Cholesterol follies

11. January 2008 William Davis (5)
Rudy is a 59-year old man. He's had three heart catheterizations, two of which resulted in stent implantations. Obviously, Rudy should be the beneciary of a prevention program.

His basic cholesterol values:

Total cholesterol 164 mg/dl--pretty good, it seems.

LDL cholesterol 111 mg/dl--Wow! Not too bad.

HDL cholesterol 23 mg/dl--Uh oh, that's not too good.

Triglycerides 148 mg/dl--By national (NCEP ATP-III) guidelines, triglycerides of 150 mg/dl and below fall within the desirable range.


So we're left with an apparently isolated low HDL cholesterol, nothing more. On the surface, it doesn't seem all that bad.

Of course, we need to keep in mind that this pattern landed Rudy in the hospital on several occasions and prompted several procedures.

Should we rely on these results? How about Rudy's lipoproteins?

Here they are (NMR; Liposcience):

LDL particle number 2139 nmol/l--Representing an effective LDL of 213--over 100 mg higher than the standard value (above) suggests.

Small LDL particles 2139 nmol/l--In other words, 100% of all Rudy's LDL particles are small. (Thus, weight-based measures of LDL cholesterol fail to tell us that he has too many small particles.)

Large HDL 0 (zero) mg/dl--Rudy has virtually no functional HDL particles.


If we had relied only on Rudy's standard cholesterol values, we would have focused on raising HDL. However, lipoprotein analysis uncovered a smorgasbord of additional severe patterns. The high LDL particle number comprised 100% of small particles is especially concerning.

Truly, conventional cholesterol testing is a fool's game, one that time and again fails to fully uncover or predict risk for heart disease. One look at Rudy's lipoproteins and it becomes immediately obvious: This man is at high risk for heart disease and the causes are clear.

Of course, many physicians and insurance companies argue that the added information provided by this portion of the lipoprotein test added around $70 more to the expense.

When you see results like this, is there even a choice?

Equal calories, different effects

9. January 2008 William Davis (15)
A great study was just published in the Journal of the American College of Cardiology:

Metabolic effects of weight loss on a very-low-carbohydrate diet compared with an isocaloric high-carbohydrate diet in abdominally obese subjects.

88 obese adults with metabolic syndrome were placed on either of two diets:

1) A very low-carbohydrate, high-fat diet (VLCHF): 4% calories from carbohydrates (truly low-carb); 35% protein; 61% fat, of which 20% were saturated. In the first 8 weeks, carbohydrate intake was severely limited to <20 grams per day, then <40 grams per day thereafter.

2) A high-carbohydrate, low-fat diet (HCLF): 46% calories from carbohydrates; 24% protein; 30% total fat, of which <8% were saturated.

Both diets were equal in calories (around 1400 calories per day--rather restrictive) and participants were maintained on the program for six months.

At the end of the six month period, participants on the VLCHF diet lost 26.4 lb, those on the HCLF diet 22.2 lbs (though the difference did not reach statistical significance). Thus, both approaches were spectacularly successful at weight loss.

Surprisingly, blood pressure, blood sugar, insulin and insulin sensitivity (a measure called HOMA) were all improved with both diets equally. Thus, these measures seemed to respond more to weight loss and less to the food composition.

Lipids differed between the two diets, however:


VLCHF:
Total cholesterol: initial 208.4 mg/dl final 207.7 mg/dl

LDL: initial 125 mg/dl final 123 mg/dl

HDL: initial 55 mg/dl final 64.5 mg/dl

Triglycerides: initial 144 mg/dl final 74 mg/dl

Apoprotein B: initial 98 mg/dl final 96 mg/dl


HCLF
Total cholesterol: initial 208.4 mg/dl final 187.5 mg/dl

LDL: initial 126 mg/dl final 108 mg/dl

HDL: initial 51 mg/dl final 54.5 mg/dl

Triglycerides: initial 157.6 mg/dl final 111 mg/dl

Apoprotein B: initial 100 mg/dl final 95 mg/dl


Some interesting differences became apparent:
--The VLCHF diet more effectively reduced triglycerides and raised HDL.
--The HCLF diet more effectively reduced total and LDL.
--There was no difference in Apo B (no statistical difference).

The investigators also made the observation that individual responsiveness to the diets differed substantially. They concluded that both diets appeared to exert no adverse effect on any of the parameters measured, both were approximately equally effective in weight loss with slight advantage with the carbohydrate restricted diet, and that lipid effects were indeed somewhat different.


What lessons can we learn from this study? I would propose/extrapolate several:

When calories are severely restricted, the composition of diet may be less important. However, when calories are not so severely restricted, then composition may assume a larger role. When calories are unrestricted, I would propose that the carbohydrate restriction approach may yield larger effects on weight loss and on lipids when compared to a low-fat diet.

The changes in total cholesterol are virtually meaningless. Part of the reason that it didn't drop with the VLCHF diet is that HDL cholesterol increased. In other words, total cholesterol = LDL + HDL + trig/5. A rise in HDL raises total cholesterol.

Despite no change in Apo B, if NMR lipoprotein analysis had been performed (or other assessment of LDL particle size made), then there would almost certainly have seen a dramatic shift from undesirable small LDL to less harmful large LDL particles on the VLCHF diet, less change on the HCLF diet.

The lack of restriction of saturated fat in the VLCHF that failed to yield adverse effects is interesting. It would be conssistent with the re-analysis of saturated fat as not-the-villain-we thought-it-was put forward by people like Gary Taubes (Good Calories, Bad Calories).

In the Track Your Plaque experience, small LDL is among the most important measures of all for coronary plaque reversal and control. Unfortunately, although this study was well designed and does add to the developing scientific exploration of diet, it doesn't add to our insight into small LDL effects. But if I had to make a choice, I'd choose the low-carbohydrate, high-fat approach for overall benefit.

Is skinny necessary for reversal?

6. January 2008 William Davis (19)
Nothing we do in the Track Your Plaque program guarantees that coronary atherosclerotic plaque or your heart scan score is reduced or reversed.



But everything we do weighs the odds in your favor of successfully achieving reversal: correction of lipoprotein patterns, uncovering hidden patterns like Lp(a), vitamin D, being optimistic--it all tips the scales in your favor.

But how necessary is it to be skinny, meaning somewhere near your ideal weight?

It is important, but not as important as it used to be. Let me explain.

I used to tell people that plaque would not regress unless ideal weight was achieved and all the parameters of abdominal obesity and metabolic syndrome were corrected. This includes blood pressure, blood sugar, low HDL, small LDL, high triglycerides, and high c-reactive protein. Curiously, though, as we've gotten better and better at reducing coronary calcium scores, I've been finding that complete correction of all parameters, including achieving ideal weight, don't seem to be as necessary to achieve plaque reversal.

I almost hate to say this, but I've even witnessed significant drops in heart scan scores in people with body mass indexes (BMI) of 30--obese.

The necessary change doesn't seem to be weight, per se, but the consequences of weight. In other words, if you remain overweight, but blood sugar, HDL, small LDL, etc. have shown substantial improvement, then reversal is still achievable.

Then is it okay to be fat or overweight?

Reducing weight to ideal weight does indeed tip the scales in your favor, since it represents an observable, perceptible measure of all associated patterns. Dropping weight can also minimize the need for efforts to correct the consequences of overweight--you might need less niacin, fish oil, exercise, blood pressure medication, etc. to succeed at plaque reversal. Achieving ideal weight may also provide benefits like reduced risk of cancers and degenerative diseases of the hips and knees. But, to my recent surprise over the last two years, achieving ideal weight is not an absolute requirement to achieve reversal.

This is contrary to what some others say. For instance, in an upcoming interview with Dr. Joel Fuhrman on the Track Your Plaque website, Dr. Fuhrman argues that 10% body fat for males, 22% body fat for females, accelerates plaque and symptom reversal. Dr. Fuhrman is author of Fasting and Eating for Health, Eat to Live, and a new upcoming 2-part book, Eat for Health, and proponent of high-nutrient vegetarian diets and fasting. Dr. Fuhrman has been helpful in teaching us some important lessons on how to apply periodic fasting to accelerate plaque reversal.

So, which is it, fat or skinny?

If given a choice (which everyone has), I'd choose skinny. But, provided all the parameters associated with overweight are corrected, then remaining overweight doesn't necessarily mean that you can't still succeed at plaque reversal.

If you are interested in knowing what your ideal weight is, there are a number of software calculators and tables available, including the HealthCentral.com calculator and the National Heart, Lung, and Blood Institute BMI Calculator.


Image courtesy Wikipedia.

Copyright William Davis, MD 2008

MESA Study: Track Your Plaque-Lite?

4. January 2008 William Davis (11)
The long-awaited data analyses from the Multi-Ethnic Study of Atherosclerosis (MESA) are finally making it to press.

The MESA Study is an enormously ambitious and important study of 6800 people, 45 to 84 years old, that includes white, black, Hispanic, and Chinese participants from six communities around the U.S. (Forsyth County, NC; Northern Manhattan and the Bronx, NY; Baltimore and Baltimore County, Md; St Paul, Minn; Chicago, Ill; and Los Angeles County, California.) Participants had no history of heart disease at enrollment. All underwent a heart scan (either EBT or multi-detector heart scans) at the start. It is therefore the largest prospective study involving heart scans ever performed. It is, not unexpectedly, yielding some fascinating observations relevant to the Track Your Plaque program. The MESA study is, incidentally, funded by the non-commercial, publicly-funded National Heart, Lung, and Blood Institute and is therefore presumably free of commercial bias.

Among the most recent publications is Risk factors for the progression of coronary artery calcification in asymptomatic subjects: Results from the Multi-Ethnic Study of Atherosclerosis (MESA) In this analysis of 5700 of the MESA participants, a repeat heart scan was obtained an average of 2.4 years after the first. Conventional risk factors for heart disease were obtained at the start (see below for details under Measurement of Covariates.)

After analyzing the data and risk factors assessed, such as age, sex, race, blood pressure, body mass index (BMI), presence of diabetes, blood sugar, and family history of heart disease, two questions were asked:

1) What risk factors predict heart scan scores?

2) What risk factors predict progression (i.e., increase) in heart scan scores?

(The second question is particularly relevant to us and the Track Your Plaque experience.)

The MESA analysis showed that essentially all the risk factors assessed correlated with both the initial heart scan score, as well as the rate of progression. No surprises here.

But the most eye-opening finding was that the conventional risk factors assessed explained only 12% of the variation and progression in heart scan scores (coefficient of determination, or R squared, = 0.12.) In other words:

--Conventional risk factors like LDL cholesterol, diabetes, and excess weight explain only a tiny fraction of why someone develops coronary atherosclerotic plaque as represented by a heart scan score.

--The great majority of risk for a high heart scan score remains unexplained by conventional risk factors.

--The great majority of risk for progressive increase in heart scan scores also remains unexplained by conventional risk factors.


In light of the MESA analysis, it's no surprise that strategies like reducing LDL cholesterol with statin drugs fails to prevent most heart attacks. It's no surprise that conventional prevention programs that talk about "knowing your numbers," eating a "balanced" or low-fat diet, etc., fail miserably to prevent the vast majority of heart attacks and heart procedures.

MESA confirms what we've been saying these past few years: If you want control over coronary heart disease, you won't find it in Lipitor, a low-fat diet, and other limited conventional notions of risk. Correction of conventional risk factors like cholesterol and blood pressure are, in a word, a failure. I wouldn't even call the conventional approach Track Your Plaque-Lite All posts by william-davis

Mediterranean diet vs. American Heart Association Diet

18. June 2007 William Davis (4)
In 1994, the Lyon Heart Study demonstrated a 50-70% reduction in coronary events in participants who followed a diet rich in vegetables, olive oil, fish, nuts, red wine, and enjoyed meals as a family activity. Various other studies have documented similar phenomena with less metabolic syndrome, better lipid patterns, less obesity with the Mediterranean lifestyle.

There are two fundamental differences between the Mediterranean diet and the diet advocated by the American Heart Association (AHA) for people with heart disease: the Mediterranean diet uses olive oil more liberally, such that fat calories can reach 40% of total; and, unlike the AHA diet, processed foods are not a part of the Mediterranean diet. Greeks, for instance, are far less likely to eat Count Chocula cereal for breakfast, or snack on Healthy Choice Premium Caramel Swirl Sandwich (ice cream sandwiches) or Malt-O-Meal Honey Nut Scooters. All three of these foods on listed on the AHA Heart-Check Mark heart-healthy program.

In other words, remove all the processed foods, and the AHA diet pretty closely resembles the Mediterranean diet. There are differences but they tend to be relatively small. If the only major difference is the presence of processed foods, wouldn't you therefore expect the AHA to embrace the Mediterranean diet?

Here's what their official stand on the Mediterranean diet states:

Does a Mediterranean-style diet follow American Heart Association dietary recommendations?

Mediterranean-style diets are often close to our dietary recommendations, but they don’t follow them exactly. In general, the diets of Mediterranean peoples contain a relatively high percentage of calories from fat. This is thought to contribute to the increasing obesity in these countries, which is becoming a concern.



The AHA is actually lukewarm towards the diet that was the first to show a dramatic decrease in heart attack and death. Why?

The answer is obvious, once cast in this light. To wholeheartedly endorse the Mediterranean diet might be seen as an indirect rejection of American processed foods. You know, the foods that have caused an extraordinary and unprecedented epidemic of obesity in the U.S., the foods that are manufactured by ConAgra, General Mills, Kelloggs--all also major financial contributors to the AHA, according to the AHA Annual Report.

I tell my patients: If you want heart disease, follow the American Heart Association diet. In my view, it is a diet founded on politics and money, not on health. How else could Cocoa Puffs be regarded as heart healthy?

Track Your Plaque in 50,000 BC

16. June 2007 William Davis (3)
Imagine we could send you back in a time machine to 50,000 BC.

However, our agreement: no modern tools or equipment. Just your brain, hands, and legs. And your landing spot will be tropical or semi-tropical, the same climate that humans spent much of their evolutionary time in.

Not only might you rub elbows with contemporaries like homo erectus and neanderthalensis, you'd also have to fend for your life and survival.

To eat, you will have to chase and kill wild game, all with your bare hands or crude tools crafted from sticks and stones. You will have to learn what wild berries, roots, and plants are edible and distingusih them from those that make you retch, make your bowels run, or kill you. You won't be able to cultivate grain, at least for a good long time, since you don't have a community that makes such an undertaking easier.

Instead, you are constantly on the run, from the moment you awake until you finally settle back as the sun sets, hopefully with a full stomach, but often empty and growling, anticipating the hunt and forage of tomorrow.

You are outdoors all day, except for the period when you hide in your cave or self-made shelter. You wear what little clothing you can make yourself from your kills, a skin or two. Your skin becomes a dark brown, a 5 foot 10 inch male will weigh 140 lbs, a 5 foot 5 inch woman 95 lbs. There are obvious downsides: your teeth will rot, you will be prone to infections, and predators view you as fair game.

But the result will be that many chronic diseases of modern life will no longer be worries for you. Heart disease? Highly unlikely. Do you need vitamin D? No, because you are outdoors virtually all day with most of your body surface area exposed to sun. Omega-3 fatty acids? You get those from the wild game you eat, since they have higher omega-3 content feeding in the wild, not eating corn like modern livestock. Since your body fat is minimal, just enough for survival, you don't need niacin.

In other words, many of the strategies of the Track Your Plaque program are modern necessities, responses to the "deficiencies" of modern life. Of course, I don't really have a time machine. I also doubt that you wish to hunt wild game every day, forage for plants and roots, run nearly-naked in the sun. You probably also have become accustomed to brushing your teeth and not viewing every animal as a potential threat to your life.

Nonetheless, I find this an interesting exercise for understanding the role of all the tools we use in the Track Your Plaque program for plaque control.

When pessimism wins

15. June 2007 William Davis (3)
When I first met Hank, I immediately sensed it: anger, hostility, fear. His heart scan score of 685 just made it worse.


He didn't want to be there talking to me. His wife was giving him a hard time. Work was a constant source of irritation. The receptionist at the front desk screwed up his paperwork. Our office charges were too much.


In short, Hank was a pessimist. A bad one.


All the nutrition information out there is bunk. Only he knew how he should eat right. It's stupid to take a lot of fish oil. "You want me to grow gills?"


Among the parameters we use in the Track Your Plaque program is blood pressure during exercise, which provides a surrogate measure of blood pressure during emotional stress, anxiety, etc. "No, I don't need that. I already exercise." No amount of justification could change his mind. "A guy at work had a stress test. They said everything was fine, then Bang! He drops dead. What good is that?"


Hank did go along with a few pieces of advice.


A repeat heart scan 12 months after the first: 870, a 27% per year rate of increase. That's about what would happen if Hank had done nothing, had taken no action to try and stop or reduce his heart scan score.


I don't know if Hank will ever succeed in dropping his score. In fact, I suspect that he will fail, meaning that plaque will grow and he will eventually, perhaps in a year, two or three, require several stents, heart bypass, or have a heart attack. In other words, Hank's pessimism is a self-fulfilling phenomenon: If he believes he will fail, he will. If he believes the world is a rotten place, it is.


Is it possible to "cure" someone like Hank of his deeply-rooted pessimistic attitudes? I don't know of any easy solutions for someone with attitudes as deeply-ingrained as Hank's. (See my prior post, "Cure for pessimism?" at http://heartscanblog.blogspot.com/2007_05_01_archive.html.)

I believe it does help to make someone aware of their attitudes and that it does indeed exert ill health-effects--if they will believe it. But this is a very tough nut to crack.

Bad news on CoQ10?

13. June 2007 William Davis (8)
A review of the effects of Coenzyme Q10 (CoQ10) on the muscle aches and weakness (myopathy) of statin drug therapy was just published in the Journal of the American College of Cardiology.

(Marcoff L, Thompson PD. The role of coenzyme Q10 in statin-associated myopathy. J Amer Coll Cardiol 2007;49(23):2231-2237.)

This is not a study, but a review of the existing scientific and clinical data available on this topic. The study authors conclude with a lukewarm statement:

". . .there is insufficient evidence to prove the etiologic [causal] role of CoQ10 deficiency in statin-associated myopathy and that large, well-designed clinical trials are required to address this issue. The routine use of CoQ10 cannot be recommended in statin-treated patients. Nevertheless, there are no known risks to this supplement and there is some anecdotal and preliminary trial evidence of its effectiveness. Consequently, CoQ10 can be tested in patients requiring statin treatment, who develop statin myalgia, and who cannot besatisfactorily treated with other agents. Some patients may respond, if only via placebo effect."

Should the media get hold of this report, be prepared for the usual "Nutritional supplement no help for drug toxicity" headlines, or "Yet another nutritional supplement shows no benefit" with parallels drawn to vitamin C or E.

There are several issue that need to be factored into the discussion:

1) This is not a study, just a review. Thus, any biases of the authors are more likely to exert themselves.

2) The understanding of CoQ10 absorption among different preparations may be an issue. I just received a mailing from Life Extension that made extravagant claims about the superior absorption of ubiquinol, to be distinguished from ubiquinone, the more common form. They claim that eight-fold increased absorption and blood levels of CoQ10 are achievable with ubiquinol. Unfortunately, virtually all the supportive data are unpublished, proprietary observations, i.e., generated by companies who make or sell it. This is as reliable as drug manufacturers who publish glowing reports on their own drugs--perhaps it's true, but it requires unbiased corroboration.

3) Despite the lack of a large, well-funded clinical trial (all are small), the issue continues to live and breathe because of the powerful anecdotal experience.

In our experience, CoQ10 does work. It doesn't work all of the time, perhaps just 80-90% of the time. It does generally require higher doses (100 mg per day, occasionally more). It very clearly must be an oil-based gelcap (just like vitamin D) to work; capsules containing powder do not work.

It's difficult to doubt when someone starts a statin drug, develops the muscle aches and weakness, begins CoQ10 and obtains distinct relief, stops CoQ10 and aches and weakness return, then only to go away again with resumption of CoQ10 . I've seen this countless times.

We do need better information on CoQ10. There's no doubt about it. For people who obtain benefit from statin therapy, I think CoQ10 remains a useful solution. A better solution would be to get rid of the offending drug. But that's not always possible--e.g., LDL cholesterol 190 mg/dl despite the best diet and "adjunctive" food effort. Then CoQ10 can be very useful.

More on the American Heart Association Check Mark program

11. June 2007 William Davis (3)
Take a look at the list of foods on the American Heart Association's (AHA) Check Mark endorsement program (below). After I saw the list, I was convinced either that the people who designed the program are either startlingly ignorant, or the AHA simply does this for money.

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

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



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

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

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

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

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

Cooper Farms
Cooper Farms All Natural Turkey Breast Fillet

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

Dare Foods Incorporated
Breton Reduced Fat & Sodium Wheat Crackers

El Aguil