All posts by william-davis

Just a muse.

Endogenous substances are those that are already contained within our bodies. They are part of basic human equipment.

Exogenous substances are those that come from outside of our bodies. This includes various substances in foods, drugs (most, though not all), and pesticides.

I often mull over all of the tools we use in the Track Your Plaque program to achieve control over this thing called coronary plaque. It struck me that just about all the supplements we use that seem to provide outsized benefits are all endogenous substances themselves:

--Omega-3 fatty acids from fish oil
--Vitamin D
--l-arginine
--Niacin (vitamin B3)

Many of the other substances, though not directly relevant to our plaque-control efforts, but are among the most effective nutritional supplements, also supplement endogenous levels: calcium pyruvate, creatine, acetylcarnitine, DHEA, testosterone, progesterone, growth hormone, pregnenolone, phenylalanine, tyrosine, melatonin, etc.

Curiously, most drugs are not meant to directly supplement endogenous levels, but are designed either to enhance or block an enzyme (e.g., acetylcholinesterase inhibitors that block breakdown of acetylcholine; HMG CoA reductase inhibitors to block cholesterol synthesis; angiotensin converting enzyme inhibitors to reduce blood pressure), to exert toxic effects on an organism (antibiotics, antivirals), or to exert an entirely unique effect that does not ordinarily occur in the human body (some anti-cancer drugs, for instance). (This is an admitted, vast over-simplification.)

That's not to say that any endogenous substance is desirable or safe when supplemented. Cortisol, thyroid hormone, and estrogens are three examples of endogenous substances that have downsides when administered at slightly more than physiologic concentrations.

Nonetheless, it makes me wonder if the world of endogenous substance supplementation has not been fully explored. Are there other endogenous substances that are as potent and wonderful, for instance, as vitamin D but not yet fully appreciated? I'm sure there are.

Reprinted here is the unfailingly informative Vitamin D Newsletter from Dr. John Cannell. Although there's little here specifically about heart disease, there's so much great information about vitamin D that I thought most would still appreciate it.

The Vitamin D Newsletter

May, 2008

Yesterday's Washington Post article, Too-Good-To-Be-True Nutrient?, sums up the April 9th vitamin D symposium at UCSD in San Diego, which was nothing short of spectacular. Carole Baggerly outdid herself organizing it and explaining how she got involved. Make no mistake; Carole is both serious and energetic. She told about her efforts to introduce resolutions at upcoming meetings of various professional groups. Then she introduced the volunteers from the San Diego Black Nurses Association who made sure the conference went off without a hitch. Then Carole introduced the four speakers. The slides of each speaker are available at Grassroots Health.

Before I tell you the highlights of the conference, I'd like to tell you about another conference, this one in Germany, this May 17th and 18th. It is the Third International Symposium on Vitamin D Analogs in Cancer Prevention and Therapy. Readers know how I feel about giving analogs to vitamin D deficient patients instead of vitamin D but speakers include Michael Holick, Reinhold Veith, Bill Grant, Tai Chen, Heidi Cross, David Feldman, and Roger Bouillon, all of whom know the importance of the nutrient. Most of this conference is for scientists, not lay people. However, Michael Holick is the first speaker and if you have not heard his latest talk about vitamin D, it might be worth a trip to Germany.

The first San Diego speaker was Dr. William Grant. Since leaving NASA to begin a full-time career as a vitamin D researcher, Bill has published dozens of studies and has another dozen in the works. Using ecological studies (from Greek oikos, house + German -logie, study or studying your own house) of UVB irradiance and cancer, Bill reported that 15 cancers (colon, esophageal, gallbladder, gastric, pancreatic, rectal, small intestinal, bladder, kidney, prostate, breast, endometrial, ovarian, Hodgkin's lymphoma, and non-Hodgkin's lymphoma) are associated with lower UVB light. He concluded that 257,000 cancer deaths in 2007 in the USA were accounted for by inadequate vitamin D levels. Of course the problem with ecological studies is that it easy to be vitamin D deficient in Miami, all you have to do is listen to your doctor's advice and stay out of the sun. Recently, a group from the Arizona Cancer Center found almost 80% of Arizonians had levels below 30 ng/ml. So much for sunny spots.

Jacobs ET, et al. Vitamin D insufficiency in southern Arizona. Am J Clin Nutr. 2008 Mar;87(3):608-13.

The next speaker was Professor Cedric Garland. I found myself wondering how he did it. I became convinced that vitamin D prevents cancer five years ago. Cedric and his brother Frank and his colleague Ed Gorham knew it 30 years ago! I know what it is like to tell someone that vitamin D prevents cancer and see them think, "Here we go again, another miracle vitamin." I know what it is like to try and explain and watch people die unnecessarily. But I've only had that experience for five years. Cedric has dealt with that frustration for thirty years. Almost thirty years ago, Cedric and Frank Garland published evidence that vitamin D prevents cancer. In fact, it was Cedric's first publication. Thankfully, the paper was recently recognized as being so important that it was republished in 2006 by the International Journal of Epidemiology. You can read the entire paper for free by clicking on the second link below and then clicking on "free final text", courtesy of Oxford Journals.

Garland CF, Garland FC. Do sunlight and vitamin D reduce the likelihood of colon cancer? Int J Epidemiol. 1980 Sep;9(3):227-31.

Garland CF, Garland FC. Do sunlight and vitamin D reduce the likelihood of colon cancer? Int J Epidemiol. 2006 Apr;35(2):217-20.

Cedric began by showing the incidence of type-1 diabetes and multiple sclerosis by latitude. I had no idea that the latitudinal data was so strong for type 1 diabetes in children. This disease is almost nonexistent around the equator. Type-1 diabetes is but one of the three modern childhood epidemics caused by the sunlight-hating dermatologists, the other two, I think, are autism and asthma. Next he showed latitude and 25(OH)D levels, which reminded me to be suspicious of high levels, unless they use accurate methods of detecting 25(OH)D. Some methods used, even in this country, are over detecting vitamin D and telling patients their levels are above 50 ng/ml when they are, in reality, much lower. Cedric's data showed Thailand had mean levels of 70 ng/ml, which I doubt and suspect were due to inaccurate 25(OH)D tests. He then reviewed evidence of the 25(OH)D levels needed to prevent numerous cancers. The safest levels are somewhere above 50 ng/ml. Cedric spent most of his time presenting an entirely new theory of carcinogenesis, one dependent on vitamin D maintaining cellular junctions. I suspect this paper will also be reprinted in 20 years. The only disagreement I have is with his recommendation for cancer patients to start at fairly low doses. For reasons I recently explained, the risk benefit analysis indicates cancer patients should take 5,000 to 10,000 IU per day and they may have no time to lose. Why worry about the phantom of vitamin D toxicity if you may be dying of cancer? Just have your calcium checked along with frequent 25(OH)D levels. Get your levels up to 70-90 ng/ml if you have cancer.

Does vitamin D treat cancer?

The next speaker was Professor Bruce Hollis. He reviewed basic physiology of vitamin D and emphasized that the entire system is designed to deal with an excess not with an insufficiency of vitamin D. Numerous mechanisms are available in your body to prevent vitamin D toxicity but few are available to deal with insufficiency. Then he briefly mentioned one of the most important discoveries about vitamin D in the last few years, one where Professor Neil Binkley of the University of Wisconsin was senior author. (In the last four years, Professor Binkley has become a prolific vitamin D expert and I hope Carol Baggerly is able to get him to speak at some of the upcoming conferences she hopes to sponsor.) As I have pointed out before, Hollis and Binkley's crucial discovery was that the body doesn't start storing the parent compound, cholecalciferol, until 25(OH)D levels reach about 50 ng/ml. They showed, using basic steroid pharmacology, that 50 ng/ml should be considered the lower limit of adequate 25(OH)D levels.

Hollis BW, Wagner CL, Drezner MK, Binkley NC. Circulating vitamin D3 and 25-hydroxyvitamin D in humans: An important tool to define adequate nutritional vitamin D status. J Steroid Biochem Mol Biol. 2007 Mar;103(3-5):631-4.

Bruce kept the audience enthralled with a review of all the disease states that indicate 25(OH)D levels need to be much higher than they are now, that is, the multiple biomarkers that suggest the lower limit of 25(OH)D levels should be above 40 ng/ml and closer to 50 ng/ml. Then Professor Hollis spoke of his ongoing study in pregnant women and how he got approval to use 4,000 IU of vitamin D per day back in 2003, quite an accomplishment. He also reviewed another one of his research projects, one that answered an age old question, why is breast milk a poor source of vitamin D? How were prehistoric infants supposed to get their vitamin D, by lying out in the sun where saber tooth tigers would eat them? No, they were hidden in caves and had to have another source or the human race would have died out long ago because rickets destroys a woman's and infant's chance to live through childbirth due to rachitic deformations of the mother's pelvis. Carol Wagner and Bruce Hollis, together with their colleagues, answered that age old question, human breast milk is a poor vitamin D source because virtually all modern mothers are vitamin D deficient. That is, when pregnant women keep their levels where we think prehistoric human levels were, about 50 ng/ml, breast milk becomes a rich source of vitamin D. First Carol and Bruce gave 2,000 IU per day, then 4,000 IU per day and finally 6400 IU of D3 per day to lactating women. Only at 6400 of D3/day did the women maintain both their own 25(OH)D levels and the levels of their breast feeding babies above 50 ng/ml. On 6400 IU/day, the vitamin D activity of the breast milk went from about 80 to 800 IU/L. Quite a discovery, and another reason for all of us to keep our levels above 50 ng/ml.

Wagner CL, Hulsey TC, Fanning D, Ebeling M, Hollis BW. High-dose vitamin D3 supplementation in a cohort of breastfeeding mothers and their infants: a 6-month follow-up pilot study. Breastfeed Med. 2006 Summer;1(2):59-70.

Professor Robert Heaney went last, discussing 74 slides. So much of what we know about vitamin D today is due to Robert's unceasing dedication to vitamin D, the most recent example being his and Joanne Lappe's randomized controlled trial showing that increasing baseline levels from 29 to 38 ng/ml reduced the risk of getting cancer by around 70%. He again pointed out that the body does not begin to consistently store much vitamin D until your levels get to around 50 ng/ml. He also went through multiple biomarkers of vitamin D. That is, what level or intakes do you have to have to reduce the incidence of multiple diseases? He covered calcium absorption, osteoporosis, risk of falling, muscle function, death and disability of the aged, TB, influenza, cardiovascular disease, hypertension, diabetes, cancer, multiple sclerosis, and gum disease. How can one vitamin be involved in so many diseases? Simple said Dr. Heaney, "vitamin D is the key that unlocks the DNA library." He then reviewed toxicity and concluded there is no evidence that it occurs at levels below 200 ng/ml or with intakes (total) below 30,000 IU per day. Of course, we have no reason to think anyone needs 30,000 IU per day or levels of 200 ng/ml, which would be irresponsible. But someone with a serious cancer should consider getting their level up to 70-90 ng/ml and that may take 10,000 IU per day or even more in some people. As a rule of thumb, 1,000 IU will raise 25(OH)D levels by about 10 ng/ml.

Then Professor Heaney addressed a public health question. How much would we have to give all Americans to get 98% of people above 32 ng/ml without causing toxicity in anybody? The answer: 2,000 IU per day. Of course 32 ng/ml is not adequate but it would be a great first step. Furthermore, of the people left out, a high percentage would be African Americans. In fact, Dr. Talwar recently reported that 40% of African American women fail to achieve a level of 30 ng/ml even after taking 2,000 IU/day for a year.

Talwar SA, Aloia JF, Pollack S, Yeh JK. Dose response to vitamin D supplementation among postmenopausal African American women. Am J Clin Nutr. 2007 Dec;86(6):1657-62.

He also discussed his recent study giving healthy adults 100,000 IU as a single dose. If you start with a baseline level of 28 ng/ml and take 100,000 IU as a single dose, mean levels will remain above 32 ng/ml for two months. If you rely on such stoss doses, but you start with a lower level, or want your levels above 50 ng/ml, how often do you need to take 100,000 IU? We don't know the answer to the last question but we know that Grey et al gave 50,000 IU per week for four weeks then 50,000 per month for a year to 21 patients with hyperparathyroidism. Blood levels rose from a mean of 11 ng/ml at baseline to 30 ng/ml at one year and levels did not continue to rise after six months. Remember, that means half the patients had levels lower than 30 ng/ml at the end of the year. Also remember that the metabolic clearance (how quickly you use it up) might be higher in certain disease states.

Grey A, et al. Vitamin D repletion in patients with primary hyperparathyroidism and coexistent vitamin D insufficiency. J Clin Endocrinol Metab. 2005 Apr;90(4):2122-6.

That last point, metabolic clearance, is only one of a number of reasons that patients vary in their response to vitamin D. Remember, a surprising number of patients will tell their physician they are taking vitamin D when they are not, some will be taking preparations that have less in it than the label says, some will not absorb it, and some people weigh more than others. As Dr. Heaney points out, even if you know patients took 100,000 IU, great variably exists in individual response. At the end of two months some will have shown a minimal response and other much more. This is a field where little is known. Do different disease states use up vitamin D quickly? The answer is probably yes. Furthermore, variability also exists in how one metabolizes and catabolizes (breaks down) vitamin D. Also, what is the interactive effect of drugs that use the same liver enzymes for catabolism? We just don't know and that is why vitamin D blood testing is crucial. Remember, the only test to have is a 25-hydroxy-vitamin D. Do not let anyone get a 1,25-dihydroxy-vitamin D; it will not tell you if you are vitamin D deficient and is usually only indicated in evaluating high blood calcium.

As far as 25(OH)D levels go, many of you have written complaining about the high cost of a 25(OH)D levels at some labs. I've got some good news. For the next month, Life Extension Foundation is having a sale on their 25(OH)D blood tests, only $32.25, including the fee for drawing the blood. (No, we don't get funding from Life Extension, I wish we did.) Life Extension uses LabCorp, which, in turn, uses an accurate method to determine 25(OH)D levels, the DiaSorin Laiason method. The only problem is that DiaSorin, LabCorp, and Life Extension all say that 30 ng/ml is acceptable. It is not. Take enough vitamin D or get enough UVB radiation to get your levels above 50 ng/ml. To order the test, call Life Extension at 800 208-3444. Unfortunately, this offer is not available in New York, New Jersey or Rhode Island.

Also, Dr. James Dowd has written a fine book about vitamin D, The Vitamin D Cure. Get this, he is board certified in internal medicine, adult rheumatology, and pediatric rheumatology, an associate professor at Michigan State University, and runs his own Arthritis Institute and the Michigan Arthritis Research Center. He gives a formula for how much vitamin D you need but stresses the importance of testing to know for sure. He uses the formula of 2000 IU for every 100 pounds of body weight, which is as accurate an estimation as one can make without knowing baseline levels. Of course it depends on so many things, as Dr. Dowd points out, such as percentage body fat, latitude, skin type, sun exposure and age. He gives case after case examples of how vitamin D not just prevents disease, but seems to have a treatment effect. He also stresses three other things I've written about before, acid base balance, magnesium and potassium. If you can't get eat enough fruits and green leafy vegetables to obtain your potassium and magnesium and to get rid of low-grade chronic metabolic acidosis, then you should consider magnesium supplements and potassium bicarbonate supplements.

With these four experts and with this month's vitamin D news articles about breast cancer, brain function, artery blockage in the legs, soft skulls in babies, peripheral neuropathy in diabetics, childhood type-1 diabetes, colon cancer, and stress fractures and with the increasing number of scientists around the world jumping on the vitamin D express, why doesn't the government do something? What will it take? Like Carole says it will take a grassroots effort.

The first thing to do is tell your family and friends about vitamin D. Tell your doctor. Get your family's 25(OH)D tested, including your children. Once people begin to see it works, they will get their family and friends to take it. They will feel better and then the word will spread. All the government can do is make vitamin D illegal or limit the amount in each pill. The first is unlikely but not the second. With 5,000 IU capsules widely available, many people give no thought to taking one a day. But if the government limits the sale of anything over 400 IU and people had to take 12 of the 400 IU tablets, instead of one of the 5,000 IU, they might balk at so many pills. Before our officials in Washington take such a step, let's hope they read the Washington Post.

John Cannell, MD
The Vitamin D Council

This is a periodic newsletter from the Vitamin D Council, a non-profit trying to end the epidemic of vitamin D deficiency. This newsletter is not copyrighted. Please reproduce it and post it on Internet sites. We are a nonprofit tax-exempt educational organization and depend on your donations.

The Vitamin D Council
9100 San Gregorio road
Atascadero, CA 93422

Judging by the conversations here, in the Track Your Plaque Forums, and elsewhere, it's clear that many people are searching for the perfect diet.

Should we reconsider the role of saturated fat? Are there fractions of fatty acids in saturated fat that are more or less harmful? How about the role of fats on cancer risk? How about the role of proteins like casein on cancer risk? Are there flavonoid sources, or combinations of flavonoids, that yield outsized health benefits? Is there a ceiling for omega-3 fatty acid supplementation? Is there a role for linolenic acid sources in cardiovascular disease prevention? And on and on.

All important issues, to be sure, ones that we've all zig-zagged through over the past 30 years.

I also see patients every day, however, who are not interested in micro-managing their diet. Their goals are less ambitious: lose 20 lbs, feel good, raise HDL, reduce triglycerides and small LDL, all while meeting all the other responsibilities in their lives, like children, spouses, maintaining a household and jobs.

So, if your interest is not to consider whether we should distinguish myristic acid sources from palmitic, or if epigallocatechin is better when combined with quercetin, then the biggest bang from your nutritional buck can come from one single strategy:

Eliminate wheat flour products

Secondarily, avoiding corn starch products and "goodies" (candy, fruit juices, fruit drinks, cookies, potato chips, etc.--you know what they are) is important, as well.

It means weighing your diet more heavily in favor of vegetables and fruits; lean meats; healthy oils; and raw nuts and seeds, all in unlimited quantities. Dairy products should be limited, however, because of sugar effects.

Of course, this advice clearly contradicts the pronouncements of the USDA Food Pyramid (6-8 servings of grains per day), the American Heart Association, and the diabetes-causing American Diabetes Association diabetic diets.

But, follow this approach, a diet strategy that appears too simple to be effective, and the majority of people lose dramatic amounts of weight, raise HDL, reduce triglycerides, reduce small LDL, reduce C-reactive protein and other inflammatory measures, reduce blood pressure, and raise self-esteem.

It's also a lot easier than it sounds (after habits are broken) because the appetite stimulating effect of wheat is removed. Many, if not most, people also experience increased energy, including elimination of the afternoon "slump," improved sleep, less mood swings, less intestinal problems.

It may not be perfect, but if your interest is to get the most with a modest amount of effort, it works like a charm for the majority of people.

Copyright 2008 William Davis, MD

You're going to hate this.

Dr. Romero-Corral and colleagues from the Mayo Clinic presented an analysis of the National Institutes of Health-funded National Health and Nutrition Examination Survey (NHANES-3) at the recent American College of Cardiology meetings. (Science Daily also has some coverage on this report.)

Their analysis identified 2127 adults from the NHANES database who had normal body-mass indexes (BMI) between 18.5 and 24.9 units), average age 41 years old. When broken down by percent body fat (measured with bioimpedance, meaning a small electrical current is passed through the body, much like what the store-bought Tanita devices do), with normal-weight obesity defined as >20% body fat in males, >30% body fat in females, 55% of participants met criteria for designation as normal-weight obesity.

Compared to people with similar BMI's but who fell below these body fat percentage cut-offs, the normal-weight obese men had increased ratios of Apo B to Apo A1; were much more likely to have increased blood sugars or be diabetic; have higher C-reactive protein (CRP); were several-fold more likely to meet other criteria for diagnosis of metabolic syndrome; had lower HDL cholesterols; and had higher blood pressure. Women with normal-weight obesity were four-fold more likely to have coronary disease.

While preliminary, this suggests that a substantial number of people with apparently favorable body weights and BMIs are, in actuality, overweight when judged by metabolic parameters. This then probably leads to increased risk for heart disease. We can then fairly readily extrapolate the argument that a reduction in weight to even lower BMIs likely reduces or corrects these patterns.

This argument is similar to that proposed by several others, arguing that BMI is a flawed measure, since it does not incorporate muscle mass or skeletal factors ("big- or small-boned"). Instead, they have argued that waist circumference is preferable.

The normal-weight obesity syndrome was originally identified by Dr. Antonio de Lorenzo and colleagues at the University of Tor Vergata, Rome, Italy, and reported in Normal weight obese (NWO) women: an evaluation of a candidate new syndrome. Their studies of women with this "syndrome" have suggested that heightened measures of inflammation are present despite apparently normal body weight and BMIs. One such report, Normal-weight obese syndrome: early inflammation?, is available in full-text.

Is there a lesson to be learned for the Track Your Plaque program? I believe there is. I believe it means that, if you have any weight-sensitive parameter, such as low HDL, small LDL, high triglycerides, high CRP, high blood sugar, high blood pressure, etc., then further weight loss might be considered, even if BMI is around 25. Obviously, there is a rational limit to how far you can push this concept. (Anorexia is not good for you either.)

I find this a useful concept. It provides yet another potential strategy to pursue when the above patterns are encountered. Perhaps it's also a way to cap reliance on niacin, whose effects closely mimic that of weight loss.

Now that's a lot more preferable to more and more statin drug, isn't it?

Copyright 2008 William Davis, MD

Since vitamin D has been the topic of a fair amount of media coverage, I've received many questions about this fascinating "nutrient." A day doesn't go by without several nurses, friends, even fellow physicians stopping me to ask about vitamin D.

When I inform them that the average dose for females in this region (upper Midwest) is 4000-5000 units per day, 5000-6000 units per day for males, they are all surprised. "Then why did they say just take your multivitamin every day, or just drink your milk on the news?"

Many people are even more surprised, sometimes completely turned off, when they hear that, to be truly confident of adequate vitamin D dosing, a blood level of 25(OH) vitamin D3 needs to be checked. Now we're talking real hassle!

But there is no other way to do it. In order to obtain the full potential benefits of vitamin D, such as reduction in blood sugar and sensitization to insulin, reduction in cancer risk (especially prostate, colon, and breast), reductions in blood pressure, increased bone density, not to mention markedly increasing the likelihood of stopping or reducing your heart scan score, then achieving a desirable blood level of 25(OH) vitamin D is necessary.

Checking a blood level of vitamin D is no more difficult than having a cholesterol test, unless, of course, your doctor balks at the idea. (Time for a new doctor if that occurs.)

All too often, someone will be convinced they are taking a sufficient dose of vitamin D of, say 2000 units per day, only to discover that their blood level of 25(OH) vitamin D is something like 17 ng/ml--severe deficiency, sufficient to leave them exposed to all the undesirable consequences of vitamin D deficiency. Even though 2000 units per day represents 500% of the Institute of Medicine's recommended Adequate Intake for adults, to those familiar with the Track Your Plaque program it likely sounds like a child's dose.

Many variables enter into the equation in your body that determines your need for vitamin D: body size (heavier or larger people need more, with obese people often requiring enormous doses); sex (men need more than women); age (aging results in dramatic loss of ability to activate vitamin D in the skin); race; skin color (darker skinned people require more). Trying to guess your need is a fool's game. It's also a game that can seriously compromise your health and your hopes of ever stopping or reducing your heart scan score.

The message is clear: You cannot guess what your vitamin D need is. You cannot properly judge your vitamin D requirement by your age, body size, sex, or any other characteristic. Having a tan or a lack of a tan is a lousy indicator, as well. A simple blood level of 25(OH) vitamin D is an absolute necessity to gauge your vitamin D status, both before starting and while on your supplement.

Members of Track Your Plaque: Watch for the 30-some page booklet, The Track Your Plaque Complete Handbook on Vitamin D and Heart Health, which will be released in the next day or two.

Copyright 2008 William Davis, MD

According to the poll just completed by 80 participants on The Heart Scan Blog, 50% of respondents said they were less likely to take a drug after viewing an advertisement for it. A whopping 3 (4%) said that they would be more likely to take the drug after viewing an advertisement.

I find that interesting. If half the people responding are less likely to become customers of a drug company, then how does the drug industry justify running around-the-clock, every-few-minute ads? Spending by the drug industry for direct-to-consumer (DTC) advertising has ballooned over the past few years, and is now well over $30 billion dollars per year.

Unfortunately, despite the views of the highly-educated, curious, think-for-yourself, health information-seeking sorts of people who read this blog, drug companies still come out on top by DTC advertising. Estimates vary, with a 2006 U.S. Government Accountability Office study reporting that, for every $1 DTC advertising, sales are increased by $2.20. A 2000 Harvard study showed a higher return of $4.40 for every advertising dollar spent.

I'm sure the drug companies themselves have a very tight accounting handle on their own set of figures. We may not be terribly fond of these people and their often suspect tactics, but they're not stupid. They are certainly not stupid when it comes to making money.

Interestingly, 80% of the funds spent on DTC advertising focus on the 20 or so most popular drugs, all of which are used for treatment of chronic conditions like high cholesterol and high blood pressure, markets that are large and long-term. It pays very little to advertise drugs that may serve small markets for a short period. The implicit message is that this is not at all about informing the public. It is about advertising to grow revenues and profits--pure and simple.

It makes me wonder what the results of our poll would have been had we conducted it in 2000 before many people hadn't yet been brought to the brink of vomiting from the endless onslaught of commercial after commercial, complete with smarmy spokespeople (a la Lipitor's Dr. Robert Jarvik). What will it show in two years? Will the broader public join the more informed people who read this blog and become increasingly inured to the hard sell tactics?

For further discussion of this topic, click here for a reprint of an August, 2007 New England Journal of Medicine study, A Decade of Direct-to-Consumer Advertising of Prescription Drugs provides background, along with commentary on the impact of DTC drug marketing since the FDA allowed it 10 years ago. (Because it is a study and not an editorial, the editors fall short of making any recommendations for improvement or calling for a moratorium.)

Copyright 2008 William Davis, MD

Anna responded to the Heart Scan Blog post, Can you say "sugar"? with the following wonderfully telling comment:

A measured bowl of Cheerios and a bit of milk (whole, because it's what I had), equal to 75 grams of carbohydrate, gave me the highest ever blood glucose reading from a food (not counting glucose solution from a Glucose Tolerance Test). I was attempting a "homemade" version of a 3 hr GTT before going to my doctor with my concerns about my BG.

My BG started to rise very fast within 15 minutes after eating the cereal, peaked at about 250 mg/dL at 45 minutes, then slowly dropped. By about 60-75 minutes, I experienced strong hunger and carb cravings as the BG began to slowly drop, and by about 2.5 hours after eating, my BG had suddenly dropped quite low (in the low 70s) and I had developed a nasty hypoglycemic feeling (shaky, irritable, craving sugary foods, headache, etc.).

It's hard for me to see "heart healthy" Cheerios (or any other highly processed breakfast cereal) as anything other than a bowl of pre-digested sugar that contributes to roller coaster blood glucose and insulin levels, which a great way to start anyone's day. Certainly, I don't do well with Cheerios because I clearly have a damaged glucose regulatory system (probably a diminished or absent first phase insulin response, but I can't imagine that it is doing any good for people with healthy glucose regulation, either.

I banned prepared cold cereals from our house. If my 9 yr old son gets cereal at all at home, it's whole groats (not even rolled or steel cut because those aren't truly "whole grain" anymore), soaked overnight in some water and a tsp of plain yogurt (soaking neutralizes phytates and reduces cooking time), then cooked about 8-10 minutes (water added as necessary). Sometimes I add a bit of quinoa or almond meal prior to soaking to boost the protein content a bit. I garnish with a pat of butter, some heavy cream, and a dusting of cinnamon. If I'm feeling *really* indulgent, I drizzle about 1 tsp of Grade B maple syrup on top (Grade B is stronger in flavor and so less can be used). I don't eat this cereal myself, and truthfully, I'd rather my son not, either, but he sometimes wants cereal. It's the least damaging compromise I can come up with that we can both live with.

I have also seen diabetic effects from Cheerios: rises in blood sugar, exagerration of small LDL, drops in HDL, rises in triglycerides. Yes, it may reduce LDL a small quantity, but so what?

The Cheerios "heart healthy" claim is based on a piece of research apparently performed by Dr. Donald Hunninghake at the University of Minnesota and reported in 1998:

A study conducted at the University of Minnesota Heart Disease Prevention Clinic and published as "Cholesterol-Lowering Benefits of a Whole Grain Oat Ready-to-Eat Cereal" in the May issue of the Nutrition in Clinical Care journal in 1998, showed that people can lower their blood cholesterol by an average of 3.8% over six weeks by enjoying 3 cups of cold cereal made with 100% whole grain oats everyday as part of the meals and snacks in a healthy lower-fat diet.

(Unfortunately, I could not locate the actual publication. It doesn't mean it doesn't exist; I just couldn't locate it. Perhaps it's in a small journal not entered into the online publication database.)

The purported effects of Cheerios should not be confused with that of actual, intact oat bran, as suggested by studies such as those of Brenda Davy et al, High-fiber oat cereal compared with wheat cereal consumption favorably alters LDL-cholesterol subclass and particle numbers in middle-aged and older men, in which significant reductions in LDL particle number and small LDL (NMR) were obtained. (This study was also supported by Quaker Oats.) Several studies have shown that oat bran does indeed reduce LDL cholesterol, sometimes as much as 30-50 mg/dl. Cheerios can not even come close to this.

If Cheerios were nothing more than finely pulverized oats, then perhaps it wouldn't be so bad. But add corn starch and sugar, and you have ingredients that have potential to distort LDL particle size and yield blood sugar-escalating effects like those described by Anna.

The gravity of perpetuating these myths is brought home by a testimonial posted on the website for Cheerios:

“I had unexpected open heart surgery a year ago. As I adopted heart health habits during my recovery, I realized that I should have been eating the Cheerios cereal I carried around in a plastic baggie so many years for my kids!”

Beverly
Scotch Plains, NJ

It makes me shudder.

Copyright 2008 William Davis, MD

There's a wonderful blog called The IF Life: Intermittent Fasting and Instant Freedom. It is written by personal trainer (and apparently former corporate bigshot), Mike O'Donnell.

Mike has a great take on brief, intermittent fasting that I found helpful and I believe you will also.

Intermitent Fasting 101: How to Start, Part I

The biggest question people have is how to effectively use IF (intermittent fasting) to achieve their goals and maximum results. These results and goals can vary by each person with fat loss, muscle gain, better health, improved performance in your sport of choice and more. With that comes the individuality of what is a person’s insulin resistance, current body composition (bodyfat%), daily lifestyle, eating habits, macronutrient ratios (carbs/protein/fat), type of exercise program, frequency and volume of training, recovery demands, and so forth. You are unlikely to find 2 people with the same set of parameters and same exact responses to an IF protocol. What does this mean? Well just that we need to start with a basic IF program, and then learn how to monitor results and adjust as we go. Even down the road things will change as you will improve health, lower insulin resistance and maybe change performance and recovery needs. So nothing is ever just one set way. Life is dynamic (always changing and evolving) and so should be the way we see our own journey for health and fitness.

What is IF?

For those that may not be familiar to the term, intermittent fasting is just taking times of fast (no food) and working them into your lifestyle. This can be either daily or a couple times a week (will get into that more below). Benefits include improving insulin resistance (which you will hear alot about as being the #1 key marker in so many health factors including weight loss, muscle gain, performance, recovery, anti-ageing and disease prevention) and giving the body a chance to do some internal cleaning (or housework), which can lead to improved immune function and overall health. If you want to see studies of all the benefits of IF/CR, please the resources page.

How do I begin to IF?

Is there only one set way in which to do IF? No. I could easily come up with 10 different IF protocols based on 10 people’s individual’s needs, lifestyle, exercise, goal, macronutrient ratios, and so forth. We will keep it simple and give the 2 most frequent and basic options.

Daily Fasting: Typically done every day and only giving the person a smaller eating window in which to get their calories. (for example, a 18hr daily fast would mean someone would only eat every day between the hours of Noon and 6pm). You will see varying times from 15-19 hours for daily fasting.
Fasting 1-3x a week: This could also be called alternate day fasting/calorie restriction (for those doing it every other day). This is just fasting of usually longer periods 18-24 hours but only 1-3x a week. Many variations to play with here.
“But which one is better and how to I do it now if I want…….”. Whoa, slow down. I know many have questions but let’s still try to keep this simple for now and expand into more specifics later. So far many people have experimented with both types of IF and have seen great results. But you also have to take into account all the other variables such as what is the person eating in that window? Is is junk food? Is it low carb? How many times a week are they doing it? Are they overweight and wanting just fat loss? Are they lower bodyfat but looking for improved performance and health? How many times a week are they exercising? What kind are they doing and what intensity? The list can go on and on, but let’s start to analyze the 2 types of IF and let you decide which one best suits your lifestyle.

Daily Fasting (15-19 hours):

The Advantages are:

--simple eating strategies for every day
--even people that may not eat 100% clean foods can see weight loss due to the smaller window and lower calorie total per day

The Disadvantages are:

--Can possibly lower metabolism if calories are too low for too long (not what you want if your #1 goal is weight loss)
--Not getting enough food in the smaller window may also lead to muscle loss for more active people (not good)
Fasting 1-3x a week:

The advantages are:

--Allows a person to make sure they are getting enough calories on the non-fasting days, and then just keeps to a simple small feed window (if any) on the IF days.
--Simple thinking for people who do not have experience in how to eat clean to eat one day, and then eat in a smaller window the following day (alternate day fasting/CR). This can achieve fat loss for people who are mostly overweight and may not be too active. (of course don’t get me wrong, that eating healthy is our main goal but this can be a good step for some people to start their weight loss jounrey and learn how to make better choices as they go)

Disadvantages:

--Doesn’t force a person to make better choices with their food (as one could probably eat junk one day, and then fast the next and still lose weight). Not something we want long term because this is not going to improve your other health markers (diseases prevention, insulin resistance) like a good IF program on healthy foods.

Again I can’t say it enough, as there are so many variables to play with in an IF program. Some people may say “well it didn’t work for me” or “I didn’t gain any muscle”. Well unless I know everything about what you do for exercise daily, your total calories, when you eat and your macronutrient ratios (protein/carbs/fats), I can’t even begin to help. IF is a simple tool to start with, but you have to take full responsibility for your own health and progress and learn when it is not working and when to change things up! Like I said, if it is NOT working then stop IF and rethink your attack plan (or get a professional to coach you on it).

So to sum up, here are some examples of what you can play with:

Daily Fasting of 15-19 hours. I would highly suggest that if you do this make sure you are recovering from your exercise and start only Mon-Fri and give yourself the weekends to eat all day (hopefully with healthy choices of course)

Fast 1-2x a week to start if you have never done any fasting or do not know how to eat healthy and control your macronutrients. Start with 1-2 days a week with fasts of 18-20 hours (I wouldn’t start with 24 hr fasts to begin as most people can not handle the hunger cravings and in turn will just end up eating all the wrong foods when they do eat) and say eat only from say 1pm-6pm for example. Drink lots of water (add lemon, your liver will appreciate it! and it will help with the hunger). For example, fast Wed and Sun (or whatever days fit into your schedule)

Or you can do a mixed approach and fast every other day for a small eating window. For example eat all day Mon, only 12-6pm on Tues, all day Wed, 12-6pm on Thurs, etc. Start with bigger eating windows and make them smaller as you get used to fasting. This approach may work for people who have alot of weight to lose and can not (I should really say “will not” as everything is a choice!) eat 100% healthy for the moment. This approach may not work for more advanced people who have a high activity level unless you are getting a ton of health calories in that fasting window.
“So What Do I Eat on the Fasting Days?”

That’s the best part, you should be able to eat unlimited healthy foods (healthy proteins, fats, veggies, fruit, nuts…see Paleo Diet in the resources page). If you are eating more processed foods, breads and other high calorie intakes then you may have to monitor and control portions. Please know this is NOT about chronic calorie restriction or starving yourself. When I do weeks of eating 1-7pm, I am eating a ton of protein and veggies (complex carbs pwo also). I am hardly starving myself. I am not taking in 4000 cal a day however, so my daily average of say 2200-2500 cal is still low compared to the alternative. If you want to lose weight of course you will need a calorie deficit to pull the “stored energy” out of fat cells. That is the advantage to eating “Paleo”, you can’t over eat on protein, healthy fats, fruits (in moderation) and veggies. If you are making bad choices or starving yourself on IF, you may lose the effectiveness or slow progress. All goes back to the fact that if it is not working, then change something up! (there is always something that can be changed…and food choices is the #1 place to start!) I don’t count calories, and by eating natural foods that have been around for 100s of years….I don’t need to! (eating healthy natural foods will not only help you lose weight but also improve your health and lower your risks of diseases….so eating for health should always be the #1 goal in any program)

Hopefully this will give a good overview while trying to keep it simple. Remember it’s your journey to take, measure progress and adjust things that are not working. Start with one approach, and modify it. Who knows, your approach may change every couple months and that is ok. Life is always changing and so should your approach to health and fitness (as the body always responds better to change than sticking with the same eating/exercise approach for a long period of time).

All of these products bear the American Heart Association Check Mark of approval emblem, signifying that they are "heart healthy":

Kellogg's Frosted Mini-Wheats cereal

Ingredients:WHOLE GRAIN WHEAT, SUGAR, STRAWBERRY FLAVORED CRUNCHLETS (SUGAR, CORN CEREAL, CORN SYRUP, MODIFIED CORN STARCH, PARTIALLY HYDROGENATED COTTONSEED AND/OR SOYBEAN OIL, CITRIC ACID, GLYCERIN, NATURAL AND ARTIFICIAL FLAVOR, RED #40, BLUE #2), NATURAL AND ARTIFICIAL STRAWBERRY AND CREME FLAVOR, SORBITOL, GELATIN, REDUCED IRON, NIACINAMIDE, ZINC OXIDE, RED #40, PYRIDOXINE HYDROCHLORIDE (VITAMIN B6), RIBOFLAVIN (VITAMIN B2), THIAMIN HYDROCHLORIDE (VITAMIN B1), FOLIC ACID, BLUE #1, AND VITAMIN B12. TO MAINTAIN QUALITY, BHT HAS BEEN ADDED TO THE PACKAGING.

Orville Redenbacher popcorns

Dora the Explorer Cereal

Cheerios

The following requirements must be met to gain approval of the Check Mark program:

1) total fat 3.0 grams or less per serving

2) saturated fat 1.0 gram or less per serving

3) 20 grams or less cholesterol per serving

4) 480 mg or less sodium per serving

5) "Jelly Bean Rule": 10% of the Daily Value of 6 nutrients (e.g., fiber, vitamins A and C, etc.) must also be contained in each serving.

Had the Check Mark program focused on genuine nutrition and rated products by:

1) Healthy oil content

2) Sugar content or sugar-equivalents, i.e., glycemic index or load

3) Impact on HDL, small LDL, triglycerides

none of these products would have made the list, not even close.

Gilbert is a 58-year old high school science teacher.

When I first met Gil, he'd been having bouts of atrial fibrillation and had required various medications to suppress recurrences of the rhythm. However, because his rhythm proved somewhat difficult to control, his electrophysiologist (heart rhythm specialist) prescribed warfarin to reduce the risk of stroke. With atrial fibrillation, because of blood stagnation (in the left atrial appendage) in the heart, there is a stroke risk of approximately 8% per year. Warfarin reduces this risk substantially, to about 2%.

I met Gil because he had a cholesterol disorder. In my practice, the first step in gauging the implications of a lipid or lipoprotein disorder is to obtain a heart scan. If the heart scan score is zero, great. It means that we have plenty of time to treat the disorder since risk for cardiovascular events is near zero also; it means less intensive efforts less intensive efforts are necessary. But if the heart scan score is, say, 1200, then an aggressive approach in short order is required, since the risk for heart attack may as high as 20-25% per year, even in the absence of symptoms.

Gil's heart scan score: 787--high and posing a risk for heart attack of about 5-10% per year without preventive efforts. Gil did indeed prove to have a complex lipoprotein disorder, as well as high blood pressure, vitamin D deficiency, and several other potential contributors to coronary plaque.

Gil did just about everything right: He exercised, followed the recommended diet, achieved better than the Track Your Plaque 60-60-60, lost 18 lbs of abdominal fat.

Gil's rhythm stabilized for several months, only to have atrial fibrillation break through again. So Gil's electrophysiologist re-prescribed warfarin.

18 months later, Gil's 2nd heart scan score: 1410--a near doubling. Unsettling to Gil and to us, to say the least.

How can this happen in the face of perfect lipids/lipoproteins, correction of hidden causes like lipoprotein(a) and inflammation, along with a vigorous lifestyle effort?

I fear that the culprit might be warfarin.

Warfarin, better known by its brand name, Coumadin, may have some effects that intersect with the Track Your Plaque mission of reducing coronary plaque.

It is no secret that, beyond the obvious risk of bleeding from blood thinning, warfarin also may:

--Accelerate aortic valve calcification
--Accelerate calcification of the framework of the mitral valve (the mitral "anulus")
--Accelerate osteoporosis
--Induce an artificial situation of vitamins K1 and K2 deficiency.

The vitamin K1 deficiency is the route by which blood thinning is achieved. However, the K2 deficiency may have undesirable consequences, among which are the above list of various pathologic calcifications.

I therefore wonder if warfarin dramatically accelerated the coronary calcium that we track to gauge the progression of coronary atherosclerosis. One experience is hardly sufficient reason to sound the alarm. It is also difficult to pinpoint the cause of the explosive growth in Gil's coronary calcium specifically on warfarin.

That all said, I am quite certain it was the warfarin.

Unfortunately, some people are unavoidably committed to warfarin, such as those with specific genetic blood clotting disorders, prosthetic valves, prior deep vein thromboses and pulmonary emboli, etc.--serious reasons. Until an alternative emerges, warfarin remains a necessity for some people. (No, nattokinase is NOT an alternative, at least not one that would permit survival.)

My personal policy is that warfarin be used only when absolutely necessary and the gains markedly outweight the risks--including that of possible accelerated calcification of multiple sites.

Whether we will be able to get Gil off warfarin and potentially gain control over his coronary disease/plaque/calcium remains to be seen. I sure hope so.

Caraballo PJ, Heit JA, Atkinson EJ et al. Long-term use of oral anticoagulants and the risk of fracture. Arch Intern Med 1999; 159 (15): 1750–6. PMID 10448778.

Pilon D, Castilloux AM, Dorais M, LeLorier J. Oral anticoagulants and the risk of osteoporotic fractures among elderly. Pharmacoepidemiol Drug Saf 2004;13(5): 289–294.PMID 15133779.

Gage BF, Birman-Deych E, Radford MJ, Nilasena DS, Binder EF. Risk of osteoporotic fracture in elderly patients taking warfarin: results from the National Registry of Atrial Fibrillation 2. Arch Intern Med 2004; 166(2):241–246.PMID 16432096.

Copyright 2008 William Davis, MD

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.

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.

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 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.

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.

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!

John received a coronary stent in 2003 following a small heart attack. The artery causing the heart attack was a diagonal artery, a branch of the important left anterior descending coronary artery (in the front of the heart). His cardiologist at the time advised him, "Take Lipitor and we'll do stress tests every year. Come back if you have any more chest pain." That was the full extent of John's preventive care.

He came to me for a second opinion and, naturally, we enrolled him in our program. We began by obtaining a CT heart scan score, though we had to exclude the stented diagonal artery. His score: 471. At age 51 and physically active, John had 7 additional abnormal lipoprotein patterns identified. We counseled John on better approaches to food choices, his weight target, fish oil, and correction of all lipoprotein patterns.

Two years later, John's repeat heart scan score: 511 . John was initially disappointed with the increase. But a closer look yielded something entirely different: the right coronary artery and circumflex (no stents) showed 20-30% reduction in their scores. The increase in total score was entirely due to substantial increase in score just outside the stent, in the left anterior descending artery. In other words, all of the increase in score was due to growth of a plaque at the mouth of the stent in the diagonal artery.

This is curious: profound regression of plaque with a big drop in score in the "un-instrumented" arteries, but tremendous growth of plaque and an increase in score in the "instrumented", or stented, artery, all in the same person's heart.

I don't know how controllable this specific situation in the left anterior descending and stented diagonal will be, and I'm unaware of any specific strategies to impact on this situation. The whole world of tissue growth within or around stents is littered with high hopes followed by failures. The drug-coated stents have been the only partial solution to this problem, though that's precisely the sort of stent John received.

Is there a message here? The message I take from this is that you and I should work like mad to keep from receiving a stent. Once they're implanted, we have less control over our coronary future. We can indeed regress ("reverse") coronary plaque. But we may not be able to regress the sort of tissue that grows in response to a stent implantation.

Imagine two people.

Tom is a 50-year old man. Tom's initial heart scan score is 500--a bad score that carries a 5% or more risk for heart attack per year.

Harry is also 50 years old. His heart scan score is 100--also a concerning score but not with the same dangers of Tom's much higher score.

Tom follows a powerful heart disease prevention program like the Track Your Plaque program. He achieves the 60:60:60 lipid targets; chooses healthy foods; takes fish oil; raises his blood vitamin D level to >50 ng/ml, etc. One year later, Tom's heart scan score is 400, a 20% reduction from his starting score.

Harry, on the other hand, doesn't understand the implications of his score. Neither does his doctor. He's casually provided a prescription for a cholesterol drug by his doctor but nothing else. One year later, Harry's heart scan score is 200, a doubling (100% increase) of the original score.

At this point, we're left with Tom having a score of 400, Harry with a score of 200. That is, Tom has twice the score, or 200 points higher, compared to Harry. Who's better off?

Tom is better off. Even though he has a significantly higher score, Tom's plaque is regressing. It is therefore quiescent with its components being extracted, inflammation subsiding, the artery is in a more relaxed state, etc.

Harry's plaque, in contrast, is active and growing: inflammatory cells are abundant and producing enzymes that degrade supportive tissue, excessive constrictive factors are constantly causing the artery to pinch partially closed, fatty materials are accumulating and triggering a cascade of abnormal responses.

This is therefore a peculiar situation in which a higher score is actually better than a lower score. It reflects the power of adhering to a preventive program. It also demonstrates how two scans are better than one because they show the rate of increase given a particular preventive approach.

Warren had a moderately high LDL cholesterol for years and took a statin drug sporadically over the past 7 years. Finally retired from a successful real estate investment business, he had a CT heart scan to assess his heart disease status.

Warren's score: 49. At age 59, this put him in the lowest 25%, with an estimated heart attack risk of 1% per year or less--a relatively low risk. At this heart scan score, the likelihood of an abnormal stress test was less than 3%, or a 97% likelihood of a normal stress test. Most would argue that a stress test would be unproductive, given its low probability of yielding useful information. In other words, there would be a 97% probability of normal blood flow through Warren's coronary plaque, and less than 3% likelihood that a stent or bypass surgery would be necessary.

Warren was also without symptoms. He hiked and biked without any chest discomfort or breathlessness. A prevention program like Track Your Plaque to gain control over future coronary plaque growth was all that was necessary and Warren had high hopes for a life free of heart attack and major heart procedures.

Then why did he go through a heart catheterization?

Warren did indeed undergo a heart catheterization on the advice of his cardiologist. When I met Warren for another opinion, it became immediately obvious that the heart catheterization was completely unnecessary. Then why was this invasive procedure done? There can only be a few reasons:

--The cardiologist didn't truly understand the meaning of the heart scan score. "We need to do a 'real' test."

--The cardiologist was terrified of malpractice risk for underdiagnosing or undertreating any condition, no matter how mild.

--The cardiologist wanted to make more money. Talking about heart disease prevention is a money-saving, not a money-making, approach.

Regardless of which of the three motivations was at work here, they're all inexcusable. A disservice was done to this man: he had an unnecessary procedure, incurred some risk of complication in the process, and gained nothing.

An ignorant or profit-seeking cardiologist is worse than the unscrupulous car mechanic who, when presented with an unknowing car repair customer, proceeds to replace the carburetor and rebuild the engine when a simple 5-minute adjustment would have taken care of the problem.

I estimate that no more than 10% of my colleagues follow such practices, but it's often hard to know who is in that 10%. Ask pointed questions: Why is the catheterization necessary? What is the likelihood of finding information useful to my health? What are the alternatives? (By the way, the emerging CT coronary angiograms can be a useful alternative in some situations like this.)

Track Your Plaque is your source for credible information. Be well armed.

Art undeniably had high blood pressure.

At age 53, he had all the “footprints” of high blood pressure that’d been present for at least several years: abnormal patterns by EKG, abnormally thick heart muscle, and an enlarged aorta by an echocardiogram. These sorts of changes require many years to develop. Art’s blood pressure was 140/85 sitting quietly in the office.

“That’s about what my primary care doc gets, too. Whenever it’s high, he takes it again after a few minutes and it always comes down.”

Art tried to persuade me that his blood pressure was high today only because of the traffic on the way into the office. When I dismissed this as a cause, he insisted that stress he’d been suffering because of his teenage son was the cause. “I just know I don’t have high blood pressure!”

Who’s right here? Well, Art is not here to defend himself. But one fact is crystal clear: you cannot develop complications of high blood pressure unless you truly have high blood pressure!

In other words, Art’s abnormal changes in heart structure (thickened heart muscle and enlarged aorta) are serious changes that develop only with years and years of sustained blood pressure at least as high as the one in the office. His blood pressure almost certainly ranged much higher at other times, particularly during stressful situations like waiting in the check-out line at the grocery store, watching a suspenseful TV show, petty irritations at his job, and on and on.

Blood pressure does not have to be high all the time to generate complications of high blood pressure. It can be sporadic, variable, even occasional. Clearly, sustained high blood pressure is the worst situation that creates adverse consequences more quickly. But blood pressure that wavers from low to high only some of the time can still, given sufficient time, cause the very same unwanted effects.

Control of blood pressure is crucial to your coronary plaque control program. Blood pressure may be boring: not as exotic, say, as lipoproteins, and not as fun as talking about nutritional supplements. But neglect blood pressure issues and you will not gain full control over coronary plaque growth—-your heart scan score will increase.

Watch for an upcoming Special Report on the Track Your Plaque Membership website, a full detailed discussion of how to recognize when blood pressure is an important issue, along with a full discussion of nutritional methods to reduce it, often sufficient to minimize or eliminate the need for medication.

In the Track Your Plaque program, we tend to rely a great deal on niacin. When used properly, 90-95% of people will do just fine and achieve their lipid and lipoprotein goals with the help of niacin, along with their other efforts.

Unfortunately, around 5% of people simply can't take niacin without intolerable "hot flush" effects, or occasionally excessive skin sensitivity--itching, burning, etc.

Why does this happen? These 5% tend to be "rapid metabolizers" of niacin, i.e. they convert niacin (nicotinic acid, or vitamin B3) into a metabolite called nicotinuric acid. Nicotinuric acid is the compound responsible for the skin flush. Most people can slow or reduce the effects of nicotinuric acid by:

--Taking niacin with dinner, so that food slow tablet dissolution.

--Taking with plenty of water. Two 8-12 oz glasses usually eliminates the flush entirely in most people.

--Taking with an uncoated 325 mg tablet of aspirin in the first few weeks or months. Eventually, you will need to revert back to a better stomach tolerated dose of 81 mg, preferably enteric coated. But a full 325 mg uncoated can really help in the beginning, or when you have any niacin dose increases, e.g., 500 mg to 1000 mg.

But even with these very effective strategies, some people still struggle. That's when the question arises: Are there any alternatives to niacin?

Well, it depends on why niacin is being used. If you and your doctor are using niacin for:

Raising HDL--Then weight loss to your ideal weight; reduction of processed carbohydrates, especially wheat products; avoidance of hydrogenated ("trans") fats; a glass or two of red wine per day; dark chocolates (make sure first ingredient is chocolate or cocoa, not sugar), 40 gm per day; fish oil; exercise; other prescription agents (fibrates like Tricor; TZD agents for diabetes; cilostazol (Pletal)). Niacin is by far the most effective agent of all, but, if you're intolerant, raising HDL is still possible through a multi-faceted effort.

Reduction of small LDL--The list of effective strategies is the same as for raising HDL, but add raw almonds (1/4-1/2 cup per day), oat bran and other beta-glucan rich foods like oatmeal. Reduction of processed carbohydrates is especially important to reduce small LDL.

Reduction of Lipoprotein(a)--This is a tricky one. For men, testosterone and DHEA are effective alternatives; for women, estrogen and perhaps DHEA. Hormonal preparations of testosterone and estrogen are stricly prescription; DHEA is OTC. I have not seen the outsized benefits on lipoprotein(a) claimed by Rath et al by using high-dose vitamin C, lysine, and profile, unfortunately. We are clearly in need of better alternatives to treat this difficult and high-risk disorder.

Reduction of triglycerides/VLDL/IDL--I lump these three together since they all respond together. If you're niacin intolerant, maximixing your fish oil can be crucial for reduction of these patterns using doses above the usual starting 4000 mg per day (providing 1200 mg EPA+DHA). Reduction of processed carbohydrates, eimination of processed foods that contain high-fructose corn syrup, and weight loss to ideal weight are also very effective. "Soft" strategies with modest effects include green tea (>6 cups per day) or theaflavin 600-900 mg/day; raw nuts like almonds, walnuts, and pecans; exercise; soy protein.

Reduction of LDL--Lots of alternatives here including oat bran (3 tbsp per day), ground flaxseed (3 tbsp per day), soy protein (25 grams per day), Benecol butter substitute (for stanol esters), soluble fibers like pectin, psyllium, glucomannan; raw nuts like almonds, walnuts, and pecans.

In future, should torcetrapib become available (by prescription), this will add to our available tools for these areas when niacin can't be used. Until now, the alternatives to niacin depend on what you and your doctor are trying to achieve. In the vast majority of cases, HDL, small LDL, triglyceride, etc. goals for heart scan score control can be achieved, even when niacin is not well tolerated.

This question comes up so frequently that it's worth going over.

Flaxseed oil is a wonderful oil rich in linolenic acid, which may provide health benefits all by itself. Some authorities have speculated that the substantial reduction in heart attack seen in the Lyon Heart Study, the study that demonstrated the healthy power of the Mediterranean diet, is due to linolenic acid.

Flaxseed oil is also rich in monounsaturates and low in saturates, both desirable qualities. Of course, I'm talking here about flaxseed oil, to be distinguished from flaxseed , which are the intact seeds. The seeds themselves also contain the same oils, but contain other components, specifically lignan, a plant fiber with suspected health benefits like reduction in cancer risk.

Despite all flaxseed oil's wonderful properties, it is definitely not a substitute for fish oil. Why do we use fish oil for our coronary plaque control program (trying to reduce your heart scan score)? Several reasons. Fish oil:

--Dramatically reduces triglycerides, usually by 50% or more.
--Dramatically reduces specific lipoprotein classes like VLDL
--Dramatatically reduces, often eliminates, abnormal postprandial (after-eating) lipoprotein patterns, like IDL (intermediate-density lipoprotein)
--Has been conclusively shown to reduce risk of heart attack and death from heart attack (GISSI Prevenzione Trial).
--Has been shwon to reduce risk of stroke.
--Modifies blood clotting parameters, particularly a 20% reduction in fibrinogen.

Flaxseed oil, or linolenic acid concentrate for that matter, do not accomplish any of these effects, all crucial if you are to gain control over your coronary plaque.

Flaxseed oil and flaxseed remain wonderful nutritional agents for their own reasons. But they will not substitute for fish oil in your program. Only fish oil--the real thing--does the job.

This conversation is aimed primarily at non-followers of the Track Your Plaque program, because if you were a follower, you’d already know the answer!

I saw a woman in the hospital today. She’d just survived her second heart attack one week earlier. At 51 years old, she was understandably shaken, perhaps terrified. She felt that her future was uncertain and, in fact, had discussed with her husband what he should do to prepare for a future without her.

One week earlier, she’d received three stents that successfully aborted her heart attack. But, as is always the case, the modest delays of ambulance transport, the emergency room preliminaries, then of mobilizing an available cardiologist and catheterization laboratory team, totaled nearly two hours before her stent procedure. Inevitably, a moderate amount of damage had been done to her heart.

Her first “event” had been very similar: very little warning, then 911 and the flurry of activity. Both times, the cardiologists (two different physicians) complimented the patient on her prompt action. Both also called her heart attacks “close calls”.

She defied the odds with two near-death events. So, when I met her a week after her last heart attack, I asked an obvious question: “Has anyone told you why you’re having these heart attacks?”

She looked completely puzzled at first. She then said, “No, not really. I just assumed it was genetic. My mother went through the same thing when she was my age. But she didn’t get as far as I have, since they didn’t have these procedures back then.”

To me, this seems inexcusable: This woman had experienced two brushes with death and no doctor had established a cause. Could this woman’s belief be true, that it’s just genetic?

While there are, indeed, genetic causes for heart disease, the vast majority of these genetic causes are 1) identifiable, and 2) correctable. Genetic does not necessarily mean hopeless. It just means that the usual equation of heart disease risk management (heart disease = LDL cholesterol = need for Lipitor) has limited value. It would be like giving penicillin to people for any and all infections. It will work occasionally, but it will fail miserably in a great many cases. Treating LDL cholesterol with statin drugs is just like that.

Perhaps this woman has lipoprotein(a), a serious genetic trait that predicts heart disease at a young age and is largely unaffected by statin drugs. Or, she may have a severe excess of small LDL, only partially suppressed by statins. If she has the combined pattern of lipoprotein(a) and small LDL, that means she has two statin-unresponsive and significant genetic traits. But they respond to niacin, specific nutritional strategies, and several other agents.

The message: If you have coronary disease, you need to insist on knowing why. “It’s genetic” is not an acceptable answer. “There’s no proof of any heart disease causes beyond cholesterol” is also nonsense. “Everyone gets heart disease, or “hardening of the arteries”, eventually. You just got it a little before everyone else” is also patently ridiculous.

Identifying the causes of your coronary disease (or coronary plaque if you’ve had a CT heart scan) is the first step in developing a program of treatment that provides you with control over this disease.

If you haven't yet tried it to facilitate weight loss, it's really worth giving the new inulin-containing product, Fiber Choice "Weight Management", a try.

Recall (from a prior Heart Scan Blog) that inulin is a vegetable-based fiber found in celery, green peppers, etc. that, when exposed to water, expands to many times original volume. This simple phenomenon yields satiety--a feeling of fullness.

The manufacturer of the product has also added green tea, which has been shown in two small clinical studies to enhance weight loss, though by a different route.

We've been advising patients to chew two of the strawberry flavored tablets one hour before every meal (or with breakfast if you eat immediately in the morning). You'll be satisfied with less food and you'll experience less intense food cravings.

Though no one so far has achieved a huge drop in weight, it does seem to enhance a slow, gradual weight loss larger than achieved by diet and exercise alone. And it's very safe and inexpensive. If you give it a try to help you lose weight, let us know what kind of results you've obtained.

An article of mine came out in Life Extension Magazine and is available on the online version at:

http://www.lef.org/magazine/mag2006/sep2006_report_omega1_01.htm

This is an update on the heart health applications of fish oil.

Or, go to to www.lef.org and put fish oil into your on-site search and you'll come back to it in future.

Of course, it comes with Life Extension's promotion of its supplements.

Although it's not yet available online, the hard copy version of an article I wrote on homocysteine is available in the October, 2006 Life Extension Magazine. If you're not a member of their program, they'll send you a free copy just for signing up for it without obligation. Go to the home page of www.lef.org to do so. Or, Life Extension is available at newstands if you're in a rush or don't want to sign up for a free copy.

If you haven't done so already, you should subscribe to Dr. John Cannell's free newsletter on vitamin D issues. His newest issue is available at:

http://www.vitamindcouncil.com/newsletter/2006-aug.shtml

A sign-up to subscribe is available on the same page.

I continue to be shocked and amazed at the prevalence and magnitude of vitamin D deficiency in the people I see every day. It's been a beautiful summer with very little rain. Most days have been in the 70-80 degree range--very comfortable to be outdoors in the sun and getting skin expoxure to activate vitamin D in the skin.

Yet, in the vast majority of people I see, summer blood levels of vitamin D are virtually indistinguishable from winter levels. Both hover around the 30 ng/ml range. Summer levels in Wisconsin people seem to be no more than 10 ng/ml higher than winter levels. This remains true even in people who spend a lot of their day outdoors gardening, walking, etc. wearing shorts and a short-sleeved shirt, i.e. with plenty of skin surface area exposed.

I'm at a loss to explain precisely why. Yes, it is Wisconsin. But a direct sun overhead, 75 degree day should be providing plenty of sun. My suspicious is that a combination of factors are at work: people are not spending as much time outdoors as they claim; they often seek shade; use sunscreen; and they're overweight. (Excess weight decreases vitamin D blood levels dramatically, yet another reason not to get fat!)

Read more about vitamin D by checking out Dr. Cannell's insightful comments on the unfolding vitamin D story. He holds nothing back.

I don't mean to beat this discussion to a pulp, but looking back over the comments posted on www.theHeart.org forum, I am so deeply impressed with Dr. William Blanchet's grasp of the issues, that I posted his articulate and knowledgeable comments again.

Here is one post in which Dr. Blanchet, in response to accusations of trying to profit from heart scans, provides a wonderful summary of the logic and evidence behind the use of heart scans as the basis for heart disease prevention.

Yes, I have seen a dramatic reduction in coronary events.

Of 6,000 active patients, 48% being Medicare age and over, I have seen 4 heart attacks over the last 3+ years. 2 in 85 year old diabetics undergoing cancer surgery, one in a 90 year old with known disease and one in a 69 year old with no risk factors, who was healthy, and had never benefited from a heart scan.

The problem with coronary disease is that we rely on risk factors. Khot et al in JAMA 2003 showed that of 87,000 men with heart attacks, 62% had 0 or 1 major risk factor prior to their MI. According to ATP-III, almost everyone with 0-1 risk factors is low risk and most do not qualify for preventive treatment. EBT calcium imaging could identify 98% of these individuals as being at risk before their heart attack and treatment could be initiated to prevent their MI.

Treating to NCEP cholesterol goals prevents 30-40% of heart attacks. Treating to a goal of coronary calcium stability prevents 90% of heart attacks. Where I went to school, a 40% was an F. Why are we defending this result instead of striving to improve upon it? I am not making this up, look at Raggi's study in Arteriosclerosis, Thrombosis, and Vascular Biology 2004;24:1272, or Budoff Am J Card.[I believe it's the study Dr. Blanchet was referring to.]

I strongly disagree with the assertion that the stress test is a great risk stratifier. Laukkanen et al JACC 2001 studied 1,769 asymptomatic men with stress tests. Although failing the stress test resulted in an increased risk of future heart attack, 83% of the total heart attacks over the next 10 years occurred in those men who passed the stress test. Falk E, Shah PK, Fuster V Circulation 1995;92:657-671 demonstrated that 86% of heart attacks occur in vessels with less than 70% as the maximum obstruction. A vast majority of
patients with less than 70% vessel obstruction will pass their stress test.

Regarding [the] question of owning or referring for EBT imaging, I would be amused if it were not insulting. The mistake that is often made is that EBT imaging is a wildly profitable technology. It is not nearly as profitable as nuclear stress imaging. Indeed there are few EBT centers in the country that are as profitable as any random cardiologist's stress lab.

How can we justify not screening asymptomatic patients? Most heart attacks occur in patients with no prior symptoms and according to Steve Nissen, 150,000 Americans die each year from their first symptom of heart disease. My daughter is at this moment visiting with a friend who lost her father a few years ago to his first symptom of heart disease when she was 8 years old. That is not OK! We screen asymptomatic women for breast cancer risk. Women are 8 times more likely to die from heart disease than breast cancer. We do mass screening for colon cancer and we are over 10 times more likely to die from heart attacks than colon cancer. An EBT heart scan costs 1/8th the cost of a colonoscopy.

So what say we drop the sarcasm and look at this technology objectively. Read the literature, not just the editorial comments. This really does provide incredibly valuable information that saves lives.

Yes, a 90% reduction in heart attacks in my patients compared to the care I could provide 5 years ago when I was doing a lot of stress testing and referring for revascularization. Much better statistics than expected national or regional norms. I welcome your scrutiny.

That's probably the best, most concise summary of why heart scanning makes sense that I've ever heard. And it comes from a primary care physician in the trenches. With just a few paragraphs, Dr. Blanchet, in my view, handily trumps the arguments of my colleagues arguing to maintain the status quo of cholesterol testing, stress tests, and hospital procedures.

Note:
Dr. Blanchett talks openly about his affiliation with an imaging center in Boulder, Colorado, Front Range Preventive Imaging. I'm no stranger to the accusations Dr. Blanchet receives about trying to profit from the heart scan phenomenon. Ironically, heart scanning loses money. It is a preventive test, not a therapeutic, hospital-based procedure. Free-standing heart scan centers that do little else (perhaps virtual colonoscopies) usually manage to pay their bills but make little profit. Hospitals that offer heart scans usually do so as a "loss-leader," i.e., an inexpensive test that brings you in the door in the hopes that you will require more testing.

Accusations of profiteering off heart scans are, to those in the know, ridiculous and baseless. On the contrary, heart scans are both cost-saving and life-saving.

Here's a sampling of prescription vitamin D2/ergocalciferol products available:

Prescription ergocalciferol (vitamin D2) (Drisdol brand), 50 caps for $130.84.

Alfcip brand of erogocalciferol (vitamin D), 30 capsules for $28.20.

Ergocalciferol (vitamin D2) as Drisdol oral solution, 1 bottle $146.26.

How about vitamin D3/cholecalciferol?

Carlson's brand cholecalciferol (vitamin D3), 120 capsules $5.09.

Cholecalciferol, vitamin D3, is far less expensive than ergocalciferol, vitamin D2. Cholecalciferol is available as a supplement without prescription. Ergocalciferol is available only by prescription.

The price difference must mean that the plant-based form, ergocalciferol, must be far superior to the naturally-occurring human form, vitamin D3.

Of course, that's not true. Dr. Robert Heaney's study is just one of several documenting the inferiority of D2/ergocalciferol, Vitamin D2 Is Much Less Effective than Vitamin D3 in Humans. D2 exerted less than a third of the effect of D3.

In my experience, D2/ergocalciferol often exerts no effect whatsoever. One woman I consulted on came into the office having been prescribed Drisdol capsules, 50,000 units every day for the past 18 months (by mistake by her physician). Blood level of active 25-OH-vitamin D3: Zero.

But the pharmacy and drug manufacturer collected $1413 for her 18-month course. Cost for a 4000 unit per day dose of D3/cholecalciferol: $45--and it would have actually worked.

In my view, prescription vitamin D2 is yet another example of drug manufacturer scams, a product that provides no advantages, costs more, but yields bigger profits.

Yet this wonderful supplement called cholecalciferol, among which Carlson's is an excellent choice, is available to you inexpensively, without prescription, and actually provides the benefits you desire.

One of the most common misunderstandings encountered by both physicians and the public is that, to create an effective heart disease prevention program, we need tools for atherosclerotic plaque detection. What we do not need is a tool for stenosis detection. (Stenosis means percent blockage. A 50% stenosis means 50% of the diameter of an artery is reduced by atherosclerosis.)

This issue came to mind recently with the ongoing conversation at Heart.org forum, in which the conversation predictably degenerated into a "what good are heart scans when there are better tests to detect blockage" sort of mentality.
They are right: There are better tests to detect stenoses or blockages, such as stress tests, heart catheterization, and CT coronary angiography. If someone is having chest pain or breathlessness, these tests are useful to help understand why. These tests are preludes to stents, bypass surgery, and the like. They are the popular tools in hospitals, the ones that provide entry into the revenue-yielding world of heart disease procedures.

Plaque detection, on the other hand, is principally a tool for the person without symptoms. In this regard, it is more like cholesterol testing. I doubt my colleagues would bash cholesterol because it doesn't reveal blockages. Plaque detection identifies the person who has already started developing atherosclerosis.

Dr. William Blanchett of Colorado articulates this idea well:

EBT calcium imaging not only identifies the vast majority of individuals at risk, it also identifies individuals with minimal risk. In other words, it distinguishes those who are likely to benefit from treatment . . .and it identifies those unlikely to benefit from treatment. Furthermore, the greatest value of EBT calcium imaging is that with serial imaging you can determine who is and who is not responding to treatment.

Those patients not responding to the initial treatment are identified by progression of their calcified plaque on a subsequent scan are then placed on additional therapies. The net result is a remarkable reduction in heart attack rates.

Ahh, the voice of reason. Plaque detection empowers you in your prevention program. If you know how much plaque your begin with, you can track that value to know whether you have having a full effect or not. Stenosis detection, on the other hand, empowers your doctor and provides the irresistible impulse to stent.

Another common objection raised to plaque detection is "why bother if you're going to give everybody a statin anyway?" We know the origins of that argument, don't we? If the only strategy known to your doctor is cholesterol reduction with statin drugs, then perhaps that's right. But, with awareness of all the things that go beyond statin drugs, often make them unnecessary, then knowledge of who should engage in an intensive program of prevention or not is enabled by plaque detection.

In response to an earlier Heart Scan Blog post, I don't care about hard plaque!, reader Dave responded:

Hello Dr Davis,

Interesting post about hard and soft plaque. I recently had a discussion with my GP regarding my serious increase in scan score (Jan 2006 = 235, Nov 2007 = 419).

After the first scan we started aggressively going after my LDL, HDL and Trig...196,59,221

And have them down to 103, 65, 92 - we still have a way to go to 60/60/60 [The Track Your Plaque target values]-

So the increase is a surprise, but my doctor said that the increase could in part be cause some of the soft plaque had been converted to hard plaque and the scan would show that conversion.

Dave's doctor then responded to him with this comment:

"Remember that although your coronary calcium score has gone up, this does not mean that you are at greater risk than you were a year ago. Remember that the most dangerous plaque is the not-yet calcified soft plaque, which will not show up on an EBT [i.e., calcium score]. It is only the safe, calcified plaque that can be measured with the EBT. [Emphasis mine.] For your score to go up like it did, while your lipids came down so much, what had to happen was that lots of dangerous unstable plaque was converted to stable, calcified plaque. There are no accepted guidelines for interpreting changes in calcium scores over time, because the scores tend to go up as treatment converts dangerous plaque to safer plaque. We do know that aggressively lowering LDL reduces both unstable and stable plaque, and we know that risk can be further lowered by adjuvant therapy such as I listed above."

Huh?

This bit of conventional "wisdom" is something I've heard repeated many times. Is it true?

It is absolutely NOT true. In fact, the opposite is true: Dave's substantial increase in heart scan score from 235 to 419 over 22 months, representing a 78% increase, or an annualized rate of increase of 37%. This suggests a large increase in his risk for heart attack, not a decrease. Big difference!

Dr. Paulo Raggi's 2004 study, Progression of coronary artery calcium and risk of first myocardial infarction in patients receiving cholesterol-lowering therapy in 495 participants addresses this question especially well. Two heart scans were performed three years apart, with a statin drug initiated after the first scan, regardless of score.

During the period of study, heart attacks occurred in 41 participants. When these participants were analyzed, it was found that the average annual increase in score over the three year period was 42%. The average annual rate of increase in those free of heart attack was 17%. The group with the 42% annual rate of increase--all on statin drugs--the risk of heart attack was 17.2-fold greater, or 1720%.

The report made several other important observations:

--20% of the heart attack-free participants showed reduction of heart scan scores, i.e., reversal. None of the participants experiencing heart attack had a score reduction.
--Only 2 of the 41 heart attacks occurred in participants with <15% per year annual growth, while the rest (39) showed larger increases.
--The intensity of LDL reduction made no difference in whether heart attacks occurred or not. Those with LDL<100 mg/dl fared no better than those with LDL>100 mg/dl.

Dr. Raggi et al concluded:

"The risk of hard events [heart attack] was significantly higher in the presence of CVS [calcium volume score] progression despite low LDL serum levels, although the interaction of CVS change and LDL level on treatment was highly significant. The latter observation strongly suggests that a combination of serum markers and vascular markers [emphasis mine] may constitute a better way to gauge therapeutic effectiveness than isolated measurement of lipid levels."

This study demonstrates an important principle: Rising heart scan scores signal potential danger, regardless of LDL cholesterol treatment. Yes, LDL reduction does achieve a modest reduction in heart attack, but it does not eliminate them--not even close.

These are among the reasons that, in the Track Your Plaque program, we aim to correct more than LDL cholesterol. We aim to correct ALL causes of coronary plaque, factors that can be responsible for continuing increase in heart scan score despite favorable LDL cholesterol values.

So, Dave, please forgive your doctor his misunderstanding of the increase in your heart scan score. He is not alone in his ignorance of the data and parroting of the mainstream mis-information popular among the statin-is-the-answer-to-everything set.

Just don't let your doctor's ignorance permit the heart attack that is clearly in the stars. Take preventive action now.

There's a fascinating and vigorous debate going on at the Heart.org website among Dr. Melissa Shirley-Walton, the recently publicized proponent of "a cath lab on every corner": Dr. William Blanchet, a physician in northern Colorado; and a Track Your Plaque Member who calls himself John Q. Public.

John Q. has been trying to educate the docs about the Track Your Plaque program. Unfortunately, Dr. Shirley-Walton essentially pooh-poohs his comments, preferring to lament her heavy work load. In her last post, when she discovered that John Q. was not a physician, she threatened to block his posts and delete all prior posts.

However, Dr. Blanchet has emerged as a champion of heart scanning, intensive lipid management, and lipoproteins, much similar to our program. In fact, many of Dr. Blanchet's comments were so similar to mine that John Q. asked me if it was really me! (It is definitely not.)

Here's a sampling of some of the discussion going on now:

Dr. Blanchett started out the discussion by saying:

Stent Insanity
I have no trouble agreeing with the argument that we have initiated the widespread use of DES without adequate study regarding outcomes. Shame on us.

That said, we are ingoring the DATA that shows that most heart attacks occur as a result of non-obstructing plaque and all the talk about which stent to use ignors the majority of individuals at risk. In addition, for a decade we have known that stenting does not improve net outcomes anyway.

What ever happened to effective primary prevention? We discarded EBT calcium imaging like moldy cabbage without even looking at the outcomes DATA. With direction provided by EBT calcium imaging and effective primary prevention, I have been able to reduce myocardial infarction by 90% in my very large Internal Medicine practice. Through effectively identifying patients at risk and measuring success or failure of treatment with serial EBT, I have made the argument as to which stent to use moot. No symptomatic angina and rare infracts equals little need for any stent.

Is anybody listening? Certainly not the cardiologists whose wealth and fortunes are based on nuclaer imaging, angiography and stenting.

Dr. Shirley-Walton, skeptical of Dr. Blanchet's claim of >90% reduction of heart attacks using a prevention program starting with a heart scan:

To rely soley upon a calcium score will deprive you of a lot of information that could be otherwise helpful in the management of your patients.

Without seeming sarcastic, I must refute : "of 6,000 patients I've seen 4 heart attacks in 3 years". Although I certainly hope your statistics are accurate, I will suggest the following:

You've not seen all of the heart attacks since up to 30% of all heart attacks are clinically silent. So unless you are echo'ing or nuclear testing all of these patients in close followup, you aren't certain of your stats.

Secondly, in order to attribute this success to your therapy, you would have to have nearly 100% compliance. In the general population, compliance is often less than 50% with any regimen in any given year of treatment. If you can tell us how you've achieved this level of compliance, we could all take a lesson.

Dr. Blanchett, commenting on his use of heart scanning as a primary care physician:

CAC [coronary artery calcium] is an inexpensive and low radiation exam to identify who is at increased risk for heart attacks.

A study of 222 non-diabetic patients admitted with their first MI found 75% of them did not qualify for cholesterol modifying therapy prior to their initial MI (JACC 2003:41 1475-9). In another study of 87,000 men with heart attacks, 62% had 0 or 1 major risk factors (Khot, et al. JAMA. 2003). Almost all individuals with 0 or 1 risk factor are Framingham "Low risk" and therefore will not qualify for cholesterol lowering therapies. (JAMA. 2001;285:2486-2497)

Risk factors alone are not sufficient. In my practice, of the last 4 patients who have died from heart attacks, none qualified for preventive therapies by NCEP guidelines.

Studies have shown that CAC by EBT provides an independent and incremental predictor of heart attack risk. (1. Kondos et al, Circulation 2003;107:2571-2176, 2. Am Heart J 141. 378-382, 2001, 3. St Francis Heart Study Journal of the American College of Cardiology July, 2005) The old saw that CAC simply reflects risk factors and age is just wrong.

Although CT angiography shows great promise to reduce unnecessary conventional angiography and is helpful in emergency room chest pain evaluation, I do not see CT angiography as a screening study in asymptomatic individuals. 10 times more radiation than EBT calcium imaging plus the risk of IV dye exposure makes CT angiography inconsistent with the principles of a screening test. Taken in the context of a primary care physician's evaluation of heart attack risk, EBT calcium imaging has great value.

Coronary calcium changes management by: 1. Identifying those at risk who do not show up with standard risk stratification (St Francis Heart Study: Journal of the American College of Cardiology July, 2005). 2. Motivating patients to be compliant with therapies (Atherosclerosis 2006; 185:394-399). 3. By measuring serial calcium, we can see who is and who is not responding to our initial treatment so that we can further refine our therapeutic goals (Atherosclerosis, 2004;24:1272).

When used in the primary care preventive setting, CAC imaging is indeed of great incremental value. In my practice, in improves my outcomes so greatly that it compels Melissa Walton-Shirley to question my veracity.

Dr. Melissa Walton-Shirley:

Ahhhhhh.......the aroma of profit making, I thought I smelled it. [Accusing Dr. Blanchett of referring patients for heart scans for personal profit.]

I will tell you that I was a little hurt when I was called "a typical cardiologist with a butcher block mentality" after my primary pci piece for med-gen Med was reviewed by the track your placque [sic] folks.

Though, it's clear that they misunderstood and thought I was cathing for dollars, instead my intention was to "push" for primary PCI for AMI, it left me seething until the blessing of a busy schedule and a forgetful post menopausal brain took its toll.
None the less, an honest open discussion is always welcome here but I would appreciate it if everyone would just divulge their affiliations up front so that the context of their opinions could be better understood.

I also insist that the compliance described by you William B. is rather astounding and a bit unbelieveable, however if it's accurate, you are to be congratulated.

Dr. Blanchett, in response to Dr. Shirley-Walton's statement that she relies on stress testing:

I think that the threshold of comfort you get from stress test stratification is different than what I consider acceptable. It is hard for me to tell a bereaved spouse that the departed did everything I suggested and still died from a MI. Coronary calcium imaging provides me the tool that I need.

Are you aware that there are a number of studies that show a dramatic increase in risk of MI in individuals with an annualized increase in calcified plaque burden of >14%? I consider this to be a valuable measure of inadequacy of medical management. A stress test does not become positive until we have catastrophically failed in medical management. Consequently, even in the patient with “high risk” stratification, one can justify a calcium score to establish a baseline to measure adequacy of primary prevention. Calcium scores by EBT cost about 1/5th the cost of a nuclear stress test and subject the patient to 1/10th the radiation of nuclear imaging and provides more precise information.

Regarding John Q, I do not think that non-medical prospective should be excluded from this blog. I think we as physicians benefit from hearing how the non-physician public views medicine. I have become much better at what I do by listening to my patients and learning from them.

Dr. Blanchett continues:

Yes, I have seen a dramatic reduction in coronary events. Of 6,000 active patients, 48% being Medicare age and over, I have seen 4 heart attacks over the last 3+ years. 2 in 85 year old diabetics undergoing cancer surgery, one in a 90 year old with known disease and one in a 69 year old with no risk factors, who was healthy, and had never benefited from a heart scan.

The problem with coronary disease is that we rely on risk factors. Khot et al in JAMA 2003 showed that of 87,000 men with heart attacks, 62% had 0 or 1 major risk factor prior to their MI. According to ATP-III, almost everyone with 0-1 risk facto is low risk and most are do not qualify for preventive treatment. EBT calcium imaging could have identify 98% of these individuals as being at risk before their heart attack and treatment could be initiated to prevent their MI.

Treating to NCEP cholesterol goals prevents 30-40% of heart attacks. Treating to a goal of coronary calcium stability prevents 90% of heart attacks. Where I went to school a 40% was an F. Why are we defending this result instead of striving to improve upon it? I am not making this up, look at Raggi's study in Ateriosclerosis, Thrombosis, and Vascular Biology 2004;24:1272, or Budoff Am J Card

Melissa, I strongly disagree with the assertion that the stress test is a great risk stratifier. Laukkanen et al JACC 2001 studied 1,769 asymptomatic men with stress tests. Although failing the stress test resulted in an increased risk of future heart attack, 83% of the total heart attacks over the next 10 years occurred in those men who passed the stress test.
Falk E, Shah PK, Fuster V Circulation 1995;92:657-671 demonstrated that 86% of heart attacks occur in vessels with less than 70% as the maximum obstruction. A vast majority of patients with less than 70% vessel obstruction will pass thier stress test.

William, regarding your question of owning or referring for EBT imaging, I would be amused if it were not insulting. The mistake that is often made is that EBT imaging is a wildly profitable technology. It is not nearly as profitable as nuclear stress imaging. Indeed there are few EBT centers in the country that are as profitable as any random cardiologists stress lab.

How can we justify not screening asymptomatic patients? Most heart attacks occur in patients with no prior symptoms and according to Steve Nissen, 150,000 Americans die each year from their first symptom of heart disease. My daughter is at this moment visiting with a friend who lost her father a few years ago to his first symptom of heart disease when she was 8 years old. That is not OK! We screen asymptomatic women for breast cancer risk. Women are 8 times more likely to die from heart disease than breast cancer. We do mass screening for colon cancer and we are over 10 times more likely to die from heart attacks than colon cancer. An EBT heart scan costs 1/8th the cost of a colonoscopy.

So what say we drop the sarcasm and look at this technology objectively. Read the literature, not just the editorial comments. This really does provide incredibly valuable information that saves lives.

Yes, a 90% reduction in heart attacks in my patients compared to the care I could provide 5 years ago when I was doing a lot of stress testing and referring for revascularization. Much better statistics than expected national or regional norms. I welcome your scrutiny.

John Q. Public jumps into the fray with:

Fascinating, isn't it, that there appear to be two doctors, William Blanchet in this forum and Dr. William Davis, FACC, of cureality.com that both claim to have dramatically reduced risk of heart attack among their patients and/or actual calcium plaque score regression and BOTH are ardent proponents of CT Calcium Scoring?

Despite Dr. Blanchet's persuasive arguments backed up with numerous scientific citations and John Q.'s support, I sense they had no effect whatsoever on Shirley-Walton's way of thinking.

Such are the deeply-entrenched habits of the cardiology community. It will be many years and impassioned pleas to see things in a different light before the wave of change seizes hold.

Curious thing about fasting: It teaches you how to eat.

In previous posts, I've discussed the potential benefits of fasting: reduction of blood pressure, reduction of inflammatory responses, drop in blood sugar, weight loss, and reduced heart attack risk. In my recent Heart Scan Blog post, Fasting and Heart Disease, I discussed the just-released results of a study in people who fast for religious reasons and experience less heart disease.

Fasting can mean going entirely without food and just making do with (plenty of) water, or it can mean variations on "fasting" such as vegetable juice fasts, soy milk fasts, etc.

How can fasting teach you any lessons about food and eating?

People who fast will tell you that the experience:

--Helps you appreciate food tastes when you resume eating. After a fast, flavors are stronger; sensations like sweet, sweet, or salty are sharper; you become reacquainted with the variety of wonderful food textures.

--Makes you realize how you ate too much before your fast. After a fast, you are satisfied with less. You will eat more for taste and enjoyment, less for satiety and mindless indulgence.

--Makes you more mindful of the act of eating. For many of us, eating is an automatic activity that provides fleeting satisfaction. After a fast, each bite of food brings its own special enjoyment.

--Reveals to you how awful you felt when many foods were eaten. For example, many people are physically slightly ill after eating pancakes, pizza, or other highly processed foods but cease to recognize it. Remove the offensive foods entirely and you might realize just how bad you felt.

--Takes away fear of hunger. Many people have a gut-wrenching fear of hunger. It's probably partly instinctive, that animal-like fear of not knowing when your next meal is coming, partly the abnormal, artificial drive to eat ignited by processed foods like wheat and corn syrup.

--Makes you realize just how much of your day is spent in some activity associated with food. Shopping, eating, cleaning up afterwards, thinking and talking about food all occupy an extraordinary portion of everyone's life. A fast can open your eyes to just how much time is spent in these pursuits. Sometimes, gaining an awareness of a mindless, repetitive behavior can provide the first step towards changing direction.

Most people consider a fast for rapid weight loss. But fasting is far more than that. Perhaps fasting has become an integral part of many religious practices because of its capacity for enlightenment, reawakening, revelation, but not of only the spiritual, but also of how far many of us have strayed in diet.

Fasting is what Omnivore's Dilemma author Michael Pollen might describe as looking the pig you're about to eat in the eye, an opportunity to open your eyes to what it is you 've been doing all these years.

In the Track Your Plaque program, we aim to stop or reduce your heart scan score.

Recall that, without any preventive efforts, heart scan scores can be expected to increase at the average rate of 30% per year (faster at lower scores, slower at higher scores by a quirk of arithmetic).

I am continually surprised at how often people--that is, people not in the Track Your Plaque program--are often content with what I term "deceleration," or the slowing of plaque growth. In truth, most people are content with deceleration of plaque growth because they simply don't know that plaque continues to grow.

For instance, the BELLES Trial (Beyond Endorsed Lipid Lowering with EBT Scanning (BELLES)), reported in 2005 showed that 650 women participants continued to increase heart scan scores 15% whether they took "high-intensity" statin therapy in the form of Lipitor 80 mg or "low-intensity" statin therapy as pravastatin 40 mg, even though the group taking Lipitor experienced twice the amount of LDL reduction. In other words, heart scan scores continued to increase at the same rate of 15% per year regardless of the intensity of LDL lowering by statin drug.

Another study reported in 2006, Effect of intensive versus standard lipid-lowering treatment with atorvastatin on the progression of calcified coronary atherosclerosis over 12 months: a multicenter, randomized, double-blind trial reported similar results. Of the 471 participants, those taking Lipitor 80 mg per day experienced 27% per year plaque growth (LDL cholesterol 87 mg/dl); those taking 10 mg Lipitor experienced 25% plaque growth (LDL 107 mg/dl). The intensity of statin therapy made no difference on the rate of plaque growth.

In other words, if we are content to sit back and take Lipitor or other statin drug, follow the conventional American Heart Association low-fat, low-cholesterol diet, we will experience somewhere between 15 to 27% annual plaque growth--year after year.

No wonder that conventional advice offered by your friendly neighborhood doctor will avoid (postpone?) only one heart attack in four.

Such is the nature of coronary plaque deceleration: growth is modestly slowed, but is not stopped. Nor is it reversed.

In the Track Your Plaque program, we grade deceleration of plaque growth into three distinct stages out of a total of five. (See Winning Your Personal War with Heart Disease: The Track Your Plaque 5 Stages of Success.)

Why be satisfied with deceleration? Why not aim for a total stop to plaque growth? Why not aim for stage 5 of Track Your Plaque success: reversal?

(For followers of the Heart Scan Blog, below is a re-posting of a recent post. I've moved it up to make it accessible to a number of patients that I asked to look at this post for some conversation about the concept of wheat-free diets.)

TV ads, media conversations, magazine articles, even advice from the American Heart Association and USDA (a la Food Pyramid) all agree: eat more whole grains, get more fiber.

What happens when you follow this advice to add more and more whole grains to your diet? Look around you: People gain weight, they become pre-diabetic and diabetic. Lipids and lipoprotein patterns emerge: increased triglycerides and VLDL, reduced HDL, small LDL. Blood sugar goes up, inflammatory responses are ignited. You feel crumby, cancer risk is increased.

"Official" agencies have urged us to eat more grains, get more fiber and most Americans have complied. We now have a nationwide health disaster that will eventually lead to more people with coronary plaque, more heart disease, more heart attack, more heart procedures.

This is why I've been urging patients to go wheat-free. It has proven an extraordinarily and surprisingly effective strategy for:

1) rapid and profound weight loss
2) raising HDL and reducing triglycerides, VLDL, and small LDL
3) reducing blood sugars, pre-diabetes and diabetes

So here I (re-) post just a sampling of the comments sent by readers of the Heart Scan Blog who have given this idea a try.

Barbara W said:

It's true! We've done it. My husband and I stopped eating all grains and sugar in February. At this point, we really don't miss them any more. It was a huge change, but it's worth the effort. I've lost over 20 pounds (10 to go)and my husband has lost 45 pounds (20 to go). On top of it, our body shapes have changed drastically. It is really amazing. I've got my waist back (and a whole wardrobe of clothes) - I'm thrilled.

I'm also very happy to be eating foods that I always loved like eggs, avocados, and meats - without feeling guilty that they're not good for me.

With the extremely hot weather this week in our area, we thought we'd "treat" ourselves to small ice cream cones. To our surprise, it wasn't that much of a treat. Didn't even taste as good as we'd anticipated. I know I would have been much more satisfied with a snack of smoked salmon with fresh dill, capers, chopped onion and drizzled with lemon juice.

Aside from weight changes, we both feel so much better in general - feel much more alert and move around with much greater flexibility, sleep well, never have any indigestion. We're really enjoying this. It's like feeling younger.

It's not a diet for us. This will be the way we eat from now on. Actually, we think our food has become more interesting and varied since giving up all the "white stuff". I guess we felt compelled to get a little more creative.

Eating out (or at other peoples' places) has probably been the hardest part of this adjustment. But now we're getting pretty comfortable saying what we won't eat. I'm starting to enjoy the reactions it produces.

Weight loss, increased energy, less abdominal bloating, better sleep--I've seen it many times, as well.

Dotslady said:

I was a victim of the '80s lowfat diet craze - doc told me I was obese, gave me the Standard American Diet and said to watch my fat (I'm not a big meat eater, didn't like mayo ... couldn't figure out where my fat was coming from! maybe the fries - I will admit I liked fries). I looked to the USDA food pyramid and to increase my fiber for the constipation I was experiencing. Bread with 3 grams of fiber wasn't good enough; I turned to Kashi cereals for 11 years. My constipation turned to steattorrhea and a celiac disease diagnosis! *No gut pains!* My PCP sent me to the gastroenterologist for a colonscopy because my ferritin was a 5 (20 is low range). Good thing I googled around and asked him to do an endoscopy or I'd be a zombie by now.

My symptoms were depression & anxiety, eczema, GERD, hypothyroidism, mild dizziness, tripping, Alzheimer's-like memory problems, insomnia, heart palpitations, fibromyalgia, worsening eyesight, mild cardiomyopathy, to name a few.

After six months gluten-free, I asked my gastroenterologist about feeling full early ... he said he didn't know what I was talking about! *shrug*

But *I* knew -- it was the gluten/starches! My satiety level has totally changed, and for the first time in my life I feel NORMAL!

Feeling satisfied with less is a prominent effect in my experience, too. You need to eat less, you're driven to snack less, less likely to give in to those evil little bedtime or middle-of-the-night impulses that make you feel ashamed and guilty.

An anonymous (female) commenter said:

My life changed when I cut not only all wheat, but all grains from my diet.

For the first time in my life, I was no longer hungry -no hunger pangs between meals; no overwhelming desire to snack. Now I eat at mealtimes without even thinking about food in between.

I've dropped 70 pounds, effortlessly, come off high blood pressure meds and control my blood sugar without medication.

I don't know whether it was just the elimination of grain, especially wheat, or whether it was a combination of grain elimnation along with a number of other changes, but I do know that mere reduction of grain consumption still left me hungry. It wasn't until I elimnated it that the overwhelming redution in appetite kicked in.

As a former wheat-addicted vegetarian, who thought she was eating healthily according to all the expert advice out there at the time, I can only shake my head at how mistaken I was.

That may be a record for me: 70 lbs!!

Stan said:

It's worth it and you won't look back!

Many things will improve, not just weight reduction: you will think clearer, your reflexes will improve, your breathing rate will go down, your blood pressure will normalize. You will never or rarely have a fever or viral infections like cold or flu. You will become more resistant to cold temperature and you will rarely feel tired, ever!

Ortcloud said:

Whenever I go out to breakfast I look around and I am in shock at what people eat for breakfast. Big stack of pancakes, fruit, fruit juice syrup, just like you said. This is not breakfast, this is dessert ! It has the same sugar and nutrition as a birthday cake, would anyone think cake is ok for breakfast ? No, but that is exactly the equivalent of what they are eating. Somehow we have been duped to think this is ok. For me, I typically eat an omelette when I go out, low carb and no sugar. I dont eat wheat but invariably it comes with the meal and I try to tell the waitress no thanks, they are stunned. They try to push some other type of wheat or sugar product on me instead, finally I have to tell them I dont eat wheat and they are doubly stunned. They cant comprehend it. We have a long way to go in terms of re-education.

Yes. Don't be surprised at the incomprehension, the rolled eyes, even the anger that can sometimes result. Imagine that told you that the food you've come to rely on and love is killing you!

Anne said:

I was overweight by only about 15lbs and I was having pitting edema in my legs and shortness of breath. My cardiologist and I were discussing the possible need of an angiogram. I was three years out from heart bypass surgery.

Before we could schedule the procedure, I tested positive for gluten sensitivity through www.enterolab.com. I eliminated not only wheat but also barley and rye and oats(very contaminated with wheat) from my diet. Within a few weeks my edema was gone, my energy was up and I was no longer short of breath. I lost about 10 lbs. The main reason I gave up gluten was to see if I could stop the progression of my peripheral neuropathy. Getting off wheat and other gluten grains has given me back my life. I have been gluten free for 4 years and feel younger than I have in many years.

There are many gluten free processed foods, but I have found I feel my best when I stick with whole foods.

Ann has a different reason (gluten enteropathy, or celiac disease) for wanting to be wheat-free. But I've seen similar improvements that go beyond just relief of the symptoms attributable to the inflammatory intestinal effects of gluten elimination.

Wccaguy said:

I have relatively successfully cut carbs and grains from my diet thus far.

Because I've got some weight to lose, I have tried to keep the carb count low and I've lost 15 pounds since then.

I have also been very surprised at the significant reduction in my appetite. I've read about the experience of others with regard to appetite reduction and couldn't really imagine that it could happen for me too. But it has.

A few weeks ago, I attended a party catered by one of my favorite italian restaurants and got myself offtrack for two days. Then it took me a couple of days to get back on track because my appetite returned.

Check out Jimmy Moore's website for lots of ideas about variations of foods to try. The latest thing I picked up from Jimmy is the good old-fashioned hard boiled egg. Two or three eggs with some spicy hot sauce for breakfast and a handful of almonds mid-morning plus a couple glasses of water and I'm good for the morning no problem.

I find myself thinking about lunch not because I'm really hungry but out of habit.

The cool thing too now is that the more I do this, the more I'm just not tempted much to do anything but this diet.

Going wheat-free, along with a reduction in processed sugary foods like Hawaiian Punch, sodas, and candy, is the straightest, most direct path I know of to lose weight, obtain all the health benefits listed by our commenters, as well as achieve the lipoprotein corrections we seek, like reduction of small LDL particles and rise in HDL, in the Track Your Plaque program.

Followers of the Track Your Plaque program know that we advocate periodic fasts to reduce heart disease risk.

I came across an interesting report form an abstract presented at last week's American Heart Association meetings in Orlando:

(Read the report at HeartWire. You will need to register or sign-in.)

In this study, the investigators tried to determine why members of the Church of Jesus Christ of Latter-Day Saints (LDS) tended to have reduced risk of heart disease compared to others in the area but not in the LDS faith. While the reduced risk of heart disease in LDS members had been traditionally attributed to the no smoking policy advocated by the Mormon church, the investigators suspected that there was more to the reduced risk.

Of 515 people interviewed, periodic fasting, whether for religious or other reasons, was found to distinguish people who were less likely to have coronary disease by conventional catheterization (59% vs. 67%). (Since the study was published in only abstract form, it's not clear why all these people underwent heart catheterization in the first place.)

Nonetheless, it's an interesting observation and one consistent with the benefits we see when someone fasts: reduced blood pressure, reduced inflammatory responses, improved lipids and lipoproteins, weight loss.

Fasting can be an especially effective method to gain control over heart disease and coronary plaque if rapid control is desired. In fact, I wonder if the normally year-long process of plaque control that I advocate can be much abbreviated. Fasting, I believe, is a crucial component of rapid control, what I've talked about in Instant Heart Disease Reversal

There's also additional thoughts on fasting in my Heart Scan Blog post, For rapid success, try the "fast" track.

Fasting is not something to fear. It can be an enlightening process that can serve to abruptly sever bad habits, perhaps even turn the clock back on prior dietary and lifestyle excesses. My favorite variation on fasting is to use soy milk (yes, yes, I know! I can already hear the the soy bashers screaming!) as a meal substitute. It is an easy, less dramatic way that still maintains most of the benefit of a full, water-only fast.

Why do stress tests so often fail to detect coronary atherosclerotic plaque? Why do even heart catheterizations--the "gold standard"--fail to disclose the full extent of plaque within the walls of coronary arteries?

We owe much of the explanation of these phenomena to Dr. Seymour Glagov, retired professor of pathology at the University of Chicago.

When studying the coronary arteries of people who died, he observed that people commonly had plenty of atherosclerotic plaque lining the artery wall, yet it did not necessarily impinge on the artery "lumen," or the internal path for blood to flow.

The only time the lumen became obstructed by plaque was when either 1) plaque grew to overwhelming levels and was severe and extensive, or 2) when a plaque had "ruptured," meaning its thin covering had been penetrated and eroded by the underlying plaque tissue like a volcano emerging from the surface and erupting.

This groundbreaking observation, now dubbed "the Glagov phenomenon," explains why someone can have a normal stress test on Tuesday but erupt a plaque on Wednesday.

The Glagov phenomenon also explains why heart scans can detect plaque when both stress tests and heart catheterizations fail to do so. Many physicians will then interpret this to mean that the heart scan was wrong. With the Glagov phenomenon in mind, you can see that the heart scan is not wrong, it is simply detecting coronary atherosclerotic plaque at a stage that is not yet detectable by the other methods.

In the illustration, you can see that the lumen of the vessel is maintained--despite the artery on the left having minimal plaque, the artery on the right containing moderate plaque. If either artery were examined by a test that relies on blood flow--stress test or heart catheterization--both would appear normal. But a test that examines the artery wall, such as a heart scan, would readily detect the artery on the right and probably even the artery on the left.

I am very grateful to Dr. Glagov and his insight into this important process. Otherwise, we might still be floundering around trying to understand the apparent discrepances between these tests that simply provide different perspectives on the same problem.

Take a look at the list of foods on the American Heart Association's (AHA) Check Mark endorsement program (below). After I saw the list, I was convinced either that the people who designed the program are either startlingly ignorant, or the AHA simply does this for money.

Many of these foods have nothing to do with health, heart or otherwise. In fact, many of these foods are prominent culprits that contribute to the American epidemic of obesity. There are cured meats with sodium nitrite (a potent cause of colon cancer). Some of these companies have been accused of unhealthy food manufacturing practices. Tyson Foods, for instance, has been in court many times defending their brutal factory farm practices and were the focus of a federal investigation for paying bribe money to USDA Secretary, Mike Espy. (Espy was acquitted but two Tyson executives were convicted, only to be later pardoned by then President Bill Clinton.)

This is a smarmy list to be included on. Though there are some rare healthy exceptions on the list, from the Track Your Plaque viewpoint, this is a list of shame, foods that have no place in a genuinely heart healthy nutrition program.

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Healthy Choice Café Selections Grilled Chicken Caesar
Healthy Choice Café Selections Grilled Chicken Marinara
Healthy Choice Café Selections Grilled Whiskey Steak
Healthy Choice Café Selections Italian Style Pepperoni Pizza
Healthy Choice Café Selections Roasted Chicken Chardonnay
Healthy Choice Café Selections Roasted Chicken Marsala
Healthy Choice Complete Selections Asiago Chicken Portabello
Healthy Choice Complete Selections Beef Pot Roast
Healthy Choice Complete Selections Beef Stroganoff
Healthy Choice Complete Selections Beef Tips Portabello
Healthy Choice Complete Selections Beef with Classic BBQ Sauce
Healthy Choice Complete Selections Blackened Chicken
Healthy Choice Complete Selections Chicken Broccoli Alfredo
Healthy Choice Complete Selections Chicken Parmigiana
Healthy Choice Complete Selections Chicken Teriyaki
Healthy Choice Complete Selections Classic Grilled Chicken BBQ
Healthy Choice Complete Selections Country Breaded Chicken
Healthy Choice Complete Selections Country Herb Chicken
Healthy Choice Complete Selections Creamy Garlic Shrimp
Healthy Choice Complete Selections Fiesta Chicken
Healthy Choice Complete Selections Four Cheese Manicotti
Healthy Choice Complete Selections Glazed Chicken
Healthy Choice Complete Selections Grilled Chicken Monterey
Healthy Choice Complete Selections Grilled Turkey Breast
Healthy Choice Complete Selections Grilled White Meat Chicken with Smokehouse BBQ Sauce
Healthy Choice Complete Selections Honey Balsamic Chicken
Healthy Choice Complete Selections Lemon Pepper Fish
Healthy Choice Complete Selections Meatloaf
Healthy Choice Complete Selections Mushroom Roasted Beef
Healthy Choice Complete Selections Roasted Chicken
Healthy Choice Complete Selections Salisbury Steak
Healthy Choice Complete Selections Sweet Bourbon Steak
Healthy Choice Complete Selections Sweet and Sour Chicken
Healthy Choice Complete Selections Traditional Turkey Breast
Healthy Choice Low Fat Premium Sorbet & Cream Bars-Orange or Strawberry
Healthy Choice Premium Caramel Swirl Sandwich
Healthy Choice Premium Fudge Sandwich
Healthy Choice Premium Fudge Swirl Sandwich
Healthy Choice Premium Low Fat Ice Cream Bar
Healthy Choice Premium Vanilla Sandwich
Healthy Choice Simple Selections Breaded Chicken Breast Strips with Gravy
Healthy Choice Simple Selections Cheese French Bread Pizza
Healthy Choice Simple Selections Cheesy Chicken and Rice
Healthy Choice Simple Selections Chicken Enchilada
Healthy Choice Simple Selections Chicken Fettuccini Alfredo
Healthy Choice Simple Selections Chicken Rigatoni
Healthy Choice Simple Selections Four Cheese Manicotti
Healthy Choice Simple Selections Glazed Chicken
Healthy Choice Simple Selections Grilled Chicken White Meat Chicken & Pasta
Healthy Choice Simple Selections Grilled White Meat Chicken & Gravy
Healthy Choice Simple Selections Lasagna Bake
Healthy Choice Simple Selections Macaroni & Cheese
Healthy Choice Simple Selections Mandarin Chicken
Healthy Choice Simple Selections Pepperoni French Bread Pizza
Healthy Choice Simple Selections Roast Turkey Breastin Savory Sauce with Mushrooms
Healthy Choice Simple Selections Salisbury Steak
Healthy Choice Simple Selections Sesame Chicken
Healthy Choice Simple Selections Slow Roasted Turkey Breast with Gravy
Healthy Choice Simple Selections Spaghetti
Healthy Choice Simple Selections Supreme French Bread Pizza

ConAgra Grocery Foods
ACT II 94% Fat Free Butter Microwave Popcorn
ACT II 94% Fat Free Butter Mini Bags Microwave Popcorn
ACT II 94% Fat Free Kettle Corn Microwave Popcorn
Healthy Choice Bean & Ham Soup
Healthy Choice Beef Pot Roast Microwavable Bowl Soup
Healthy Choice Chicken & Dumplings Soup
Healthy Choice Chicken Tortilla Soup
Healthy Choice Chicken with Rice Microwavable Bowl Soup
Healthy Choice Chicken with Rice Soup
Healthy Choice Country Vegetable Microwavable Bowl Soup
Healthy Choice Country Vegetable Soup
Healthy Choice Fiesta Chicken Soup
Healthy Choice Garden Vegetable Soup
Healthy Choice Garlic & Herb Pasta Sauce
Healthy Choice Hearty Chicken Soup
Healthy Choice New England Clam Chowder Soup
Healthy Choice Old Fashioned Chicken Noodle Microwavable Bowl Soup
Healthy Choice Old Fashioned Chicken Noodle Soup
Healthy Choice Split Pea & Ham Soup
Healthy Choice Traditional Pasta Sauce
Healthy Choice Vegetable Beef Soup
Healthy Choice Zesty Gumbo with Chicken & Sausage Soup
Hunt's Family Favorites Seasoned Tomato Sauce for Lasagna
Hunt's Organic Crushed Tomatoes
Hunt's Organic Diced Tomatoes
Hunt's Organic Pasta Sauce Roasted Garlic
Hunt's Organic Whole Tomatoes
Hunt's Tomatoes Crushed in Thick Tomato Puree
Hunt's Tomatoes Diced
Hunt's Tomatoes Diced in Sauce
Hunt's Tomatoes Diced with Mild Green Chilies
Hunt's Tomatoes Diced-Green Pepper, Celery & Onions
Hunt's Tomatoes Petite Diced
Hunt's Tomatoes Stewed-No Salt Added
Hunt's Tomatoes Whole
Hunt's Tomatoes Whole-No Salt Added
Orville Redenbacher's Mini Bags Smart Pop Butter Microwave Popcorn
Orville Redenbacher's Mini Bags Smart Pop Butter/Kettle Corn Microwave Popcorn Variety Pack
Orville Redenbacher's Mini Bags Smart Pop Kettle Corn Microwave Popcorn
Orville Redenbacher's Organic Kernal Jar
Orville Redenbacher's Organic Smart Pop Butter Microwave Popcorn
Orville Redenbacher's Original Kernal Jar
Orville Redenbacher's Original Kernal Jug
Orville Redenbacher's Smart Pop Butter Microwave Popcorn
Orville Redenbacher's Smart Pop Kettle Corn Microwave Popcorn
Orville Redenbacher's Smart Pop Movie Theater Butter Microwave Popcorn
Orville Redenbacher's White Kernal Jar
Rosarita Diced Green Chilies
Rosarita Green Chilies Strips
Rosarita Whole Green Chilies

ConAgra Refrigerated Foods
Healthy Choice Deli Thin Baked Cooked Ham
Healthy Choice Deli Thin Honey Ham
Healthy Choice Deli Thin Honey Ham & Honey Roasted & Smoked Turkey Breast Variety Pack
Healthy Choice Deli Thin Honey Roasted & Smoked Turkey Breast
Healthy Choice Deli Thin Mesquite Turkey Breast
Healthy Choice Deli Thin Oven Roasted Chicken Breast
Healthy Choice Deli Thin Oven Roasted Turkey Breast
Healthy Choice Deli Thin Pastrami
Healthy Choice Deli Thin Smoked Ham
Healthy Choice Deli Thin Smoked Turkey Breast
Healthy Choice Deli-97% Fat Free Honey Ham
Healthy Choice Deli-97% Fat Free Honey Maple Ham
Healthy Choice Deli-97% Fat Free Medium Cooked Roast Beef-20% Marination
Healthy Choice Deli-97% Fat Free Mesquite Smoked Honey Ham
Healthy Choice Deli-97% Fat Free Roast Beef-20% Marination
Healthy Choice Deli-97% Fat Free Smoked Ham
Healthy Choice Deli-97% Fat Free Virginia Brand Ham
Healthy Choice Deli-98% Fat Free Browned Chicken Breast
Healthy Choice Deli-98% Fat Free Chicken Breast
Healthy Choice Deli-98% Fat Free Golden Oven Roasted Turkey Breast
Healthy Choice Deli-98% Fat Free Honey Roasted & Smoked Turkey Breast with Broth
Healthy Choice Deli-98% Fat Free Mesquite Smoked Chicken Breast
Healthy Choice Deli-98% Fat Free Mesquite Smoked Turkey Breast
Healthy Choice Deli-98% Fat Free Smoked Turkey Breast
Healthy Choice Deli-98% Fat Free Southwest Grill Turkey Breast
Healthy Choice Deli-Honey Cured Ham
Healthy Choice Deli-Honey Roasted & Smoked Turkey Breast
Healthy Choice Deli-Oven Roasted Chicken Breast
Healthy Choice Deli-Oven Roasted Turkey Breast
Healthy Choice Deli-Roast Beef-20% Marination
Healthy Choice Deli-Virginia Brand Cooked Ham
Healthy Choice Deluxe Thin-Sliced Baked Cooked Ham
Healthy Choice Deluxe Thin-Sliced Honey Ham
Healthy Choice Deluxe Thin-Sliced Honey Ham/Oven Roasted Turkey Breast Variety Pack
Healthy Choice Deluxe Thin-Sliced Oven Roasted Turkey Breast
Healthy Choice Honey Ham
Healthy Choice Low Fat Smoked Sausage
Healthy Choice Pre-Sliced Sandwich Solutions Roast Beef
Healthy Choice Pre-Sliced Sandwich Solutions Skinless Oven Roasted Turkey Breast
Healthy Choice Pre-Sliced Sandwich Solutions Skinless Smoked Turkey Breast
Healthy Choice Pre-Sliced Sandwich Solutions Virginia Brand Ham
Healthy Choice Virginia Brand Ham
Healthy Choice Zip Pack Cooked Ham
Healthy Choice Zip Pack Honey Ham
Healthy Choice Zip Pack Oven Roasted Chicken Breast
Healthy Choice Zip Pack Oven Roasted Turkey Breast
Hebrew National 97% Fat Free Beef Franks

ConAgra Retail Foods
Healthy Choice Hearty 100% Whole Grain Bread
Healthy Choice Hearty 7-Grain Bread

Coolham Holdings, Inc. DBA SunMilk Dairy Co.
SunMilk-Fat Free Milk with Sunflower Oil (The Taste of 1%)
SunMilk-Fat Free Milk with Sunflower Oil (The Taste of 2%)

Cooper Farms
Cooper Farms All Natural Turkey Breast Fillet

Crider, Inc.
Kirkland Signature Premium 99% Fat Free Chunk Chicken Breast

Dare Foods Incorporated
Breton Reduced Fat & Sodium Wheat Crackers

El Aguila Food Products, Inc.
El Aguila Stoneground Corn Tortillas

Eurofresh Inc.
Eurofresh Campari Tomatoes

FPL Foods, LLC
96/4 All Natural Extra Lean Ground Beef

Farmland Foods
Farmland 97% Fat Free Fresh Ground Pork
Farmland Nutrition Wise 97% Fat Free Boneless Center Cut Pork Loin Filet
Farmland Nutrition Wise Boneless Butterfly Cut Pork Loin Chops
Farmland Nutrition Wise Boneless Center Cut Pork Loin
Farmland Nutrition Wise Boneless Center Cut Pork Loin Chops
Farmland Nutrition Wise Boneless Center Cut Pork Loin Roast
Farmland Nutrition Wise Boneless Pork Chops - America's Cut
Farmland Nutrition Wise Boneless Pork Tenderloin
Farmland Nutrition Wise Boneless Pork Top Round Roast
Farmland Nutrition Wise Boneless Pork Top Round Steak
Farmland Nutrition Wise Boneless Sirloin Tip Pork Roast
Farmland Nutrition Wise Pork Cube Steak
Farmland Nutrition Wise Pork Cubes
Farmland Nutrition Wise Pork Scallopini
Farmland Nutrition Wise Pork Strips

Fieldale Farms Corporation
Jewel All Natural 99% Fat Free Boneless Skinless Chicken Breasts with Rib Meat
Jewel All Natural 99% Fat Free Chicken Breast Tenders
Our Premium 98% Fat Free Boneless Skinless Breast with Rib Meat - 15% Marination
Springer Mountain Farms All Natural 98% Fat Free Boneless Skinless Breasts

Florida's Natural Growers
Florida's Natural Calcium & Vitamin D No Pulp Orange Juice
Florida's Natural Growers Style Most Pulp Orange Juice
Florida's Natural Home Squeezed Calcium & Vitamin D with Pulp Orange Juice
Florida's Natural Home Squeezed with Pulp Orange Juice
Florida's Natural Original No Pulp Orange Juice

FoodTech International
Veggie Patch California Veggie Burgers

Foster Poultry Farms
Foster Farms 98% Fat Free Honey Roasted & Smoked Breast of Turkey
Foster Farms 98% Fat Free Oven Roasted Breast of Turkey
Foster Farms 98% Fat Free Oven Roasted Chicken Breast
Foster Farms 99% Fat Free 100% Natural Boneless & Skinless Breast Fillets
Foster Farms 99% Fat Free 100% Natural Boneless & Skinless Breast Steaks
Foster Farms 99% Fat Free 100% Natural Boneless & Skinless Breast Tenders
Foster Farms 99% Fat Free Honey Roasted & Smoked Turkey Breast
Foster Farms 99% Fat Free Oven Roasted Turkey Breast
Foster Farms All Natural 99% Fat Free Boneless & Skinless Chicken Breast Tenders (8% Marination)
Foster Farms Fresh & Easy 99% Fat Free 100% Natural Boneless & Skinless Breast Fillets
Kirkland Signature/Foster Farms 99% Fat Free 100% Natural Boneless & Skinless Breasts
Kirkland Signature/Foster Farms All Natural 99% Fat Free Boneless & Skinless Chicken Breasts (8% Marination)

Fresh Express Incorporated
Chiquita Apple Bites
Fresh Express American Salad
Fresh Express Hearts of Romaine Salad
Fresh Express Italian Salad
Fresh Express Triple Hearts Salad

GFA Brands, Inc.
Smart Balance Smart 'N Healthy Deluxe Microwave Popcorn
Smart Beat Healthy Fat Free Non-Dairy Slices - American Flavor
Smart Beat Healthy Fat Free Non-Dairy Slices - Lactose Free
Smart Beat Smart Squeeze Nonfat Margarine Spread

General Mills, Inc.
Apple Cinnamon Cheerios
Berry Berry Kix
Berry Burst Cheerios-Strawberry Banana
Berry Burst Cheerios-Triple Berry
Berry Lucky Charms
Cheerios
Cheerios Crunch
Chocolate Lucky Charms
Cocoa Puffs
Cookie Crisp
Count Chocula
Dora The Explorer
Frosted Cheerios
Fruity Cheerios
Heart Smart Bisquick
Honey Nut Cheerios
Kix
Lucky Charms
Multi-Grain Cheerios
Oatmeal Crisp Crunchy Almond
Oatmeal Crisp Hearty Raisin
Oatmeal Crisp Maple Brown Sugar
Pillsbury Oven-Baked Whole Wheat Dinner Rolls
Progresso Healthy Favorites Chicken & Wild Rice Soup
Progresso Healthy Favorites Chicken Gumbo Soup
Progresso Healthy Favorites Chicken Noodle Soup
Progresso Healthy Favorites Garden Vegetable Soup
Progresso Healthy Favorites Italian-Style Wedding Soup
Progresso Healthy Favorites Minestrone Soup
Total Cranberry Crunch
Total Honey Clusters
Total Raisin Bran
Total with Strawberries
Trix
Whole Grain Total
Yogurt Burst Cheerios Strawberry
Yogurt Burst Cheerios Vanilla

Hain Celestial Group, Inc., The
DeBoles Organic Ancient Grain Penne
Health Valley Empower Cereal
Hodgson Mill, Inc.
Hodgson Mill Oat Bran All Natural Hot Cereal
Hodgson Mill Whole Wheat Angel Hair
Hodgson Mill Whole Wheat Fettuccine
Hodgson Mill Whole Wheat Lasagna
Hodgson Mill Whole Wheat Penne
Hodgson Mill Whole Wheat Spinach Spaghetti
Hodgson Mill Whole Wheat Whole Grain Elbows
Hodgson Mill Whole Wheat Whole Grain Spaghetti

Indiana Packers Corp.
Indiana Kitchen All Natural Boneless Pork Sirloin Roast
Indiana Kitchen All Natural Pork Tenderloin

Interstate Brands Corporation
Home Pride Whole Grains 100% Honey Whole Wheat Bread
Home Pride Whole Grains 100% Whole Wheat Bread
Merita Country Whole Grains 100% Whole Wheat Bread

KFP International, Ltd.
Kedem 100% Pure Concord Grape Juice-No Sugar Added

Kansas City Steak Company
Kansas City Seasoned Beef Chuck Tender Steak
Kansas City Seasoned Beef Medallions

Kashi Company
Kashi Heart to Heart Honey Oat Waffles
Kashi Heart to Heart Honey Toasted Cereal
Kashi Heart to Heart Instant Oatmeal - Apple Cinnamon
Kashi Heart to Heart Instant Oatmeal - Golden Brown Maple
Kashi Heart to Heart Instant Oatmeal - Raisin Spice
Kashi Heart to Heart Oat Flakes & Wild Blueberry Clusters

Kellogg USA, Inc.
Kellogg's All-Bran Bran Buds
Kellogg's All-Bran Extra Fiber
Kellogg's All-Bran Original
Kellogg's Frosted Mini-Wheats - Strawberry Delight
Kellogg's Frosted Mini-Wheats - Vanilla Creme
Kellogg's Frosted Mini-Wheats Big Bite
Kellogg's Frosted Mini-Wheats Bite Size
Kellogg's Frosted Mini-Wheats Maple & Brown Sugar
Kellogg's Smart Start Antioxidants - Original
Kellogg's Smart Start Healthy Heart - Maple & Brown Sugar
Kellogg's Smart Start Healthy Heart - Original
Kellogg's Smart Start Healthy Heart Cinnamon Raisin

King Soopers
Ground Beef 96/4 Extra Lean

Kroger Company, The
Kroger Moist & Tender Silver Platter Pork Tenderloin

Laura's Lean Beef Company
Laura's Lean Beef - Beef Pot Roast Au Jus
Laura's Lean Beef - Shredded Beef with Barbecue Sauce
Laura's Lean Beef 4% Fat Ground Round
Laura's Lean Beef 4% Ground Sirloin
Laura's Lean Beef Sirloin Steak

LiDestri Foods, Inc.
Francesco Rinaldi No Salt Added Traditional Pasta Sauce

Lido Veal & Lamb Inc.
Veal USA Boneless Veal Shoulder Roast from Lido Veal
Veal USA Low Fat Ground Veal from Lido Veal
Veal USA Veal Leg Cutlets from Lido Veal
Veal USA Veal Stew from Lido Veal

M & I Seafood Manufacturing Inc.
Chesapeake Bay Gourmet Crab Cakes

MW Polar Foods
Polar All Natural Chunk Light Tuna in Water
Polar All Natural Solid White Albacore in Water
Polar Chunk Light Tuna in Water
Polar Solid White Albacore Tuna in Water

Malt-O-Meal Company
Malt-O-Meal Balance
Malt-O-Meal Crispy Rice
Malt-O-Meal Frosted Mini Spooners
Malt-O-Meal Honey & Oat Blenders
Malt-O-Meal Honey Nut Scooters
Malt-O-Meal Hot Wheat Cereal - Chocolate
Malt-O-Meal Hot Wheat Cereal - Maple & Brown Sugar
Malt-O-Meal Hot Wheat Cereal - Original
Malt-O-Meal Maple & Brown Sugar Mini Spooners
Malt-O-Meal Mom's Best 100% Natural Quick Oats
Malt-O-Meal Mom's Best Instant Oatmeal - Apples & Cinnamon
Malt-O-Meal Mom's Best Instant Oatmeal - Maple & Brown Sugar
Malt-O-Meal Mom's Best Instant Oatmeal Variety Pack - Maple & Brown Sugar/Apples & Cinnamon/Cinnamon & Spice
Malt-O-Meal Raisin Bran
Malt-O-Meal Scooters

Maple Leaf Consumer Foods
Maple Leaf Sodium Reduced 98% Fat Free Cooked Ham with Natural Juices

Maverick Ranch Association
Maverick Ranch 96/4 Extra Lean Grass Fed Organic Ground Beef
Maverick Ranch 96/4 Extra Lean Natural Ground Buffalo
Maverick Ranch 96/4 Extra Lean Natural Ground Pork Sirloin
Maverick Ranch Free-Range Chicken-All Natural Air Chilled Boneless Skinless Chicken Breast
Maverick Ranch NaturaLite 96/4 Extra Lean Ground Beef Round
Maverick Ranch NaturaLite Beef - 96/4 Extra Lean Ground Beef Chuck
Maverick Ranch NaturaLite Beef - 96/4 Extra Lean Ground Beef Sirloin
Maverick Ranch Natural Beef Cubed Steak
Maverick Ranch Natural Beef Top Sirloin Steak
Maverick Ranch Natural Buffalo Top Sirloin Steak
Maverick Ranch Natural Center Cut Pork Loin Chops
Maverick Ranch Natural Lite 96/4 Extra Lean Natural Ground Beef
Maverick Ranch Natural Pork 4% Fat Extra Lean Pork Tenderloin
Maverick Ranch Natural Skinless Chicken Drumsticks
Maverick Ranch Natural Skinless Chicken Thighs
Maverick Ranch Organic Air-Chilled Boneless Skinless Chicken Breasts

Mayoli Inc.
Mayoli All Natural Reduced Fat Mayonnaise Dressing with Pure Olive Oil

McNeil Nutritionals, LLC
LACTAID® Calcium-Fortified Fat Free Milk
LACTAID® Fat Free Milk

Meijer Distribution, Inc.
Meijer Purple Grape Juice

Michael Foods, Inc.
All Whites Egg Whites - White Cheddar
Better 'n Eggs Ham & Cheese
Better 'n Eggs Plus
Better 'n Eggs Three Cheese
Kirkland Signature Egg Starts
Kroger Break-Free 100% Liquid Egg Whites
Kroger Break-Free Real Egg Product
Papetti Foods All Whites - 100% Liquid Egg Whites
Papetti Foods Better 'n Eggs

Mills Family Farms
Mills Family Farms Green Cascade Mix-Baby Romaine & Baby Green Leaf
Mills Family Farms Wholeaves Sandwich & Salad Lettuce - Green Leaf
Mills Family Farms Wholeaves Sandwich & Salad Lettuce - Red Leaf
Mills Family Farms Wholeaves Sandwich & Salad Lettuce - Romaine
Milton's Baking Company
Milton's Baking Classics Cinnamon Raisin Wheat Bread
Milton's Baking Classics Corn Bread
Milton's Baking Classics Oat Bran Bread
Milton's Baking Classics Wheat Bread
Milton's Healthy Multi-Grain Plus Bread
Milton's Healthy Whole Grain Plus Bread
Milton's Original Healthy Multi-Grain Bread
Milton's Whole Grains 100% Whole Wheat Bread

Motts LLP
Yoo-hoo Lite Chocolate Drink

Murray's Free Roaming Chicken, Inc.
Murray's Extra Lean 99% Fat Free Boneless & Skinless Chicken

New World Pasta Company
Ronzoni Healthy Harvest Multi-Grain Pasta-Fusilli
Ronzoni Healthy Harvest Multigrain Pasta - Spaghetti Style
Ronzoni Healthy Harvest Whole Wheat Blend Extra Wide Noodle - Style
Ronzoni Healthy Harvest Whole Wheat Blend Pasta - Linguine
Ronzoni Healthy Harvest Whole Wheat Blend Pasta - Penne Rigate
Ronzoni Healthy Harvest Whole Wheat Blend Pasta - Rotini
Ronzoni Healthy Harvest Whole Wheat Blend Pasta - Spaghetti Style
Ronzoni Healthy Harvest Whole Wheat Blend Pasta - Thin Spaghetti
Ronzoni Healthy Harvest Whole Wheat Blend Pasta-Lasagna
Ronzoni Healthy Harvest Whole Wheat Blend Wide Noodle - Style

Nonna's Kitchen, Inc.
Columbus Reduced Sodium Turkey Breast

North American Beverage Company
Chocolate Moose - All Natural Premium Milk Chocolate Drink
Chocolate Moose - Cookies & Cream Premium Milk Chocolate Drink
Mega Moose Energy Drink-Strawberry Blast

Nulaid Foods Inc.
Nulaid ReddiEgg Real Egg Product

Oberto Sausage Company
Kirkland Signature Premium Brisket Roast Beef

Old Orchard Brands LLC
Old Orchard 100% Grape Juice
Old Orchard 100% Grape Juice - Frozen Concentrate

POM Wonderful, LLC
POM Wonderful Fresh Pomegranate Arils
POM Wonderful Frozen Pomegranate Arils
POM Wonderful Pomegranates

Packerland Processing Co., Inc.
Meijer Extra Lean Ground Beef 96/4

Peco Foods, Inc.
Member's Mark All Natural Boneless Skinless Chicken Breasts with Rib Meat
Member's Mark All Natural Boneless Skinless Chicken Tenderloins

Pepperidge Farm, Inc.
Pepperidge Farm 100% Natural 100% Whole Wheat Bread
Pepperidge Farm 100% Natural 9 Grain Bread
Pepperidge Farm 100% Natural German Dark Wheat Bread
Pepperidge Farm 100% Natural Honey Flax Bread
Pepperidge Farm 100% Whole Wheat Bagels
Pepperidge Farm 100% Whole Wheat English Muffins
Pepperidge Farm 100% Whole Wheat Hearty Texture Whole Grain Bread
Pepperidge Farm 100% Whole Wheat Mini Bagels
Pepperidge Farm 15 Grain Hearty Texture Whole Grain Bread
Pepperidge Farm Farmhouse Soft 100% Whole Wheat Bread
Pepperidge Farm Golden Harvest Grains Hearty Texture Whole Grain Bread
Pepperidge Farm Light Style 7 Grain Bread
Pepperidge Farm Light Style Soft Wheat Bread
Pepperidge Farm Oatmeal Hearty Texture Whole Grain Bread
Pepperidge Farm Soft Honey Oat Smooth Texture Whole Grain Bread
Pepperidge Farm Soft Honey Whole Wheat Smooth Texture Whole Grain Bread
Pepperidge Farm Very Thin Soft 100% Whole Wheat Bread
Pepperidge Farm Whole Grain Multi-Grain Bagels
Pepperidge Farm Whole Grain Swirl Bread - Cinnamon
Pepperidge Farm Whole Grain Swirl Bread - Cinnamon with Raisins

Perdue Farms, Inc.
Perdue Individually Frozen All Natural 99% Fat Free Chicken Tenderloins
Perdue Tender & Tasty 99% Fat Free Individually Frozen Boneless Skinless Chicken Breasts
Perdue Tender & Tasty 99% Fat Free Individually Wrapped Boneless Skinless Chicken Breasts
Perdue/Kirkland Signature Individually Frozen All Natural 99% Fat Free Boneless Skinless Chicken Breasts

Pilgrim's Pride Corporation
Eat Well Stay Healthy Chicken Breast Salad
Eat Well Stay Healthy Fresh Boneless Skinless Chicken Breasts with Rib Meat (15% Chicken Broth)
Eat Well Stay Healthy Fresh Boneless Skinless Chicken Thin Sliced Breasts with Rib Meat (15% Chicken Broth)
Eat Well Stay Healthy Fresh Chicken Breast Tenderloins (15% Chicken Broth)
Eat Well Stay Healthy Fully Cooked Rotisserie Skinless Chicken Split Breasts - Garden Herb
Gold Kist Farms 100% Natural 99% Fat Free Boneless Skinless Chicken Breast
Gold Kist Farms All Natural 99% Fat Free Boneless Skinless Breasts
Gold Kist Farms/Kirkland Signature All Natural 99% Fat Free Boneless Skinless Breasts
HyVee/Country Pride 97% Fat Free Boneless Skinless Chicken Breast Fillets with Rib Meat (15% Chicken Broth)
HyVee/Country Pride 97% Fat Free Skinless Split Chicken Breasts with Ribs (12% Chicken Broth)
HyVee/Country Pride 99% Fat Free Boneless Skinless Chicken Breast Tenderloins (15% Chicken Broth)
Meijer Fresh Boneless Skinless Chicken Breast Tenderloins (15% Marination)
Meijer Fresh Boneless Skinless Chicken Breasts with Rib Meat (15% Marination)
Pilgrim's Pride Eat Well Stay Healthy Grilled Chicken Breast Fillets
Pilgrim's Pride Eat Well Stay Healthy Grilled Chicken Breast Strips
Pilgrim's Pride Eat Well Stay Healthy Italian Style Grilled Chicken Breast Fillets
Pilgrim's Pride Eat Well Stay Healthy Key Lime Flavor Chicken Breast Fillets
Pilgrim's Pride Eat Well Stay Healthy Kids Fully Cooked Breaded Chicken Nuggets
Pilgrim's Pride Eat Well Stay Healthy Kids Fully Cooked Breaded Popcorn Chicken
Pilgrim's Pride Eat Well Stay Healthy Lemon Herb Chicken Breast Fillets
Pilgrim's Pride Eat Well Stay Healthy Savory Chicken Breast Fillets
Pilgrim's Pride Eat Well Stay Healthy Szechwan Chicken Breast Tenderloins
Pilgrim's Pride Fresh Boneless Skinless Chicken Breasts with Rib Meat Individually Wrapped (15% Chicken Broth)
Pilgrim's Pride Fresh Chicken 100% Natural Boneless Skinless Breasts with Rib Meat
Pilgrim's Pride Fresh Chicken 100% Natural Boneless Skinless Breasts with Rib Meat (15% Chicken Broth)
Pilgrim's Pride Fresh Chicken 100% Natural Breast Tenderloins
Pilgrim's Pride Fresh Chicken 100% Natural Breast Tenderloins (15% Chicken Broth)
Pilgrim's Pride Fresh Chicken 100% Natural Skinless Split Breasts with Ribs
Pilgrim's Pride Fresh Chicken 100% Natural Skinless Split Breasts with Ribs (12% Chicken Broth)
Pilgrim's Pride Fresh Chicken Breast Tenderloins Individually Wrapped (15% Chicken Broth)
Pilgrim's Pride Individually Frozen Fully Trimmed 99% Fat Free All Natural Boneless Skinless Chicken Breasts (15% Chicken Broth)
Schnucks 99% Fat Free Chicken Breast Tenderloins
Schnucks 99% Fat Free Skinless Chicken Breast Fillets
Schnucks 99% Fat Free Thin Sliced Skinless Chicken Breast Fillets

Quaker Oats Company/Tropicana Products, Inc., The
Crystal Wedding Oats
Old-Fashioned Quaker Oats
Quaker Cinnamon Life
Quaker Essentials Oat Bran
Quaker Essentials Oatmeal Squares - Brown Sugar
Quaker Essentials Oatmeal Squares - Cinnamon
Quaker Essentials Toasted Oatmeal - Brown Sugar
Quaker Essentials Toasted Oatmeal - Honey Nut
Quaker Honey Graham Life
Quaker Instant Oatmeal - Apple Crisp
Quaker Instant Oatmeal - Apples & Cinnamon
Quaker Instant Oatmeal - Cinnamon & Spice
Quaker Instant Oatmeal - Cinnamon Roll
Quaker Instant Oatmeal - Flavor Variety
Quaker Instant Oatmeal - Maple & Brown Sugar
Quaker Instant Oatmeal - Raisins & Spice
Quaker Instant Oatmeal - Regular Flavor
Quaker Instant Oatmeal Bakery Favorites Variety Pack (Apple Crisp/Cinnamon Roll/Banana Bread)
Quaker Instant Oatmeal Crunch - Apples & Cinnamon
Quaker Instant Oatmeal Crunch - Magicolor Cinnamon
Quaker Instant Oatmeal Crunch - Maple & Brown Sugar
Quaker Instant Oatmeal Crunch - Mixed Berry
Quaker Instant Oatmeal Lower Sugar - Apples & Cinnamon
Quaker Life
Quaker Life Chocolate Oat Crunch
Quaker MultiGrain Hot Cereal
Quaker Oat Bran Hot Cereal
Quaker Take Heart Instant Oatmeal - Blueberry
Quaker Take Heart Instant Oatmeal - Golden Maple
Quick 1 Minute Quaker Oats
Tropicana Pure Premium Calcium + Vitamin D No Pulp Orange Juice
Tropicana Pure Premium Fiber Some Pulp Orange Juice
Tropicana Pure Premium Golden No Pulp Grapefruit Juice
Tropicana Pure Premium Grovestand Calcium + Vitamin D Lots of Pulp Orange Juice
Tropicana Pure Premium Grovestand Lots of Pulp Orange Juice
Tropicana Pure Premium Healthy Heart No Pulp Orange Juice with Omega 3
Tropicana Pure Premium Homestyle Some Pulp Orange Juice
Tropicana Pure Premium Light 'n Healthy Calcium No Pulp Orange Juice
Tropicana Pure Premium Light 'n Healthy Calcium No Pulp Orange Juice
Tropicana Pure Premium Low Acid No Pulp Orange Juice
Tropicana Pure Premium Original No Pulp Orange Juice
Tropicana Pure Premium Ruby Red Some Pulp Grapefruit Juice

R.A.B. Food Group LLC
Manischewitz Premium 100% Grape Juice

Rader Farms, Inc.
Rader Farms Nature's Three Berries

Red Gold, LLC
Sacramento Tomato Juice from Concentrate with Enhanced Tomato Flavor

Ruprecht Company
Sommers 100% Organic Extra Lean Beef Burgers

Sal & Judy's Products, LLC
Sal & Judy's Heart Smart Italian Sauce

Sealord North America, Inc.
Sealord Deep Sea Dory Fillets
Sealord Orange Roughy Fillets

Setton International Foods, Inc.
Setton Farms Heart Healthy Mix

Simmons Foods, Inc.
Member's Mark All Natural 99% Fat Free Boneless Skinless Chicken Breast

Smithfield Lean Generation Cuts
SLG: All Natural Pork Tenderloin
SLG: Marinated Hickory Sweet Center Cut Boneless Pork Loin
SLG: Marinated Hickory Sweet Pork Chops
SLG: Marinated Hickory Sweet Pork Loin Filet
SLG: Marinated Hickory Sweet Pork Tenderloin
SLG: Marinated Peppercorn & Garlic Pork Tenderloin
SLG: Marinated Pork Loin Fillet - Peppercorn & Garlic
SLG: Self-Basting Boneless Pork Loin Center Cut Chops
SLG: Self-Basting Boneless Whole Pork Loin
SLG: Self-Basting Pork Tenderloin

Smithfield Lean Generation Deli
SLG Deli: 98% Fat Free Canadian Brand Maple Ham
SLG Deli: 98% Fat Free Cooked Ham
SLG Deli: 98% Fat Free Honey Cured Ham
SLG Deli: 98% Fat Free Tavern Ham
SLG Deli: 98% Fat Free Virginia Brand Ham

Smithfield Premium Cuts
Smithfield: Self-Basting Pork Tenderloin

Solis Brands, Inc.
ZOIC Belgian Chocolate Nutrition Drink
ZOIC French Vanilla Nutrition Drink

Springerhill Ranch Meat Products
Springerhill Ranch Brand All Natural 98% Fat Free Beef Tenderloin Steaks
Springerhill Ranch Brand All Natural Ground Beef-98% Lean 2% Fat

StarKist Seafood Company
StarKist Chunk Light Tuna in Water
StarKist Chunk White Albacore Tuna in Water
StarKist Gourmet Choice Albacore Tuna Fillet in Water
StarKist Gourmet Choice Chunk Light Tuna in Water
StarKist Gourmet Choice Solid Light Tuna Fillet in Water
StarKist Low Sodium Chunk Light Tuna in Water
StarKist Solid White Albacore Tuna in Water
StarKist Very Low Sodium Chunk White Albacore Tuna in Water

Sunrise Growers, Inc.
Sunrise Growers California Strawberries

Swift Foods dba Swift & Company
Extra Lean Ground Pork
Swift Boneless Pork Sirloin Cutlets
Swift Natural Fresh Pork-Boneless Pork Center Cut Loin Chops
Swift Natural Fresh Pork-Boneless Pork Leg for London Broil
Swift Natural Fresh Pork-Boneless Pork Top Loin Roast
Swift Natural Fresh Pork-Pork Strips for Barbecue
Swift Pork Center Cut Loin
Swift Pork Sirloin Tip Roast
Swift Pork Tenderloin
Swift Premium Guaranteed Tender Pork-Boneless Bottom Round
Swift Premium Guaranteed Tender Pork-Boneless Center Cut Loin Chops
Swift Premium Guaranteed Tender Pork-Boneless Pork Loin Filet
Swift Premium Guaranteed Tender Pork-Boneless Pork Tenderloin
Swift Premium Guaranteed Tender Pork-Boneless Sirloin Cutlets
Swift Premium Guaranteed Tender Pork-Boneless Strips for Barbecue
Swift Premium Guaranteed Tender Pork-Pork Top Round
Swift/Kirkland Signature Pork Sirloin Tip Roast
Trader Joe's Butcher Shop - Pork Sirloin Tri Tip
Trader Joe's Butcher Shop Boneless Center Cut Pork Loin Cutlets
Trader Joe's Butcher Shop Natural Pork-Boneless Pork Loin Chops
Trader Joe's Butcher Shop Natural Pork-Pork Shoulder Boneless Strips
Trader Joe's Butcher Shop-Pork Tenderloin

T. J. Kraft, Ltd.
Hawaiian Pacific Ahi Tuna Steaks

Taylor Packing Co., Inc.
Century Farm 96/4 Extra Lean Ground Beef

The Baker
The Baker 7-Grain Sourdough Whole Wheat Bread

Thumann's Inc
Thumann's All Natural Black Forest Brand Ham
Thumann's All Natural Capless Roast Beef
Thumann's All Natural Oven Roasted Gourmet Chicken Breast
Thumann's All Natural Oven Roasted Gourmet Turkey Breast
Thumann's Buffalo Style Oven Roasted Chicken Breast
Thumann's Capless Roast Beef
Thumann's Golden Roasted Filet of Turkey - Rotisserie Flavor
Thumann's Golden Roasted Gourmet Turkey
Thumann's Our Short Cut Deluxe Cooked Ham - Lower Sodium
Thumann's Oven Roasted Premium Chicken Breast

Tony Downs Foods Company
Member's Mark 98% Fat Free Premium Chunk Chicken Breast in Water

Topco Associates, LLC
Food Club Individually Frozen Boneless Skinless Chicken Breasts-15% Seasoned Chicken Broth
Food Club Individually Frozen Chicken Tenderloins-15% Seasoned Chicken Broth

Tumaro's Inc.
Tumaro's Chipotle Chili & Peppers Healthy Flour Tortillas
Tumaro's Garden Spinach & Vegetables Healthy Flour Tortillas
Tumaro's Honey Wheat Healthy Flour Tortillas
Tumaro's Jalapeno & Cilantro Healthy Flour Tortillas
Tumaro's Pesto & Garlic Healthy Flour Tortillas
Tumaro's Premium White Healthy Flour Tortillas
Tumaro's Sun-Dried Tomato & Basil Healthy Flour Tortillas

Tyson Foods, Inc.
Tastybird Individually Frozen Chicken-Boneless, Skinless Breast Portions with Rib Meat
Tastybird Individually Quick Frozen Chicken-Boneless, Skinless Tenderloins
Tyson 100% All Natural Thin 'N Fancy Boneless Skinless Chicken Breasts with Rib Meat (<3% Water)
Tyson 100% All Natural Boneless Skinless Chicken Breasts with Rib Meat (<1%/,2% Water)
Tyson 100% All Natural Boneless Skinless Chicken Thighs (15% Natural Chicken Broth)
Tyson 100% All Natural Chicken Breast Tenderloins (15% Natural Chicken Broth)
Tyson 100% All Natural Chicken Breast Tenderloins (<1% Water)
Tyson 100% All Natural Premium Boneless Skinless Chicken Breasts with Rib Meat (15% Natural Chicken Broth)
Tyson 100% All Natural Skinless Split Chicken Breasts with Ribs (12% Natural Chicken Broth)
Tyson 100% All Natural Skinless Split Chicken Breasts with Ribs (>3% Water)
Tyson 100% All Natural Thin 'N Fancy Boneless Skinless Chicken Breasts with Rib Meat (15% Natural Chicken Broth)
Tyson Ice Glazed Chicken Individually Frozen 99% Fat Free Boneless, Skinless Breast Tenderloins (8% Seasoned Chicken Broth)
Tyson Individually Fresh Frozen All Natural 99% Fat Free Boneless Skinless Chicken Tenderloins (8% Water & Kosher Salt)
Tyson Individually Fresh Frozen Boneless Skinless Chicken Breasts with Rib Meat (15% Chicken Broth)
Tyson Individually Fresh Frozen Chicken Tenderloins (15% Chicken Broth)
Tyson Individually Frozen 100% All Natural Individually Wrapped Boneless Skinless Chicken Breasts (15% Natural Chicken Broth)
Tyson Individually Frozen All Natural 99% Fat Free Boneless Skinless Chicken Breast Tenderloins (8% Chicken Broth)
Tyson Individually Frozen All Natural Boneless Skinless Chicken Breasts with Rib Meat (8% Broth Glaze & 15% Seasoned Chicken Broth)
Tyson Individually Frozen All Natural Extra Lean Boneless Skinless Chicken Breast with Rib Meat (8% Chicken Broth)
Tyson Individually Frozen Boneless Skinless Chicken Breasts with Rib Meat (15% Chicken Broth)
Tyson/Kirkland Signature All Natural 99% Fat Free Boneless Skinless Chicken Breast (8% Water & Kosher Salt)
Tyson/Tastybird Individually Frozen Boneless Skinless Breasts with Rib Meat (10% Seasoned Chicken Broth)
Tyson/Tastybird Individually Frozen Chicken-Boneless Skinless Breasts with Rib Meat (10% Natural Chicken Broth)

Tyson Fresh Meats, Inc.
100% Pure Extra Lean Ground Beef 96/4
96/4 All Natural Extra Lean Ground Beef

United Food Group, LLC
Miller's 100% Pure Ground Beef - 4% Fat
Moran's All Natural 4% Fat 100% Ground Beef Hamburger Patties
Moran's All Natural 4% Fat Ground Beef
Trader Joe's Butcher Shop 4% Fat Ground Beef

Welch Foods, Inc.
Welch's 100% Grape Juice (Purple)
Welch's 100% Grape Juice (Purple) - Frozen Concentrate
Welch's 100% Grape Juice (Purple) - Pourable Concentrate
Welch's 100% Grape Juice Calcium (Purple)
Welch's 100% Grape Juice with Fiber
Welch's Organic 100% Concord Grape Juice
Welch's Organic 100% Concord Grape Juice - Frozen Concentrate

West Liberty Foods, LLC
Honey Roasted & Smoked Breast of Turkey - 98% Fat Free
Kirkland Signature All Natural Fully Cooked Sliced Turkey Breast
Oven Roasted Breast of Turkey Browned in Soybean Oil - 98% Fat Free

I'm very troubled by the American Heart Association's (AHA) willingness to lend its logo and stamp of approval to a multitude of garbage foods like Cocoa Puffs and Berry Kix cereals.

So I contacted the AHA and spoke to the manager of the Food Certification Program, Ms. Linda Rupp. Ms. Rupp proved very helpful in helping me to understand.

I originally called her to find out just how many products were turned down. In view of 768 products on the approved list, I wondered how many had been rejected to generate this "select" group.

Unfortunately, she said that the number of products rejected was not tracked, though she did intimate that it was not a lot. Sometimes, she added, a rejected product will undergo a few "improvements" to help it achieve the criteria necessary for AHA approval.

What exactly is considered in an application for the Food Certification Program?

A food must have 1)total fat 3.0 grams or less, 2) saturated fat 1.0 gram or less, 3) 20 grams or less cholesterol, 4) 480 mg or less sodium, all per serving.

She also pointed out that, given the fact that a food as useless and lacking in health qualitites as jelly beans could meet this criteria, the AHA employs a special "Jelly Bean Rule" that stipulates that 10% of the Daily Value of 6 nutrients (e.g., fiber, vitamins A and C, etc.) must also be contained in a serving.

So those are the startlingly lax requirements to gain the privilege of affixing the AHA Heart Check Mark on your product and informing the public that your box of Cocoa Puffs, Cookie Crisp cereal, or Berry Kix is "heart healthy."

There is an epidemic of obesity in the U.S. I don't believe that the AHA endorsement helps. In fact, I believe that it has been a contributor to obesity.

Pardon me while I eat this bag of M&M's for my heart.

Stan did everything right.

He followed the Track Your Plaque "Rule of 60". He was slender, had run a marathon a few months earlier, in fact. He included fish oil at therapeutic doses. He replenished vitamin D to a blood level of 57 ng/ml 25-OH-vitamin D3. Though ambitious and hard-working, he was a generally happy, optimistic person.

Yet his CT heart scan score increased 28% in one year, from a starting score of 379 to 485.

What did he do wrong?

Well, Stan did nothing wrong. But I suggested to him that one "hole" in his program could be exercise-induced high blood pressure. I've witnessed this effect many times. Blood pressure normal or "borderline" high while seated and relaxed, sky-high with exercise.

So we put Stan on a treadmill. Starting blood pressure: 123/76. Blood pressure with exericse (13 mets): 220/78--sky high. That's why Stan's heart scan score went up. A good pressure with this level of exercise: 150/70, but certainly no higher than 170/80.

If blood pressure is high with exercise, it's probably high with emotional upset, anxiety, being in a hurry, etc., also, all the irritations and pressures of life.

We'll see in future how much of a role reducing Stan's blood pressure will play in gaining better control over his heart scan score. A practical difficulty will be in assessing the adequacy of blood pressure control in Stan, since its full potential only becomes evident with exerise. It means that future blood pressure assessments are more likely to be on a treadmill.

It would also explain why Stan's thoracic aorta was mildly enlarged and his aortic valve was mildly leaky when I met him, both potential consequences of intermittent high blood pressure.

If you've been following the Track Your Plaque conversation, you know that, contrary to prevailing opinion among many cardiologists, there is an emerging notion that coronary calcification is an active process, a true part of the disease.

Vitamin D3 is an important aspect of this question. So is vitamin K2. Not to be confused with K1 that plays a role in blood coagulation, K2 has an important role in calcium metabolism. Thus, vitmain K2 deficiency is related to osteoporosis and to coronary calcification.

Getting K2, like getting D, is difficult from food sources. The choices for K2 sources includes:

--Natto--generally, an impalatable choice. I've had it and it was intolerably gooey and weird-tasting. It is, nonetheless, the most concentrated food source of K2.

--Pate--Though liver products have the potential for containing many other unhealthy things, like pesticide residues, since the liver acts as a filter for the blood.

--Fermented cheeses--Since K2 is a product of fermentation of cheese, as it is in Natto.

For years, we've advised people to avoid or minimize cheese because of saturated fat or cholesterol content. I think that there's reason to re-think this advice based on the emerging data.

How can you tell the difference between fermented and non-fermented cheese? First, look for the holes in the cheese. The holes are the remnants of gas pockets created during fermentation. Second, look for the word "cultures" on the label, meaning organisms for fermentation were added. If "processed cheese" is anywhere on the label, this is a dairy product that has been chemically coagulated and is not fermented.

Fermented cheeses are generally "gourmet" cheeses, not eaten a pound at a time on a pizza, but meant to be eaten in small portions.

How much fermented cheese is necessary for its presumed inhibitory benefits on coronary calcification and osteoporsis? Are some fermented cheeses better than others? These issues remain unsettled. Stay tuned.

Anyone following the Track Your Plaque conversation know that we are rabid fans of normalizing blood vitamin D blood levels (25-OH-vitamin D3).

A wonderful report on vitamin D was aired this morning on the NBC Today show. The interviewed guests did a good job of describing the health effects of vitamin D, thought the focus was on some new data on the use of vitamin D for breast and prostate cancer.

I learned that shiitake mushrooms have some vitamin D--I didn't know that! (They contain 260 units per 4 mushrooms.)

Unfortunately, the closing comments from the guests, among whom was nutritionist and author, Joy Bauer,MS, was that you should get vitamin D from your multivitamin or your calcium with vit D.

That is absolutely wrong. When you check blood levels of vitamin D, as we do in everybody we see, you quickly learn what works and what doesn't.

Vitamin D in multivitamins is very poorly absorbed, if at all. Likewise, about 90% of the D in most calcium preparations is not absorbed. The vast majority of tablet or powder preparations, such as those in calcium tablets, are not absorbed to any significant extent. Take all you want and you remain vit D-deficient with osteoporosis, growing coronary plaque, low HDL, and exposed to risk for prostate and colon cancer.

If you take vitamin D in supplement form, it must--MUST--be in an oil-based capsule. The tablets are simply much too poorly and erratically absorbed to be reliable. There's nothing more frustrating to take, for instance, 4000 units of vitamin D in tablet form, only to have a blood level of 12 ng/ml--severe deficiency. Take the same 4000 unit dose in capsule form and blood level skyrockets to 58 ng/ml. And it's no more expensive.

One other thing: If you want to waste time and money, take the prescription vitamin D prescribed by many doctors. This is vitamin D2, also known as "ergocalciferol". Why use the synthetic vitamin D2 when D3 is the form your body needs? Because the D2 is patent-protectable and profitable to the drug manufacturer, similar to using Premarin (horse estrogens) when human preparations would suffice--or be superior. I saw a woman today taking 50,000 of prescription D2 once per week. Her blood level of 25-OH-vitamin D3? 17 ng/ml--severe deficiency. Don't waste your time with this garbage.

I am continually amazed at the amount of time and energy we all expend in the search for truth.

Rely on your hospital and you will be steered towards strategies that, at worst, aim to increase your use of hospital procedures. At best, they steer you towards physicians who are often under their employ.

How about your doctor? This is a source of immense frustration. Doctors remain interested in treating the catastrophic illness. They remain lukewarm towards prevention and self-empowerment. Thus, supplements are dangerous, everything requires a doctor's endorsement.

Drug companies? That's like relying on a used car salesman for truth. Exagerration, slick talk, and plain deception might be better descriptions of what you can count on from the drug manufacturers.

The internet? Perhaps, if you're selective. WebMD? An obvious voice-box for the drug industry. Just look at the proliferation of drugs ads that accompany each report. In fact, the majority (80%) of WebMD's revenues come from drug manufacturers.

The profit motive has created a mountain of good information. It has also created a sea of mis-information, all created to provide personal financial enrichment.

But I continue to be optimistic that the internet will also become a forum for truth, particularly through its capacity for networked interaction among participants. As our collective wisdom permits us to more effectively separate the wheat from the chaff in looking for the truth, I believe that we will zigzag towards a system of healthcare that is self-empowering, self-directed, and resorts to hospitals and procedures only in the most dire circumstances, saving billions of dollars every year.

The American Heart Association (AHA) has a program called the Heart-Check Mark, an "approval" process that permits a food manufacturer to affix the AHA logo and stamp of approval on various food products.

A company simply makes application to the AHA. The application and product details are reviewed and then approved or turned down.

To date, 106 companies have obtained the AHA stamp of approval on 768 products. What kinds of products are on the approved list? Here's a sample:

--Honey Bunches of Oats

--Kellogg's Frosted Mini-Wheats

--Cocoa Puffs cereal

--Cookie Crisp cereal ("The great taste of chocolate chips in every bite!")

There are 764 others. If you doubt this, just go to the store and take a look at the product containers.

What the heck is going on here? Most of us with any judgment know that these products are pure sugar. They may contain "no more" than 15-40 grams sugar per sugar, but the principal products--corn, wheat, fructose--mean that these products are, in effect, nearly pure sugar. Yet they carry the AHA stamp of approval.

What do products like this cause? It's a long list but the major effects include:

--Obesity

--Diabetes

--Drop in HDL

--Rise in triglycerides

--Small LDL particles

--Heightened inflammation (i.e., C-reactive protein)

--Mental cloudiness

Need I go on? Why are products like these and many others deserving of the AHA heart-check approval? Because they lack high fat and saturated fat (3.0 grams, 1.0 grams respectively, by AHA criteria). In other words, just lacking these ingredients means that, to the AHA, they qualify as "heart healthy."

By that same line of reasoning, many candy bars are "heart healthy", as are many cookies and cupcakes.

What's the reason behind this extraordinary absurdity? Is the AHA stupid?

There may be many reasons, but one very suspicious fact becomes immediately obvious when you realize these endorsements product a substantial revenue source for the AHA, since companies must pay for the right to use the heart-check approval mark. Also, just look at the major contributors (millions of dollars) to the AHA: ConAgra, General Mills, Kraft, etc.) You get the picture.

Does this make the AHA evil? Not necessarily. But it seriously erodes credibility. it also should make you very leery of any advice that comes from such an agency that is reluctant to bite the food manufacturer hands that feed it.

In my view, we simply cannot rely on the AHA for genuine, unbiased heart health advice.

Charles was visibly confused.

He'd gotten his CT heart scan after hearing one of the local scan center's ads on the radio. His score 2773, obviously in the 99th percentile for any age.

"Do you think the score means anything? My primary doctor said that it was meaningless because it was all in the deep wall of the artery. He said that it has nothing to do with risk for heart attack. As long as I feel good, he says don't do anything."

What exactly did his doctor mean, in the "deep wall of the artery"?

What the doctor is referring to is the fact that some people with a long history (many years) of diabetes or kidney failure (also for many years) tend to develop calcium deposits in the media, or muscular layer of arteries. The media is the tissue thin layer just below the intima, the most inner layer of arteries that we usually associate with atherosclerotic plaque and the layer that is most prone to calcium accumulation that we score on heart scans.

Aging, generally into your late 70s, 80s, and onwards, also increases the likelihood of medial calcification. Lastly, longstanding deficiency of vitamin D encourages medial calcification.

Is there any way to distinguish intimal vs medial calcification on a heart scan? No, there is not. Having read many thousands of CT heart scans, I can tell you that there is no practical way in 2007 to tell the difference.

Then how did this doctor "know" that Charles' calcium was "deep walled" or medial? Simple: He didn't. This was yet another example of ignorance based on old thinking. Unfortunately, he did Charles a serious disservice by dismissing his heart scan score that predicted a 25% per year risk for heart attack.

Interestingly, whether calcium is intimal as in atherosclerotic plaque, or medial, both are strongly associated with risk for heart attack. In other words, if calcium is confined to the intima, heart disease risk is present. If calcium is limited to the media, risk is still present.

In all practicality, the only difference we make of the intima vs. media argument (that is, when the distinction has been made by some other means like intracoronary ultrasound, the test that is truly necessary to distinguish the two patterns) is that medial calcification may be more powerfully related to vitamin D deficiency. Thus, someone with heavy medial calcification may require closer attention to maintaining a perfect year-round blood level of 25-OH-vitamin D3. But that's the only practical difference.

"My primary care doctor said to stop the vitamin D because it's toxic. So I stopped it and I just take a multivitamin. He said that a multivitamin and two glasses of milk a day was all I needed."

So proclaimed Eleanor to me. This happens around once every week by doctors frightened of the vitamin D.

So I reminded Eleanor that, before starting vitamin D supplementation, her blood level of 25-OH-vitamin D3 had been 17 ng/ml--severe deficiency.

On 4000 units per day (oil-based gelcap), her blood level had been 37 ng/ml--still deficient, below the desirable range of 50-60 ng/ml. That's the dose Eleanor's doctor had declared "toxic."

When exactly does deficiency develop? There's not full agreement on this, but Dr. Michael Holick of Boston University, among the most experienced and insightful authorities on vitamin D, states that toxicity is more likely when blood levels exceed 150 ng/ml (Nutr Clin Pract. 2007 Jun;22(3):297-304).

In other words, Eleanor and her doctor should not be concerned with toxicity, but with the persistent levels of deficiency she is suffering.

Some authorities call the behavior of vitamin D "bi-phasic": Deficiency is toxic, excessive levels are toxic. We're really just trying to achieve a middle ground in vitamin D levels that are above deficiency but below toxicity.

In reality, deficiency is exceptionally common. In fact, it's the rule around here (northern U.S.), with >95% of everybody we check severely deficient in winter, mildly-moderately deficient in summer. Very few people approach normal levels year round without supplementation.

Toxicity, on the other hand, is exceedingly rare. I have seen it once in a woman who was taking a toxic dose of 50,000 units a day on the instructions of her (mis-guided) doctor. Thankfully, no ill-effects developed from this little "experiment."

So, it's not toxicity that is the overwhelmingly common worry, but deficiency, severe and sustained.

Take a look at your local hospital and you're likely to notice several curious things:

1) It is likely non-profit, meaning it enjoys a non-profit status with the Internal Revenue Service and enjoys the tax benefits of not paying taxes on profits. This provides an advantage to tax-protected hospitals. 70% or more of hospitals in the U.S. are "non-profit."

2) Non-profit or no, many hospitals operate under the guise of a religious affiliation, e.g., St. Mary's Hospital, Trinity Hospital, All Saints', Jewish Hospital, etc.

3) Executives in non-profit hospitals can make capitalistic salaries. One CEO of a Milwaukee hospital took home $3.7 million dollars in salary last year. That's not including the very substantial perks and business interests in the spin-off businesses the hospital owns, including pharmacies, drug and medical device disitributors, even a venture capital division. "Non-profit" does not have to mean that executives within the operation can't benefit handsomely.

That same hospital system spends over $10 million dollars in a year in local marketing for TV ads, print advertising, etc. Ads are slick and professionally produced.

Make no bones about it: These are "non-profit" for tax purposes only . They are for-profit in every other sense of the phrase, including rich rewards for the insiders.

Guess how those fat executive salaries and large marketing budgets are paid for? That's right: the 12-inch incision in your chest; the four stents, defibrillator, and repeated nuclear stress tests; the revolving door of hospitalization after hospitalization that typifies the "heart patient" experience.

See the hospital for what it is: In the 21st century, it is no longer a charitable operation worthy of your volunteer time and donations. It is a business no different than Home Depot, IBM, or--Enron. Yes, they do perform needed services, as well. But the perverse equation that often determines who needs hospitalization and who doesn't, who needs a heart procedure and who doesn't, is not always based on necessity but on financial return. Just ask the CEO.