I don't care about hard plaque!

25. September 2006 William Davis (10)
I ran into a cardiology colleague this weekend. He was aware of my interest in CT heart scanning and plaque reversal.

Out of the blue, he declared "I don't care about hard plaque! I only care about soft plaque." He then proceeded to describe to me how everyone--EVERYONE--needs a CT coronary angiogram to identify "soft plaque".

Is there any truth to this view? Are we only identifying "hard plaques" by focusing on calcium and calcium scores on simple CT heart scans?

Several issues deserve clarification. First of all, CT heart scans don't identify hard plaque. They identify total plaque. Because calcium is a component of the majority of atherosclerotic plaque, comprising approximately 20% of its volume, a calcium "score" can be used to indirectly quantify total plaque, both "hard" and "soft".

Anyone cardiologist who performs a lot of the procedure, intracoronary ultrasound, knows that most human plaque is also not purely soft or hard, it is mixture of both. (I've been performing this procedure since 1995.) Quantifying only soft or only hard plaque is therefore only possible in theory, not in practice.

I believe my colleague does have a valid point in one regard, however. There is indeed a small percentage of people, probably around 5% of all people who have CT heart scans, who have scores of zero yet have a modest quantity of pure "soft" plaque. These people may be misled by having a zero score. How can these people benefit from better information?

Several ways. First, people like this tend to have very high LDL cholesterols, generally 180 mg/dl or greater. They may have a very worrisome family history, e.g., father with heart attack in his 30s or 40s. This small proportion of people with zero heart scan scores may benefit from receiving X-ray dye with their heart scan, i.e., a CT coronary angiogram. Keep in mind that we're assuming everyone is without symptoms, also. If symptoms are part of the picture, everything changes.

But should everybody get a CT coronary angiogram? I don't believe so. A CT coronary angiogram involves far more radiation exposure, greater expense (usually $1800 to $4000), and, with present day technology, does not yield quantitative (measurable) information that is useful for longitudinal use for repeated scans. You don't want to undergo yearly CT coronary angiograms, for instance.

Stay tuned for more on this issue. In the meantime, I continue to try and inform my colleagues about what is right, what is wrong, what is preferable for patient safety and yields truly empowering information, and try to impress on them that the practice of cardiology is not just about enriching their retirement accounts.

Try an experiment in a wheat-free diet

23. September 2006 William Davis (1)
Years back, I'd heard some people argue that wheat-based products were detrimental to health. At the time, I thought they were nuts. After all, wheat is the principal ingredient in a huge number of American staples like breakfast cereals and bread.

What changed my mind was the low-fat movement of the 1980s and 1990s. Proponents of low-fat diets claim that heart disease is caused by excess fat in the diet. A diet that is severely restricted in fat therefore might cure or reverse heart disease.

But low-fat diets evolve into high-carbohydrate diets. This nearly always means an over-reliance on wheat products. People will say to me "I had a healthy breakfast: shredded wheat cereal in skim milk and two slices of whole wheat toast." Yes, it is low-fat, but is it healthy?

Absolutely not. Followers of the Track Your Plaque program know that low-fat diets ignite the formation of small LDL particles (a VERY potent trigger of coronary plaque growth), drops HDL, raises triglycerides, causes resistance to insulin and thereby diabetes, raises blood pressure. They also make you fat, with preferential accumulation of abdominal visceral (intestinal lining) fat.

Look at people with gluten enteropathy, a marked intolerance to wheat products that results in violent bowel problems, arthritis, etc. if unrecognized. These people, if the diagnosis is made early, are strikingly slender and commonly unusually healthy otherwise. There's a message here.

If you need convincing, try an experiment. Eliminate--not reduce, but eliminate wheat products from your diet, whether or not the fancy label on the package says it's healthy, high in fiber, a "healthy low-fat snack", etc. This means no bread, pasta, crackers, cookies, breads, chips, breading on chicken, rolls, bagels, cakes, breakfast cereal...Whew!

You won't be hungry if you replace the lost calories with plentiful raw almonds, walnuts, pecans, sunflower and pumpkin seeds; more liberal use of healthy olive oil, canola oil and flaxseed oil; adding ground flaxseed and oat bran to yogurt, cottage cheese, etc.; and more lean proteins like lean beef, chicken, turkey, and fish.

I predict that, not only will you lose weight, sometimes dramatically, but you will feel better: more energy, more alertness, sleep better, less moody. Time and again, people who try this will tell me that the daytime grogginess they've suffered and lived with for years, and would treat with loads of caffeine, is suddenly gone. They cruise through their day with extra energy.

Success at this can yield great advantage for your heart scan score control and reversal efforts. It will give you greater control over small LDL and pre-diabetic patterns, in particular.

Bigger, faster plaque reversal

22. September 2006 William Davis (0)
Perhaps it's too early to tell whether it's true, but believe that we're seeing coronary plaque reversal--i.e., reduction of CT heart scan score--that is BIGGER and FASTER than ever before. We are now witnessing 20-30% reductions in score, even in the first year.

Early in our experience, I was thrilled with a slowing of plaque growth. Recall that coronary plaque grows at the rate of 30% per year. We would often seen slowing to 10-15% per year in the first year, then a levelling off to little or no increase in the 2nd or 3rd year. Regression, or reduction of score, was less common.

Now, with some further tweaking of our program, we are seeing these large magnitudes of coronary plaque reversal routinely. Not in everybody, of course. There are exceptions that mostly includes people who are less motivated and occasional people with more difficult to control lipoprotein patterns.

I believe that part, or perhaps most, of our recent success is from normalizing blood levels of 25-OH-vitamin D3 levels to 50-70 ng/ml. I'm unable to tell you why this occurs, but I am convinced that it has added huge advantage. Raising blood vitamin D levels to normal carries enormous implication: reduction of colon and prostate cancer risk, reduction of blood pressure, sensitization to insulin, prevention of arthritis and multiple sclerosis, and--I believe--control over coronary plaque calcification and growth.


Watch for a profile of one of our latest success stories, a physician who was experiencing 20% per year plaque growth three years in a row until he followed the Track Your Plaque approach and promptly experienced an 18% reduction in heart scan score. You'll find it in our next newsletter. To subscribe, go to the www.cureality.com homepage and click on the free book download.

I need to do more procedures!

22. September 2006 William Davis (0)
I sat next to a cardiology colleague of mine last evening at a dinner. He was lamenting the fact that, because of changes in hospital affiliations of his several-member cardiology group, he'd seen a drop in the volume of heart catheterizations he was performing.

"I'm used to doing 5 cases a day! Now I'm down to 3 or 4 a day." He went on to tell me how he's working to increase his volume. "I'm branching out into doing carotid stents and anything I can find in the legs." He also described how he was cultivating referring physicians to send him more procedural patients.

Now, this colleague, I believe, is a hard-working, conscientious physician. But his attitude reflects the perverse logic of many physicians: I need to do more procedures, not because it benefits patients, but because that's what I want to do--to be busy, make more money, acquire more experience, build my ego, etc.

Doing more procedures has nothing to do with an altruistic goal of doing more good for society. It is purely for selfish reasons. Beware of this shockingly common, pervasive attitude. There's a proper time and place for heart procedures, or any procedure, for that matter. But feeding your doctor's ambitions is not a good reason.

Fast food and quick plaques

20. September 2006 William Davis (0)
Such was the title of Dr. William Roberts' editorial back in 1987 discussing the health effects of fast foods.

If you need a graphic illustration of the extraordinarily damaging health effects of fast foods, take a look at trends in mainland China. A recent editorial in the American Journal of Cardiology written by Dr. Tsung Cheng of George Washington University makes several points:

--The popularity of fast food in China is booming, with Chinese now more likely than Americans to eat in a fast food restaurant. Each week, 41% of Chinese eat in a fast food restaurant at least once, compared to 35% in the U.S.

--Average total cholesterol levels have skyrocketed from 150 mg/dl in 1958 to 230 mg/dl in 2003.

--50% of Chinese with normal blood pressure in 1992 are now hypertensive.

--Hospitalization for heart disease rose from the 5th most common diagnosis to #1, now constituting nearly 50% of all hospital admissions.

McDonald's and KFC dominate the fast food landscape in China, but up and coming competitors are growing at exponential rates. A media conversation that will surely be reported in the near future is the boom in obesity and diabetes in China as these trends express themselves in weight gain, as it has in the U.S.


I hope you've all seen the entertaining but frightening documentary, Supersize Me chronicling the travails of 30-something Morgan Spurlock as he eats all his meals for one month at McDonald's restaurants in 20 cities. Though focusing on McDonald's, the movie is about a lot more than that. It paints a picture of how fast food as well as food manufacturers in general have changed--distorted--our eating habits.

If you haven't yet seen it, I would urge you to do so and watch it with the rest of the family. My kids (ages 8, 12, and 14) were shocked (and entertained) and they haven't set food in a fast food restaurant since.

But fish oil is too drastic!

20. September 2006 William Davis (0)
Ted is a 74-year old physician, still conducting a busy practice. He came to me because of some vague fatigue and breathlessness. He also got himself a CT heart scan. His score: 1277.

When he came to my office, he clearly became breathless with just minimal effort. A stress test confirmed an area of much reduced blood flow to the front of his heart muscle. A heart catheterization identified a severe blockage of 95% in the left anterior descending artery and a stent was inserted. This resulted in relief of Ted's symptoms.

When Ted returned to the office after his discharge from the hospital, I advised him that some major changes in his prevention program were overdue. "After all, Ted, you were lucky this time. You were provided some warning. It doesn't always work that way." So I advised Ted to make a number of changes in his diet (he was following an old-fashioned, and quite self-destructive, low-fat diet), have lipoproteins assessed to identify hidden causes of coronary plaque, and take fish oil.

"Fish oil? I don't think so. That's pretty drastic!" he exclaimed. He felt that all the nutrition he needed was contained in the food he ate. Even after several lipoprotein abnormalities were uncovered like small LDL and excessive after-eating (post-prandial) patterns, he still resisted any changes. "I'm going to just wait and see how I feel. But I will take aspirin."

Such is the state of mind of the older physician: procedures are okay, low-fat diets prevent heart disease, and the Beatles are touring America. But fish oil? No way!

Unfortunately, Ted's attitude encapsulates the attitudes of many of my medical colleagues who don't share the excuse of age. They still practice the woefully outdated ways of physicians like Ted, clinging to notions of "balanced diets", nitroglycerin representing a rational treatment for coronary disease, and adequate rest being curative for heart conditions.

The world is changing. We're entering an exciting age of self-empowerment. The ridiculous notions of health practiced in the last half of the 20th century are withering and dying. Poor Ted. He must view the current healthcare landscape as increasingly incomprehensible to a guy who started out delivering babies at home. Perhaps, in some respects his world was better. But, in coronary disease prevention, attitudes like this need to go the way of steam engines and racial segregation--good riddens!

A curious case of coronary plaque regression and progression

18. September 2006

Triglyceride and chylomicron "stacking"

10. November 2009 William Davis (24)
Continuing the comments started in Grazing is for cattle, here's an interesting study from the Oxford Center for Diabetes, Endocrinology and Metabolism.

Volunteers were fed a test meal breakfast of Rice Krispies, a banana, and a chocolate milkshake (76.4 grams carbohydrates, 51.9 grams fat, 12.2 grams protein). Lunch was served 5 hours later and consisted of a cheese sandwich and a second chocolate milkshake 43.4 grams carbohydrates, 49.6 grams fat, 24.0 grams protein). Frequent blood samples were then assessed over the day. (Don't try this at home: These are obviously very dangerous foods!)

Here's the pattern of triglycerides that was observed (1st dotted vertical line = breakfast, 2nd dotted vertical line = lunch):



Note that triglycerides only begin to decline 3-4 hours after breakfast, only to peak higher after lunch.


Here's the pattern observed for chylomicrons, the "granddaddy" of lipoproteins that derives from intestinal absorption of fatty acids:



Both graphs from Heath RB et al Am J Phyiol Endocrinol Metab 2006.


With chylomicrons, note a similar pattern to triglycerides: Chylomicrons begin to decline at 3-4 hours, only to peak higher after lunch.

This is the first study to examine the effect of sequential meals on such postprandial (after-eating) patterns. But it makes the graphic point that, if insufficient time is permitted between meals, both triglycerides and chylomicrons will "stack" themselves higher and higher. (Chylomicrons are subjected to processing by the enzyme, lipoprotein lipase, to form highly atherogenic, or plaque-causing, chylomicron remnants.)

While not examined in this study, my bet is that "grazing," i.e., eating small meals or snacks frequently, is an extreme instance of triglyceride, chylomicron, and chylomicron remnant stacking. That can only lead to one thing: accelerated heart and vascular plaque.

What is a healthy vitamin D blood level?

9. November 2009 William Davis (32)
When measuring blood levels of vitamin D (as 25-hydroxy vitamin D), what constitutes a desirable level?

There's no study that directly examines this question, no study that enrolled thousands of people and assigned a placebo group and groups receiving escalating doses of vitamin D and/or achieved higher levels of vitamin D, then observed for development of cancer, diabetes, depression, heart disease, multiple sclerosis, osteoporosis, osteoarthritis, etc. Such a study would requires many thousands of participants (particularly to observe cancer and multiple sclerosis incidence), many years of observation, and many tens of millions of dollars. Nope, only a drug company could afford such costs.

So we have to piece together various observations and extrapolate what we believe to be the ideal level of vitamin D. Epidemiologic observations in several cancers (breast, colon, prostate, and bladder) suggest that a 25-hydroxy vitamin D level of 30 ng/ml or higher is desirable (with less cancer incidence above this level). Other data suggest a level of 52 ng/ml or greater is desirable. Unfortunately, much cancer research looked at intake of vitamin D from food and supplement sources, rather than actual blood levels. We also have to factor in the great individual variation in vitamin D metabolism, with a single dose yielding variable blood levels (as much as a 10-fold difference). There's also the variation introduced by vitamin D-receptor variation (genetic polymorphisms).

A new study using vitamin D administration helps chart the desirable levels of vitamin D.

Vitamin D supplementation reduces insulin resistance in South Asian women living in New Zealand who are insulin resistant and vitamin D deficient - a randomised, placebo-controlled trial.

In this New Zealand study, 42 women (23 to 68 years old) were given 4000 units vitamin D, 39 women given placebo. Median 25-hydroxy vitamin D levels increased from 21 nmol/L (8.4 ng/ml) to 75 nmol/L (30 ng/ml). Both HOMA (a measure of insulin sensitivity) and fasting insulin levels improved, with greatest improvement seen at 25-hydroxy vitamin D levels of 80-119 nmol/L (32-47.6 ng/ml) or greater.

We also know that a vacation on a Caribbean beach in a bathing suit will increase vitamin D blood levels to the 80-110 ng/ml range without ill-effect (at least in young people who maintain the capacity to activate vitamin D in the skin, a phenomenon that declines as we age).

So do we really know the truly ideal level of vitamin D to achieve? I believe that, given the above observations, it is reasonable to extrapolate that the ideal vitamin D blood level likely lies somewhere above 50 ng/ml. We also know that vitamin D toxicity (i.e., hypercalcemia) is virtually unheard of until vitamin D blood levels approach 150 ng/ml, and even then is inconsistent. The health benefits of vitamin D supplementation are so tremendous, that I am not willing to wait for the prospective data to explore this question fully. For now, I aim for a blood level of vitamin D of 60-70 ng/ml (150-175 nmol/L).

Grazing is for cattle

5. November 2009 William Davis (17)
Many dietitians and nutritionists advise many people today to "graze," i.e., to eat small snacks every couple of hours. They argue that it blocks the drop in insulin and blood sugar that can trigger greater appetite and claim it can facilitate weight loss.



This is an absurd notion. Humans are not meant to graze. Humans are meant to find a wild boar or other animal, kill it, gorge on the meat, organs, and fat, then revert to berries, roots, leaves, and other foraged foods until the next kill. A human living in the wild does not have a cupboard or refrigerator full of ready-to-eat snacks to graze on.

The several hours after a meal is the most dangerous for creating coronary atherosclerotic plaque, i.e., the post-prandial period. In other words, eat dinner and, for the next 6-12 hours, your intestinal tract degrades the food; food byproducts are absorbed into the blood or lymph system. The blood is literally flooded with the byproducts of your meal.

Postprandial abnormalities are emerging to be a potent, and much underappreciated, means of causing heart disease and atherosclerosis in other vascular territories (especially carotid arteries and thoracic aorta).

Not eating--i.e., the fasting state--for extended periods is good for you. Encouraging people to graze amplifies atherosclerotic risk, since it creates an abnormal prolonged postprandial state.

The disastrous results of a low-fat diet

4. November 2009 William Davis (16)
Rob was never that committed to following the program in the first place.

I met Rob because of a modest heart scan score and consultation for a cholesterol abnormality. Rob had been cycled through all the statin agents by his primary care physician, all of which resulted in terrible muscle aches that he found intolerable.

I started out, as usual, characterizing his cholesterol abnormality with lipoprotein testing (NMR):

LDL particle number 1489 nmol/L
LDL cholesterol (Friedewald calculation) 143 mg/dl
Small LDL 52% of total LDL
HDL 50 mg/dl
Triglycerides 82 mg/dl

(LDL particle number is the emerging gold standard for LDL quantification, superior to calculated or Friedewald LDL cholesterol for prediction of cardiovascular events.)

Rob is a busy guy. After only a couple of brief visits, life and work got in the way and Rob let his attentions drift away from heart health. Since the information I provided made little impact on his thinking, he reverted to the low-fat diet his primary care doctor had originally prescribed and that he read about in magazines and food packages. He also ran out of the basic supplements I had advised, including fish oil and vitamin D, and just never restarted them.

A couple of years passed and Rob decided that just poking around on his own might not cut it. So he came back to the office. We repeated his NMR lipoprotein analysis:

LDL particle number 2699 nmol/L
LDL cholesterol (Friedewald calculation) 229 mg/dl
Small LDL 81% of total LDL
HDL 53 mg/dl
Triglycerides 78 mg/dl


Two years of a low-fat diet had caused Rob's LDL particle number to skyrocket by 81%, nearly all due to an explosion of small LDL. Recall that small LDL is more susceptible to oxidation, more inflammation-provoking, more adhesive--the form of LDL particles most likely to cause heart disease.

Also, note that, despite the enormous increase in small LDL, HDL and triglycerides remained favorable. This counters the popular rule-of-thumb offered by some that small LDL is not present when HDL is "normal."

Low-fat diets as commonly practiced are enormously destructive. In Rob's case, a low-fat diet caused both calculated Friedewald LDL as well as LDL particle number to increase dramatically. In many other people, low-fat diets increase calculated Friedewald LDL modestly or not at all, but cause the more accurate LDL particle number to increase significantly, all due to small LDL.

I'm happy to say that, once Rob witnessed how far wrong he could go on the wrong program, he's back on Track. (Sorry, pun intended.) He has resumed his supplements and eliminated the food triggers of small LDL--wheat, cornstarch, and sugars.

Dr. David Grimes reminds us of vitamin D

3. November 2009 William Davis (13)
In response to the Heart Scan Blog post, Fish oil makes you happy: Psychological distress and omega-3 index, Dr. David Grimes offered the following argument.

Dr. Grimes is a physician in northwest England at the Blackburn Royal Infirmary, Lancashire. He is author of the wonderfully cheeky 2006 Lancet editorial, Are statins analogues of vitamin D?, questioning whether the benefits of statin drugs simply work by way of increased vitamin D blood levels.


There is a fashionable interest in Omega-3 fatty acids, and these become equated with fish oil.

But fish oil is much more. Plankton synthesise the related squalene (shark oil) which, in turn, is converted into 7-dehydrocholesterol (7-DHC). The sun now comes into play and it converts 7-DHC into vitamin D (a physico-chemical process).

Small fish eat plankton, large fish eat small fish, and we eat large fish. So vitamin D passes through the food chain.

This has been a vital source of vitamin D for the the Inuits and also for the Scots and other dwellers of northwest Europe. (Edinburgh is on the same latitude as Hudson Bay and Alaska, further north than anywhere in China). In these locations there is not adequate sunlight energy to guarantee synthesis of adequate amounts of vitamin D, again by the action of sunlight on 7-DHC in the skin.

When the Scots moved from coastal fishing villages to industrial cities such as Glasgow, they became seriously deficient in vitamin D, and so the emergence of rickets. This was followed by a variety of other diseases resulting from vitamin D deficiency: tuberculosis, dental decay, coronary heart disease, and even multiple sclerosis and depression (the Glasgow syndrome).

And so it was with the Inuits. When their diet changed from fish for breakfast, fish for lunch, fish for dinner, they became deficient of vitamin D and they developed diseases characteristic of industrial cities, where there is indoor work for long hours, indoor activities, and atmospheric pollution.

It is the vitamin D component of fish and fish oils that is important.

I recently saw an elderly lady from Bangladesh living in northwest England. I would have expected her to have a very low blood level of vitamin D, as her exposure to the sun was minimal. However the blood level was 47ng/ml, not 4 as expected. She eats oily fish from Bangladesh every day, showing its value as a source of vitamin D with subsequent good health. I expect her blood levels of omega-3 fatty acids would also be high.

But it is unfashionable vitamin D that is important, not fashionable omega-3.

David Grimes
www.vitamindandcholesterol.com


Excellent point. The health effects of omega-3 and vitamin D are intimately intertwined when examining populations that consume fish.

In this study of Inuits, it is indeed impossible to dissect out how much psychological distress was due to reduced vitamin D, how much due to reduced omega-3s. My bet is that it's both. Thankfully, we also have data examining the use of pure omega-3 fatty acids in capsule (not intact fish) form, including studies like GISSI Prevenzione.

Nonetheless, Dr. Grimes reminds us that