995-2000 Should we do coronary calcium scans?

2000-2002 Do high or low risk patients benefit from coronary calcium scoring?

2003-2004 What is the better scanner, EBT or MDCT?

2006 How often should we perform coronary calcium imaging?


I believe that Dr. Budoff summarizes wonderfully where the Track Your Plaque programs fits into the overall scheme of things: Serial (repeated)CT heart scans to gauge progression or reversal is the wave of the future. We shouldn't just be interested in identifying persons at risk for heart attack. We should also be interested in showing the person at risk exactly how to reduce or eliminate that risk.

Report from Washington





I'm presently attending the Society for Cardiovascular Computed Tomography meetings in Washington, DC, along with 500 of my colleagues. It's exciting to see how interest in CT scanning for heart disease has balloonned in the past couple of years.

Several trends are noticeable today, based on the content and tone of the discussions:

--CT scanning of the heart, and imaging in general, is just getting started. In other words, the capabilities for CT scanners and other devices to detect heart disease (coronary and otherwise) are where the gasoline engine was in the 19th century. Scanning is getting faster, easier, safer, and more precise. Just as few people in 1905 could have predicted that automobiles would be computer-enhanced, high-speed, ubiquitous devices with several per household, the potential for CT imaging for heart disease is truly in its infancy.

--CT coronary angiography (so-called "64-slice CT scans") are not screening tests for hidden coronary disease in people without symptoms. I was grateful that this point has been made and reiterated by several speakers, as this is consistent with our views. Simple CT heart scans for coronary calcium scoring, in contrast, are screening tests. When the radiation exposure of CT angiograms are reduced to tolerable levels, then they may be used as screening tests. We are probably 3-4 years away from this point.

--Both stress testing and heart catheterizations will be partially replaced by CT scanning. In particular, over the next decade, you will see a dramatic drop in unnecessary catheterizations, i.e,, far less people saying "I had a heart cath but they told me that it was normal."


There has been heavy focus on applications of CT scanning for acute settings, particularly the emergency room and hospitals.

What has surprised me is that there is virtually no conversation whatsoever about the preventive uses of CT heart scanning. So far, only Dr. Daniel Berman of UCLA has shown that he has "seen the light": CT scans are a crucial tool for identification of early coronary plaque, and this tells us whether prevention is necessary and with what intensity.

There has been, however, no discussion at all about quantification of plaque in a program of reversal. Perhaps that should come as no surprise, given the imaging-technology focus of this convention. For most of my colleagues, prevention is also not terribly interesting. Identification and treatment of acute disease like impending heart attack is.

Of course, applying the information from your CT heart scan to empower you in a program and reversal is what the Track Your Plaque program is all about. I hope you see the light. I admit that it's not always easy to follow what we are advocating here. Perhaps not too different than telling someone in his horse-drawn buggy that one day he'll be driving a sleek car with onboard computerized mapping, air-conditioning, and micro-chips to modulate engine performance. He's probably tell us we're nuts.

I'll continue to update if any news relevant to our interests crops up in these meetings.

What about the Track Your Plaque failures?

I’d love to tell you that the Track Your Plaque program track record is of 100% success. It’s not.

It is very successful. But we’ve had some people who have failed and failed BIG. These are the people who've undergone bypass surgery, received one or more stents, or had heart attacks. Lesser failures are the people who’ve had large, undesirable increases in heart scan scores of >30% in one year. (The expected rate of increase in your heart scan score without preventive efforts is 30% per year, on average.)

What can we learn from those failures? There were several characteristics that stand out among this small group:

· Non-compliance--meaning they just didn’t stick with it. They started out right but then rapidly lost interest in maintaining all the pieces of the program and neglected their fish oil, niacin, gain weight, etc. Matthew did this and ended up with three stents to his left anterior descending. His slow start was due to skepticism that the program worked and just plain forgetfulness.

· Extreme stress--One of our earliest failures was a 38-year old man whose heart scan score doubled in one year, despite doing everything right. But three family members, all close to him, died within the space of six months, including his mother and a brother. I regard this as one of those instances in which we were powerless, unfortunately, though it is a graphic example of the power of unresolved stress and grief.

· Having a “better way”--These are the couple of people who were convinced that they had a better way to control their heart scan score. David firmly believed that his two dozen supplements and exercise program would drop his score. Instead, they permitted a 42% increase. Lee relied exclusively on chelation, along with several supplements of his own design. Lee had three-vessel bypass surgery.

· Starting too late--Gerome started with a score of 1179, but also was having chest pressure with emotional stress. His stress test was abnormal, with the entire upper half of his heart not receiving blood with exercise on a stress nuclear study (“anterior ischemia”). Gerome received four bypass grafts. Unfortunately, Gerome never really had a chance to engage in the Track Your Plaque program, since his health and safety were in jeopardy as soon as he started.

Have we had any big failures of people who did everything right, were compliant, were not subject to extreme stress (more than just job stress, or financial worries), didn’t neglect the basic requirements of the Track Your Plaque program, and had sufficient time (at least 6 months to 1 year)? No, thankfully, we have not.

No one who has stuck to the program has had a big failure.

Be smarter than your cardiologist

“Do you need a stent?”

Sad to say, but that sentence condenses the wisdom of over 90% of practicing cardiologists.

Prevention of heart disease means take Lipitor or some other statin and cutting the saturated fat in your diet. That’s it. Maybe throw in exercise.

Regression of coronary plaque? That phrase has only entered the conversation since the AstraZeneca-supported trial of Crestor succeeded in achieving 8% regression of plaque (Track Your Plaque Members: See News) as demonstrated by intracoronary ultrasound.



In other words, in the minds of my colleagues, it can’t be true until a drug company tells them it’s true. It’s beyond me why this brainwashing of otherwise intelligent people has occurred, but it is blatantly evident in practice.

Fish oil is another example. The spectacular benefits of fish oil have been known for 20 years. But only recently has it become a “mainstream” practice to recommend fish oil, largely because a drug manufacturer has put a preparation through the rigors of FDA approval (Omacor) and is now marketing directly to physicians. All of a sudden, fish oil is a good thing? No, it’s just achieved legitimacy in the eyes of practitioners because it graces marketing literature.

If you’re reading this, you’re likely interested in coronary plaque regression using the only tool available for you to measure, track, and regress coronary plaque: CT heart scans. Intracoronary ultrasound will achieve the same goal, but it is an invasive procedure performed at heart catheterization, involves threading a wire and imaging probe all the way down the artery, involves real risk of tearing the inner lining of the artery, and is costly (around $14,000-$20,000 for the entire package). Do it every year? That’d be nuts.

If you’re thinking about coronary plaque regression, using fish oil, concerned about patterns like low HDL and small LDL, aware of the vitamin D deficiency issue as a coronary risk factor, etc., you are far more aware than the vast majority of practicing cardiologists. They are interested in what new brand of anti-coagulant to use during their heart catheterization (because the product representative gushes about the new agent—only $1200 a dose!). Or, they are interested in gaining the procedural skills to put in a new device like a biventricular pacemaker. Regress/reverse coronary plaque? What for?

You already know that a conversation about coronary plaque reversal will not be obtained in your cardiologist’s office. Your family practice doctor or internist? Fat chance! Knee arthritis, pap smears, pneumovax inoculations, sore throats, gout, back pain—they’re spread far too thin to know anything more than the most superficial amount about coronary plaque control. Most know nothing.

That’s where we come in. That’s our mission: Educate people about the extraordinary tools that you have available to you, all in the cause of control or reversal of coronary plaque.

Why am I here?

Frank came to the office for an opinion, sent by his (proactive) family physician.

"I really don't know why I'm here, to be honest."

Two years earlier, Frank had a heart attack, survived and received two stents to his circumflex coronary artery. He now took Zocor and his LDL cholesterol was a reasonably favorable 89 mg, total cholesterol 183 mg.

"I walk with my wife every other day. I've been avoiding fish fries. You'll never see me eat fast food."

Frank was correct: If we were going to engage in the conventional approach to coronary disease, Frank was on the right track. We would have postponed his next heart attack or procedure by a couple of years. Stroke, aneurysm, and other atherosclerotic manifestations would be set back, likewise, a few years.

Would Frank have profound control over his disease? Absolutely not. In fact, his disease had probably advanced a huge amount just in the two years since his stents were placed and he was on his "prevention" program. Without his current effort, his coronary plaque would be expected to grow 30% per year. On Zocor and his modest lifestyle efforts, plaque growth was probably in the 14-28% per year range.

So I explained the unique Track Your Plaque approach to Frank. First, we start with a CT heart scan to establish where he was starting. Although he had two stents in his circumflex artery, we still had two other arteries (LAD, right coronary) to score and track.

We then attempt to identify all hidden causes of his heart disease and then correct them.

Of course, Frank had multiple hidden causes:

--HDL too low at 38 mg/dl
--Small LDL-severe, in fact, with 95% of all LDL particles in the small category
--Triglycerides too high
--Excesses of several triglyceride-containing particles (VLDL, IDL)
--Pre-diabetes--Frank had both a borderline high blood sugar and a high insulin level. This is a sure-fire stimulus to coronary plaque growth.
--A severe deficiency of vitamin D (<20 ng/ml)
--An excessivelyhigh blood pressure during exercise--With a blood pressure of 190/102 on the treadmill.

There were others(!), but that was the bulk of the causes behind Frank's coronary disease.

Once Frank recognized that there was indeed a huge panel of hidden causes for heart disease, not just too much fat in his diet and LDL cholesterol, he jumped into the program head first.

The message: The conventional approach is absurdly oversimplified, a certain path to failure for the majority of people. Even if you don't have known coronary disease like Frank, but just have a heart scan score >zero, the same principles apply to you.

Catheterization to “define coronary anatomy”

Gary is an avid jogger. On an average day, he runs 5-6 miles at a good clip. On two occasions recently, however, Gary experienced an ache in his left shoulder at mile 4. It was a toothache-like feeling, but he kept on going without difficulty.

Gary also had a heart scan score of 370.

Upon hearing of Gary’s score and his shoulder sensation, the cardiologist who saw him advised a heart catheterization “to define coronary anatomy”. (This is a real incident.)


What exactly does that mean? Why would Gary’s cardiologist need to define it?

In my view, this is an absurd notion. No one needs to “define coronary anatomy”. This catch-all phrase is commonly used to justify heart procedures. I believe what the cardiologist is saying is that it’s the easiest (for the cardiologist) and perhaps most generously reimbursed method to determine whether Gary’s symptoms are warning of an impending heart attack or not.

The problem is that the question can also be answered quite well by doing a stress test. Though not perfect diagnostic tests, stress tests are useful when symptoms are present that are doubtful in nature. Gary’s left shoulder ache could have been related to his heart, but the likelihood was that it was not. A stress test would have answered the diagnostic question quite adequately.

Instead, this man was subjected to an invasive test that was likely unnecessary. This happens dozens, if not hundreds, of times per day just around here. Nationwide, it is an epidemic of malpractice.

There are, indeed, times when a person should proceed directly to a heart catheterization. This is commonly and appropriately performed when a person develops unstable heart symptoms, such as chest discomfort or breathlessness at rest while not doing anything physical, or if the frequency is increasing, or if a stress test shows an important abnormality. There is no question that heart procedures can be lifesaving at times.

The problem is that thousands of people every year are scared into these procedures inappropriately. Beware!

It doesn't matter what I eat!

"How are your food choices?" I asked.

"What does it matter, doc? I take Lipitor. Doesn't that take care of it? I eat what I want!"

So declared Matthew. What he "wanted" was pretty much the diet of a teenager: pizza, cheeseburgers, soft drinks, snacks. His "beer belly" (visceral fat) gave it away. So did his blood work that showed flagrant lipoprotein abnormalities--small LDL, an HDL of 37 mg, and a severe after-eating flood of fat represented by increased "intermediate-density lipoprotein" (IDL).

Like many people, Matthew had been persuaded (or chose to believe) that LDL cholesterol was the sole cause for heart disease. Lipitor was therefore was all he needed. It must be great--how else could they afford all those slick TV commercials?

Well, it is definitely not true. In fact, with the persistence of Matthew's abnormal lipoprotein patterns, we should expect his heart scan score to continue to grow by 30%--the very same rate of increase as if he were taking nothing.

Specifically, Lipitor and drugs like it do not:

--Raise HDL.

--Correct or reduce the proportion of small LDL.

--Block after-eating flood of fat, nor do they accelerate clearance of unhealthy fats persisting in the bloodstream after eating.


Yes, what you eat does have real consequences, even if you take a statin drugs. In fact, the foods you ingest have a remarkably rapid and dramatic effect on what your blood contains. Any diabetic who checks his/her blood sugar knows this. They eat a slice of whole wheat toast and watch their blood sugar skyrocket.

Mind what you eat. Make it enjoyable, of course. But drugs do not provide impunity.

People with higher scores need to try harder

Sam is a 69-year retired physician. He was thoroughly enjoying retirement: golf, travelling, going out to dinner two or three times a week, spending weekends with his grandchildren. His lifestyle tended towards overindulgence, but he managed to stay fit and trim. At 6 ft 1 inch, he weighed 194 lbs and could still run 3 miles without too much difficulty. Not as good as his marathon-running days, but still not too bad for 69.

Sam's heart scan score in 2003 was a concerning 1983--extensive plaque. His doctor wasn't much help in interpreting the scan and so Sam simply chose to ignore it.

A chance conversation with a physician friend 18 months later made Sam think that perhaps this shouldn't be ignored. That's when he came to my office.




I find that sometimes the best way to motivate someone to take action is to demonstrate just how fast plaque grows if action isn't taken. So I advised Sam to get another scan first, since 18 months had passed. His score: 2441, or a 23% increase.




Sam was now starting to catch on. We made several changes in his prevention program (starting from virtually nothing). He did undergo a stress nuclear (thallium type) of test, which he passed without difficulty--normal blood flow in all heart territories despite the extensive plaque.

But, for some reason, Sam simply allowed himself to drift back to old habits: poor choices in food, overindulging in hard liquor, missing his fish oil and other supplements, and his medication, sometimes up to several days a week.

Sam started having unusual feelings in his chest. He described a sort of nervousness along with skipped heart beats. So we repeated a stress test. This time, a large area of reduced blood flow in the front of his heart ("anterior left ventricle") was detected. Sam ended up receiving three stents in a difficult procedure.

The moral: If you're starting out with a lower heart scan score of, say, 100 or 200, maybe you'll get by without trying too hard--maybe. But if your score is higher, say, several hundred or in the thousands, you got to try harder.

You're starting later in the process. Your disease will allow you very little slack. Let your guard down and it will get you. Control over your plaque is, indeed, very possible--we do it all the time. Score reduction is also possible. But your effort must be more serious and consistent.

Money can't buy health

Fallen Enron CEO, Kenneth Lay, was pronounced dead early this a.m. after suffering a heart attack.

Mr. Lay apparently had no history of heart disease and there's been no indication that symptoms provided any warning. His death was therefore classified as "sudden cardiac death".


Yet here's a man previously worth hundreds of millions of dollars with access to any test or medical system he desired--many times over. Even more recently, with his wealth reduced following his legal troubles, he and his wife managed to put away $4 million dollars to ensure an income from the interest through annuities, untouchable by the courts.

Detecting Mr. Lay's heart disease would have cost him around a few hundred dollars or whatever it costs for a CT heart scan in his city. This would have alerted his (hopefully knowledgeable) doctor that he was a time-bomb. Pile on all the stress he'd been suffering, whether deserved or no, and the diagnosis would have required little thought.

Instead, Mr. Lay has joined the thousands of Americans who will die this year because of failing to get a simple, 30-second test that costs one-tenth the cost of a stress test. Mr. Lay wasn't as lucky as former President Bill Clinton, whose doctors likewise blundered their way through and missed obvious levels of heart disease.

All Mr. Lay needed was better information: get a heart scan, then follow a program of prevention like the Track Your Plaque program. You may not have hundreds of millions of dollars, but you have the information on how to not follow in Ken Lay's footsteps. Track Your Plaque--and stay alive.

What's important, what's not in your plaque-control program

Sometimes it's hard to know what is really important in your plaque-control or plaque-reducing efforts.

There are, indeed, crucial make-it-or-break-it factors that are necessary to gain control over plaque. If you hope to stack the odds of reducing your heart scan score as much as possible in your favor, then fish oil, vitamin D, 60-60-60 in the way of standard lipids, elimination of small LDL, etc. -- all the elements of the Track Your Plaque program--are necessary.

But there's lots of things that sidetrack people. I spend much of my day fielding questions from patients about all the things that either provide very little benefit for plaque control, or provide none at all.

Among the things that we have found to be too weak or useless for plaque control, or are "non-issues", include:

--Caffeine--Go ahead and enjoy a couple cups a day (though not a pot). The effect is too trivial to make much difference.

--Hawthorne--Yes, it may dilate coronary arteries modestly, but not enough to make any difference.

--Garlic--with the possible exception of a specific preparation called Aged Garlic Extract (an acqueous, non-oil-based, extract from Kyolic), garlic's effects are too tiny to help, e.g., drop in blood pressure 1-2 points. Use it, but don't expect much. Aged Garlic Extract may be an exception, in that a single study from UCLA suggested specific effects on slowing coronary plaque growth. We await more info on this.

--Anti-oxidants--There is no shortage of extravagant claims about the benefits of anti-oxidants. Unfortunately, there's very little human exerience with pine bark extract, pycnogenol, grapeseed extract, and so on. Is the purported benefit from anti-oxidation or through some other means, e.g., enhancement of nitric oxide synthase? No data.

--Policosanol--If you've followed the Track Your Plaque Special Reports, you already know what a disappointment this agent has been, despite the too-good-to-be-true clinical data. It doesn't work.

--"No-flush niacin"--Unfortunately, no flush, no effect. This high-priced supplement is still sold widely in the U.S. despite its complete lack of efficacy. It does not work in humans. (It works great in rats!)

Track Your Plaque continues to try to be the arbiter of truth in what works, what doesn't in truly stopping or reversing your coronary plaque. The proof positive? Stopping or dropping your heart scan score.