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.

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Roger's near-miss CT angiogram experience

Heart Scan Blog reader, Roger, described his near-miss experience with CT coronary angiograms.

Hoping to obtain just a simple CT heart scan, he was bullied to get a CT coronary angiogram instead. Roger held strong and just asked for the test that we all should be having, a CT heart scan.


I posted yesterday that I was about to have my first CT heart scan...well, it was an interesting experience for reasons I coudn't possibly have anticipated. Dr. Davis has commented in the past on the confusion in the media about the difference between a CT calcium score scan, and a CT angiography, the latter requiring a far higher dose of radiation. I assumed this was a source of confusion only among patients and lay folks, but, lo and behold, I discovered today that doctors--or at least their helpers--can be just as confused.

Here's my story:

After checking in, I asked the receptionist to see if she had any information on whether my medical insurance was covering the scan. She called someone, and I heard her say over the phone, "He's here for a CT angiogram." At that point my ears perked up. I explained I wasn't here for a CT angiogram, only a regular CT scan. "Well, do you want to call your doctor and talk about this?" she asked. No, I said, I would like to ask one of their folks to verify exactly what test my doctor had ordered. As luck would have it, the technician was walking by at that point. "Is this a CT angiogram?" the receptionist asked. "No, it's just a CT calcium score scan" was the reply. But apparently the technician had been unclear herself, and had called my doctor just to verify. In other words, the "default" procedure they were accustomed to doing at this august Houston vascular clinic was a CT angiogram.

In fact, my appointment was even listed on their calendar as a "CT angiogram." For all I know, my insurance will be billed for the same. Later, during the procedure, the technician acted surprised I wasn't doing the "full test." I explained I had minimal risk factors (actually only one, an HDL of 34 a couple of years ago, which has since been raised to 50 partly as a result of taking advice from this site), but that my doctor was progressive (he is an MD for the Houston Astros) and thought it was a good idea since there is heart disease in my immediate family. My doctor did indeed prescribe only a CT calcium score scan, but it seems to have been an order that this clinic, at least, wasn't all that used to seeing.

So, I guess the message is: we have a lot of educating to do. Had I not been a faithful reader of these pages, I certainly wouldn't have known what kind of test I was about to get, or what questions to ask!

As for the heart scan itself, a piece of cake. If you can hold your breath, you can take this test. Just be sure it is the right one!



Why the "push" towards CT coronary angiograms and not "just" a CT heart scan? Well, I know it's shocking but it's . . . money!

CT coronary angiograms yield around $1800-$4000 per test. CT heart scans yield somewhere around $200. Though the scan center support staff might not care too much about the money themselves, their administrators likely make the cost distinctions clear to them.

Another reason: Most scan center staff, ironically, don't understand what a heart scan means, nor do they understand how it might serve to launch a program of prevention. They do understand that severe blockage by CT angiogram "needs" to be stented or bypassed. So they push patients towards things they understand.

Nobody makes money from CT heart scans, just as nobody makes money from a mammogram. Heart scans also don't lead to heroic, "lifesaving" procedures. They just lead to this sleepy, unexciting, inexpensive thing called prevention.

The Myth of Prevention: Letter to the Wall Street Journal





The June 20-21, 2009 Wall Street Journal Weekend Journal featured a provocative front page article written by physician, Dr. Abraham Verghese:

The Myth of Prevention

While eloquently written, I took issue with a few crucial points. Here is the letter I sent to the Editor at Wall Street Journal:


Dear Wall Street Journal Editor,

Re: Dr. Abraham Verghese’s article, The Myth of Prevention in the June 20-21, 2009 Weekend Journal.


I believe a more suitable title for Dr. Verghese’s article would be: “The Myth of What Passes as Prevention.”

As a practicing cardiologist, I, too, have witnessed firsthand the systemic “corruption” described by Dr. Verghese, the doing things “to” people rather than “for” them. Heart care, in particular, is rife with this form of profit-driven health delivery.

There is a fundamental flaw in Dr. Verghese’s otherwise admirable analysis: He assumes that what is called “prevention” in mainstream medicine is truly preventive.

Dr. Verghese makes issue of the apparent minor differences between preventing a condition and just allowing a condition to run its course. Prostate cancer screening is one example: Men subjected to repeated screenings have little length-of-life advantage over men who just allow their prostate to suffer the expected course of disease.

What if, instead, “prevention” as practiced today is nothing more than a solution that has been adopted in mainstream practice to suit yet another doing “to” strategy than doing “for”? In the prostate cancer example, PSA and prostate exam screenings often serve as little more than a means of harvesting procedures for the local urologist.

That’s not prevention. It is a prototypical example of “prevention” being subverted into the cause of revenue-generating procedures.

I submit that Dr. Verghese has fallen victim to the very same system he criticizes. His views have unwittingly been corrupted by the corrupt profit-driven system he describes.

What if, instead, prevention were just that: prevention or elimination of the condition. What if “prevention” of prostate cancer eliminated prostate cancer? What if heart disease “prevention” prevented all heart disease? What if this all proceeded without regard for profit or revenue-generating procedures, but just on results?

Dr. Verghese specifically targets heart scans or coronary calcium scoring, a test he likens to “miracle glow-in-the-dark minnow lures,” calling them “moneymakers.” Yes, when subverted into a corrupt algorithm of stress test, heart catheterization, stent, or bypass, heart scans are indeed a test used wrongly to “prevent” heart disease.

But what if the risk insights provided by heart scans prompt the start of a benign yet effective “prevention” program that inexpensively, safely, and assuredly prevents--in the true sense of the word--or eliminates heart disease? Then I believe the differences in mortality, quality of life, and costs would be substantial. Such strategies exist, yet do not necessarily include prescription drugs and certainly do not include the aftermath of heart catheterization and bypass surgery. Yet such programs fail to seize the limelight of media attention with no new high-tech lifesaving headline nor a big marketing budget to broadcast its message.

The problem in medicine is not prevention and its failure to yield cost- and life-saving results. It is the pervasively profit-driven mindset that keeps true preventive strategies from entering mainstream conversation. It is a repeat of Dr. Ignaz Semmelweis’ late 19th-century pleads for physicians to wash their hands before delivering babies to reduce puerperal sepsis, ignominious advice that earned him life and death in an asylum. We are essentially continuing to deliver children with unwashed hands because there is no revenue-generating procedure to clean them.

No, Dr. Verghese, the economic and medical failings of preventive strategies are not at fault. The failure of the medical system, in which everyone is bent on seizing a piece of the financial action for himself, has resulted in the failure to support the propagation of true preventive strategies that could genuinely save money and lives.

President Obama’s goal of cultivating preventive practices in medicine can work, but only if the profit-motive for “prevention” does not serve as the primary determinant of practice. Results-driven practices that are applied without regard to profit have the potential to yield the sorts of cost-saving and life-saving results that can reduce healthcare costs.


William Davis, MD
Milwaukee, Wisconsin
Medical Director, The Track Your Plaque Program (www.cureality.com)
Blog: http://heartscanblog.blogspot.com

A victory for SHAPE, CT heart scans, and doing what is RIGHT

The efforts of Texas House of Representatives Rep. Rene Oliveira and the SHAPE Guidelines committee have paid off: The Texas legislature passed a bill that requires health insurers to cover CT heart scans.

(NOTE: Don't make the same mistake that the media often makes and confuse CT heart scans with CT coronary angiography: two different tests, two different results, two different levels of radiation exposure. The difference is discussed here.)

Track Your Plaque previously reported the release of the SHAPE Guidelines, an ambitious effort to open CT heart scanning to people who would benefit from a simple screening test for coronary disease. Rep. Rene Oliveira initially introduced the bill in 2006, after having a heart scan uncovered extensive coronary plaque that resulted in coronary bypass surgery.

The bill requires that health-benefit providers cover the cost of CT heart scans (and carotid ultrasound) in men between the ages of 45-76, women 55-76, as well as anyone with diabetes or at "intermediate-risk" or higher for coronary disease by Framingham risk score.

The usual panel of cardiology knuckleheads stepped to the media podium, expressing their incredulity that something as "unvalidated" as heart scans could gain the backing of legislative mandate. Heartwire carried this comment:

"Contacted by heartwire, Dr Amit Khera (University of Texas Southwestern Medical Center, Dallas) confirmed there are still no comprehensive, adequately powered studies showing that these screening tests lead to better outcomes. In a phone interview, Khera said he has major concerns about how physicians will use these tests, particularly primary-care physicians. "I gave a talk last week to primary-care doctors, and there were probably 250 people in the room, and when I asked how many people had ordered a calcium scan, just one person raised a hand. . . . Most people don't even know what to do with the Framingham risk score, so they're going to follow an algorithm that they don't know how to follow to order a test result that they don't know what to do with."

It's the same criticisms hurled at heart scans over the years despite literally thousands of studies validating their application.

Studies have conclusively shown that:

--Coronary calcium scores generated by a CT heart scan outperform any other risk measure for coronary disease, including LDL cholesterol, c-reactive protein, total cholesterol, HDL cholesterol, blood pressure.
--Coronary calcium scores yield a graded, trackable index of coronary risk. Scores that increase correlate with increased risk of cardiovascular events; scores that remain unchanged correlate with much reduced risk.
--A coronary calcium score of zero--no detectable calcium--correlates with extremely low 5-year risk for cardiovascular events.
--Coronary calcium scores correlate with other measures of coronary disease. Heart scans correlate with coronary angiography, quantitative coronary angiography, carotid ultrasound (intimal-medial thickness and plaque severity), ankle-brachial index, and stress tests, including radionuclide (nuclear) perfusion imaging.

The reluctance of my colleagues to embrace heart scans stems from two issues, for the most part:

1) No study has yet been performed showing that knowing what the score is vs. not knowing what the score is changes prognosis. That's true. But it is also true of the great majority of practices in medicine. While many wrongs don't make a right, the miserable and widespread failure of other coronary risk measures, like LDL cholesterol or c-reactive protein, to readily and reliably detect hidden coronary disease creates a gaping void for improved efforts at early detection. If your LDL cholesterol is 140 mg/dl, do you or don't you have coronary disease? If your doctor's response is "Just take a statin drug anyway" you've been done a great disservice. (If and when this sort of study gets done, its huge cost--outcome studies have to be large and last many years--it will likely be a statin study. It is unlikely it will include such Track Your Plaque strategies that help reduce heart scan scores, like vitamin D and correction of small LDL particles.)

2) Fears over overuse of hospital procedures triggered by heart scans. This is a legitimate concern--if the information provided by a heart scan is misused. Heart scans should never--NEVER--lead directly to heart catheterization, stents, bypass surgery. Heart scans do not change the indications for performing revascularization (angioplasty, stents, bypass). Just because 20% of my cardiology colleagues are more concerned with profit rather than patient welfare does not invalidate the value of the test. Just because the mechanic at the local garage gouged you by replacing a carburetor for $800 when all you need was a new spark plug does not mean that we should outlaw all auto mechanics. Abuse is the fault of the abuser, not of the tool used to exercise the abuse.


All in all, while I am not a fan of legislating behavior in healthcare, the blatant and extreme ignorance of this simple tool for uncovering hidden heart disease makes the Texas action a huge success for heart disease prevention. I hope that this success will raise awareness, not just in Texas, but in other states and cities in which similar systemic neglect is the rule.

Remember: CT heart scans are tools for prevention, not to uncover "need" for procedures. They serve as a starting point to decide whether or not an intensive program of prevention is in order, and I don't mean statin vs. no statin.

Though not a multi-million dollar statin drug study, I have NEVER seen a heart attack or "need" for procedure in any person who has stopped progression or reduced their heart scan score. A small cohort from my practice was reported:

Effect of a Combined Therapeutic Approach of Intensive Lipid Management, Omega-3 Fatty Acid Supplementation, and Increased Serum 25 (OH) Vitamin D on Coronary Calcium Scores in Asymptomatic Adults.

Davis W, Rockway S, Kwasny M.

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

Sleep: A to Zzzzzzzzzz

Take a look at the results from the Heart Scan Blog's most recent reader poll (399 respondents):

How many hours do you sleep per night (on average)?


9 or more hours per night
15 (3.7%)

8-9 hours per night
72 (18%)

7-8 hours per night
152 (38.1%)

6-7 hours per night
111 (27.8%)

5-6 hours per night
38 (9.5%)

Less than 5 hours per night
11 (2.8%)


Like many issues in health, too much or too little of a good thing can present undesirable consequences.

Too much sleep: While psychologists and sleep researchers advise us that at least 9 hours are required to fully eliminate sleep "debt" and achieve optimal vigilance and mental performance, epidemiologic studies have shown increased mortality with this quantity of sleep.

Too little sleep: Getting less than 7 hours habituallly increases blood sugar, appetite, inflammatory measures, and encourages weight gain. Mortality is also increased, just as with sleeping too much. It is also associated with increased likelihood of a positive heart scan score.

7-8 hours per night from a health viewpoint is that Goldlilocks "just right" value: just enough to not erode mental performance substantially, but not so little that inflammatory, insulin-disrupting, and appetite-increasing effects develop.

Of our 399 respondents in the poll, 56.1% (38% + 18%) slept what appears to be an optimal amount for health. While only 3.7% slept too much (9 hours or more), the remaining 40.1% slept too little.

Our informal poll confirms what most of us observe in everyday life: The majority of people shortchange sleep in order to meet the demands of their high-pressure, squeeze-as-much-as-possible-into-every-day lives. But not paying off your sleep "debt" is like not paying the mortgage for a couple of months. You wouldn't expect your friendly neighborhood bank to say, "Oh, you forgot to pay your mortgage? Forget about it. Just pay next month's." Sure, fat chance. But if you don't pay off your sleep "debt," you will pay it back with health.

Beating the Heart Association diet is child's play



In response to the Heart Scan Blog post, Post-Traumatic Grain Disorder, Anne commented:


While on the American Heart Association diet my lipids peaked in 2003. I even tried the Ornish diet for a short time, but found it impossible.

Total Cholesterol: 201
Triglycerides: 263
HDL: 62
LDL: 86

After I stopped eating gluten (I am very sensitive), my lipid panel improved slightly. This past year I started eating to keep my blood sugar under control by eliminating sugars and other grains. Now this is my most recent lab:

Total Cholesterol: 162
Triglycerides: 80
HDL: 71
LDL: 75


Isn't that great? This is precisely what I see in practice: Elimination of wheat and sugars yields dramatic effects on basic lipids, especially reductions in triglycerides of up to several hundred milligrams, increased HDL, reduced LDL.

Beneath the surface, the effects are even more dramatic: reductions or elimination of small LDL particles, reduction or elimination of triglyceride-containing lipoproteins, elimination of the marker for abnormal post-prandial (after-eating) lipoproteins, IDL, reduced c-reactive protein. Add weight loss from abdominal fat stores and reduced blood pressure.

In fact, I would go so far as to speculate that, if the entire nation were to follow Anne's lead and eliminate wheat and sugars, "need" for 30% of all prescription medications would disappear. The incidence of diabetes would be slashed, the U.S. would no longer lead the world in obesity.

Anne and I are not the first to make this observation. It has also been made in several studies, such as:

The Duke University study of low-carbohydrate diets in type II diabetics. In this study, 50% of low-carb participants became non-diabetic: They were cured.

One of the many studies conducted by University of Connecticut's Dr. Jeff Volek, demonstrating dramatic improvement in glucose, insulin (reduced 50%) and insulin responses, and lipids.

Dr. Ron Krauss' early studies that hinted at this effect, even though the "high-fat" diet wasn't really low-carbohydrate.

If wheat and sugar elimination has been shown to achieve all these fabulous benefits, why hasn't the American Heart Association spoken in favor of this dietary approach and other- low-carbohydrate diets ? Why does the American Heart Association maintain its "Check-Mark" stamp of approval on Cocoa Puffs and Count Chocula cereals?

Victim of Post-Traumatic Grain Disorder

Heart Scan Blog reader, Mike, shared his story with me. He was kind enough to allow me to reprint it here (edited slightly for brevity).



Dr. Davis,

I was much intrigued to stumble onto your blog. Heart disease, nutrition, and wellness are critically important to me, because I’m a type 2 diabetic. I’m 53 and was diagnosed as diabetic about 5 years ago, though I suspect I was either diabetic or pre-diabetic 5 years before that. Even in a metropolitan area it's next-to-impossible to find doctors sympathetic to any approach beyond the standard get-the-A1c-below 6.5, get LDL <100, get your weight and blood pressure normal, and take metformin and statins.

I’m about 5’10-and-a-half and when I was young I had to stuff myself to keep weight on; it was an effort to get to 150 pounds, and as a young man, 165 was the holy grail for me. I always felt I’d look better with an extra 10-15 pounds.
I ate whatever I wanted, mostly junk, I guess, in my younger years.

When I hit about age 35, I put on 30 pounds seemingly overnight. As I moved toward middle age I became concerned with the issue of heart health, and around that time Dr. Ornish came out with his stuff. I was impressed that he’d done a
study that supposedly showed measurable decrease in atherosclerotic plaque, and had published the results of his research in peer-reviewed journals. It looked to me as though he had the evidence; who could argue with that? I tried his plan on and off, but as so many people note, an almost-vegan diet is really tough. It was for me, and I could never do it for any length of time. But given that the “evidence” said that I should, I kept trying, and kept beating up on myself when I failed. And I kept gaining weight. I got to almost 200 pounds by the time I was 40 and have a strong suspicion that that’s what caused my blood sugar to go awry, but my doctor at the time never checked my blood sugar, and as a relatively young and healthy man, I never went in very often.

I’ve had bouts of PSVT [paroxysmal supraventricular tachycardia, a rapid heart rhythm] every now and again since I was 12 or so. I used to convert the rhythm with Valsalva, but as I moved into my forties, occasionally my blood pressure would be elevated and it made me nervous to do the procedure because it was my understanding that it spikes your blood pressure when you do it. So I began going to the ER to have the rhythm converted, which they do quite easily with adenosine. On one of my infrequent runs to the ER to get a bout of PSVT converted, they discovered my blood glucose was 500 mg/dL, and I’d never experienced any symptoms! They put me in the hospital and gave me a shot of insulin, got it town to 80 mg/dL easily,
diagnosed me as diabetic, and put me on 500 mg. metformin a day.

I was able to get my A1c down to 7, then down to 6.6, and about that time I read a number of Dr. Agatston’s books, and began following the diet, and pretty quickly got my A1c down to 6.2, and my weight down, easily, to 158. That was fine with my doctor; he acted as though I was in good shape with those numbers. Soon I ran into Dr. Bernstein’s material, and came face to face with a body of research that suggested I needed to get the A1c down to below 5! That was both discouraging and inspiring, and frankly it’s been difficult for me to eat as lo-carb as I appear to need to, so I swing back and forth between 6.2 and 6.6. I know I need to work harder, be more diligent in my carb control, and I see with my meter that if I eat low-carb I have great postprandial and fasting blood sugars, but since I don’t particularly get any support or encouragement from
either my doctor or my wife for being so “radical,” it’s hard to pass the carbs by.

One thing that always confused me was that though I saw on my meter that BG [blood glucose] readings were better with a lo-carb diet, and though I saw the preliminary research suggesting that lo-carb could be beneficial in controlling CVD, I didn’t understand why Ornish had peer-reviewed research demonstrating reversal of atherosclerosis on a very-lowfat diet. How could two opposing approaches both help? I wondered if it were possible that one diet is good for diabetes, and the
other good for heart health. That would mean diabetics are screwed, because they always seem to end up with heart disease.

From time to time I’d look for material that explained this seeming contradiction. I was determined to try to stay lo-carb, simply because I saw how much better my blood sugars are when I eat lo-carb; but it’s hard in the face of this or that website that tells you about all the dangers of a lo-carb diet and that touts the lo-fat approach. That tends to be the conventional wisdom anyway.

Finally in one of those searches I came across your material, and saw you offer what was at last an explanation of what Ornish had discovered--it wasn’t a reversal of atherosclerotic plaques he was seeing; it was that his diet was improving endothelial dysfunction in people who had had high fat intakes.

Odd as it may seem to you, that little factlet has been enough to allow me to discard entirely the lingering ghost of a suspicion that I ought to be eating very-lowfat. In fact, I was very excited to see your claim that your approach can reverse atherosclerotic plaque.

It would be nice to find a doctor who’d be supportive of your approach. My doctor isn’t much interested in diet or
nutrition. He just wants my weight in the acceptable range, my blood pressure good, and my LDL 100 or below (which I know isn’t low enough). He’s not particularly interested in getting a detailed lipid report. I hope I can talk him into ordering one so that it’s more likely I can get it covered by my insurance.

I very much appreciated the links you gave to Jenny’s diabetes websites, and I’ve resolved to get even better control of my BG by being more diligent with my diet. I’m planning on joining your site, reading your book, and following your advice. I just have this sort of deflating feeling that it would have been better if I’d stumbled upon this before I had diabetes. Still, it’s nice to have a site that offers to laypeople the best knowledge available concerning how to take care of their heart.



Mike is yet another "victim" of the "eat healthy whole grains" national insanity, the Post-Traumatic Grain Disorder, or PTGD. The low-fat dietary mistake has left many victims in its wake, having to deal with the aftermath of corrupt high-carbohydrate diets: diabetes, heart disease, and obesity.

We should all hope and pray that "low-fat, eat healthy whole grains" goes the way of Detroit gas guzzlers and sub-prime mortgages.

Drug industry "Deep Throat"

A Heart Scan Blog reader brought the following letter from a former pharmaceutical sales representative to congress to my attention.

Interesting excerpts:

As a former drug representative for Eli Lilly, I spent 20 months increasing the market share of my company’s drugs. I was recruited fresh from college with an eager desire to employ my degree in molecular biology and biochemistry. Shortly after my hiring, it became clearly apparent that a drug sale had much more to do with establishing personal relationships than it did with understanding the latest science. However, any doubts I held regarding the effectiveness of such methods were dispelled by the results of my persuasiveness and the financial rewards I received for my efforts. The latter also helped me rationalize the many ethically dubious situations I routinely encountered in my work. Upon my departure from the industry, I began working for the public’s health. Seven years later, as a result of my experiences and education I am more convinced than ever that the goals of the pharmaceutical industry often stand in direct conflict with the practice of ethical and responsible medicine. Nothing in my recent research causes me to believe that my experiences were anything but typical of the training and practice of the majority of drug reps plying their trade today.


“There’s a big bucket of money sitting in every [doctor’s] office.” – Michael Zubillaga, Astra Zeneca Regional Sales Director, Oncology


The majority of drug reps entering the work force today are young and attractive. The ranks of reps are replete with sexual icons: former cheerleaders, ex-military, models, athletes. Of course, as a sales job, the reps must be eloquent and convincing. Depending on the population, certain ethnicities are preferred either to make the rep distinct among other reps or to provide them with a cultural advantage in connecting with their clients. Noticeably lacking among most new reps is any significant scientific understanding. My personal case illustrates this point rather vividly: In my training class for Eli Lilly's elite neuroscience division, selling two products that constituted over 50% of the company's profits at the time, none of my 21 classmates nor our two trainers had any college level scientific education. In fact, that first day of training, I taught my class and my instructors the very basic but crucial process by which two nerve cells communicate with one another. It is very likely that the majority of my class couldn't explain the difference between a neuron and a neutron prior to sales school. While it's certainly a bonus to have a scientifically educated representative, it is far from a primary recruitment criterion. Youth is a much higher criterion for the sales position.

Sales representative trainers are almost always veteran sales representatives and consequently, much of the training they offer is implicit in the anecdotes they give. This informal training parallels the standard training offered by the industry and in many ways compliments it. It is tacitly accepted by management and perceived as the "real" training by many veteran sale representatives. Among the more dubious "unofficial" lessons a new rep learns are: how to manipulate an expense report to exceed the spending limit for important clients, how to use free samples to leverage sales, how to use friendship to foster an implied "quid pro quo" relationship, the importance of sexual tension, and how to maneuver yourself to becoming a necessity to an office or clinic.

The most troubling aspect of pharmaceutical sales is systematic befriending of our clients. In addition to the psychological profiling mentioned above, drug reps are taught to constantly be on the lookout for personal effects that will help us connect to our doctors. When entering an office for the first time, we nonchalantly survey it for clues to ingratiate ourselves with our client. Similarly, conversations are intentionally steered into the realm of personal details such as religion, family, or hobbies to acquire similar information. As a matter of training, we collect this data subtly. In the course of a conversation with clients, we may glean facts about their prescribing preferences, the dates of their children’s birthdays, where they were born, or what music they enjoy. Training encourages us to commit these details to memory just long enough to return to our cars and instantly type up a “call report” listing the details of our conversation. On a daily basis, we connect our computers to a central database that uploads the information we’ve acquired, allowing us to share it with our partner drug reps and company marketers. Subsequently, drug reps interweave pieces of conversation specifically tailored to appeal to their client drawn from personal information that wasn’t necessarily shared with them. For example, Dr. Jones will be nothing but grateful when I supply him with a cake celebrating his children’s birthday when, in fact, he told my partner (and not me) the birthdates several months prior in a personal conversation.


The writer's comments ring true: The relentless attention-grab of sales representatives, using clever tactics that include access to detailed records of physician prescribing habits, big smiles and eye-winking, are detailed perfectly.

There's nothing wrong with a business doing its job by marketing its products and services. What is so wrong about this picture is that one side is so well-equipped, heavily funded, with access to extraordinary resources that the other side (physicians) don't have. And the physicians aren't the victims--YOU are.

A middle-aged, receding hairline physician, faced with a 28-year old attractive woman asking all manner of ingratiating questions but knowing full well what she is doing, having strategized for weeks on how to manipulate the behavior of her "mark," is helpless.

Like the mortgage-backed security crisis, we've reached another phenomenon of crisis proportions. Direct-to-consumer drug advertising, drugs for non-conditions and well people, pinpoint marketing of drugs to physicians--it's all gone too far.

Personally, drug representatives are not welcome in my office. This generally prompts puzzled, followed by angry, looks from the representatives, often traveling with a district supervisor hoping to help polish their pitch. If patients didn't request free samples, the reps would not step foot in the office.

Triglyceride Buster-Update

In the last Heart Scan Blog post, I described Daniel's experience reducing his triglycerides from 3100 mg/dl to around 1100 mg/dl with use of omega-3 fatty acids from fish oil, along with modifications in his diet. This was accomplished in the space of around two weeks.

An update: Daniel has continued another 10 days on his fish oil, along with elimination of wheat, cornstarch, and sugars.

Repeat triglyceride: 202 mg/dl. That's 93.5% reduction in the space of three weeks--no drugs involved.

Daniel really did nothing extraordinary. He simply followed the simple advice I provided to take a moderate dose of EPA+DHA from over-the-counter fish oil supplements, along with elimination of the foods that are extravagant triggers of triglycerides.

He's got just a little further to go to achieve the biologically ideal level of less than 60 mg/dl. You can see that it is not really that difficult--provided someone didn't load you down with nonsense about "cutting your fat," or statin or fibrate drugs.

Triglyceride buster

Two weeks ago, Daniel started with a triglyceride level of 3100 mg/dl, a dangerous level that had potential to damage his pancreas. The inflammatory injury incurred could leave him with type I diabetes and inability to digest foods, since the insulin-producing capacity and the enzyme producing capacity of the pancreas are lost.

Daniel added 3600 mg of omega-3s per day. Within 10 days, his triglycerides dropped nearly 2000 mg to just over 1100 mg/dl--still too high, but an incredible start.

The power of omega-3 fatty acids from fish oil to reduce triglycerides is illustrated most graphically by people with a condition called "familial hypertriglyceridemia" that is responsible for triglyceride levels of 500, 1000, even several thousand milligrams. That's what Daniel has. Given appropriate doses of omega-3s, triglycerides drop hundreds, even thousands, of milligrams.

No question: Omega-3 fatty acids from fish oil are the best tool available for reduction of triglycerides. The effect is dose-dependent, i.e., the more you take, the greater the triglyceride reduction.

How omega-3s exerts this effect is unclear, though there is evidence to suggest that omega-3s suppress several nuclear receptors involved in triglyceride (VLDL) production and increase the expression or activity of the enzyme lipoprotein lipase, an enzyme that clears triglycerides from the blood.

I am continually surprised at the number of people with high triglycerides who are still treated with a fibrate drug, like Tricor, or a statin drug, when fish oil--widely available, essentially free of side-effects, with a proven cardiovascular risk-reducing track record--should clearly be the first choice by a long stretch.

Among its many benefits, omega-3 fatty acids from fish oil also:

Reduce matrix metalloproteinases (MMP)--Two fractions of MMPs, MMP-2 and MMP-9, are inflammatory enzymes present in atherosclerotic plaque that are suspected to trigger plaque "rupture." Omega-3s have been shown to reduce both forms of MMP.

Block uptake of lipids in the artery wall--Suggested by a study in mice.

Modify postprandial responses--In the first few hours after eating (the "postprandial" period), a flood of digestive byproducts of a meal are present in the bloodstream. While research exploring postprandial effects is still in its infancy, it is clear that omega-3 fatty acids have the capacity to favorably modify postprandial patterns. One common surrogate measure for postprandial abnormalities is intermediate-density lipoprotein, or IDL, that we obtain in fasting blood through lipoprotein panels like NMR and VAP. With sufficient omega-3s alone, IDL is completely eliminated.

Unfortunately, most of my colleagues, if they even think to use omega-3s, choose to use the prescription form, Lovaza. Indeed, several representatives from AstraZeneca, the pharmaceutical outfit now distributing this miserably overpriced product, frequently barge their way into my office poking fun at our use of nutritional supplements instead of the prescription Lovaza. "But insurance covers it in most cases!" they plead. "And your patients will know that they're getting the real product, not some fake. And they'll have to take fewer capsules!"

I never use Lovaza to reduce triglycerides, even in familial hypertriglyceridemia--the FDA-approved indication for Lovaza--and have not yet seen any failures, only successes.

Newsweek, Time, and other fronts for the drug industry

I used to believe that conventional print media--newspapers, magazines--were unbiased, untouchable flames of truth. Perhaps there was a time when this was true, when the young reporter, eager to change the world, uncovered the story that righted some huge wrong.

Those days are drawing to a close.

Today, the once powerful print media are collapsing due to the competition of the cheaper, broader reach of the internet.