Fish oil: The natural triglyceride form is better

2. February 2011 William Davis (43)
If you have a choice, the triglyceride form of fish oil is preferable. The triglyceride form, i.e., 3 omega-3 fatty acids on a glycerol "backbone," is the form found in the body of fish that protects them from cold temperatures (i.e., they remain liquid at low ambient temperatures).

Most fish oils on the market are the ethyl ester form. This means that the omega-3 fatty acids have been removed from the glycerol backbone; the fatty acids are then reacted with ethanol to form the ethyl ester.

If the form is not specified on your fish oil bottle, it is likely ethyl ester, since the triglyceride form is more costly to process and most manufacturers therefore boast about it. Also, prescription Lovaza--nearly 20 times more costly than the most expensive fish oil triglyceride liquid on a milligram for milligram basis--is the ethyl ester form. That's not even factoring in reduced absorption of ethyl esters compared to triglyceride forms. Remember: FDA approval is not necessarily a stamp of superiority. It just means somebody had the money and ambition to pursue FDA approval. Period.

Taking any kind of fish oil, provided it is not overly oxidized (and thereby yields a smelly fish odor), is better than taking none at all. All fish oil will reduce triglycerides, accelerate clearance of postprandial (after-eating) lipoprotein byproducts of a meal (via activation of lipoprotein lipase), enhance endothelial responsiveness, reduce small LDL particles, and provide a physical stabilizing effect on atherosclerotic plaque.

But if you desire enhanced absorption and potentially lower dose to achieve equivalent RBC omega-3 levels, then triglyceride forms are better.

Here are cut-and-pasted abstracts of two of the studies comparing forms of fish oil.

Bioavailability of marine n-3 fatty acid formulations.

Dyerberg J, Madsen P, Moller JM et al. 
Department of Human Nutrition, Faculty of Life Sciences, University of Copenhagen, Copenhagen, Denmark.

Abstract

The use of marine n-3 polyunsaturated fatty acids (n-3 PUFA) as supplements has prompted the development of concentrated formulations to overcome compliance problems. The present study compares three concentrated preparations - ethyl esters, free fatty acids and re-esterified triglycerides - with placebo oil in a double-blinded design, and with fish body oil and cod liver oil in single-blinded arms. Seventy-two volunteers were given approximately 3.3g of eicosapentaenoic acid (EPA) plus docosahexaenoic acid (DHA) daily for 2 weeks. Increases in absolute amounts of EPA and DHA in fasting serum triglycerides, cholesterol esters and phospholipids were examined. Bioavailability of EPA+DHA from re-esterified triglycerides was superior (124%) compared with natural fish oil, whereas the bioavailability from ethyl esters was inferior (73%). Free fatty acid bioavailability (91%) did not differ significantly from natural triglycerides. The stereochemistry of fatty acid in acylglycerols did not influence the bioavailability of EPA and DHA.
(Full text of the Dyerberg et al study made available at the Nordic Naturals website here.)



Eur J Clin Nutr 2010 Nov 10. 

Enhanced increase of omega-3 index in response to long-term n-3 fatty acid supplementation from triacylglycerides versus ethyl esters.

Neubronner J, Schuchardt JP, Kressel G et al. 
Institute of Food Science and Human Nutrition, Leibniz Universität Hannover, Am Kleinen Felde 30, Hannover, Germany.

Abstract

There is a debate currently about whether different chemical forms of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are absorbed in an identical way. The objective of this study was to investigate the response of the omega-3 index, the percentage of EPA+DHA in red blood cell membranes, to supplementation with two different omega-3 fatty acid (n-3 FA) formulations in humans. The study was conducted as a double-blinded placebo-controlled trial. A total of 150 volunteers was randomly assigned to one of the three groups: (1) fish oil concentrate with EPA+DHA (1.01?g+0.67?g) given as reesterified triacylglycerides (rTAG group); (2) corn oil (placebo group) or (3) fish oil concentrate with EPA+DHA (1.01?g+0.67?g) given as ethyl ester (EE group). Volunteers consumed four gelatine-coated soft capsules daily over a period of six months. The omega-3 index was determined at baseline (t(0)) after three months (t(3)) and at the end of the intervention period (t(6)). The omega-3 index increased significantly in both groups treated with n-3 FAs from baseline to t(3) and t(6) (P < 0.001). The omega-3 index increased to a greater extent in the rTAG group than in the EE group (t(3): 186 versus 161% (P < 0.001); t(6): 197 versus 171% (P < 0.01)). Conclusion: A six-month supplementation of identical doses of EPA+DHA led to a faster and higher increase in the omega-3 index when consumed as triacylglycerides than when consumed as ethyl esters.
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Comments (43) -

  • Flavia

    2/2/2011 2:05:51 PM |

    Thank you for the heads up! Once I exhaust my fish oil, I will switch to the triglyceride form.

    I wanted to drop by and thank you for scaring the sh*t out of me regarding a high wheat carby diet and atenolol.

    My blood pressure seems to be genetic and quite stubborn, but since taking your advice (plus some supplements) I have been able to lower it from 150/100 to around 128/92 and going down.

    Something I have also noticed...my pulse used to be quite high all the time- Around 80-90 (I am 29). Now it is always in the 60s. Could this be due to the supplements? Or low carb? Is this healthy?

  • Anonymous

    2/2/2011 2:27:44 PM |

    Which brands do you recommend?
    I can't find where my cotsco fish oil states which type it is?

  • TedHutchinson

    2/2/2011 2:28:02 PM |

    In case anyone else uses Nature's Answer, I've just contacted their customer services who say
    " This product IS the triglyceride form.
    Thank you,
    Ellen Kamhi PhD RN"
    At $14.95 from Iherb 16 fl oz it's good price and tastes fine.
    CODE WAB666 saves $5 off initial IHERB purchase. Maybe cheaper elsewhere but IHerb ship cheap to UK.

  • Dr. William Davis

    2/2/2011 3:21:47 PM |

    Hi, Flavia--

    Those are all positive changes, including the drop in heart rate. It reflects a reduction in adrenaline. A reduction in heart rate is a powerful marker for overall health.


    Anon-

    Costco is the ethyl ester. It is a fine brand, just less well absorbed, of course.

  • Anonymous

    2/2/2011 4:03:36 PM |

    I have some vitamin D gelcaps and they smell like fish. Are these oxidized too?

  • Michael

    2/2/2011 4:19:33 PM |

    You say not "overly oxidized" at one point in the post.  

    I am generally concerned about the fish oil I buy being oxidized.  There is a brand of fermented fish oil which purports to avoid this problem of oxidation with storage.  

    Is it your position that concerns about oxidation are sometimes (or at least mine) are overblown?  Or that the oxidation that occurs with normal storage etc. is acceptable?

  • Jack

    2/2/2011 4:26:08 PM |

    Hi Dr Davis,

    If I eat high omega-3 wild salmon once a week, high omega-3 wild sardines once a week, grass pasture butter with 225mg of naturally occurring omega-3 per serving, and organic eggs that have a bit in there as well, do you think I am getting enough for a healthy ratio? I also take the Green Pastures FLCO and HVBO blend.

    I do not eat ANY vegetable oils, ever. I only use coconut oil and ghee to cook, so my O6 intake has got to be pretty low.

    What are your thoughts on being able to obtain adequate levels of healthy omega-3 from foods where it is naturally occurring?

    Thanks,
    Jack Kronk

  • Anonymous

    2/2/2011 4:29:17 PM |

    Dr. Davis (or others): Based on what you say, since my fish oil brand is silent on what kind, I'm assuming it's the ethyl ester form.  But, I just wanted to check to see if anyone knows for sure: the brand I've been using is Carlson ("The Very Finest Fish Oil"), liquid form in a bottle - not the capsules.

  • Anonymous

    2/2/2011 5:01:52 PM |

    I take the Carlson lemon cod liver oil. Is their any disadvantage to this over fish oil?

  • Anonymous

    2/2/2011 5:13:20 PM |

    What about Krill oil?

  • Flavia

    2/2/2011 6:00:08 PM |

    Dr. Davis said: "Those are all positive changes, including the drop in heart rate. It reflects a reduction in adrenaline."

    No wonder every time I take my BP at Walmart my pulse is higher!!

  • Anonymous

    2/2/2011 7:01:13 PM |

    Where does krill oil fit into this?

  • Might-o'chondri-AL

    2/2/2011 7:18:24 PM |

    Natural Factors omega-3 is ethyl ester processed form.

  • Lucy

    2/2/2011 7:21:44 PM |

    Dr. Davis,

    Can you comment on the recommended dose for an ApoE 3/4 like me?  I've been told by a BHL educator not take any, but I don't like the idea of that.  I was thinking I may try just 500-600mg/day.  Of course, I've been using Kirkland's which apparently is less bioavailable anyway...

  • Vin Kutty

    2/2/2011 10:53:27 PM |

    As a nutritionist who's worked in the fish oil industry for 20+ years, I may be able to add some insight.

    Yes, Triglyceride (TG) and Re-esterified triglyceride (rTG) forms are better absorbed than the Ethyl Ester form (EE). At least in the short term. And the Phospholipid (PL) form is roughly 50% better absorbed than rTG.

    Then why don't we all take PL form found in Krill oil? Well, there isnt much Omega-3 in Krill to begin with. And the PL-bound Krill Omega-3 are very temperature sensitive, so you won't see anyone concentrating it.

    BTW, the folks at Neptune Krill Oil have some unpublished data that shows the difference between TG and EE diminishes to insignificance over time.

    TG form is natural, no need for pre-conversion before absorption. That does not mean that your body won't use EE. It will. Just requires another step. It's just that TRUE natural TG is not very concentrated. Usually about 30% Omega-3 or so. Anything above 50% is likely to be EE. But most EU nations only allow TG form, so if you want a concentrated fish oil, you jack it up to 60 or 70% as EE and then re-esterify it. Additional process and can be done, but it will cost you. I'm currently working with some 90% rTG material. This raw material is 10 to 20X more expensive than what goes into Walmart brand fish oil.

    I'm guessing (but it's a good guess) but more than 95% of fish oil studies are done on EE form. So all the benefits you've read about don't go out the window if you are taking EE instead of TG. Forget Lovaza, next-gen EPA-based drugs like Epadel, Epanova and still-pending AMR-101 are all EE.

    Most fish oils, if not all, sold at retail stores are EE. Because it is cheaper. Specialty and online sources are your best bet for TG and rTG.  Go to 3rd party testing IFOS website and look under product type - it will tell you if it is EE or TG. http://www.ifosprogram.com/ifos/consumerreport.aspx

    Issues with the Dyerberg study: 1) 2 weeks is way too short a duration to figure this out. 2) they did not compare TG oil to a placebo (corn oil?). Instead, they compared it to EE. Comparison to placebo would have put things in perspective. The Neubronner paper addresses this issue.

  • Anonymous

    2/2/2011 11:19:46 PM |

    As I understand it, part of the tradeoff involves potency and how much EPA/DHA you can pack into a capsule. Ethyl esters are going to be more "compact" than trigylceride chains. I take Life Extension brand, and I honestly don't know which form it is. Perhaps it is the ester form. I get 3600 mg of combined Omega 3 activity from six capsules a day. If the trigyleride form would mean 10 or 12, I don't know that the trade is worth it in money or hassle. I know some of these other brands like Pharmax are supposed to be good, but I draw the line at doing "shots" of unencapsulated fish oil!

    As an aside, does anyone have any suggestions for me? I'm 40, pretty close to ideal weight, non diabetic and I still struggle with high TG, now 292 even with fish oil and 1 gram a day of IR niacin... Not a big wheat eater either although I do have a nasty breakfast cereal habit.

  • Ned Kock

    2/2/2011 11:40:30 PM |

    It is worth noting that as little as 38 g of sardines provide more "net" O3, of the "good" type, than 2 fish oil softgels: bit.ly/gsaJI3.

  • Anonymous

    2/3/2011 1:00:28 AM |

    Dr Davis

    do you know which is the best KOsher fish oil?
    most of brands have vegetarian capsules, but there is a liquid one from Nutri-supreme research

  • Davide Palmer

    2/3/2011 3:21:31 AM |

    Thank you, thank you. At least there are some honest doctors (as Dr. Davis) who are not robots and don't view the FDA's stamp of approval as divinely authoritative and perfect.

  • Rick

    2/3/2011 3:53:04 AM |

    Just to check: Are triglyceride forms always in bottles? Or can we also get them in capsules?

  • Anonymous

    2/3/2011 5:02:07 AM |

    While exploring this subject I came upon this article which clearly expands on the difference between TG and EE fish oil forms.

    http://www.ascentahealth.com/health-science/science-articles/fish-oil-triglycerides-vs-ethyl-esters-as-nature-intended

  • Donald Kjellberg

    2/3/2011 6:09:27 AM |

    Rick said...
    "Just to check: Are triglyceride forms always in bottles? Or can we also get them in capsules?"

    To say it lightly, I prefer to get them off the back of my fish like wild caught salmon but especially with sardines like Ned referred to since the mercury content is extremely low to nonexistent.

    Also, it may be more beneficial consuming supplements naturally in whole foods, if you can get enough. That in itself is not an easy endeavor. Don't get me wrong, I do take my fish oil capsules especially when consuming high 6:3 ratio foods but am trying to incorporate more nutrient dense foods that contain known rich supplement content.

    It would be nice to see more research addressing synergistic effects of nutrients in foods like Dr. Price's findings regarding fermented cod liver oil and high vitamin butter oil.

  • Dr. William Davis

    2/3/2011 3:02:12 PM |

    Hi, Jack--

    No, not even close.

    It also depends on why you take fish oil and/or obtain omega-3 fatty acids and whether or not you have coronary atherosclerotic plaque, among other things.

  • Jack

    2/3/2011 3:16:28 PM |

    The only brand of canned salmon/tuna and canned sardines I eat is from Wild Planet. I am not affiliated with them and this is not an advertisement, but they really seem to do the whole process perfectly. They also do not add any vegetable oil or water. They have very low mercury content and very high natural omega-3 content. The omega-3 in their tuna is even higher than the salmon. Also, they explain the importance of low mercury and how it all works.

    Have a look at their site:

    Wild Planet

    cheers,
    Jack Kronk

  • Davide Palmer

    2/3/2011 4:34:05 PM |

    I often wonder if krill oil is an even more superior source of DHA and EPA simply because they come within the matrix of phospholipids. Phospholipids, of course, are what makes up our cell membranes, making krill oil extremely bio-available to the cells. I guess we will have to wait for tests to confirm.

  • Sara

    2/3/2011 7:11:36 PM |

    The triglyceride form is too expensive for me.
    I'll pop an add'l ethyl ester gelcap daily and be done with it.

  • Rick

    2/3/2011 10:06:10 PM |

    Does the same caveat apply to krill oil or to seal oil?

  • Anonymous

    2/4/2011 1:35:33 PM |

    Great Detailed discussion of fish oil
    Can someone please dumb it down for me and just recommend a few brands?

  • John Townsend

    2/4/2011 7:17:46 PM |

    Dr. Davis:

    I'm curious to know where GNC's so-called "Triple Strength Fish Oil"
    product ranks. It comes in a softgel form, each capsule containing EPA+DHA strength of 900mg. It has only a slight hint of fishy-ness in taste. It's not clear to me from the bottle label whether it's in a triglyceride form. I'm not necessarily an advocate of GNC products which are not generally a bargain by any means, but have been satisfied with their quality.

  • Timothy Johanek

    2/5/2011 3:24:53 PM |

    I am a Technical Representative from Carlson and the following fish oils are all TG or rTG form:

    -EPA Gems

    -Super DHA Gems

    -MedOmega Fish Oil 2800

    -All Mothers and Kids products

    -All Very Finest Fish Oil products

    -All Cod Liver Oil products

    -All Salmon Oil products

    -Smart Catch softgels

    -CalaOmega liquid (calamari oil)


    The following products are EE:

    -Super Omega-3 Gems

    -Elite Omega-3 Gems

    -CalaOmega Softgels (calamari oil)

    -CalaDHA Sofgels (calamari oil)

  • Anonymous

    2/6/2011 2:08:07 PM |

    "struggle with high TG, now 292 even with fish oil and 1 gram a day of IR niacin... "

    1grm just is not high enough in my opinion.  I take 2grms of Now brand Niacin and had a 30% reduction in my Trigs. At C$7 for 100 x 500mg tablets it is a cheap treatment. somewhere between 2-3grms is the level required but you can check studies at www.lipidsonline.org.

    btw.  just wanted to announce that my latest HDL is 50 !  I started with a reading of 28 and had been on a low fat no meat diet for years. Added meat, reduced wheat and other grains over the last 6 months. I guess I am a convert.
    Trevor

  • omega3tron

    2/6/2011 7:28:10 PM |

    It is nothing more than just another market gimmick -

    http://www.doctormurray.com/index.php?option=com_content&view=article&id=52:the-ethyl-ester-vs-triglyceride-form-of-fish-oils

  • Bob Savage

    2/6/2011 7:59:46 PM |

    Timothy Johanek,  Do you have any reference to independent test that proof Carlson's products in TG/rTG form?

  • Anonymous

    2/7/2011 5:31:15 PM |

    I'm also interested if Dr. Davis can comment here or in one of his articles about the proper dosing for Apo 3/4 people.

    I do notice that lowish doses (1 g or less) doesn't seem to affect my LDL much negatively. However, if I go high, say 3g EPA/DHA or so, then my LDL tends to rise... and it's not the particle size thing giving a false high reading, as it's measured by VAP.

    Somewhat oddly, I have noticed that the EE form causes this rise more often than the TG form, but that could be coincidence.

    And for those interested:

    Barleans (orange, low dose): TG
    (high dose): EE
    Minami (EE, except for MarineEPA)
    Nordic Naturals: rTG
    Meg3: Can be either, but unless specified, it's EE
    Epax: rTG
    Carlson has both forms, as mentioned here
    Coromega (rTG Epax oil (I think))
    Natural Factors: EE

    And pretty much all cheapo store brands are EE.

    Krill oil does absorb better than fish oil, as found in a recent study. However, it's like a 50% or so improvement only (at best), and due to price differences between fish/krill, it doesn't make much economical sense. If the esterified astaxanthin provides a specific benefit, then maybe it's worth it... but no data showing it's the EPA/DHA in krill.

  • Weierstrass

    2/9/2011 5:01:13 AM |

    That's good news on the Carlson's. I really don't understand why anyone uses fish oil capsules. You get a much better deal with the fish oil in bottles; I order mine online, 4 or 5 bottles at a time.

  • Anonymous

    2/9/2011 1:09:17 PM |

    Which brands of Fish Oils doesn't use Soy Bean oil?

  • Timothy Johanek

    2/9/2011 10:46:31 PM |

    Bob Savage,

    I'm not aware of any third party tests that have been done.  I am certain that I am correct though because I write the spec sheets.

    A quick test to see whether an oil is EE or not is to put it on polystyrene (styrofoam) because EE will dissolve it but TG will not.  And before anyone gets nervous, this has nothing to do with how EE oils affect your body (unless you eat or are made of styrofoam that is).

  • farseas

    2/21/2011 6:29:36 PM |

    Hi readers.  With all this talk about O3 and fish oil I thought that I would chime in with my experience.  I had a heart attack about 1.5 years ago and got a stent placed in one of my arteries.

    Since then I have been taking Walmart fish oil because it was so cheap.  My chest pains gradually receded after my heart attack and I was doing really great for awhile.  I was actually working pretty hard, doing aerobics for about 30 minutes and lifting weights for about 20 minutes.  My weight on a low carb diet went from 305 to 260 so far.

    I have been on Plavix but my cardiologist told me I could back off from it slowly, so I started taking 6 capsules of Walmart fish oil, 400mg VE, 1000 mg VC, 325 mg aspirin, and only half a 75 mg Plavix.

    Then, I went to Walmart and got a new supply of fish oil.  Upon taking it I started to get pretty strong chest pains and had to stop working out.  I did not associate the problem with the fish oil though.

    One day I came to this blog and read about rancidity in fish oil.  I broke open one of the fish oil caps from Walmart and was overwhelmed by the spoiled fish smell.  I immediately stopped taking the oil and my chest pains gradually diminished.

    My question is whether I am likely right that it was the oxidized fish oil causing the chest pains?  This wasn't a very rigorously controlled experiment. I am not looking for an absolute answer but is it possible that rancid fish oil can cause chest pains?

  • Anonymous

    2/23/2011 12:56:27 PM |

    Farseas that is very interesting. Glad to hear you have been doing better.

    in for answer on rancid oil.

    I've been using Ascenta fish oil. They're based out of nova scotia. All their oils are in triglyceride form.

    Ascentahealth.com....although can be found much cheaper elsewhere like iherb.com

  • Anonymous

    2/23/2011 12:56:39 PM |

    Farseas that is very interesting. Glad to hear you have been doing better.

    in for answer on rancid oil.

    I've been using Ascenta fish oil. They're based out of nova scotia. All their oils are in triglyceride form.

    Ascentahealth.com....although can be found much cheaper elsewhere like iherb.com

  • Anonymous

    2/25/2011 10:30:39 AM |

    Should we worry about this?
    Fish Oil Increases Risk of Colitis, Colon Cancer in Mice

    http://www.emaxhealth.com/1275/fish-oil-increases-risk-colitis-colon-cancer-mice

  • john

    4/9/2011 6:49:51 AM |

    Thank you so much for the post. Fish oil is best for our health.This is very informative blog.
    -fish oil

  • Gailtoo

    4/27/2013 1:19:39 PM |

    Personally, I don't put a lot of faith in studies done on mice. Their biological makeup is different than ours and these studies often give mice mega-doses of whatever they are testing for over very short periods of time, which could have adverse consequences for anyone. I like human trials better.

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Is health the absence of disease?

30. September 2007 William Davis (2)
It sounds like a word game, but is health the absence of disease?

In other words, if you're not sick, you must be well. If you don't have cancer, heart disease (overtly, that is, like angina and heart attack), the flu, diarrhea, fevers, pain someplace . . . well then, you must be well.

Of course, most of us would disagree. You can be quite unhealthy yet have no overt, explicit disease. Yet this is the philosophy followed in conventional medicine when it comes to many aspects of health.

With regards to heart disease, if you have no chest pain or breathlessness, you don't have heart disease. "Oh, all right, we'll perform a stress test to be sure." Track Your Plaque followers, as well as former President Bill Clinton, recognize the enormous pitfalls of this approach: It fails to identify the vast majority of hidden heart disease. In heart disease, the apparent lack of overt, sympatomatic "disease" does NOT equal the true absence of disease, even life-threatening.

How about nutritional supplements? Vitamin D is a perfect example. Blood levels of vitamin D of 10 ng/ml--profound deficiency--are common, yet people feel fine. Beneath the surface, blood sugar rises because of poor insulin response, hidden inflammatory responses are magnified, HDL is lower and triglycerides are higher, coronary plaque grows at an accelerated rate, colon cancer activity is heightened . . . Though you feel fine.

Can an abnormal "endothelial response" be present while you feel fine? You bet it can. This refers to the abnormal constrictive behavior of arteries that is present in many people who have hidden coronary plaque or risk for coronary plaque, but is entirely beneath consciousness.

How about a triglyceride level of 200 mg/dl, fatally high from the Track Your Plaque experience? (We aim for <60 mg/dl.) This is typical in people who follow the diets endorsed by agencies like the American Heart Association and the American Diabetes Association, organizations too eager to keep the money flowing from corporate sponsors and thereby offer us their advice based more on politics and less on health. Triglyceride levels of 200 mg/dl cause no symptoms.


At so many levels, the absence of disease is NOT the same as health. Health is something that is expressed by, yes, feeling good, but it's also measured by so many other factors hidden beneath the surface. An annual physical is one lame effort to address this aspect of "health." But it needs to go farther, much farther.

Heart scan, lipoprotein testing, vitamin D blood level--those are the basic requirements to go beyond the shortsighted practice of the conventional approach in the world of heart disease.

Cuckoo for Cocoa Puffs

30. September 2007 William Davis (8)




Take a look at the list of ingredients in Cocoa Puffs: corn, sugar, corn syrup--all high glycemic index foods.

In other words, Cocoa Puffs is the physiologic equivalent of pure table sugar. Sure, it comes packaged with this wacky bird and the back of the box usually has fun games and offers. There's also the clever, fast-paced TV commercials to remind you of how fun Cocoa Puffs can be.


What is the actual consequence of a breakfast of a food like Cocoa Puffs in a cup of skim milk? That's easy: A big surge in insulin and blood sugar (from the corn and sugar), a drop in HDL cholesterol, surge in triglycerides (from the sugar and sugar-equivalents), increase in small LDL. Beyond this, you raise blood pressure and experience an insatiable increase in appetite. Then you get fat.

Obviously, none of this is desirable. Then why does the American Heart Association allow its Heart CheckMark endorsement on the package?

The Heart Association is trapped in 1982. Low-fat was in, saturated fat was the sole enemy of heart disease.

In 1982, the evils of small LDL, for instance, were unappreciated. LDL cholesterol was LDL cholesterol--all of it was bad and saturated fats seem to raise LDL. But the story has evolved enormously since then: LDL is not all the same. Small LDL is among the principal culprits in heart disease, the same small LDL hugely magnified by Cocoa Puffs and other similar products that fill 70% of supermarket shelves.

The American Heart Association needs to get with the times. The conversation on healthy diets has progressed considerably. Yet garbage foods that wreak havoc on health like Cocoa Puffs continue to be endorsed by an organization that still carries substantial clout with the American consumer.

My advice: Until they change their tune, anything that carries the endorsement of the American Heart Association should be eliminated from your diet.

Further validation of the Track Your Plaque 60:60:60 targets

29. September 2007 William Davis (3)
The latest analysis of the data from Treat to New Targets (TNT) Trial shows that higher HDL cholesterol values are associated with reduced risk of heart attack, even in those with low LDL cholesterol values.

This counters the argument that some have made that, if a person takes a statin drug, raising HDL adds no additional benefit.

In the 9770-participant trial (randomized, double-blind), participants were given atorvastatin (Lipitor®) 10 mg or 80 mg per day. The study was sponsored by Pfizer, the manufacturer of Lipitor®. All participants were survivors of heart attacks, significant coronary disease by heart catheterization, or had previously undergone coronary angioplasty, stent placement, or bypass surgery—a high-risk group.

At the third month of enrollment, lipid (cholesterol panel) values were obtained and used as the basis for analysis. Participants on 80 mg atorvastatin achieved an average LDL cholesterol (Friedewald) of 77 mg/dl; participants taking 10 mg achieved a level of 101 mg/dl. Using these values, 8.7% of participants taking the higher dose of drug experienced an event, compared to 10.9% on the lower dose (which the investigators called a 22% relative reduction).

However, when the groups were re-analyzed by HDL cholesterol levels, higher HDLs remained predictive of less heart attack and other events, with the group having the highest HDL of =55 mg/dl experiencing 25% less events. Most interestingly, this effect was upheld even in participants with very low LDL cholesterols of <70 mg/dl.

I'm always a bit leery of drug company-sponsored studies, especially ones in which virtually all the participants tolerated a drug like Lipitor 80 mg, a dose in my experience that is very poorly tolerated for more than a few months. (Muscle aches are, in my experience, inevitable. I do not even recommend this dose.) In other words, the data are, in that respect, too good to believe.

Anyway, despite my reservations about these big money studies, there was nothing to gain from the HDL observation. (Of course, at one time, there would have been, given Pfizer's efforts to commercialize the now-kaput torcetrapib, scrapped because of excess mortality in phase II trials.)

Thankfully, there's other data that likewise suggest that the higher the HDL, the better. Yet more validation for the Track Your Plaque lipid targets of LDL 60 mg/dl, triglycerides 60 mg/dl or less, HDL 60 mg/dl or greater.



Copyright 2007 William Davis,MD

My sister called today . . .

28. September 2007 William Davis (5)
My younger sister, aged 48 years (sorry, sis), called this morning.

"I'm going to my doctor today. What labs should I tell him to draw?" she asked.

"Why do you have to tell him? Can't you just ask him what he thinks should be drawn?"

"No," she said. "He just draws what I tell him to."


Maybe my sister is bossier than most. But I've heard this from many patients, as well. They go to their primary care physician and end up requesting this or that test. Sometimes their doctor complies. Often, they resist and refuse to do so.

I've heard many complaints from patients about doctors refusing to order even fairly benign tests like a vitamin D blood level or lipoproteins, even a C-reactive protein.

The number of these sorts of complaints seems to be growing. Ten years ago, it rarely happened. Today, I hear this nearly every day.

I think it is symptomatic of the growing discontent we all have with the status quo in healthcare. We are all expected to submit to the paternalistic, what-can-you-possibly-know mentality that still rules the day in medical offices. Only 40-50 years ago, if you wanted to look at a medical book, you'd have to ask the librarian for special permission so that they could make sure you weren't just a pervert trying to look at naked bodies. Today, every manner of medical and health information can be found online. Quite a contrast.

We are entering a new age, one in which people are far better informed, have surfed the internet and read media reports on health topics, have been exposed to drug company advertising, and know a fair amount about nutritional supplements. I think the system needs to change to accommodate this rapidly growing hyper-knowledgeable society.

In past, when a health problem turned up, you'd turn to your doctor first. I predict that,in the next few years, we will use the doctor as a place of last resort, the person we turn to when all else has failed, after you've exhausted your information sources.

I hope that the Track Your Plaque process will become one of the engines of change, an information resource that provides empowering tools that don't replace your doctor, but provide many information tools that are superior and may minimize your reliance on a health care provider.


Copyright 2007 William Davis, MD

Failure to diagnose

27. September 2007 William Davis (6)
I picked up a hospital publication today. Featured prominently on the cover was a glossy photo of an attorney and his wife, both smiling.

The headline: "Atorney grateful for the lifesaving work of the ______ Hospital."

The story detailed the near-tragic story of how this 59-year old man was exercising at his local gym, only to lose consciousness after stepping off one of the exercise machines. Bystanders--hospital employees, as luck would have it--checked the man's pulse: none. They performed CPR. Ambulance called, blah blah blah.

Severe coronary disease discovered, extensive atherosclerotic plaque in all three coronary arteries, a 12-inch chest incision later and he and his wife are eternally grateful for the fine work done at X hospital. And so they should be for a job well done.

But wait a minute. After the urgent hospital dust settled, did anyone ask the one crucial question: Why wasn't this man's far-advanced heart disease identified? Why did he have to die and be resuscitated before his disease was recognized?

If this man was an indigent, homeless alcoholic . . . well, perhaps it would be no surprise. Health is neglected in this population. But a successful attorney?

Detecting hidden coronary atherosclerotic plaque simply isn't that tough. In Milwaukee, $199 would have diagnosed his disease unequivocally.

Unfortunately, we still have to set off drumrolls and crash cymbals to even begin to get the attention of the practicing physicians around us who continue to fail to diagnose hidden coronary disease. I wouldn't be at all surprised to hear if this man had a $4000 nuclear stress recently that was normal. Why would a nuclear stress test be normal? Easy: Wrong test.

The hidden message: The failure to diagnose paid somebody and some hospital over $100,000. So, why bother detecting disease before the payoff?

The profit motive in all this is all too obvious. The only other explanation is the enormous, repetitive, and systematic stupidity of the conventional approach to heart disease detection. You have the solution, at least for you and the people around you, in a CT heart scan and in the Track Your Plaque program.


Copyright 2007 William Davis, MD

Interview with world heart scan authority, Dr. John Rumberger

26. September 2007 William Davis (1)











Dr. John Rumberger has, from its start, been a good friend of the Track Your Plaque program.

We are very proud to have his friendship. Dr. Rumberger is not only a world-renowned scientist in the world of cardiac imaging and heart scanning, but also a humanitarian and gentleman. From the very first day I met Dr. Rumberger many years ago, when he answered my many silly and naive questions about heart scans, I came to appreciate his deep and genuine interest in improving the world of heart disease detection.

I tracked Dr. Rumberger down from his busy schedule, now on a new project at the Princeton Longevity Center in Princeton, New Jersey.




TYP: Dr. Rumberger, we understand that your career has taken a new direction. Can you tell us about your current project?

Dr. Rumberger: I have not really taken a new direction, but further expanded on my opportunities.

I remain Medical Director of PrevaHealth Wellness Diagnostic Center (formerly Healthwise) in Columbus, Ohio. At that center, we see patients referred by their doctors for further refinement in cardiac risk stratification using heart and body scanning. However, by only doing scans alone there are limited opportunities for me to react in a meaningful way with the individual patients and thus I miss opportunities to do direct one-on-one teaching.

Currently, I spend most of my time in Princeton, NJ as Director of Cardiac Imaging for the Princeton Longevity Center. At the PLC, we perform comprehensive medical examinations along with screening CT scans, blood work, fitness and diet consultation to affect a more thorough one-on-one experience. Each patient then receives a comprehensive de-briefing.

In addition, since I have been involved with cardiac CT for now nearly 24 years, the PLC also affords me an opportunity to develop a CT coronary angiography training program for cardiologists and radiologists (www.cardiaccta.us). Together, these new efforts are merely an extension of my interests in prevention, patient care, and teaching.



TYP: Based on your book, The Way Diet, we understand that you advocate gravitating away from processed foods and incorporating more nuts, monounsaturated oils, lean proteins like fish, and a reduction in processed carbohydrates. You’ve also been a proponent of the Mediterranean diet that demonstrated a dramatic reduction in cardiovascular events in the Lyon Heart Study.

Has your philosophy or practice regarding nutritional strategies evolved or changed in any way since your book was published?

Dr. Rumberger: No, the strategies put forward in The Way Diet have, if anything, been reinforced by further and further research in selecting foods that are naturally high in anti-oxidants with lean sources of protein and reduced intake of processed sugar-containing preparations. The book, however, is what I call a ‘philosophy’ book which looks at three major aspects: proper diet, adequate exercise, and stress management. I also include some recipes which follow the dietary plans, but are done using ingredients that are commonly found in the average home.



TYP: We regard you as the source of much of the wisdom in heart scanning as the basis for early heart disease detection. Much of the original and subsequent scientific data, in fact, bears your name. Can you touch on some of the new directions your research has taken over the past couple of years?

Dr. Rumberger: We have come a long way from the beginning and there is a long way to go to get this incorporated into routine preventive care in the United States.

The most recent research has provided not so much more information as continuing to reinforce the old research. As I always say: if your research continues to show the same thing, then maybe there is a clear pattern here! The biggest challenge is getting this message into the mainstream and also trying to get cardiologists (and internists and, in fact, the general public) away from ‘stenosis’ detection to define the real cause of heart attacks (plaque) and into ‘plaque detection.’ This is where basic heart scanning has the greatest potential to reduce the expanding burden of heart disease.

You may be aware of our SHAPE initiave in which an international group of cardiologists and scientists have advocated getting a heart scan FIRST and then, if abnormal, checking your cholesterol values; rather than using cholesterol (which is valuable, but highly variable in predictive power) to determine who needs medications or further testing. The heart scan can define the current level of plaque and THEN you can determine what to do about it. [See the Track Your Plaque report on the release of the Shape Guidelines at SHAPE Guidelines]



TYP: We understand that you are performing CT coronary angiography in your center. What are your thoughts on the role of CTA in 1) screening for coronary disease, and 2) its role in the diagnostic process?

Dr. Rumberger: CT coronary angiography (CTA) is an incredible method to really define the extent of disease, beyond just coronary calcium. Its role is most appropriate in ruling OUT a significant ‘stenosis’ while really defining the absence or presence (and thus ‘how much’) of plaque. It is the ultimate ‘plaque detector’. CTA is best used in patients who have some symptoms, but in whom the clinician feels may NOT have clear cardiac chest pain. By risk-stratifying using CTA, we also gain information about heart size, heart function, whether there is prior heart damage, as well as other important information. This then becomes a very universal means to risk-stratifying individuals.



TYP: Thanks for your wonderful insights, Dr. Rumberger! We look forward to hearing about your future projects and research directions.





About John Rumberger, PhD, MD:
Dr. Rumberger is among the world's leading authorities on cardiac and vascular imaging using EBT and CT Scanning. Dr. Rumberger was among the first to pioneer the use of new CT technologies for heart scanning. He currently serves as Director of Cardiac Imaging at the Princeton Longevity Center, Princeton, NJ.

Dr. Rumberger is formerly Professor of Medicine and Consultant in the Department of Cardiovascular Diseases at the Mayo Clinic in Rochester, Minnesota. Dr. Rumberger received his doctorate in engineering from The Ohio State University in 1976 and graduated from the University of Miami School of Medicine in 1978.

During his over 20 year career as a clinician, educator, and researcher, Dr. Rumberger has published nearly 500 scientific papers and book chapters. He has lectured worldwide on EBT, early heart disease diagnosis, and wellness. He is an Established Investigator of the American Heart Association and a Founding Member of the International Society of Atherosclerosis Imaging. Dr Rumberger is an active Reviewer for the Journal of the American Medical Association, Archives of Internal Medicine, and the New England Journal of Medicine.

Summer in Wisconsin

25. September 2007 William Davis (10)
It's been a glorious summer in Wisconsin.

For weeks straight, we've enjoyed bright, sunny days with temperatures in the 70s and 80s. Even now, in late September, our windows are wide open and the days are warm and sunny. Yesterday, it was 84 degrees. Yes, it did rain for a stretch of about 10 days in August, but for the most part it has been a wonderfully sunny summer.

So it struck Andy as a big surprise when we checked his 25-OH-vitamin D3 blood level: 15 ng/ml--severe deficiency.

"I don't get it. I'm outside almost every day. Look at me! How do you think I got this tan?"

Indeed, Andy sported a nice dark tan over exposed areas.

In fact, Andy was among the dozen or so people this month with deficiencies of this magnitude.

Deficiency is not the exception; it is the rule. Of course, if Andy's blood level is at the level of severe deficiency in September, he will only trend lower over the next few weeks and months. He would likely have shown vitamin D blood levels of <10 ng/ml by January--profound deficiency.

With deficiency of this severity, Andy has been exposing himself to risk for prostate and colon cancer, diabetes and metabolic syndrome, low HDL, higher triglycerides, higher blood sugars, higher C-reactive protein, osteoporosis, arthritis . . .

Correcting the deficiency is easy. But, as you can see, getting sun is not always the answer. Even with an active, outdoor lifestyle and a tan, Andy still remained significantly deficient. Oral replacement with vitamin D3, or cholecalciferol, is an absolute necessity.

Wacky statin effects

23. September 2007 William Davis (18)
In general, I try to exhaust possibilities before resorting to the statin drugs. But we still do use them, both in general practice and the Track Your Plaque program.

There are indeed a number of ways to reduce, minimize, or eliminate the need for these drugs. For instance, if your LDL is 150 mg/dl but comprised of 90% small particles, then a reduction in wheat and other high-glycemic index foods, weight loss, fish oil, and niacin can yield big drops in LDL.

But sometimes we need them. Say LDL is 225 mg/dl and is a mix of large and small. Exercise, weight loss, niacin, oat bran, ground flaxseed, Benecol, etc. and LDL: 198 mg/dl. Alright, that's when statins may be unavoidable. There's also many people who are not as motivated as all of us trying to reverse heart disease. Some just want the easy way out. Statins do indeed provide that option in some people.

So in truth, we end up using these drugs fairly regularly. How common are muscle aches and fatigue? In my experience, they are universal . If taken long enough, or if high doses are used, muscle complaints are inevitable. Most of the time, thankfully, they're modest and often relieved with a change in drug or with coenzyme Q10 supplementation.












But there's more to statin side effects than muscle aches. Among the wacky effects that I have witnessed with statin drugs:

--Insomnia-especially with simvastatin (Zocor and Vytorin). Insomnia can be quite severe, in fact, with difficulty sleeping more than 3-4 hours a night.

--Bone aches--I don't know why this happens, unless it's somehow related to muscle aches. I've seen this with all the statins, but more commonly with Crestor.

--Memory impairment--a la Dr. Duane Graveline's wacky book, Lipitor: Thief of Memory. I've seen this with Lipitor, though it's uncommon, and less commonly with simvastatin (Zocor, Vytorin).

--Diarrhea--More common with Zetia and Vytorin (which contains Zetia), because of the inhibition of bile acid reabsorption.

--Migraine headaches--This I certainly do not understand, but the cause-effect relationship is undoubtedly true in an occasional person.

--Low libido--In men more than women, though it may be more due to men being more willing to admit to it.

--Increased appetite--Rare, though I've seen dramatic instances.

--Tinnitus--Ringing in the ears. I've only seen it with Lipitor and Zocor.


In their defense (and in general I am no defender of the drug manufacturers), most people do fine with statin drugs, though the majority do eventually require coenzyme Q10 in my experience. By the way, coenzyme Q10 can be an indispensable aid to help tolerate statin agents.

I'd love to hear about your wacky experiences.

Track Your Plaque goes global

21. September 2007 William Davis (3)
I don't use this space to toot my horn (at least I don't too often), but we were looking at the listings of our viewers and members. I was surprised to learn that we now have Track Your Plaque followers in 15 different countries around the world!

We have members from Europe including England, Ireland, Switzerland, Belgium, and the Czech Republic. We have members from as far away as South Africa, Australia, India, Singapore, Thailand, and China.

I see the entire Track Your Plaque process as a grand experiment. Never before in history has a system of health been delivered via a communication medium like the web. The internet provides more interactivity than television, it's more fluid than a book, it's more dynamic and evolves more rapidly than a face-to-face interaction. While we cannot be hands-on over the internet, we can still deliver all the crucial information and, hopefully, the knowledge on how to get it done.



Track Your Plaque is part of an even grander experiment: The movement to shift control over health away from the medical system, doctors, and hospitals and back to individuals. When you think about it, the idea that "health" (more acurately sickness) should be managed by people and institutions (e.g., hospitals and insurance companies) outside of the individual is a 20th century concept. I predict that this notion will also become a relic of the 20th century.

Someday, we will look back and laugh at the folly of the 20th century style of paternalistic health care. Perhaps it was a necessary step in the sequence to transform health to a better system that returns control to the individual. But it's clearly time for a change.

Track Your Plaque is an example of the extraordinary power that can be taken by a lone individual with only minimal assistance of a health care provider. I see Track Your Plaque members who understand heart disease (at least the coronary disease aspect) far better than 95% of my cardiology colleagues, 100% of my internal medicine and family practice colleagues. Physicians maintain a role, but their role has shrunk and receded. They should be facilitators of success in health, educators, a resource to turn to when we need help. It's not that way today. It will be in 50 years.

But, right now, we can get started on this wonderfully self-empowering--liberating-- movement by participating in this global experiment known as Track Your Plaque, the program with the goofy name that has the potential to usurp and unravel this enormous institutionalized system of health care the world has created.

Go to your corners

20. September 2007 William Davis (4)
There's a heated debate being waged on the Heart Hawk Blog

Dr. Melissa Walton-Shirley authored an editorial entitled It Should Be the Right of All Americans to Have Primary Percutaneous-Based Intervention for Acute Coronary Syndrome .

Heart Hawk's response:

Dr. Walton-Shirley feels the best use of time, talent, and money is to build more cath labs and train more people in how to use them so that IF you have a heart attack, you stand a better chance of being pulled back from the brink of death. Unfortunately, you have to first let people get so sick that they are about to die. My position is to use those same resources to prevent such disasters from happening in the first place. Take your pick. You cannot spend the money twice.

I am no stranger to "direct angioplasty," meaning performing immediate coronary angioplasty (with stenting) for heart attack. Since 1990, I have personally performed hundreds, perhaps over a thousand of these procedures, particularly when I was younger and my practice was procedurally-focused. But, after a few years, I quickly recognized the futility of this approach. Yes, you might have aborted a heart attack ,perhaps even saved a life at the brink of death. But wouldn't it have been better to have prevented the entire episode in the first place?

In my mind, putting a cath lab on every corner, as Dr. Walton-Shirley suggests, is like having a fire truck on every street to prevent a house from burning down. It's an enormously expensive proposition that provides no incentive to prevent fires. Why not spend the money on preventing the fires?

Expanding access to cath lab procedures is putting the fox in the henhouse. Procedures yield money--big money--for hospitals and cardiologists. Guess what happens when you build facilities that exceed the need? Yes--the number of procedures grows, whether or not they were needed.

In my view, Dr. Shirley-Walton's opinions are symptomatic of the profit-driven, procedurally-focused quick-fixes that divert money that would be far better spent on effective dissemination of preventive practices.