Vitamin D and octagenarians

Roger practically bounced in his chair vibrating with energy.

"It must be the vitamin D! I haven't felt like this in years. I can work around the yard all day and still have energy left over."

At age 84, Roger started out with pretty good health, despite a prosthetic valve and bypass surgery 5 years earlier. He looked 74, perhaps younger.

I've seen this effect now in about 20 octagenarians. A Track Your Plaque Member mentioned this same effect in his father-in-law in a discussion in our Forum. Most are taking around 6000-8000 units per day (gelcap, of course). The average dose of vitamin D tends to be higher in this age group, since by age 80, you've essentially lost the capacity to convert 7-hydrocholesterol to active vitamin D3 in the skin. Most octagenarians start with 25-OH-vitamin D3 levels of 10 ng/ml or less--profound deficiency.

I believe the effect is real, having now witnessed it multiple times. Unfortunately, my observations are too informal to qualify as a study. (I wouldn't even know how to quantify this. I suppose some sort of muscle and coordination testing might yield quantifiable measures.) However, there are some data emerging that show less fractures, falls, improved coordination, and perhaps improved memory and mentation with vitamin D supplementation, though doses often used in studies tend to be lower than what we are using in practice.

I haven't been so excited about the effects of a nutritional supplement in a long time. Vitamin D continues to yield surprises every day in its array of positive and powerful effects.

Could we say that vitamin D restores youthfulness?

Comments (28) -

  • Anonymous

    10/10/2007 9:26:00 PM |

    I was wondering if you could breifly but exactly tell me what vitamin D does for your heart as far as reducing plague. I just always hear "its good to reduce plague" but how or what does it do?

  • Dr. Davis

    10/10/2007 9:42:00 PM |

    There is a full special report posted on the www.trackyourplaque.com website.

    Also, see my article in Life Extension Magazine on vitamin D; it should be posted online within the next couple of months if you don't have a hard copy.

  • Anonymous

    10/11/2007 1:51:00 AM |

    Are all brands of cholecalciferol interchangeable?  How do you know how much D to take?

    I am female, age 52.  I started on 2,400 IU of cholecalciferol last March because my Vitamin D levels tested at 19.  Last time I tested in August, my D levels were up to 42 (presumably because of the supplementation since I don't spend much time in the sun).  I'm also taking fish oil.

    However, I wish I could tell you that I felt more sprightly like your patients.  However, I really don't feel any better on Vitamin D than off of it.  I'm either (1) a non-responder; (2) not taking the right brand of Vitamin D; or (3) not taking a high enough dose (although 2,400 seems like a lot).

  • Dr. Davis

    10/11/2007 1:58:00 AM |

    We aim for a blood level of 50-60 ng/ml.

    However, though I've been impressed with the energy-enhancing effects, it does not develop in everybody. Why? That's another lesson to learn. But restoring vitamin D still provides all its imperceptible benefits.

  • over&out

    10/11/2007 2:59:00 AM |

    Dr Davis, 10 days ago I told you of my Diabetic wifes wonderful response to an experimental dose of 1000IU oil base gel cap D's. Her #'s dropped 20-30 points. She called her Endo requesting a prescription for a blood draw to check D level. He was unresponsive and today his nurse called and said not to take anymore, he had never read anything about D affecting Glucose levels, and He would talk to her at the next appointment. Undeterred we called our GP and he said sure,just stop in. We did and now await the #'s hoping we understand them. I am considering Faxing the Pub Med study "The roll of Vitamin D and Calcium in type 2 Diabetics" to my wifes Endo. Do you think he would be offended? .....Thanks

  • over&out

    10/11/2007 2:59:00 AM |

    Dr Davis, 10 days ago I told you of my Diabetic wifes wonderful response to an experimental dose of 1000IU oil base gel cap D's. Her #'s dropped 20-30 points. She called her Endo requesting a prescription for a blood draw to check D level. He was unresponsive and today his nurse called and said not to take anymore, he had never read anything about D affecting Glucose levels, and He would talk to her at the next appointment. Undeterred we called our GP and he said sure,just stop in. We did and now await the #'s hoping we understand them. I am considering Faxing the Pub Med study "The roll of Vitamin D and Calcium in type 2 Diabetics" to my wifes Endo. Do you think he would be offended? .....Thanks

  • Dr. Davis

    10/11/2007 3:22:00 AM |

    Yes, by all means.

    If he is offended, it's time for a new endocrinologist. Part of being a responsible professional is a willingness to learn.

  • over&out

    10/12/2007 2:35:00 AM |

    Sorry to be a pest...My wife's D checked at 42 pg/ml...what ever pg stands for? She want to take another 1000IU gel cap for a couple weeks (total of 2000IU) to see if glucose goes down more. If it does then she will retest to see if that is a safe maintenance dose. Sound like a reasonable plan?
    From 180's down to 150's has been  encouraging. Many Thanks.

  • over&out

    10/12/2007 2:35:00 AM |

    Sorry to be a pest...My wife's D checked at 42 pg/ml...what ever pg stands for? She want to take another 1000IU gel cap for a couple weeks (total of 2000IU) to see if glucose goes down more. If it does then she will retest to see if that is a safe maintenance dose. Sound like a reasonable plan?
    From 180's down to 150's has been  encouraging. Many Thanks.

  • Dr. Davis

    10/12/2007 11:44:00 AM |

    I'm puzzled.

    I've never seen vitamin D expressed in those units. It also doesn't make sense. There are 1000 pg in one ng; thus, a value of 42 pg/ml would equal .042 ng/ml, a value less than 1 ng/ml, meaning virtually zero vitamin D in the blood.

    Something is wrong. You might go back and verify the value.

  • Anonymous

    10/12/2007 4:27:00 PM |

    Oct. 12, 2007

    Dr. Davis:
    Re: Over & out:

    There are two Vitamin D test.
    One is Vitamin D,1, 25-Hydroxy (Calcitriol). This test is reported in pg/ml.
    The other Vitamin, D test is Vitamin D, 2-Hydroxy (Calcidiol).
    This reported as ng/ml.
    I think this should be the Vitamin D test to be ordered.
    I made the same mistake, before.

    So, I think Over & Out should have her test redone, on Vitamin D2-Hydroxy (Calcidiol).
    I have mine done thru, Directlabs.com., blood drawn at Labcorp.

    Thanks,

  • over&out

    10/12/2007 6:32:00 PM |

    Your a genius! We attached your text (minus your name so they wouldn't T.P. your house)and went to Paul Oliver Hosp. In Traverse City, MI. "Whats up with this" we asked. "Oh, we ran the wrong test" this is for a 1,25 OH Vitamin D test.
    So now its the weekend and we will have to wait till Mon-Tues for the real results. What a miatake we could have made without your generous help. Many Thanks ...big time.

  • over&out

    10/12/2007 6:32:00 PM |

    Your a genius! We attached your text (minus your name so they wouldn't T.P. your house)and went to Paul Oliver Hosp. In Traverse City, MI. "Whats up with this" we asked. "Oh, we ran the wrong test" this is for a 1,25 OH Vitamin D test.
    So now its the weekend and we will have to wait till Mon-Tues for the real results. What a miatake we could have made without your generous help. Many Thanks ...big time.

  • Dr. Davis

    10/13/2007 1:46:00 AM |

    Ah, that makes sense. Thanks.  

    However, it's the 25-OH-vitamin D3 that we measure, the effective form, not D2.

  • G

    10/17/2007 5:48:00 AM |

    You are actually shooting for 60-60-60-60 (LDL TG HDL, vit D-25-OH)! I can't wait to see an RCT on the results of your interventions. do you think your results will beat Vit B3 (ie niacin) + zocor 40mg/d from the HATS trial with a better than 90% reduction in secondary CAD?  I would wager the results will trump. i hope the doubts are put to rest.
    I've recently test my own vit d and am so confounded they are so low (21 ng/ml) for living in sunny Cali, taking my kids to swimming for hours in the summer 2-4 days/wk, running 3-4 half-marathons and a mini-triathlon every year...  is it really all the sunscreen causing this silent pandemic of deficiency?  is there a point in screening. it seems everyone is deficient, even if the dark toned individuals who spend hours in the sun daily. i'm only 30-something, not obese (bmi 18.5). i've even checked my glucose (i'm an educator) and surprised to find it > 160 after a rare sugary drink. also i never use my asthma inhaler in the summer but found i needed it without being sick... i may need to go sun myself and get D3 3000-4000 IU/d to get the level up to 60. i'm so bummed. but glad to not be in the dark (pun intended)  thank you again for your excellent insights.

  • G

    10/17/2007 7:32:00 AM |

    Lipitor is 'doing the D'!
    you've probably seen this (the post-1yr leves are still very low << 80 nmol/L)...  


    Effects of Atorvastatin on vitamin D levels in patients with acute ischemic heart disease.

    Am J Cardiol. 2007 Apr 1;99(7):903-5

    Authors: Pérez-Castrillón JL, Vega G, Abad L, Sanz A, Chaves J, Hernandez G, Dueñas A

    Vitamin D deficiency is a risk factor for osteoporosis and other chronic diseases, including type 1 diabetes, hypertension, metabolic syndrome, and ischemic heart disease. Cholesterol and vitamin D share the 7-dehydrocholesterol metabolic pathway. This study evaluated the possible effect of atorvastatin on vitamin D levels in patients with acute ischemic heart disease. Eighty-three patients (52 men and 31 women) with an acute coronary syndrome (75 with acute myocardial infarction and 8 with unstable angina) were included. After diagnosis, patients received atorvastatin as secondary prevention. Serum vitamin D was measured by high-performance liquid chromatography at baseline and at 12 months. Atorvastatin treatment produced a statistically significant decrease in cholesterol and triglyceride levels and an increase in vitamin D levels (41+/-19 vs 47+/-19 nmol/L, p=0.003). Vitamin D deficiency was decreased by 75% to 57% at 12 months. In conclusion, atorvastatin increases vitamin D levels. This increase could explain some of the beneficial effects of atorvastatin at the cardiovascular level that are unrelated to cholesterol levels.

    PMID: 17398180 [PubMed - indexed for MEDLINE]

  • Dr. Davis

    10/17/2007 12:27:00 PM |

    Isn't that interesting? I saw that, too, but was impressed with how little discussion it seemed to generate. Perhaps we're all becoming oversaturated with the statins do this, statins do that reports. But  I thought this one also merited special attention.

  • Dr. Davis

    10/17/2007 12:33:00 PM |

    That is impressive. Factors that contribute to vitamin D deficiency would include:

    1) season--even in LA, the sun is increasingly indirect.

    2)Lifestyles--with more time spent indoors and in cars; you probably wear clothes most of the time!

    3) Sunscreen, as you point out, is very effective to block vit D conversion.

    4) Genetic factors

    5) Skin color--The darker you are, the longer it takes to obtain D.

    I believe that our results will like be superior to a HATS-like experience, though they are two different populations, ours being lower risk. Event data will come eventually. We are currently focusing on surrogate measures of atherosclerosis first.

  • G

    10/18/2007 9:08:00 PM |

    You are awesome -- thank you for  your thoughts!!  yes, usually i'm clothed!  but wore the requisite suit at the poolside and perhaps increased the natural SPF in the skin as a consequence?  The more tan, perhaps the less skin activation of D3?  I'm a tan asian american (I was 'black' as a kid playing in the 'hood, but, now no longer to avoid you know wrinkles)

    As a rph, I read the life extension article and really appreciated the list of potential adverse effects with Vitamin D.  Do you routinely ck urine for calciuria?  When do you see this happen?  Do recommend checking annually?

    somehow you remind me of Tony Soprano but instead of knocking people off, you're HELPING PEOPLE STAY ALIVE...  Keep up your strong work.

  • Dr. Davis

    10/19/2007 2:39:00 PM |

    Thanks, much, G.

    No, I don't routinely check calcium in the urine nor in the blood. It is rare in an otherwise healthy person to see any adverse disruptions of calcium. In fact, most people who are deficient in vit D (nearly everybody!) show a modest drop in serum calcium, reflecting less mobilization of bone stores, a healthy effect.

  • Anonymous

    10/22/2007 9:18:00 PM |

    I would just like to say that your blog has really helped me.  My father just turned eighty and neither his primary doctor (who handles his heart disease) nor his Alzheimer's doctor has ever tested his vit.D levels.  When I inquired about him possibly adding fish oil and vit.D a year ago, both doctors looked at me like I was an an insane person. They dismissed me and I thought, hey, they are the ones with M.D.'s after their names.  Well, after recently educating myself with your blog, I insisted on a vit.D test and sure enough, the nurse said it was very low although she declined to tell me the actual level.  She said my father's primary doctor would follow up with us.  With the fish oil, the doctor said it is much better to get it from food and I said we don't eat an Eskimo diet!!  She said taking the fish oil wouldn't hurt.  But again, no guidance as to amounts.  Could you recommend amounts of both the vit.D gelcaps and fish oil for my 80 year old dad and myself (37 year old female)?

  • Dr. Davis

    10/22/2007 10:28:00 PM |

    Thanks for your kind comments. Unfortunately, I cannot dispense individual advice.

    However, an average dose in my patient 80 years and over is 6000 units for a male; 35-40 year old females usually require 2000-4000 units per day. Of course, needs vary depending on body size, region of the country, sun exposure, race, etc. These are ballpark figures.

    Always keep in mind that Vit D works far better when in gelcap form.

  • G

    10/28/2007 2:12:00 AM |

    I take it back!  you're not that Tony-esque... you're more akin to Emeril Largesse... spreading the LOVE (heart)!! and keeping the ticker ticking!  continue the strong work!  

    How detrimental is caffeine (ie, 2-3 shots espresso or green tea daily)?   1 glass red wine daily?  UV B tanning booth? (I'm considering the last vice since I'm tiring of taking pills)
    In Wisconsin, do you ever lay out or hit the tanning salon?

  • g

    10/28/2007 2:21:00 AM |

    BTW, I have lived your low carb, moderate fat diet -- totally works! lost 45 lbs over 4 yrs after my children were born (coupled with strength training and yoga).
    I've convinced some of my diabetes pts -- but it's very hard for people to give up the pasta and rice.
    What are your thoughts on Fibrates (very good data from the DAIS and VA-HIT)?
    How about Plant Sterols (which is sold at Trader Joes -- LOVE THAT PLACE  -- they carry the oat bran, raw nuts and flaxseed you endorse -- I love their LOW GLYCEMIC FLOURLESS Ezekiel bread!)? it apparently is being added to EVERYTHING including milk and OJ soon... it's already mixed with margarine (yeck)

  • Dr. Davis

    10/28/2007 2:27:00 AM |

    Those are all great ideas. Tanning beds can indeed activate vitamin D, similar to sun exposure.

  • Dr. Davis

    10/28/2007 2:30:00 AM |

    I love Trader Joe's, too. We just got our first in Wisconsin about one year ago. It saves me a lot of driving back and forth to Chicago.

    Fibrates--I use them only occasionally, as a second choice to niacin, since niacin is much more powerful in effect.

    Please see our newsletter archive at www.trackyourplaque.com for a full discussion of the potential DANGERS of sterol esters. Stanol esters like those in Benecol are safe. But sterol esters can potentially be absorbed into the blood.

  • G

    11/9/2007 8:03:00 PM |

    Thanks for the plant sterol FYI!

    Should D3 be renamed...  it seems to be implicated in so many other functions (cardiac, CKD/PTH, reproductive, autoimmune, TSH, dyslipidemia, Type 1 and Type 2 DM, hypertension, cancers, osteoporosis, the list goes on)... something like DVH which would stand for 'D3 VITAL hormone'

    What are your thoughts on DHEA (and Testost replacement)? Do you titrate the dose to patient's tolerance, to symptom resolution or a physiologic levels?  For testost our lab normals are female T > 20 ng/dL; male  T > 260 pg/mL)...  Thank you for any input!

    I'm so grateful for you sharing your compelling observations on the effects on HDL and CAD reversal!  here's another interesting article... D3 (and calcium -- i think it's D3 dependent effect) on HDLs!

    Am J Clin Nutr. 2007 Jan;85(1):54-9.
    Supplementation with calcium + vitamin D enhances the beneficial effect of weight loss on plasma lipid and lipoprotein concentrations.Major GC, Alarie F, Doré J, Phouttama S, Tremblay A.
    Division of Kinesiology, Department of Social and Preventive Medicine, Faculty of Medicine, Laval University, Ste-Foy, Canada.

    BACKGROUND: Adequate calcium intake can have a favorable effect on some metabolic variables. OBJECTIVE: The objective of the study was to determine the effects of daily calcium intake and of supplementation with calcium and vitamin D (calcium+D) during a weight-loss intervention on blood pressures, plasma lipid and lipoprotein concentrations, and glucose and insulin concentrations in low calcium consumers. DESIGN: Healthy, overweight or obese women (n = 63) with a daily calcium intake of < 800 mg/d were randomly assigned in a double-blind manner to 1 of 2 groups: the group consuming 2 tablets/d of a calcium + vitamin D supplement (600 mg elemental calcium and 200 IU vitamin D/tablet) or the group consuming placebo; both groups observed a 700 kcal/d energy restriction. These 63 women then completed a 15-wk weight-loss intervention. RESULTS: Initial daily calcium intake was significantly correlated with plasma HDL cholesterol (r = 0.41, P < 0.001) and with 2-h postload glycemia (r = -0.29, P < 0.05) during an oral-glucose-tolerance test, independent of fat mass and waist circumference. After the 15-wk intervention, significantly greater decreases in total:LDL and LDL:HDL (P < 0.01 for both) and of LDL cholesterol (P < 0.05) were observed in the calcium+D group than in the placebo group. The differences in total:HDL and LDL:HDL were independent of changes in fat mass and in waist circumference. A tendency for more beneficial changes in HDL cholesterol, triacylglycerol, and total cholesterol was also observed in the calcium+D group (P = 0.08). CONCLUSION: Consumption of calcium+D during a weight-loss intervention enhanced the beneficial effect of body weight loss on the lipid and lipoprotein profile in overweight or obese women with usual low daily calcium intake.

    PMID: 17209177 [PubMed - indexed for MEDLINE]

  • Dr. Davis

    11/10/2007 12:53:00 AM |

    Hi, G--

    I use both DHEA and testosterone for specific lipid/lipoprotein treatment, e.g., DHEA in men and women to (modestly) reduce Lp(a), testosterone to reduce Lp(a) in men.

    Both can also be used to increase physical stamina, erectile capacity, and mood. I'd invite you to read our full length Special Reports on each of these topics on the www.trackyourplaque.com website.

Loading

Can I stop my Coumadin?

Here I go again.

While I will try to keep this blog on topic, i.e., coronary heart disease prevention and reversal using nutritional and other natural strategies, I believe that a "critical mass" of frequently asked, though off topic, questions keep cropping up.

One such question revolves around Coumadin, or warfarin.

Somehow, my Nattokinase scam blog post draws traffic about Coumadin. I tried to make the point that a conventional blood thinning agent like Coumadin that undoubtedly has undesirable side-effects cannot be replaced by an agent that has an uncertain track record. In the case of nattokinase, no track record.

To illustrate how far wrong the "nattokinase as replacement for Coumadin" idea can go, here is a question from Anna:


I came across your blog while perusing.

I am a bit bummed because I have been on Coumadin (warfarin) for around 22 years since I was 6 years old. I have a mechanical heart valve (St. Jude's), as I have heart-related issues, including hypertrophic obstructive cardiomyopathy.

Well, it is just that the warfarin seems to interact with nearly everything. I feel like I can not get the nutrients my body requires. I desire to consume more raw foods and vegan foods, though I do not want anything to damage my heart valve or risk a stroke/heart attack or internal bleeding.

I have been underweight the majority of my life, malnourished , currently am still somewhat underweight, though enjoying food again, as I had what mimicked Crohn's Disease for several years (horrendous pain), from which I am in remission now. I was diagnosed with osteoporosis, which may or may not be caused from consuming warfarin.

Is it possible to get off of warfarin and effectively keep my blood thinned ? I currently take 1.5 mg to 2 mg dosage. Does the warfarin destroy Vitamin K and if so does that mean while on warfarin I never get the Vitamin K nutrients even if I did consume foods with it in it?

Thank you
Anna


No, sorry, Anna. Stopping Coumadin with your unique issues, i.e., a prosthetic mechanical heart valve (likely mitral, judging by your history of hypertrophic obstructive cardiomyopathy, in which the patterns of blood flow ejected from the heart disrupt the natural mitral valve function) and cardiomyopathy, can be fatal. Without blood thinning, the mechanical heart valve can trigger blood clot formation, since it is a foreign object implanted into the bloodstream.

There are no natural alternatives available with track records confident enough to bet your life on. Aspirin nor Plavix are blood thinners, but platelet inhibitors. These two agents, while they work for other forms of arterial (but not venous) blood clot inhibition, will not work for your unique situation.

Likewise, a purported oral lytic agent like nattokinase should not be substituted for Coumadin. Even if there was plausible science behind it, you should demand substantial evidence that it provides at least blood thinning equivalent to Coumadin. Should a blood clot, even a small one, form in or around the prosthetic valve, the valve can stop working within seconds. This can lead to death within minutes.

I believe it would be foolhardy to bet your life based on the marketing--let me repeat: MARKETING--of a "nutritional supplement" by supplement manufacturers eager to make a buck.

Nor are there any other nutritional supplements that can safely replace the Coumadin. I wish that were NOT true, as I am no stranger to the long-term dangers of Coumadin and I am a big believer, in general, in nutritional supplements. I am a BIGGER believer, however, in the truth. Weighing the options available to us today, there really is no rational choice but to remain on Coumadin.

By the way, I tell my patients to eat a substantial amount of green vegetables while they take Coumadin. I know that conventional advice is to reduce or eliminate green vegetables due to their content of Coumadin-antagonizing vitamin K. I think this is wrong, also. Green vegetables are the best foods on earth. They reduce risk for cancer, diabetes, bone disease, and coronary heart disease.

To obtain the benefits of green vegetables without mucking up your blood thinning (your "protime" or International Normalized Ratio, INR), I advise my patients who take Coumadin to eat green vegetables--but do so every day in relatively consistent quantities, so that the protime or INR is not disrupted and remains reasonably constant. It may mean that your total dose of Coumadin may be somewhat higher, e.g., 3 or 4 mg instead of 2 mg, but the dose is immaterial outside of blood thinning. That way, you obtain all the wonderful health benefits of green vegetables while maintaining fairly consistent blood thinning/protime/INR. Coumadin does not block all the health benefits of vegetables, only those related to vitamins K1 and K2.

With regards to protecting yourself from the osteoporosis promoting effects of Coumadin, I would be sure to follow a program of natural bone health, such as the one I discussed in Homegrown osteoporosis prevention and reversal. You will have to be extra careful, however, with the vitamin K2. Ideally, you have a doctor knowledgeable about vitamin K2 who can assist you in managing K2 intake while on Coumadin. This is something you can definitely NOT manage on your own. (I am a big believer in self-managed care, but this is way beyond the limit.)

Lastly, it is my belief that anyone with an inflammatory bowel condition, such as Crohn's disease or ulcerative colitis, should absolutely, positively, and meticulously AVOID WHEAT and all other gluten sources (such as rye, barley, and oats). Even if you test negative for celiac markers (e.g., anti-gliadin antibodies, emdomysium and transglutaminase antibodies), the enhanced intestinal permeability will allow wheat proteins, such as gluten, to gain ready entry into the bloodstream. Not to mention that wheat should have no place in the human diet anyway, in my view.

Homegrown osteoporosis prevention and reversal

I don't like to stray too far off course from discussions of heart disease and related issues in this blog. But the question of bone health comes up so often that I thought I'd discuss the strategies available to everybody to stop, even reverse, osteoporosis.

Coronary atherosclerotic plaque and bone health are intimately interwoven. People who have coronary plaque usually have osteoporosis; people who have osteoporosis usually have coronary plaque. (The association is strongest in females.) The worse the osteoporosis, the greater the quantity of coronary plaque, and vice versa. The two seemingly unconnected conditions share common causes and thereby respond to similar treatments.

Incredibly, rarely will your doctor tell you about these strategies. Your doctor orders a bone density test, the value shows osteopenia or osteoporosis, and a drug like Fosamax or Boniva is prescribed. As many people are learning, drugs like this can be associated with severe side-effects, such as jaw necrosis (death of the jaw bone), a dangerous and disfiguring condition that leads to loss of teeth and disfigurement, followed by reconstructive surgery of the jaw and face. These are not trivial effects.

Note that drugs are approved by the FDA based on assessment of efficacy and safety, NOT proven equivalence or superiority to natural treatments.

In order of importance (greatest to least), here are strategies that I believe are important to regain or maintain bone health. Indeed, I have seen many women increase bone density using these strategies . . . without drugs of any sort.

1) Vitamin D restoration--Vitamin D is the most important control factor over bone calcium metabolism, as well as parathyroid function. As readers of this blog already know, gelcap forms of vitamin D work best, aiming for a 25-hydroxy vitamin level of 60-70 ng/ml. This usually requires 6000 units per day, though there is great individual variation in need.

2) Vitamin K2--If you lived in Japan, you would be prescribed vitamin K2. While it's odd that K2 is a "drug" in Japan, it means that it enjoys the validation required for approval through their FDA-equivalent. Prescription K2 (as MK-4 or menatetranone) at doses of 15,000-45,000 mcg per day (15-45 mg), improves bone architecture, even when administered by itself. However, K2 works best when part of a broader program of bone health. I advise 1000 mcg per day, preferably a mixture of the short-acting MK-4 and long-acting MK-7. (Emerging data measuring bone resorption markers suggest that lower doses may work nearly as well as the high-dose prescription.)

3) Magnesium--I generally advise supplementation with the well-absorbed forms, magnesium glycinate (400 mg twice per day) or magnesium malate (1200 mg twice per day). Because they are well-absorbed, they are least likely to lead to diarrhea (as magnesium oxide commonly does).

4) Alkaline potassium salts--Potassium as the bicarbonate or the citrate, i.e., alkalinizing forms, are wonderfully effective for preservation or reversal of bone density. Because potassium in large doses is potentially fatal, over-the-counter supplements contain only 99 mg potassium per capsule. I have patients take two capsules twice per day, provided kidney function is normal and there is no history of high potassium.

5) An alkalinizing diet--Animal products are acidic, vegetables and fruits are alkaline. Put them together and you should obtain a slightly net alkaline body pH that preserves bone health. Throw grains like wheat, carbonated soft drinks, or other acids into the mix and you shift the pH balance towards net acid. This powerfully erodes bone. Therefore, avoid grains and never consume carbonated soft drinks. (Readers of this blog know that "healthy, whole grains" should be included in the list of Scams of the Century, along with Bernie Madoff and mortgage-backed securities.)

6) Strength training--Bone density follows muscle mass. Restoring youthful muscle mass with strength training can increase bone density over time. The time and energy needs are modest, e.g., 20 minutes twice per week.

Note that calcium may or may not be on the list. If on the list at all, it is dead last. When vitamin D has been restored, intestinal absorption of calcium is as much as quadrupled. The era of force-feeding high-doses of calcium are long-gone. In fact, calcium supplementation in the age of vitamin D can lead to abnormal high calcium blood levels and increased heart attack risk.

These are benign and easily incorporated strategies. They are also inexpensive. I challenge any drug to match or exceed the benefits of this combination of strategies. Keep in mind that strategies like vitamin D restoration provide an extensive panel of health benefits that range far beyond bone health, an effect definitely NOT shared by prescription drugs.

Your enlarged aorta

The thoracic aorta lives happily within the chest.

The aorta is the main artery of the body that emerges from the heart, located just under the sternum. It is the "tree trunk" from which all the major arteries branch off to the rest of the body: the arms, brain, abdominal organs, pelvis, and legs. The aorta receives the high-pressure blood ejected directly out of the heart muscle.

However, there are evil forces in the body that work to weaken the aorta. When the aorta is weakened, it enlarges. Enlarged aortas also tend to grow atherosclerotic plaque. Plaque in the aorta poses long-term risk for stroke and and mini-strokes ("transient ischemic attacks," or TIAs), due to fragmentation.

There are many enlarged aortas in this world. I see at least several every week. It is fairly common, particularly in people with high blood pressure and cholesterol abnormalities, as well as those who are overweight. Smokers get it really bad.

Conventional thinking is that, once an aorta enlarges, it will inevitably continue to enlarge at the average rate of 2.0 mm per year (resulting in 1.0 cm enlargement over 5 years). For this reason, conventional discussions on the topic of thoracic aortic aneurysms all say something like "Enlarged aortas should be monitored yearly. Surgical replacement should proceed when the aorta reaches a diameter of 5.5 cm."

This is because an aortic diameter of 5.5 cm is associated with much greater likelihood that the aorta will rupture (fatal within minutes) or the internal lining will tear, a "dissection." The surgery is a major undertaking that involves opening the chest and usually replacing the aortic valve and inserting a synthetic aorta. The procedure is high-risk, especially if any branch arteries are involved.

So putting a stop to any further aortic enlargement is a worthwhile goal. Unfortunately, conventional thought is that there is nothing you can do to stop the inevitable growth of the thoracic aorta.

Nonsense. There are a number of efforts you can make to halt further increase in aortic diameter. (My experience in this is anecdotal and unpublished, but now numbers several hundred patients.)

There are two categories of factors that cause the aorta to increase in diameter:

1) Internal pressure--Think of blood pressure as the internal inflating pressure on this "balloon." Keeping the "inflating pressure," i.e., blood pressure, low exerts substantial effect on slowing growth of aortic diameter. I aim for normal BP or lowish BP (less than 130/80, preferably 100/70).

2) Factors that weaken the aortic wall--Processes like inflammation, glycation, lipoprotein deposition, and nutritional deficiencies will serve to weaken the supportive tissue of the aorta. For that reason, correction of lipoprotein abnormalities (e.g., small LDL and lipoprotein(a)), reductions in carbohydrate intake and thereby blood glucose/glycation, and "normalization" of vitamin D, vitamin C supplementation (for collagen crosslinking), and omega-3 fatty acids all play a role.

To push even farther, there may be additional advantage to following strategies that impair the production and activity of a crucial enzyme that lives within the aortic wall: matrix metalloproteinase, or MMP. MMP degrades the collagen and other supportive tissues within the aorta, weakening it and permitting expansion. Blocking MMP may prove to be among the most powerful new strategies to halt aortic expansion.

Compounds that have potential MMP-inhibiting effects include:
--Vitamin D--A substantial effect
--Resveratrol--One of the polyphenols from red wine
--Doxycycline--This old antibiotic often used for acne treatment has, in preliminary studies, shown important MMP-blocking effects and slowed aortic expansion.

Anyway, there you have it. A bit complicated, but a "recipe" that has failed me only rarely.

Extreme carbohydrate intolerance

Here's an interesting example of what you might call "extreme carbohydrate intolerance."

May is a 44-year woman who has now had her 7th stent placed in her coronary arteries. She lives on a diet dominated by breads, breakfast cereals, muffins, rice, corn products, along with some real foods.

Her conventional lipid panel and other lab values:

Total cholesterol 346 mg/dl
Triglycerides: 877 mg/dl
HDL cholesterol: 22 mg/dl
LDL cholesterol: incalculable
(Recall that LDL cholesterol is usually a calculated, not a measured value. The excessively high triglycerides make the standard calculation invalid--more invalid than usual.)

Fasting blood glucose: 210 mg/dl
HbA1c (a reflection of previous 60-90 days average glucose): 7.2% (desirable 4.5% or less)
ALT (a "liver enzyme"): 438 (about five-fold normal)


At 5 ft even and 138 lbs (BMI 27.0), May appears small. But the modest excess weight is all concentrated in her abdomen, i.e., in visceral fat.

By lipoprotein analysis via NMR (Liposcience), May's LDL particle number was 2912 nmol/L, or what I would call a "true" LDL of 291 mg/dl. (Drop the last digit.) Of the 2912 nmol/L LDL particles, 2678 nmol/L, or 92%, were small.

The bad news: This pattern of extremely high triglycerides, extremely high LDL particle number, low HDL, predominant small LDL, and diabetes poses high-risk for heart disease--no surprise. It earned her 7 stents so far. (Unfortunately, she has made no effort whatsoever to correct these patterns, despite repeated advice to do so.)

The good news: This collection is wonderfully responsive to diet. LDL particle number, small LDL, triglycerides, blood glucose, and HbA1c drop dramatically, while HDL increases. Heart disease will at least slow, if not stop.

It's amazing how far off human metabolism can go while indulging in carbohydrates, particularly a genetically carbohydrate-intolerance person. (Actually, I wouldn't be surprised if May's diet, as bad as it seems to you and me, still fits within the dictates of the USDA food pyramid.) The crucial step in diet to correct this smorgasbord of disaster is elimination of carbohydrates, especially that from wheat, cornstarch, and sugars.

What's for breakfast? Egg bake

Heart Scan Blog reader and dietitian, Lisa Grudzielanek, provided this recipe in response to the post, What's for breakfast?

Lisa, by the way, is one of the rare dietitians who understands that organizations like the American Dietetic Association have made themselves irrelevant. She therefore advocates diet principles that work, not just echoing the idiocy that emanates from such organizations, often driven by economics more than science. Lisa works in the Milwaukee area and has proven a useful resource person for my patients who have required extra coaching in the Track Your Plaque diet principles.

Egg Bake
My favorite breakfast is what I call an "egg bake." Others may refer to it as a "quiche."

Take a variety of fresh vegetables. This time of year is great for farmers' markets.

I typically use fresh chopped organic spinach, bell peppers, red & white onions, scallions, broccoli, mushrooms, cherry tomatoes halved and, if desired, meat (nitrite-free ham or leftover chicken breasts).

1) Chop veggies and place in casserole dish.
2) Add meat and handful of cheese of your choice.
3) Scramble 8 eggs & little bit of milk & pepper.
4) Add to casserole dish and mix/coat veggies with egg mixture.
5) Put in oven at 450 degress for 30 minutes.

Yummy, ready to eat breakfast that is so easy for the work week.

What's for breakfast?

If you eliminate wheat from breakfast and otherwise adhere to a low-carbohydrate dietary approach, what is there to eat for breakfast?

If you take out English muffins, bagels, all breakfast cereals, pancakes, waffles, and toast, what's left to eat?

Actually, there's plenty left to eat. It just may not look like the traditional American notion of "breakfast." (The traditional idea of breakfast was is, in part, due to the legacy of Dr. John Harvey Kellogg, who, in the latter part of the 19th century, ran a sanitarium in Battle Creek Michigan. He and his brother, Will Keith Kellogg, discovered the idea of turning grains into flakes, the birth of the breakfast cereal. Subscribe to the idea of breakfast cereal for breakfast and you subscribe to the ideas of a man who would administer four enemas for you today to cure your cancer or rheumatism.)

Here are a few ideas. By no means is this meant to be a comprehensive list, just a starting point for a few new breakfast food ideas.

--Eggs--Of course, eat the yolk. Eat three yolks. Scrambled, "fried," (not really deep-fried, of course), hard-boiled, poached, as an omelette. Add pesto, olive oil, vegetables, mushrooms, salsa.

--Ground flaxseed--As a hot cereal with your choice of water, milk (not my favorite because of insulin effects; the fat is immaterial), full-fat soy milk (yeah, yeah, I know), unsweetened almond milk. Add walnuts, blueberries, etc. Ground flaxseed is the only grain I know of that contains no digestible carbohydrates.

--Lunch and dinner--Yes, if you cannot have breakfast foods for breakfast, then have lunch and dinner, meaning incorporating foods you ordinarily regard as lunch and dinner foods into your day's first meal. This means salads, leftover chicken from last night, soup, raw vegetables dipped in hummus or guacamole, stir fry, etc.

--Cheese--For something quick, grab a chunk of gouda or emmentaler along with a handful of raw almonds, walnuts, or pecans. Because of the excess acidity of cheese (along with meats, among the most acidifying of foods), I usually try to include something like a raw pepper or avocado, foods that are net alkaline.

--Avocados--Cut in half, scoop out contents. They're quick and delicious, when available.

I hesitate to mention it, but I sometimes will have tofu, cubed and flavored with whatever is available--soy sauce, miso, pickled vegetables. My mother was Japanese, so I'm comfortable with this, though many people are not.

Anyway, that's a partial list that nonetheless can get you started on a wheat-free, low-carb breakfast.

If you are just starting out, you will notice a number of fundamental changes. You may first experience the characteristic "withdrawal" effect: mental fog and fatigue that lasts about a week. Energy then picks up, often substantially. This is followed by gradually reduced appetite: You will be far less hungry. You will require less food, less often, since appetite will be driven by physiologic need, not the appetite-stimulating properties of wheat (and cornstarch, high-fructose cornsyrup and sucrose).

By the way, do not skip breakfast unless it's part of an occasional fasting effort. Skip breakfast, wind down metabolism, get fat. I am impressed at how consistent skipping breakfast backfires in those who think that it helps you control weight.

I also welcome any suggestions on what you eat as part of your wheat-free, low-carb breakfast. (Thanks for the great suggestions on the last blog post, Anna.)

Wheat hip

You've heard of wheat belly. How about wheat hip?

Recall that the innocent appearing wheat belly is actually a hotbed of inflammatory activity beneath the surface. The visceral fat of the wheat belly, i.e., fat kidneys, fat liver, fat intestines, fat pancreas, produces abnormal inflammatory signals, such as various interleukins, tumor necrosis factor, and leptin. These are the inflammatory signals that create insulin resistance and diabetes, heart disease, hypertension, and cancer.

These same inflammatory mediators are able to enter the joint spaces, such as those in your hips, knees, and hands. This leads to osteoarthritis, the exceptionally common form of arthritis that affects 1 in 7 Americans. In particular, the level of leptin in joints mirrors that in blood, a phenomenon that has been associated with joint destruction.

The previously widely-held notion that arthritis is simply a wear-and-tear phenomenon due to the mechanical stress of excess weight is proving to be an oversimplification. Arthritis is also part of the carbohydrate-driven, weight-increasing, inflammatory condition of insulin resistance or metabolic syndrome.

Throw into this cytokine storm the fact that glycation, i.e., glucose modification of proteins, also causes cartilage destruction. The cells of human cartilage lack the ability to divide, so the cartilage cells you had at age 18 are the cartilage cells that you will hopefully still have at age 80. However, high blood sugars (glucose) glycate the proteins in cartilage. (Wheat raises blood glucose higher than almost all other foods, higher than a Milky Way bar, higher than a Snickers bar.) The process is irreversible and cumulative. Because cartilage has next to no capacity for repair or regeneration, it becomes brittle. Over years, it essentially crumbles, leading to the "bone on bone" that prompts conversations about total hip and total knee replacement.

So that ciabatta or blueberry muffin in your mouth takes you a step or two closer to joint destruction via heightened inflammation arising from the visceral fat of the wheat belly, worsened by glycation of high blood sugars after carbohydrate consumption.

My solution: Lose the ciabatta.

Men's lingerie is on the second floor

Consume wheat products, like poppyseed muffins, raisin bagels, and whole grain bread, and you trigger the 90- to 120-minute glucose-insulin cycle.

Blood glucose goes way up (more than almost any other known food), triggering insulin release from the pancreas. Glucose enters cells as a result, blood glucose plummets. You get hungry, shaky, and crabby, reach for another wheat or other sugar-generating food to start the roller coaster ride all over again.

Repetitive insulin triggering grows this thing I call a "wheat belly," the protuberant, hang-over-the-belt fat you see everywhere nowadays. Wheat belly fat is really visceral fat. Visceral fat means you have fat kidneys, fat intestines, fat pancreas, and fat liver, all causing the belly to protrude in the familiar way we've all come to recognize.

Visceral fat is special fat. Unlike the fat in the backside, thighs, or arms, visceral fat triggers inflammatory responses that are evident in such measures as tumor necrosis factor, interleukins, and leptin, as well as drops in the protective hormone, adiponectin.

Visceral fat also, oddly, triggers estrogen release. Estrogen triggers growth of breast tissue. That's why females with wheat bellies have up to four-fold (400%) greater likelihood of breast cancer.

Men also experience excess estrogen from the visceral fat wheat belly, causing "man boobs." This B-cup phenomenon means that inflammation is raging beneath the surface, all due to this thing you're wearing around your waist.

I wasn't aware until recently that male breast reduction surgery is a booming business growing at double-digit rates. So are special clothes to help men conceal their expansive breasts.

Perhaps the USDA is in cahoots with Playtex.

10,000 units of vitamin D

Joanne started with a 25-hydroxy vitamin D level of 23 ng/ml--severe deficiency.

What made this starting value even worse was that it was drawn in August after a moderately sunny summer spent outdoors. (Last summer, not this summer.) It therefore represented her high for the year, since vitamin D levels trend lower as fall and winter set in. This suggests that her winter level was likely in the teens or even single digits. In addition, note that, at age 43, Joanne has lost much of her ability to activate vitamin D in the skin.

So I advised that she take 6000 units of an oil-based gelcap per day, a dose likely to generate the desired blood level, which I believe is 60-70 ng/ml.

Four months later, her 25-hydroxy vitamin D level: 39.9 ng/ml--still too low. So I advised her to increase her dose to 10,000 units per day. Several months later, her 25-hydroxy vitamin D level: 63.8 ng/ml--perfect.

However, on hearing that she was taking 10,000 units vitamin D per day, Joanne's primary care physician was shocked: "What? Stop that immediately! You're taking a toxic dose!" So Joanne called me to find out if this was true.

No, of course it's not true. It's not the dose that's toxic, but the blood level it generates. Although it varies, vitamin D toxicity, as evidenced by increased blood calcium levels, generally does not even begin to get underway until at least 120-130 ng/ml, perhaps higher. Rarely, a dose of 2000 units per day will generate a level this high. In others, it may require 24,000 or more units per day to generate such a high level.

So it's not the dose that's toxic, but the blood level of 25-hydroxy vitamin D it generates.

Provided you and/or your doctor are monitoring 25-hydroxy vitamin D blood levels, the dose is immaterial. It's the blood level you're interested in.