What vitamin D form?

In response to questions regarding why don't vitamin D tablets work, here are my observations.

When I first started correcting vitamin D levels around 3 1/2 years ago, people would begin with starting 25-hydroxy vitamin D blood levels of around 20 ng/ml.

Taking, say, 6000 units vitamin D as tablets over 3 months yielded blood levels of 24-30 ng/ml. Taking 6000 units in an oil-based form, and blood levels would commonly be 60-70 ng/ml.

In other words, tablets are very poorly absorbed. I also saw very erratic absorption with tablets, with tremendous variation in blood levels.

I witnessed this effect many times. I finally began telling patients to avoid the tablets altogether. It's simply not worth it. Taking dose X of tablets, you cannot predict what the blood level of vitamin D will be.

Now, you can sometimes make the tablets get absorbed by either taking with a teaspoon of oil (e.g., olive, flaxseed) or taking with an oil-rich meal. However, I am uncertain just how consistent the absorption is under these circumstances, not having done this enough times to know.

Oil-filled gelcaps are no more expensive than tablets (or perhaps a dollar more). Health food store employees and pharmacists don't know this. I have had many patients come to the office claiming they changed to tablets because that's all their health food store or pharmacy carried and the person behind the counter assured them it was the same. Blood level of vitamin D to confirm: right back down to the starting level or near it--little or no absorption.

The only way to know whether a preparation is absorbed is to check a blood level. But, in my experience, having checked vitamin D blood levels thousands of times, gelcaps never fail; tablets fail over 80% of the time.

Comments (36) -

  • TedHutchinson

    2/16/2009 9:13:00 AM |

    Effective strength D3 is not available over the counter in the UK. UK readers have to buy from the USA.
    http://tinyurl.com/8znjue
    Iherb do Now foods 5000iu D3 in olive oil capsules very cheap.
    Orders £18 or over are not only subject to Customs duty but our Post Office charges £8 extra to collect the tax.
    Using Iherb $5 discount code such as WAB666 reduces the price of 360 to under the tax threshold. Leaving the daily cost including P&P to 5.25p daily

  • TedHutchinson

    2/16/2009 12:01:00 PM |

    http://tinyurl.com/ch5262
    May I also draw readers attention to this half hour video from Cedric Garland about Vitamin D status and cancer incidence and progression.
    You will note Garland suggests 60ng 150nmol/l for lowest cancer incidence.

  • fritz

    2/16/2009 1:48:00 PM |

    Is the vitamin D from cod liver oil effective?

  • Anonymous

    2/16/2009 2:10:00 PM |

    Slightly off topic, but I just read that congress is going to vote on a bill to cut medicare coverage of vitamin D levels, so now we will have to rely on private insurance, or simply pay ourselves.

    Jeanne shepard

    By the way, I prefer not to be "anonymous" but the Google Blogger doesn't remember my password, and won't let me select a new one.

  • Anne

    2/17/2009 3:28:00 AM |

    Some of the vitamin D experts warn against using cod liver oil. http://www.vitamindcouncil.org/newsletter/2008-december.shtml

    One concern is too much vitamin A if you took enough of the cod liver oil to get the D you need. Another is that vitamin A and D compete with each other.

  • TedHutchinson

    2/17/2009 10:18:00 AM |

    fritz
    Read what Dr Cannell says about Cod liver oil here
    http://tinyurl.com/dh9b6k

    A typical 5ml tsp of CLO contains roughly 400iu. Most people require on average 5000iu/daily so the amount from CLO is insufficient.

    Jeanne
    Twice yearly $30, 25(OH)D blood spot tests, available by post from this source
    www.grassrootshealth.org/daction/index.php

  • Rick

    2/17/2009 10:49:00 AM |

    iHerb.com also has Country Life Vitamin D3 2500 IU (200 softgels).

    Thanks for answering the questions about tablets so quickly, by the way.

  • Tom

    2/17/2009 11:38:00 AM |

    For the benefit of UK readers, I'd like to second TedHutchinson's informative comment. I use the same product from the same supplier Smile

    It's worth noting that postage and packing cost from the US does not contribute to the value of the order for the purposes of taxes and extortionate 'fees'.

  • Matthew

    2/17/2009 1:08:00 PM |

    I don't understand why taking a vitamin D3 capsule will not raise level of 25(OH)D when consuming it with fat or meal containing fat. Should get the same results...

  • Anonymous

    2/17/2009 5:43:00 PM |

    First, let me say that I really love your blog.  I learn so much every time I come here.

    I do have a question for you.  What do you make of this site:

    http://bacteriality.com/2007/09/15/vitamind/

    On the surface, she appears to be a competent scientist, but she blames everything (and I do mean everything from macular degeneration to brain lesions) on too much Vitamin D and claims that the road to universal health should begin with driving one's Vitaman D levels to below 20 ng/mL.  A friend of mine just sent this to me in a panic.  Please let us know what you think.

    Thanks so much!
    Isabella

  • Steve L.

    2/17/2009 7:39:00 PM |

    The Costco effect.  I had been wondering why so many people use the tablet form.  Just noticed yesterday that tablet is the form of Vitamin D that Costco carries.

  • Diana Hsieh

    2/17/2009 8:54:00 PM |

    All of the vitamin D capsules that I checked in Whole Foods yesterday were composed of some kind of frankenfood oil in them, most notably soybean oil.  Can anyone recommend any brands that use something better?  

    (I have the same problem with my vitamin E complex, but I'm not convinced that I should be taking that anyway -- although it does seem to help the inevitable dry skin in winter here in Colorado.)

    BTW, my husband and I got our levels tested thanks to your recommendations.  Mine were excellent (probably thanks to many months of good supplementation), but his need some work (despite some more moderate supplementation).  Thanks for the info!

  • David

    2/18/2009 4:37:00 AM |

    Re: the http://bacteriality.com/2007/09/15/vitamind article...

    Anonymous,

    Dr. Davis wrote about this issue (more or less) last year: http://heartscanblog.blogspot.com/2008/03/marshall-protocol-and-other-fairy-tales.html

    David

  • Michael

    2/18/2009 5:55:00 AM |

    @ Diana Hsieh
    Don't know if this is available where you are (I'm in Australia) but I use this brand of D3 for this very reason. It's in fish oil, of reasonable potency.

    THOMPSON'S Vitamin D (1000mg) with Fish Oil (500mg) - 60 gelatin-free caps

    http://www.thompsons.co.nz/afa.asp?idWebPage=8403&ID=163&SID=663632930&Type=Products

    Product made in New Zealand. Hope this helps.

  • Anna

    2/18/2009 6:40:00 AM |

    Diana,

    Our family likes Carlson Vit D products.  They are definitely absorbable, because the whole family went from the low end fo the reference range to around 70-86 ng/ml in the past few months).

    Mostly we use Solar D Gems in the 2000 or 4000iU capsules.  There is a bit of Norwegian CLO & EPA?DHA in them, and lemon flavor.  They chew up easily, too, but can also be swallowed.

    The non-chewable capsules are much tinier and are made with sunflower oil, but even that is a very tiny amount in this very small capsule.

    The Carlson D drops in the 2000iU/drop dose is made with coconut oil (though it is fractionated, to keep it liquid).  But it's only a drop.

    I find very good prices at www.vitaminshoppe,com, usually for about 2-4 ¢ per each 1000iU (that's how I make price comparisons).  Plus Vitamin Shoppe has a frequent buyer program so purchases earn points toward fairly generous coupons (such as $5 off a $15+ purchase), and shipping is reasonable (sometimes free).  

    Or I buy Carlson Vit D3 at the local store when they are on sale (stores that sell a lot of Carlson product often pass along "mfg discounts" or "special buys").

  • TedHutchinson

    2/18/2009 11:09:00 AM |

    Isabella
    Mark London  MRL@PSFC.MIT.EDU has provided a detailed scientific rebuttal of the Marshall Protocol here
    http://tinyurl.com/cfod57
    Is the MP Treatment for Sarcoidosis Helpful for Other Chronic Diseases?

    MP’s Vitamin D Theories Are Not Supported by Lab Studies.
    Updated July 2, 2008

    Dr Davis has previously addressed this issue in the blog entitled
    The Marshall Protocol and other fairy tales

    Diana Hsieh
    The capsules I suggested are dissolved in olive oil.
    http://tinyurl.com/abbagz
    Carlson 2000iu sunflower oil $12.22
    http://tinyurl.com/abbagz
    Carlson also do Solar Gems in Cod liver oil.
    http://tinyurl.com/bclzom

  • Anonymous

    2/18/2009 1:35:00 PM |

    Diana Hsieh,

    I believe the NOW foods brand D3 formulations are suspended in olive oil.

    Carlson's Vitamin D3, 2,000 IU is suspended in sunflower oil.

    That being said, most of these D3 capsules are quite tiny, so I am not sure that they contain a huge amount of oil, unless you are taking more than 10,000 IU's daily (i.e., 5 capsules).

    As to sources, iHerb is the best and most user friendly, and I won't even give you my $5. discount code, as previous poster did.  You can sign up for your own discount number at the iHerb website.

    Hope that helps!

  • Sam

    2/18/2009 3:30:00 PM |

    Diana,

    I'm currently using Carlson 2000IU gelcaps which contain sunflower oil (omega-6, even if small quantities) and a few other more benign ingredients.

    When these are exhausted I'm switching to Carlson D-drops in which D3 is dissolved into medium chain triglycerides (MCT).

  • Anonymous

    2/18/2009 4:50:00 PM |

    Thanks everyone for the input.  I feel much better now and am off to take my gel-capped Vitamin D3.

    All my best,
    Isabella

  • TedHutchinson

    2/18/2009 9:21:00 PM |

    When researching Carlson Solar Gems earlier I mentioned they contain Cod liver oil but no Vitamin A Content is listed on the Carlson's website.
    So I emailed Carlson's to confirm the vitamin a content. They replied
    total Vitamin A is below 2% of the daily value which is the threshold above which the FDA requires you to list the Vitamin A content.
    As adult RDA for vitamin A is 700~900iu, below 2% of that is below 14~18iu. So there is really is no reason to avoid Solar Gems because of their potential Vitamin A content.

  • Anonymous

    2/19/2009 12:52:00 AM |

    Dr. Davis,

    Appreciate your elaborating the tablets vs. capsules point and thank you for continuing to take the time to write such informative posts!

  • Anonymous

    2/19/2009 7:46:00 PM |

    "Heart disease was once thought to be less of a problem for women than for men. Research now indicates that heart disease is the No. 1 cause of death among women in the US, while confirming that women with an intact uterus have a lower incidence of heart disease because they benefit from the uterine advantage." Visit http://www.truthout.org/021609R for the full article.

  • Anonymous

    2/20/2009 12:01:00 PM |

    Dr. Davis,
    Are gelcaps with dried powdered form of vitamin d3 as effective as oil filled gelcaps?

  • Ricardo

    3/26/2009 12:58:00 AM |

    Dr. Davis, "Americans Low on Vitamin D" - http://www.webmd.com/news/20090325/americans-low-on-vitamin-d

  • Anonymous

    4/22/2009 6:37:00 PM |

    I've had great results from powdered gelcap from D-Max (5000 IU) from Nature's health Supply, but a bit less from NOW olive oil gelcaps (5000 IU). Just a hunch, because I have an autoimmune disease and I'm trying to work out my symptoms. So no 25(OH)D test here.

    I'll try those Carlson's next.

    Great blog by the way!

  • Anna

    4/22/2009 8:49:00 PM |

    I just ordered some D3 to send to my 81 yo MIL and 46 yo SIL in London.  I'm quite sure they are going to very deficient (they just ordered the www.grassrootshealth.net home testing kit as it's a pain to get NHS to agree to test).  

    I found Bio-Tech D3-5 (5000iU cholecalciferol capsules  - powder in a tiny gelatin capsule) offered on Drs. Eades's Protein Power website at a great price, 100 qty for $8.  Shipping via UPS was $6.45 to my location for up to 10 bottles.  That makes the price per 1000iu incredibly low.  I bought a year's supply (8 bottles) to mail to my in-laws, plus two bottles for me.  Note I was very surprised at the small size of the box, but it did contain the 10 bottles I ordered, but the capsules and bottles are small and light, which is nice when ordering so much at once and mailing it again.  Fast delivery, even with UPS ground service.

    I just had another 25 (OH)D test drawn last week; I'll get the results tomorrow at my endo appt for my thyroid.  I was averaging 5000iU/day  supplementation with various Carlson D3 products, based on previous 25 (OH)D test results and supplementation levels.  So I'll switch to the Eades' Bio-Tech formula now and see how my 25 (OH)D is in late summer/early fall.

  • David

    4/22/2009 9:40:00 PM |

    Anna,

    I'd be very interested to hear a follow up from you when you retest after being on the Bio-Tech D3 for awhile. I'm of the mind that D3 in softgel form is more absorbable and hence more efficacious for raising and maintaining 25(OH)D levels, but I see many of the "big guns" (e.g. Cannell, Eades, etc.)promoting/selling the powdered Bio-Tech formula. Perhaps you could report back here with your results?

    David

  • Anna

    4/23/2009 6:27:00 PM |

    Dave,
    Sure.  I'll be retesting  thru my endo in 6 mo.  But I might do a mail-in test via www.grassrootshealth.net before that.  

    I'm guessing a gelatin capsule filled with a powder (might be an oily powder,too) is more absorbable than a hard tablet form.

    Btw, I just got my lab result for 25(oh)d---a nice 68ng/mL (after months of 5000iU D3 carlson oil gelcaps and/or oil drops .  Also was an easier winter than i've had in years, which I think might be due to more sunlight and Vit D.

  • David

    4/23/2009 7:59:00 PM |

    Thanks, Anna. 68 ng/ml-- Good for you! You know, all my life, I've had tough winters. I would always get very sluggish and depressed. I mean I would get really, really down. But ever since I've started the vitamin D, the winter blues are a thing of the past. This alone is probably the most noticeable effect I've ever had from taking any supplement. It's a very dramatic and welcomed change.

  • Herry

    5/27/2009 9:41:31 AM |

    I will read from time to time for that.

    http://allnutri.com/bid970/now+foods.aspx

  • Anonymous

    8/26/2009 6:34:03 PM |

    That means D3 in Calcium tablets like Citrical is probably poorly absorbed  too, am I correct?

  • David

    8/27/2009 10:27:06 PM |

    Yep.

  • Anonymous

    11/11/2009 8:42:39 PM |

    I found this site using [url=http://google.com]google.com[/url] And i want to thank you for your work. You have done really very good site. Great work, great site! Thank you!

    Sorry for offtopic

  • Anonymous

    12/13/2009 2:00:04 AM |

    yoo... amazing thread!

  • Anonymous

    5/4/2010 2:15:47 AM |

    GNC has Vit D drops.....do you feel this is good?

  • buy jeans

    11/3/2010 12:30:44 PM |

    Oil-filled gelcaps are no more expensive than tablets (or perhaps a dollar more). Health food store employees and pharmacists don't know this. I have had many patients come to the office claiming they changed to tablets because that's all their health food store or pharmacy carried and the person behind the counter assured them it was the same. Blood level of vitamin D to confirm: right back down to the starting level or near it--little or no absorption.

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Overweight, hungry, diabetic, and fat-free

Let me tell you about my low-fat experience from 20 years ago.

At the time, I was living in Cleveland, Ohio, and served on the faculty at a large metropolitan university-affiliated hospital, supervising fellows-in-training and developing high-tech cath lab procedures like directional athererectomy and excimer laser coronary angioplasty. (Yes, another life.)

I was concerned about personal heart disease risk, though I knew next to nothing about lipids and coronary risk prediction outside of the little I learned in training and what the drug industry promoted.

I heard Dr. Dean Ornish talk while attending the American College of Cardiology meetings in Atlanta. Dr. Ornish spoke persuasively about the dangers of fat in the diet and how he "reversed" coronary disease using a low-fat, no added oils, no meat, vegetarian diet that included plenty of whole grains. So I thought I'd give it a try.

I eliminated all oils; I removed all meat, eggs, and fish from my diet. I shunned all nuts. I ate only low-fat products like low-fat yogurt and cottage cheese; and focused on vegetables, fruit, and whole grains. Beans and brown or wild rice were a frequent staple. I loved oatmeal cookies--low-fat, of course!

After one year of this low-fat program, I had gained a total of 31 lbs, going from 155 lbs to 186 lbs. I reassessed some basic labs:

HDL 28 mg/dl
Triglycerides 336 mg/dl
Blood sugar 151 mg/dl (fasting)


I became a diabetic. All through this time, I was also jogging. I ran on the beautiful paths along the Chagrin River in suburban Cleveland for miles north and south. I ran 5 miles per day most days of the week.

It was diabetes that hit me alongside the head: I was eating low-fat meticulously, exercising more than 90% of the population, yet I got fat and diabetic!

I have since changed course in diet. Last time I checked, my lipid values on NO statin agent:

HDL 67 mg/dl
Triglycerides 57 mg/dl
Blood sugar 91 mg/dl

That was my lesson that fat restriction is a destructive, misguided notion. The data since then have confirmed that restricting total fat is unnecessary, even undesirable, when fat calories are replaced by carbohydrate calories.

This is your brain on wheat

Here's just a smattering of the studies performed over the past 30 years on the psychological effects of wheat consumption.

Oddly, this never makes the popular press. But wheat underlies schizophrenia, bipolar illness, behavioral outbursts in autism, Huntington's disease, and attention deficit hyperactivity disorder (ADHD).

The relationship is especially compelling with schizophrenia:

Opioid peptides derived from food proteins: The exorphins.
Zioudrou C et al 1979
"Wheat gluten has been implicated by Dohan and his colleagues in the etiology of schizophrenia and supporting evidence has been provided by others. Our experiments provide a plausible biochemical mechanism for such a role, in the demonstration of the conversion of gluten into peptides with potential central nerovus system actions."


Wheat gluten as a pathogenic factor in schizophrenia
Singh MM et al 1976
"Schizophrenics maintained on a cereal grain-free and milk-free diet and receiving optimal treatment with neuropleptics showed an interruption or reversal of their therapeutic progress during a period of "blind" wheat gluten challenge. The exacerbation of the disease process was not due to variations in neuroleptic doses. After termination of the gluten challenge, the course of improvement was reinstated. The observed effects seemed to be due to a primary schizophrenia-promoting effect of wheat gluten."


Demonstration of high opioid-like activity in isolated peptides from wheat gluten hydrolysates
Huebner FR et al 1984


Is schizophrenia rare if grain is rare?
Dohan FC et al 1984
"Epidemiologic studies demonstrated a strong, dose-dependent relationship between grain intake and the occurrence of schizophrenia."

Small LDL: Perfect index of carbohydrate intake

Measuring the number of small LDL particles is the best index of carbohydrate intake I know of, better than even blood sugar and triglycerides.

In other words, increase carbohydrate intake and small LDL particles increase. Decrease carbohydrates and small LDL particles decrease.

Why?

Carbohydrates increase small LDL via a multistep process:

First step: Increased fatty acid and apoprotein B production in the liver, which leads to increased VLDL production. (Apoprotein B is the principal protein of VLDL and LDL)

Second step: Greater VLDL availability causes triglyceride-rich VLDL to interact with other particles, namely LDL and HDL, enriching them in triglycerides (via the action of cholesteryl-ester transfer protein, or CETP). Much VLDL is converted to LDL.

Third step: Triglyceride-rich LDL is "remodeled" by enzymes like hepatic lipase, which create small LDL.


Carbohydrates, especially if they contain fructose, also prolong the period of time that triglyceride-rich VLDL particles persist in the blood, allowing more time for VLDL to interact with LDL.

Many people are confused by this. "You mean to tell me that reducing carbohydrates reduces LDL cholesterol?" Yes, absolutely. While the world talks about cutting saturated fats and taking statin drugs, cutting carbohydrates, especially wheat (the most offensive of all), cornstarch, and sugars, is the real key to dropping LDL.

However, the effect will not be fully evident if you just look at the crude conventional calculated (Friedewald) LDL cholesterol. This is because restricting carbohydrates not only reduces small LDL, it also increases LDL particle size. This make the calculated Friedewald go up, or it blunts its decrease. Conventional calculated LDL will therefore either underestimate or even conceal the real LDL-reducing effect.

The reduction in LDL is readily apparent if you look at the superior measures, LDL particle number (by NMR) or apoprotein B. Dramatic reductions will be apparent with a reduction in carbohydrates.

Small LDL therefore serves as a sensitive index of carbohydrate intake, one that responds literally within hours of a change in food choices. Anyone following the crude Friedewald calculated LDL will likely not see this. This includes the thousands of clinical studies that rely on this unreliable measure and come to the conclusion that a low-fat diet reduces LDL cholesterol.

Fat "conditioning"

Here's a great study from the prolific laboratory of Dr. Jeff Volek from the University of Connecticut. (Full text here.)


http://jn.nutrition.org/cgi/content/full/134/4/880

Video Teleconference with Dr. William Davis


Dr. Davis is available for personal
one-on-one video teleconferencing

to discuss your heart health issues.


You can obtain Dr. Davis' expertise on issues important to your health, including:

Lipoprotein assessment

Heart scans and coronary calcium scores

Diet and nutrition

Weight loss

Vitamin D supplementation for optimal health

Proper use of omega-3 fatty acids/fish oil



Each personalized session is 30 minutes long and by appointment only. To arrange for a Video Teleconference, go to our Contact Page and specify Video Teleconference in your e-mail. We will contact you as soon as possible on how to arrange the teleconference.


The cost for each 30-minute session is $375, payable in advance. 30-minute follow-up sessions are $275.

(Track Your Plaque Members: Our Member cost is $300 for a 30-minute session; 30-minute follow-up sessions are $200.)

After the completion of your Video Teleconference session, a summary of the important issues discussed will be sent to you.

The Video Teleconference is not meant to replace the opinion of your doctor, nor diagnose or treat any condition. It is simply meant to provide additional discussion about your health issues that should be discussed further with your healthcare provider. Prescriptions cannot be provided.

Note: For an optimal experience, you will need a computer equipped with a microphone and video camera. (Video camera is optional; you will be able to see Dr. Davis, but he will not be able to see you if you lack a camera.)

We use Skype for video teleconferencing. If you do not have Skype or are unfamiliar with this service, our staff will walk you through the few steps required.

Track Your Plaque challenges

Of all the various factors we correct in the Track Your Plaque program in the name of achieving reversal of coronary plaque, there are two factors that are proving to be our greatest challenges:

1) Genetic small LDL

2) Lipoprotein(a)

More and more people are enjoying at least marked slowing, if not zero change or reduction, in heart scan scores following the Track Your Plaque program. We achieve this by correcting a number of factors. Some factors, like vitamin D deficiency, are easily corrected to perfection--supplement sufficient vitamin D to achieve a blood level of 25-hydroxy vitamin D of 60-70 ng/ml. Correcting standard lipid values--LDL cholesterol, HDL cholesterol, and triglycerides--child's play, even to our strict targets of 60-60-60.

However, what I call "genetic small LDL" and a subset of lipoprotein(a) are proving to be the most resistant of all.

Let's first consider genetic small LDL. Small LDL is generally the pattern of the carbohydrate-ingesting, overweight person. It has exploded in severity over the past decade due to overconsumption of carbohydrates due to the ridiculous low-fat notion. Reduce or eliminate carbohydrates, especially wheat, which permits weight loss, and small LDL drops like a stone. But there is a unique subset of people who express the small LDL pattern who start at or near ideal weight. Take Chad, for instance. At 6' 2" and 152 lbs and BMI of 19.6, there's no way excess weight could be triggering his small LDL. Yet he starts with 100% small LDL particles. All efforts to reduce small LDL, such as wheat, cornstarch, and sugar elimination; niacin; vitamin D normalization; thyroid normalization; and several supplements that yield variable effects, such as phosphatidylcholine, all leave Chad with more than 90% small LDL.

Lipoprotein(a) is a bit different. Over the past 5 years, our choices in ways to reduce Lp(a) expression have improved dramatically. Beyond niacin, we now have high-dose EPA + DHA, thyroid normalization that includes use of T3, and hormonal manipulation. In the Track Your Plaque experience, approximately 70% of people with Lp(a) respond with a reduction in Lp(a). (In fact, the 4 out of the 5 record holders for reduction of heart scan scores have Lp(a) that was successfully treated.) But about 30% of people with Lp(a) prove resistant to all these treatments--they begin with a Lp(a) of, say, 260 nmol/L and, despite niacin, high-dose EPA + DHA, and various hormones, stay at 260 nmol/L. It can be frustrating and frightening.

So these are the two true problem areas for the Track Your Plaque program, genetic small LDL and a subset of Lp(a).

We are actively searching for better options for these two problem areas. Given the collective exploration and wisdom that develops from such collaborative efforts as the Track Your Plaque Forum, I am optimistic that we will have better answers for these two stumbling blocks to plaque reversal in the future.

I'll supply the tar if you supply the feathers

The results of the latest Heart Scan Blog poll are in.


DIRECT-TO-CONSUMER PHARMACEUTICAL ADVERTISING HAS:

Increased public awareness of medical conditions and their treatment
19 (11%)

Has had little overall effect on health and healthcare
29 (18%)

Needlessly increased healthcare costs
81 (50%)

Further empowered the revenue-obsessed pharmaceutical industry
130 (81%)


Clearly, there's a lot of negative sentiment against direct-to-consumer (DTC) drug advertising.

It looks as if a small minority believe that good has come from DTC advertising, judging by the meager 11% who voted for increased awareness. In fact, the poll results are heavily weighed towards the negative: 50% voted for "needlessly increased healthcare costs," while an astounding 81% voted for "empowered the revenue-obsessed pharmaceutical industry."

It is, indeed, an odd situation: Pharmaceutical agents available only by prescription being hyped directly to the consumer.

Personally, I would vote for choices 1,3, and 4. While awareness has increased, it has come with a hefty price, not all of it well spent. I believe the pharmaceutical industry still adheres to the rule that, for every $1 spent on advertising, $4 is made in revenue. They are, in effect, printing money.

What goes up can't come down

According to conventional wisdom, heart scan scores cannot be reduced.

In other words, say you begin with a heart scan score of 300. Conventional wisdom says you should take aspirin and a statin drug, eat a low-fat "heart healthy" diet, and take high blood pressure medications, if necessary.

If your heart scan score goes up in a year or two, especially at an annual rate of 20% or more, then you are at very high risk for heart attack. If the heart scan score stays the same, then your risk is much reduced. These observations are well-established.

But more than 99% of physicians will tell you that reducing your heart scan score is impossible. Don't even try: Heart scan scores can go up, but they can't go down.

Baloney. Heart scan scores can indeed go down. And they can go down dramatically.

It is true that, following conventional advice like taking a statin drug, following a low-fat diet, and taking aspirin will fail to reduce your heart scan score. A more rational approach that 1) identifies all causes of coronary plaque, 2) corrects all causes while including crucial strategies like omega-3 fatty acid supplementation, vitamin D supplementation, and thyroid function normalization, is far more likely to yield a halt or reduction in score.

While not everybody who undertakes the Track Your Plaque program will succeed in reducing their heart scan score, a growing number are enjoying success.

A small portion of our experience was documented this past summer. (I collected and analyzed the data with the help of Rush University nutrition scientist, Dr. Susie Rockway, and statistician, Dr. Mary Kwasny.)


Effect of a combined therapeutic approach of intensive lipid management, omega-3 fatty acid supplementation, and increased serum 25 (OH) vitamin D on coronary calcium scores in asymptomatic adults.

Davis W, Rockway S, Kwasny M.

The impact of intensive lipid management, omega-3 fatty acid, and vitamin D3 supplementation on atherosclerotic plaque was assessed through serial computed tomography coronary calcium scoring (CCS). Low-density lipoprotein cholesterol reduction with statin therapy has not been shown to reduce or slow progression of serial CCS in several recent studies, casting doubt on the usefulness of this approach for tracking atherosclerotic progression. In an open-label study, 45 male and female subjects with CCS of > or = 50 without symptoms of heart disease were treated with statin therapy, niacin, and omega-3 fatty acid supplementation to achieve low-density lipoprotein cholesterol and triglycerides < or = 60 mg/dL; high-density lipoprotein > or = 60 mg/dL; and vitamin D3 supplementation to achieve serum levels of > or = 50 ng/mL 25(OH) vitamin D, in addition to diet advice. Lipid profiles of subjects were significantly changed as follows: total cholesterol -24%, low-density lipoprotein -41%; triglycerides -42%, high-density lipoprotein +19%, and mean serum 25(OH) vitamin D levels +83%. After a mean of 18 months, 20 subjects experienced decrease in CCS with mean change of -14.5% (range 0% to -64%); 22 subjects experienced no change or slow annual rate of CCS increase of +12% (range 1%-29%). Only 3 subjects experienced annual CCS progression exceeding 29% (44%-71%). Despite wide variation in response, substantial reduction of CCS was achieved in 44% of subjects and slowed plaque growth in 49% of the subjects applying a broad treatment program.

Gretchen's postprandial diet experiment

Gretchen sent me the results of a little experiment she ran on herself. She measured blood glucose and triglycerides after 1) a low-fat diet and 2) a low-carb diet.









Gretchen describes her experience:

Several years ago I received a windfall of triglyceride strips that would expire in a week or so. I hated to waste them, so I decided to use them to test my triglyceride and BG responses to two different diets: low carb and low fat.

The first day I followed a low-fat diet. For breakfast I ate a lot of carbohydrate, including 1 oz of spaghetti cooked al dente and ¾ cup of white rice. For the rest of the day I ate less carbohydrate but continued to eat low fat.

The second day I followed a low-carb diet. For breakfast I ate a lot of fat, including a sausage, mushrooms fried in butter, 2 slices of bacon, and ¼ cup of the creamy topping of whole-milk yogurt. For the rest of the day I ate less fat, especially less saturated fat, but continued to eat low carb.

Both days I measured both BG and triglyceride levels every hour until I went to bed. On the low-carb day I had 3 meals. On the low-fat day, I was constantly hungry, had 4 meals, and kept snacking.

You can see the results in Figure 1. On the low-fat diet, after a “healthy” low-fat breakfast of low-glycemic pasta with low-fat sauce, my BG levels shot up to over 200 mg/dL and took more than 6 hours to come down. My triglycerides, however, remained low, and at first I thought perhaps the low-fat diet might be better overall. However, after about 6 hours, the triglyceride levels started to increase steadily, and by the next morning, they were higher than they had been the day before.
On the low-carb diet, my BG levels stayed low all day. However, after meals, the triglyceride levels skyrocketed. After meals they came down, and by the next morning they were lower than they had been the day before.

As I interpret these results, the high triglyceride levels after eating the high-fat meals represent chylomicrons, the lipoproteins that transport fat from your meals to the cells of your body. The high triglyceride levels the morning after eating the low-fat meals represent very low density lipoprotein, which takes the cholesterol your liver synthesizes when your intake of dietary cholesterol is low and distributes it to cells that need it, or again, to the fat for storage.

There are several interesting factors to consider here. First, when you have a lipid test done at the lab, it’s usually done fasting, which means first thing in the morning after not eating for 8 to 12 hours. It tells you nothing about what your triglyceride levels were all day.

Second, the low-carb diet resulted in lower fasting triglyceride levels, but much higher postprandial triglyceride levels. Which are more dangerous? I’m afraid I don’t know. You should also note that the high-fat, low-carb breakfast was extremely high in fat, including saturated fat. I don’t normally eat that much fat but wanted to test extremes.

Third, although the low-fat diet didn’t produce the very high postprandial triglyceride levels that the high-fat diet did, it produced extremely high BG levels that persisted for 6 hours. Some people think that it’s oxidized and glycated lipids that are the dangerous ones, so high BG levels and normal triglyceride levels might be more dangerous than very high triglyceride levels and normal BG levels. Note that high BG levels also contribute to oxidation rates.

Fourth, this shows the results of an experiment with a sample size of one. My physiology might not be typical. If you want to know how your own body’s lipids respond to different types of diets, you should get a lipid meter and test yourself. Unfortunately, your insurance is unlikely to want to pay for this, so it will be an expensive experiment.

The main point of this is that the results of different diets are complex. We have to eat. And what we eat can affect many different systems in our bodies. Finding the ideal diet that matches our own physiology and results in the best lipid levels as well as BG levels is a real challenge.



This was a lot of effort for one person. Thanks to Gretchen for sharing her interesting experience.

Gretchen makes a crucial point: Some of the effects of diet changes evolve over time, much as triglyceride levels changed substantially for her on the day following her experiment. Wouldn't it be interesting to see how postprandial patterns develop over time if levels were observed sequentially, day after day?

The stark contrast in blood sugars is impressive--Low-carb clearly has the advantage here. Are there manipulations in diet composition in low-carb meals that we can make to blunt the early (3-6 hour) postprandial lipoprotein (triglyceride) peak? That's a topic we will consider in future.

More of Gretchen's thoughts can be found at:

http://wildlyfluctuating.blogspot.com
http://www.healthcentral.com/diabetes/c/5068

After-eating effects: Carbohydrates vs. fats

In the ongoing debate over whether it's fat or carbohydrate restriction that leads to weight loss and health, here's another study from the Oxford group examining the postprandial (after-eating) effects of a low-fat vs. low-carbohydrate diet. (Roberts R et al, 2008; full-text here.)

High-carbohydrate was defined as 15% protein; 10% fat; 75% carbohydrate (by calories), with starch:sugar 70:30.

High-fat was defined as 15% protein; 40% fat; 45% carbohydrate, with starch:sugar 70:30. (Yes, I know. By our standards, the "high-fat" diet was moderate-fat, moderate-carbohydrate--too high in carbohydrates.)

Blood was drawn over 6 hours following the test meal.




Roberts R et al. Am J Clin Nutr 2008

The upper left graph is the one of interest. Note that, after the high-carbohydrate diet (solid circles), triglyceride levels are twice that occurring after the high-fat diet (open circles). Triglycerides are a surrogate for chylomicron and VLDL postprandial lipoproteins; thus, after the high-carbohydrate diet, postprandial particles are present at much higher levels than after the high-fat diet. (It would have been interesting to have seen a true low-carbohydrate diet for comparison.) Also note that, not only are triglyceride levels higher after high-carbohydrate intake, but they remain sustained at the 6-hour mark, unlike the sharper decline after high-fat.

It's counterintuitive: Postprandial lipoproteins, you'd think, would be plentiful after ingesting a large quantity of fat, since fat must be absorbed via chylomicrons into the bloodstream. But it's carbohydrates (and obesity, a huge effect; more on that in future) that figure most prominently in determining the pattern and magnitude of postprandial triglycerides and lipoproteins. Much of this effect develops by way of de novo lipogenesis, the generation of new lipoproteins like VLDL after carbohydrate ingestion.

We also see this in our Track Your Plaque experience. Rather than formal postprandial meal-testing, we use intermediate-density lipoprotein (IDL) as our surrogate for postprandial measures. A low-carbohydrate diet reduces IDL dramatically, as do omega-3 fatty acids from fish oil.