Fish oil: The natural triglyceride form is better

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

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

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

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

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

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

Bioavailability of marine n-3 fatty acid formulations.

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

Abstract

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



Eur J Clin Nutr 2010 Nov 10. 

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

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

Abstract

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

  • Flavia

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

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

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

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

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

  • Anonymous

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

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

  • TedHutchinson

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

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

  • Dr. William Davis

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

    Hi, Flavia--

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


    Anon-

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

  • Anonymous

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

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

  • Michael

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

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

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

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

  • Jack

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

    Hi Dr Davis,

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

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

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

    Thanks,
    Jack Kronk

  • Anonymous

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

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

  • Anonymous

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

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

  • Anonymous

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

    What about Krill oil?

  • Flavia

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

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

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

  • Anonymous

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

    Where does krill oil fit into this?

  • Might-o'chondri-AL

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

    Natural Factors omega-3 is ethyl ester processed form.

  • Lucy

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

    Dr. Davis,

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

  • Vin Kutty

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

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

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

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

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

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

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

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

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

  • Anonymous

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

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

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

  • Ned Kock

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

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

  • Anonymous

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

    Dr Davis

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

  • Davide Palmer

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

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

  • Rick

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

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

  • Anonymous

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

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

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

  • Donald Kjellberg

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

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

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

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

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

  • Dr. William Davis

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

    Hi, Jack--

    No, not even close.

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

  • Jack

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

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

    Have a look at their site:

    Wild Planet

    cheers,
    Jack Kronk

  • Davide Palmer

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

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

  • Sara

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

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

  • Rick

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

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

  • Anonymous

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

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

  • John Townsend

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

    Dr. Davis:

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

  • Timothy Johanek

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

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

    -EPA Gems

    -Super DHA Gems

    -MedOmega Fish Oil 2800

    -All Mothers and Kids products

    -All Very Finest Fish Oil products

    -All Cod Liver Oil products

    -All Salmon Oil products

    -Smart Catch softgels

    -CalaOmega liquid (calamari oil)


    The following products are EE:

    -Super Omega-3 Gems

    -Elite Omega-3 Gems

    -CalaOmega Softgels (calamari oil)

    -CalaDHA Sofgels (calamari oil)

  • Anonymous

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

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

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

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

  • omega3tron

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

    It is nothing more than just another market gimmick -

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

  • Bob Savage

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

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

  • Anonymous

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

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

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

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

    And for those interested:

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

    And pretty much all cheapo store brands are EE.

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

  • Weierstrass

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

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

  • Anonymous

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

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

  • Timothy Johanek

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

    Bob Savage,

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

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

  • farseas

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

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

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

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

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

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

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

  • Anonymous

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

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

    in for answer on rancid oil.

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

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

  • Anonymous

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

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

    in for answer on rancid oil.

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

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

  • Anonymous

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

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

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

  • john

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

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

  • Gailtoo

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

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

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Dr. Cannell comments on vitamin D lab tests

14. July 2008 William Davis (9)
As always, Dr. John Cannell of The Vitamin D Council continues to teach us new lessons about vitamin D.

Apparently, Dr. Cannell is swamped with the attention that vitamin D is drawing, largely due to his efforts to publicize the enormous deficiency of Americans and his great talent for articulating the science. The most current newsletter, while a bit haphazard, makes some excellent new points that I reprint here.

(I did not reprint his conversation about "any form of vitamin D" being acceptable. My experience differs: In nearly 1000 patients who have taken vitamin D supplements, my experience is that most tablet forms are inconsistently absorbed, sometimes not absorbed at all. I therefore advocate only use of gelcaps or liquids. I'm told by members of Track Your Plaque, however, that they are witnessing reliable increases in blood levels of vitamin D by taking the powdered form of Bio Tech Pharmacal's product.)


Does it matter what reference lab my doctor uses?

Yes, it might make a huge difference. A number of methods exist to measure 25(OH)D in commercial labs. The two most common are mass spectrometry and a chemiluminescence method, LIAISON. The first, mass spectrometry, is highly accurate in the hands of experienced technicians given enough time to do the test properly. However, in the hands of a normally trained technician at a commercial reference lab overwhelmed with 25(OH)D tests, it may give falsely elevated readings, that is, it tells you are OK when in fact you are vitamin D deficient. The second method, chemiluminescence, LIAISON, was recently developed and is the most accurate of the screening, high throughput, methods; LabCorp uses it. Quest Diagnostics reference lab uses mass spec. Again, both Quest and LabCorp are overwhelmed by 25(OH)D requests. The problem is that the faster the technicians do the mass spec test, the more inaccurate it is likely to be. If your 25(OH)D blood test says "Quest Diagnostics" on the top, do not believe you have an adequate level (> 50 ng/ml). You may or may not; the test may be falsely elevated. Let me give you an example. A doctor at my hospital had Quest Diagnostics do a 25(OH)D. It came back as 99 ng/ml of ergocalciferol. He is not taking ergocalciferol (D2), he has never taken ergocalciferol, only cholecalciferol, and he is not taking enough to get a level of 99 ng/ml, 50 ng/ml at the most. His email to Dr. Brett Holmquist at Quest about why Quest identified a substance he was not taking went unanswered other than to say "any friend of Dr. Cannell's is a friend of ours."

Long story short: if your lab report says "LabCorp" on the top, it is probably accurate; if it says Quest Diagnostic, it may be falsely elevated. While LabCorp has also been overwhelmed with 25(OH)D requests, the LIAISON method they use is relatively easy to do and does not rely on technician skill as much as the mass spec methods do. I'm not saying this because I'm a consultant for DiaSorin, who makes LIAISON, I'm saying it because it is true. If you don't believe me, get Quest to make me an offer to be their consultant at 10 times what DiaSorin is supposed to be paying me ($10,000 per year) and see how fast I turn Quest down. If Quest fixes their test, I'd love to consult. The ironic thing: I've made both Quest and LabCorp lots of money via this newsletter, the website, and by repeatedly telling the press that people need to know their 25(OH)D level, which has contributed to the skyrocketing sales of 25(OH)D blood tests.

Demand for vitamin D tests soars as nutrient's potential benefits touted.

Here you can help. Find out which labs in your town use Quest Diagnostics and which use LabCorp. Have a 25(OH)D test at both labs the same day (you will have to pay for them yourself). Then send both results to the Vitamin D Council address below. If Quest Diagnostics does not fix their 25(OH)D test, the Vitamin D Council will fix it for them.



My doctor prescribed Drisdol, 50,000 IU per week. What is it?

Drisdol is a prescription of 50,000 IU tablets of ergocalciferol or D2. Ergocalciferol is not vitamin D but it is similar. It is made by irradiating ergosterol, which is found in many living things, such as yeast. D2 is not normally found in humans and most studies show it does not raise 25(OH)D levels as well as human vitamin D (cholecalciferol or D3) does. However, Drisdol is a lot better than nothing. The best thing to do, if you are vitamin D deficient, and a human, is to take human vitamin D, cholecalciferol, A.K.A. vitamin D3.



What is the ideal level of 25(OH)D?

We don't know. However, thanks to Bruce Hollis, Robert Heaney, Neil Binkley, and others, we now know the minimal acceptable level. It is 50 ng/ml. In a recent study, Heaney et al enlarged on Bruce Hollis's seminal work by analyzing five studies in which both the parent compound, cholecalciferol, and 25(OH)D levels were measured. It turn out that the body does not reliably begin storing the parent compound (cholecalciferol) in fat and muscle tissue until 25(OH)D levels get above 50 ng/ml. The average person starts to store cholecalciferol at 40 ng/ml, but at 50 ng/ml, virtually everyone begins to store it for future use. That is, at levels below 50 ng/ml, the body is usually using up the vitamin D as fast as you make it or take it, indicating chronic substrate starvation, not a good thing.

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.

Heaney RP, Armas LA, Shary JR, Bell NH, Binkley N, Hollis BW. 25-Hydroxylation of vitamin D3: relation to circulating vitamin D3 under various input conditions. Am J Clin Nutr. 2008 Jun;87(6):1738-42.



I have advanced renal failure and I'm on dialysis, how much vitamin D should I take?

The same as everyone else. Since I have told you about commercial labs ripping you off, let's add some drug companies. Patients with advanced renal failure need activated vitamin D or one of it's analogs, available by prescription. This is very important as their kidneys cannot make enough 1,25-dihydroxy-vitamin D (calcitriol) to maintain serum calcium. However, the rest of their tissues activate vitamin D just fine and when those tissues get enough, and when the kidneys get more vitamin D, the calcitriol spills out into the blood, lowering their need for prescription calcitriol or one of its analogs. The companies that make the analogs don't like that, it means reduced sales. So these companies do nothing, the scientists behind these companies say nothing, and renal failure patients die prematurely from one of the vitamin D deficiency diseases.

Vieth R. Vitamin D toxicity, policy, and science. J Bone Miner Res. 2007 Dec;22 Suppl 2:V64-8.



When I asked my doctor for a 25(OH)D blood test, he just laughed and said it was all idiotic. What can I do?

Help me unleash the dogs of war, the plaintiff attorneys. If you read about past nutritional epidemics caused by society, such as beriberi or pellagra, you will realize that education alone will take decades. Physicians successfully fought against the idea that thiamine deficiency caused beriberi for decades. However, things are different now. The agents of change in modern America, as obnoxious as they are, are plaintiff attorneys. Once the first malpractice lawsuits claiming undiagnosed and untreated vitamin D deficiency led to breast cancer, autism, heart disease, etc., get past summary judgment, and they will, and end up in front of a jury, and they will, things will change rapidly. One of the main reason physicians do what they do is fear of lawsuits. In a matter of months, arrogance and ignorance will give way to 25(OH)D tests and vitamin D supplementation.

Goodwin JS, Tangum MR. Battling quackery: attitudes about micronutrient supplements in American academic medicine. Arch Intern Med. 1998 Nov 9;158(20):2187-91.


And, to help support Dr. Cannell's efforts (I sent him a check for $250 a few months back; time for more), here is his contact info:

John Cannell, MD
The Vitamin D Council

Send your tax-deductible contributions to:

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

Privileged information

12. July 2008 William Davis (9)
In 1910, taking a person's blood pressure was considered revolutionary, a high-tech practice that was of uncertain benefit.

Dr. Harvey Cushing of Johns Hopkins Hospital in Baltimore had observed a blood pressure device while traveling in Europe, developed by Dr. Sciopione Riva-Rocci. Cushing brought this new technology back with him to the U.S. and promptly promoted its use, convinced that this insight into gauging the forcefulness of blood pressure would yield useful clinical insights.

But, in 1910, practicing physicians rejected this new technology, preferring to use their well-established and widely practiced technique of pulse palpation (feeling the pulse), skeptical that the new tool added value. Medical practice of the day was rich with descriptions of the strength and character of the pulse: pulsus parvus et tardus (the slow rising pulse of aortic valve stenosis), the dicrotic notch of aortic valve closure transmitted to the pulse, the "water-hammer" pulse of aortic valve insufficiency.

Over the next 20 years, however, the medical community finally gave way to the new technique, although only physicians were allowed to use blood pressure devices, as nurses were regarded as incapable of mastering the skills required to perform the procedure properly.

Stethoscopes were also gaining in popularity in the early 20th century, but were also the exclusive province of physicians trained in their use. Nurses were not allowed to use stethoscopes until the 1960s. Even then, nurses were not allowed to call them "stethoscopes," but "nurse-o-scopes" or "assistoscopes," and the nurses' version of the device was manufactured to look different to avoid confusion with the "real" doctor's tool.

And just half a century ago, if you wanted to look at a medical textbook, you would have to go to the library and ask for special permission. The librarian would lower her glasses and look you up and down to determine whether or not you were some kind of pervert. Only then might you be granted permission to peer into the pictures of organs and naked bodies.

Such has been the spirit of medicine for centuries: Medicine and its practices are meant to be secret, the insider knowledge of a privileged few.

Fast forward to 2008: The Information Age has overturned the rules of privileged information. Now you have access to the same information as I do, the same information available to practicing physicians. The playing field has been levelled.

Curiously, while information access has advanced at an instantaneous digital pace, attitudes in medicine continue to evolve at the traditional analog crawl. Many of my colleagues continue to be dismayed at the new public access to health information, belittle patients for excessive curiosity about their health, lament the erosion of their healthcare-directing authority. And while new concepts race ahead as we race towards a wiki-like collective growth in healthcare knowledge, physicians are still mired by their reluctance to abdicate their once-lofty positions as chief holders of secrets.

I believe that this is part of the reason why family doctors and cardiologists have been slow to adopt technologies like heart scans and self-empowering programs like Track Your Plaque: processes that take heart disease prevention away from the hands of physicians and place more control into the hands of the people.

Imagine the horror felt by physicians in 1935 of a young upstart nurse boldly trying to use a stethoscope to take a patient's blood pressure. You can imagine the internal horror now being felt as you and I dare to take control over heart disease and deny them the chance to put in four stents, three bypass grafts, then direct our future health habits.

But technology has a way of marching on. It will encounter resistance, bumps, and blind-alleys, but it will go on.

Dr. Jeffrey Dach on the Track Your Plaque program

10. July 2008 William Davis (5)
Dr. Jeffrey Dach posted a great piece on his blog, Bioidentical Hormone Blog , about his perspective on the Track Your Plaque program.

It's worth reading even for those familiar with the program, just to see a slightly different perspective. He also included many great graphics to illustrate his points.

CAT Coronary Calcium Scoring, Reversing Heart Disease












Also, see Dr. Dach's Heart Disease: Part 2, for some novel thoughts.

Vitamin D and programmed aging?

9. July 2008 William Davis (8)
As we age, we lose the capacity to activate vitamin D in the skin.

Studies suggest that, between ages 20 and 70, there is a 75% reduction in the ability to activate vitamin D. The capacity of conversion from 25 (OH) vitamin D to 1,25 di(OH) vitamin D also diminishes.

Holick M. Sunlight and vitamin D for bone health and prevention of autoimmune diseases, cancers, and cardiovascular disease.



From Holick, M. 2006

This would explain why 70-year olds come to the office, just back from the Caribbean sporting dark brown tans, are still deficient, often severely, in blood levels of vitamin D (25(OH) vitamin D). A tan does not equal vitamin D.














Courtesy Ipanemic


A practical way of looking at it is that anyone 40 years old or older has lost the majority of ability for vitamin D activation.

This often makes me wonder if the loss of vitamin D activating potential is nature's way to get rid of us. After all, after 40, we've pretty much had our opportunity to recreate and make our contribution to the species (at least in a primitive world in which humans evolved): we've exhausted our reproductive usefulness to the species.

Is the programmed decline of vitamin D skin activation a way to ensure that we develop diseases of senescence (aging)? The list of potential consequences of vitamin D deficiency includes: osteoporosis, poor balance and coordination, falls and fractures; cancer of the breast, bladder, colon, prostate, and blood; reductions in HDL, increases in triglycerides; increased inflammation (C-reactive protein, CRP); declining memory and mentation; coronary heart disease.

Isn't that also pretty much a list that describes aging?

A fascinating argument in support of this idea came from study from St Thomas’ Hospital and the London School of Medicine:

Higher serum vitamin D concentrations are associated with longer leukocyte telomere length in women

Telomeres are the "tails" of DNA that were formerly thought to be mistakes, just coding for nonsense. But more recent thinking has proposed that telomeres may provide a counting mechanism that shortens with aging and accelerates with stress and illness. This study suggests that both vitamin D and inflammation (CRP) impact telomere length: the lower the vitamin D, the shorter the telomere length, particularly when inflammation is greater.
















Data supporting vitamin D's effects on preventing or treating cancer, osteoporosis, lipid abnormalities, inflammation, cardiovascular disease, etc., is developing rapidly.

Now the big question: If declining vitamin D is nature's way of ensuring our decline and death, does maintaining higher vitamin D also maintain youthfulness?

I don't have an answer, but it's a really intriguing idea.

Synthroid, Armour Thyroid, and the battle for T3

6. July 2008 William Davis (2)
In the last Heart Scan Blog post on thyroid issues, Is normal TSH too high?, the provocative findings of the the HUNT Study were discussed. The text of the study can be found at:

The association between TSH within the reference range and serum lipid concentrations in a population-based study. The HUNT Study

Hypothyroidism, or low thyroid that is signaled by high thyroid-stimulating hormone, TSH, is proving far more prevalent an issue than previously thought. While previous estimates put hypothyroidism as affecting only about 3% of younger populations, 10-20% of older populations (women more so), data like the HUNT Study suggest that, if lower and lower TSH levels (higher thyroid) are necessary for perfect heart health, then many more people stand to benefit than we used to think.

But another crucial issue in the world of hypothyroidism: Is T4 (thyroxine) enough? Or should we be supplementing T3 (triiodothyronine) along with T4?

Your friendly neighborhood primary care doctor or endocrinologist would likely argue vehemently that T4 (as Synthroid, Levoxyl, levothyroxine, and others) is adequate and not subject to the impurities and contaminants of natural thyroid extracts. They would also argue that T4 is effectively converted to T3 at the tissue level, and exogenous supplementation is unnecessary.

Others--most of all thyroid patients themselves, along with thyroid advocates like Mary Shomon and Janie Bowthorpe, along with some physicians--argue that supplementing T3 along with T4 can be very important. They argue that people feel better, have more physical energy, lose weight more effectively, and more completely resolve many of the phenomena of hypothryoidism with T3 added. There are also some data that argue the same.

Adding T3 to the mix may address the presumed poor conversion of T4 to T3 that is peculiar to some people. It may overcome the "reverse T3" phenomenon, the production of a useless look-alike T3 that occurs in some people. It may also (anecdotally) exert greater effects on some lipid/lipoprotein parameters, such as Lp(a).

My experiences adding T3 to T4 have been mixed: Some feel better, others do not. Some show objective improvements, others do not.

Nonetheless, hypothyroidism, or incompletely corrected hypothryoidism by way of inadequate T3, is an issue to consider in your plaque-control program.

More on this somewhat complex issue, along with practical solutions to consider, can be found on the Special Report to be released this week on the Track Your Plaque website.

Letter to New York Times

3. July 2008 William Davis (9)
All right. I sent a Letter to the Editor to the New York Times. No word from them; it's no longer news.

So here is what I tried to convey.

While the authors overall did a credible job of talking to my colleagues and laying out the issues, they made the crucial and boneheaded mistake of confusing CT heart scans with CT coronary angiograms. Sadly, many people who may have been considering having a simple screening heart scan may be scared away by the confused authors, Alexn Berenson and Reed Abelson.

They do correctly point out that, while CT coronary angiograms are fascinating examples of technology and a way of visualizing coronary arteries, this test all too often is being subverted into the "let's make money from high-tech testing" medical model. It's also a test that frequently leads to the "real" test, heart catheterization, since the "time bomb" you have in your arteries might "need" a stent.

CT coronary angiograms are also virtually useless for purposes of tracking disease, since they are not longitudinally (along the length of the artery) quantitative, nor should anyone be exposed to this much radiation repeatedly.

A simple heart scan, on the hand, provides a longitudinal summation of coronary plaque volume. Radiation exposure is sufficiently low that repeated scanning can be performed for purposes of tracking . . .yes, track your plaque.

Poorly-informed reporters can do a lot of damage. As always, you and I must dig a little deeper for the truth.




Dear Editor,

Re: Weighing the Costs of a CT Scan’s Look Inside the Heart

The Times featured an article on June 29th that discussed rapidly expanding use of CT scans for the heart:
Weighing the Costs of a CT Scan’s Look Inside the Heart.

The authors, Alex Berenson and Reed Abelson, stated that CT heart scans “expose patients to large doses of radiation, equivalent to at least several hundred X-rays, creating a small but real cancer risk.”

I’d like to offer a clarification.

Though the authors discuss both CT heart scans and CT coronary angiograms, they confuse the two and use the terms interchangeably.

A heart scan is a simple screening test for coronary atherosclerotic plaque. It detects the presence of calcium in the heart’s arteries, provided as a “score.” (Because calcium occupies 20% of total plaque volume, knowing the amount of calcium tells you how much total coronary plaque is present by applying this simple proportion.) Just having a high score should not prompt heart procedures, since people undergoing simple screening heart scans are without symptoms. However, a stress test may yield some useful information.

On present-day CT devices, heart scans expose a patient to 0.4 mSv of radiation on an electron-beam, or EBT, device, and on up to 1.2 mSv on a 64-slice multi-detector, or MDCT, device, compared to 0.1 mSv during a standard chest x-ray. CT heart scans are therefore performed with about the same quantity of radiation as a mammogram done to screen women for breast cancer, or about the equivalent of four chest x-rays on an EBT scanner, up to 12 chest-xrays on a MDCT scanner.

CT coronary angiograms, while performed on the same devices as heart scans, require x-ray dye to fill the contours of the coronary arteries. It also requires up to several hundred times more radiation. While new engineering innovations are being introduced that promise to reduce this exposure, the current devices being used today do indeed require a radiation dose equivalent to 100 to 400 chest x-rays (usually in the range of 10-15 mSv), a value that equals or exceeds that obtained during a conventional heart catheterization.

While heart scans are most useful to detect and quantify plaque that can help determine the intensity of a heart disease prevention program, CT coronary angiograms are generally used as prelude to hospital procedures like catheterizations, stents and bypass surgery. That’s because they are performed to look for (or rule out) “severe” blockages.
CT heart scans and CT coronary angiography are therefore two different tests that yield two different kinds of information, and yield two entirely different levels of radiation exposure.

This confusion from a major and respected media outlet like the New York Times is unfortunate, because it could persuade millions of people who otherwise could benefit from simple heart scans to avoid them because of misleading information on radiation exposure of a different test.

Thank you.

William Davis, MD

Red yeast rice alert

2. July 2008 William Davis (9)
While there have been some positive reports in the media lately about the cholesterol-reducing effects of red yeast rice, Consumer Lab has issued a very concerning report.

Because Consumer Lab is a subscription website (incidentally, the $20 per year membership fee is money well spent for insightful tests on many supplements, though new reports only come out a handful of times per year), I won't discuss the results of their red yeast rice in its entirety.

However, Consumer Lab testing uncovered several disturbing findings:

--The lovastatin content varied by a factor of 100, from 0.1 mg per tablet/capsule in one brand up to 10.6 mg in another brand. By FDA regulations, lovastatin is a drug and NO red yeast rice preparation is supposed to contain ANY lovastatin. Nonetheless, despite the marketing of supplement manufacturers, it is probably the lovastatin that is largely responsible for the LDL-reducing effect. The monacolins or mevinolins in red yeast rice add little, if any, further LDL-reducing effect.

--Several preparations contain a potential kidney toxin called citrinin. The Walgreen's product, specifically, contained substantial quantities of this toxin.



Interestingly, the FDA has taken repeated action against red yeast rice manufacturers and distributors because they continue to contain lovastatin. In the FDA's most recent action in August, 2007, for instance, Swanson's product and Sunburst Biorganics' Cholestrix, were both sent letters to stop selling their product because it contained lovastatin.

The Consumer Lab findings would explain the enormous variation in LDL-reducing effect of various red yeast rice products. In my experience, some work and reduce LDL 40 mg/dl or so, some fail to reduce LDL at all, others generate a modest effect, e.g., 5-10 mg/dl LDL reduction.

In effect, red yeast rice IS a statin drug, albeit a highly variable and weak one. Although readers of The Heart Scan Blog know that I am a big fan of nutritional supplements and self-empowerment in health, I am a bigger fan of truth. I despise B--- S---- of the sort that emits from some nutritional supplement manufacturers and drug companies.

I am puzzled by much of the public's readiness to embrace a statin drug if it comes from a supplement company while avoiding it if it comes from a drug manufacturer. Personally, I do not like the drug industry, their questionable (at best) ethics, their aggressive marketing tactics, their sleazy sales people.

But, in this instance, if a statin effect is desired, I'd reach for generic lovastatin before I purchased red yeast rice. The Consumer Lab report tells us that red yeast rice IS essentially a statin drug, an inconsistent one that often contains a potential toxin.

"Average amount of heart disease for age"

2. July 2008 William Davis (4)
A 72-year old woman came to my office after a complicated hospital stay (unrelated to heart disease). She'd undergone a CT coronary angiogram and heart scan as part of a pre-operative evaluation prior to a surgery for a non-heart related condition.

The heart scan portion of the test (I was impressed they even did this) yielded a heart scan score of 212. The CT coronary angiogram portion of the test revealed a 50% blockage in one artery, a lesser blockage in one other artery.

The cardiologist consulting on the case advised her that the amount of coronary disease detected was insufficient to pose risk during her surgical procedure. He also advised her that she had "an average amount of disease for age." He thought that nothing further was necessary since she was "average."

Say what?  

What if I told you that you have an average amount of cancer for your age? After all, cancers become more common the older we get. Who would find that acceptable?

Then why should ANY amount of coronary atherosclerotic plaque be "acceptable for age"? Coronary plaque is a degenerative disease that poses risk for rupture. While it is indeed common, by no means should it be acceptable.

I would bet that this same cardiologist would be from the same school of thought that would be eager to advise heart catheterization, stent, and other procedures--revenue-generating procedures--should she have a heart attack appropriate for age.

I wish that I could tell you that this silly comment was provided by some peculiar, "everyone-knows-he's-crazy" doctor. But it was not. It was a solidly mainstream physician. He pooh-poohs nutrition, laughs when asked about nutritional supplements, thinks anyone complaining about symptoms less than a full-blown heart attack is a baby. He is respected by the primary care physicians, lectures on the advantages of prescription medications. In short, he is your typical conventional cardiologist.

This is the way they think. I know, because I was one of them. Thankfully, something banged me upside my head one day (my Mother's sudden cardiac death) and tipped me off to the painful irony of the conventional approach to heart disease.

There is NO amount of coronary disease appropriate for age. This notion is a remnant of the paternalistic, "I-know-better-than-you" attitude of the last century of medicine.

The 21st century promises a new age.

Quantum leaps

29. June 2008 William Davis (6)
A reader of The Heart Scan Blog and member of the Track Your Plaque program posted this comment on The Heart.org:

*The facts speak for themselves.*

Dr. William Davis and Dr. William Blanchet, your patients thank you for the low cost PREVENTIVE care you prescribe. The published facts speak for themselves. It is indeed a sad state of affairs, that the larger cardiology community does not take the time to research the data and results you have been reporting. Unfortunately it is the patients who are the victims of the mainstream, inappropriate, treatment protocols, as evidenced with the ongoing high rate of CV death rate.

I am dumbfounded by the lack of open-minded inquisitive curiosity to thoroughly research your claims by many/most cardiologists. Understood, we are all busy, but that is no excuse to stick with practices that do not result in major breakthrough improvements in patient outcomes.

Then again, we are all humans, and when "we" are convinced that "our" approach is correct, "we" tend to conveniently ignore any evidence to the contrary. "We" like to believe "we" have been right all along.

A very insightful book, recently published, says it all in its title: "Mistakes were made (but not by me)."

From the intensity of the comments on this topic, it is clear that we are in the middle of a battlefield. It is to be hoped that the facts will become visible before too much smoke obscures the field, and before the patients are all dead.

George Orwell said it correctly, back in 1946:

“We are all capable of believing things which we know to be untrue, and then, when we are finally proved wrong, imprudently twisting the facts so as to show that we were right. Intellectually, it is possible to carry on this process for an indefinite time: the only check on it is that sooner or later a false belief bumps up against solid reality usually on a battlefield.”

And, after several posts that preventive care with EBT would be too costly.....

*Heroic*

Prevention is what matters, but it is not very heroic. A hospital that advertises the highest volumes in heart bypasses and other heart "repair" procedures, sounds to many like a go-to place when one gets into trouble with one's heart.

Cardiologists who perform impressive surgical procedures are heroes. Not unlike fire-fighters. We celebrate them (deservedly!) for rescues and life saving heroic actions.

We tend to not pay much attention to the folks that work hard to minimize risk of calamities in the first place.

Similarly, we recently learned that it is too costly to build schools that are earthquake resistant in China. Parents had to look at their children's bodies, crushed.

Is it too graphic to imagine 20,000 American bodies, who died of heart disease, piled up on a field?

What will it take before we make prevention our first priority?

AL, Ann Arbor, Michigan


The reader also tells me that, prompted by his father's death from heart attack while following conventional advice after heart catheterization, he has lost 50 lbs and corrected his lipid patterns on the Track Your Plaque program. The reader is currently struggling with full correction of his severe small LDL pattern and is following some of the advice we discussed on our webinar recently.

Another Heart Scan Blog reader, Stan the Heretic, posted this quote from scientist, Max Planck, in his comment:


"A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die and a new generation grows up that is familiar with it." - M. Planck

(Max Planck was a German physicist who developed quantum theory, a disruptive set of ideas that supplanted other explanations of energy mechanics of the day.)


I fear that may prove to be the case for heart disease. The revenue-generating formula for heart disease management that dominates practice in cardiovascular medicine today is so deeply ingrained into the thinking and revenue expectations of practicing cardiologists that a preventive or reversal approach just won't cut it--even if it is vastly superior.

That's why it is important for you to take control yourself. You will be the one who obtains and applies the information that saves your life or the lives of those around you. It is, in all likelihood, NOT your doctor who will save your life, but YOU.

Body count

28. June 2008 William Davis (7)
Imagine the following headline:

War in Iraq a growing success: 20,000 Americans now dead!


If a newspaper ran that headline, we would all be outraged, and rightly so. Deaths in war are a tragedy. They are not something we celebrate.

Then why do we hear hospitals boasting about the number of bypass operations performed every year, number of heart catheterizations performed, number of heart attacks treated?


"_______ Hospital breaks 1000-heart bypass per year milestone"

"We treat more heart attacks than other other hospital in the state!"

"More people come to ________ Hospital than any other in the region!"



I hear this stuff on the radio, on TV, see it in newspapers and magazines, even on highway billboards every single day in Milwaukee.

Heart procedures, like deaths in war, are casualties of health.

They are not successes (though, of course, you can have a "successful" bypass). I see most procedures as a failure of prevention.

Death from heart attack is a failure of prevention. Tim Russert's death was a (unnecessary) failure of prevention. But so are bypass surgery, stents, and the like.

Such is the perverse state of affairs in hospitals and health: They celebrate illness. They glamorize it with ads displaying high-tech equipment, efficient staff in scrubs, "caring and friendly staff." But it is illness they are celebrating. Why? Because it has become a business necessity, a necessary strategy to remain competitive and profitable in the business called "healthcare" that makes money from treating people. The biggest return is from major procedures like bypass operations.

Every success in prevention denies the hospital an $80,000+ opportunity. You'll never hear that advertised.