A curious case of coronary plaque regression and progression 18. September 2006 William Davis (0) John received a coronary stent in 2003 following a small heart attack. The artery causing the heart attack was a diagonal artery, a branch of the important left anterior descending coronary artery (in the front of the heart). His cardiologist at the time advised him, "Take Lipitor and we'll do stress tests every year. Come back if you have any more chest pain." That was the full extent of John's preventive care. He came to me for a second opinion and, naturally, we enrolled him in our program. We began by obtaining a CT heart scan score, though we had to exclude the stented diagonal artery. His score: 471. At age 51 and physically active, John had 7 additional abnormal lipoprotein patterns identified. We counseled John on better approaches to food choices, his weight target, fish oil, and correction of all lipoprotein patterns. Two years later, John's repeat heart scan score: 511 . John was initially disappointed with the increase. But a closer look yielded something entirely different: the right coronary artery and circumflex (no stents) showed 20-30% reduction in their scores. The increase in total score was entirely due to substantial increase in score just outside the stent, in the left anterior descending artery. In other words, all of the increase in score was due to growth of a plaque at the mouth of the stent in the diagonal artery. This is curious: profound regression of plaque with a big drop in score in the "un-instrumented" arteries, but tremendous growth of plaque and an increase in score in the "instrumented", or stented, artery, all in the same person's heart. I don't know how controllable this specific situation in the left anterior descending and stented diagonal will be, and I'm unaware of any specific strategies to impact on this situation. The whole world of tissue growth within or around stents is littered with high hopes followed by failures. The drug-coated stents have been the only partial solution to this problem, though that's precisely the sort of stent John received. Is there a message here? The message I take from this is that you and I should work like mad to keep from receiving a stent. Once they're implanted, we have less control over our coronary future. We can indeed regress ("reverse") coronary plaque. But we may not be able to regress the sort of tissue that grows in response to a stent implantation.
When is a heart scan score of 400 better than 200? 13. September 2006 William Davis (0) Imagine two people.Tom is a 50-year old man. Tom's initial heart scan score is 500--a bad score that carries a 5% or more risk for heart attack per year.Harry is also 50 years old. His heart scan score is 100--also a concerning score but not with the same dangers of Tom's much higher score. Tom follows a powerful heart disease prevention program like the Track Your Plaque program. He achieves the 60:60:60 lipid targets; chooses healthy foods; takes fish oil; raises his blood vitamin D level to >50 ng/ml, etc. One year later, Tom's heart scan score is 400, a 20% reduction from his starting score.Harry, on the other hand, doesn't understand the implications of his score. Neither does his doctor. He's casually provided a prescription for a cholesterol drug by his doctor but nothing else. One year later, Harry's heart scan score is 200, a doubling (100% increase) of the original score. At this point, we're left with Tom having a score of 400, Harry with a score of 200. That is, Tom has twice the score, or 200 points higher, compared to Harry. Who's better off?Tom is better off. Even though he has a significantly higher score, Tom's plaque is regressing. It is therefore quiescent with its components being extracted, inflammation subsiding, the artery is in a more relaxed state, etc. Harry's plaque, in contrast, is active and growing: inflammatory cells are abundant and producing enzymes that degrade supportive tissue, excessive constrictive factors are constantly causing the artery to pinch partially closed, fatty materials are accumulating and triggering a cascade of abnormal responses.This is therefore a peculiar situation in which a higher score is actually better than a lower score. It reflects the power of adhering to a preventive program. It also demonstrates how two scans are better than one because they show the rate of increase given a particular preventive approach.
Warning: Your cardiologist may be dangerous to your health! 12. September 2006 William Davis (1) Warren had a moderately high LDL cholesterol for years and took a statin drug sporadically over the past 7 years. Finally retired from a successful real estate investment business, he had a CT heart scan to assess his heart disease status. Warren's score: 49. At age 59, this put him in the lowest 25%, with an estimated heart attack risk of 1% per year or less--a relatively low risk. At this heart scan score, the likelihood of an abnormal stress test was less than 3%, or a 97% likelihood of a normal stress test. Most would argue that a stress test would be unproductive, given its low probability of yielding useful information. In other words, there would be a 97% probability of normal blood flow through Warren's coronary plaque, and less than 3% likelihood that a stent or bypass surgery would be necessary. Warren was also without symptoms. He hiked and biked without any chest discomfort or breathlessness. A prevention program like Track Your Plaque to gain control over future coronary plaque growth was all that was necessary and Warren had high hopes for a life free of heart attack and major heart procedures. Then why did he go through a heart catheterization?Warren did indeed undergo a heart catheterization on the advice of his cardiologist. When I met Warren for another opinion, it became immediately obvious that the heart catheterization was completely unnecessary. Then why was this invasive procedure done? There can only be a few reasons:--The cardiologist didn't truly understand the meaning of the heart scan score. "We need to do a 'real' test."--The cardiologist was terrified of malpractice risk for underdiagnosing or undertreating any condition, no matter how mild. --The cardiologist wanted to make more money. Talking about heart disease prevention is a money-saving, not a money-making, approach.Regardless of which of the three motivations was at work here, they're all inexcusable. A disservice was done to this man: he had an unnecessary procedure, incurred some risk of complication in the process, and gained nothing. An ignorant or profit-seeking cardiologist is worse than the unscrupulous car mechanic who, when presented with an unknowing car repair customer, proceeds to replace the carburetor and rebuild the engine when a simple 5-minute adjustment would have taken care of the problem. I estimate that no more than 10% of my colleagues follow such practices, but it's often hard to know who is in that 10%. Ask pointed questions: Why is the catheterization necessary? What is the likelihood of finding information useful to my health? What are the alternatives? (By the way, the emerging CT coronary angiograms can be a useful alternative in some situations like this.)Track Your Plaque is your source for credible information. Be well armed.
I don’t have high blood pressure! 12. September 2006 William Davis (0) Art undeniably had high blood pressure.At age 53, he had all the “footprints” of high blood pressure that’d been present for at least several years: abnormal patterns by EKG, abnormally thick heart muscle, and an enlarged aorta by an echocardiogram. These sorts of changes require many years to develop. Art’s blood pressure was 140/85 sitting quietly in the office. “That’s about what my primary care doc gets, too. Whenever it’s high, he takes it again after a few minutes and it always comes down.”Art tried to persuade me that his blood pressure was high today only because of the traffic on the way into the office. When I dismissed this as a cause, he insisted that stress he’d been suffering because of his teenage son was the cause. “I just know I don’t have high blood pressure!”Who’s right here? Well, Art is not here to defend himself. But one fact is crystal clear: you cannot develop complications of high blood pressure unless you truly have high blood pressure! In other words, Art’s abnormal changes in heart structure (thickened heart muscle and enlarged aorta) are serious changes that develop only with years and years of sustained blood pressure at least as high as the one in the office. His blood pressure almost certainly ranged much higher at other times, particularly during stressful situations like waiting in the check-out line at the grocery store, watching a suspenseful TV show, petty irritations at his job, and on and on. Blood pressure does not have to be high all the time to generate complications of high blood pressure. It can be sporadic, variable, even occasional. Clearly, sustained high blood pressure is the worst situation that creates adverse consequences more quickly. But blood pressure that wavers from low to high only some of the time can still, given sufficient time, cause the very same unwanted effects. Control of blood pressure is crucial to your coronary plaque control program. Blood pressure may be boring: not as exotic, say, as lipoproteins, and not as fun as talking about nutritional supplements. But neglect blood pressure issues and you will not gain full control over coronary plaque growth—-your heart scan score will increase. Watch for an upcoming Special Report on the Track Your Plaque Membership website, a full detailed discussion of how to recognize when blood pressure is an important issue, along with a full discussion of nutritional methods to reduce it, often sufficient to minimize or eliminate the need for medication.
Are there any alternatives to niacin? 10. September 2006 William Davis (0) In the Track Your Plaque program, we tend to rely a great deal on niacin. When used properly, 90-95% of people will do just fine and achieve their lipid and lipoprotein goals with the help of niacin, along with their other efforts.Unfortunately, around 5% of people simply can't take niacin without intolerable "hot flush" effects, or occasionally excessive skin sensitivity--itching, burning, etc. Why does this happen? These 5% tend to be "rapid metabolizers" of niacin, i.e. they convert niacin (nicotinic acid, or vitamin B3) into a metabolite called nicotinuric acid. Nicotinuric acid is the compound responsible for the skin flush. Most people can slow or reduce the effects of nicotinuric acid by:--Taking niacin with dinner, so that food slow tablet dissolution.--Taking with plenty of water. Two 8-12 oz glasses usually eliminates the flush entirely in most people.--Taking with an uncoated 325 mg tablet of aspirin in the first few weeks or months. Eventually, you will need to revert back to a better stomach tolerated dose of 81 mg, preferably enteric coated. But a full 325 mg uncoated can really help in the beginning, or when you have any niacin dose increases, e.g., 500 mg to 1000 mg. But even with these very effective strategies, some people still struggle. That's when the question arises: Are there any alternatives to niacin?Well, it depends on why niacin is being used. If you and your doctor are using niacin for:Raising HDL--Then weight loss to your ideal weight; reduction of processed carbohydrates, especially wheat products; avoidance of hydrogenated ("trans") fats; a glass or two of red wine per day; dark chocolates (make sure first ingredient is chocolate or cocoa, not sugar), 40 gm per day; fish oil; exercise; other prescription agents (fibrates like Tricor; TZD agents for diabetes; cilostazol (Pletal)). Niacin is by far the most effective agent of all, but, if you're intolerant, raising HDL is still possible through a multi-faceted effort.Reduction of small LDL--The list of effective strategies is the same as for raising HDL, but add raw almonds (1/4-1/2 cup per day), oat bran and other beta-glucan rich foods like oatmeal. Reduction of processed carbohydrates is especially important to reduce small LDL.Reduction of Lipoprotein(a)--This is a tricky one. For men, testosterone and DHEA are effective alternatives; for women, estrogen and perhaps DHEA. Hormonal preparations of testosterone and estrogen are stricly prescription; DHEA is OTC. I have not seen the outsized benefits on lipoprotein(a) claimed by Rath et al by using high-dose vitamin C, lysine, and profile, unfortunately. We are clearly in need of better alternatives to treat this difficult and high-risk disorder.Reduction of triglycerides/VLDL/IDL--I lump these three together since they all respond together. If you're niacin intolerant, maximixing your fish oil can be crucial for reduction of these patterns using doses above the usual starting 4000 mg per day (providing 1200 mg EPA+DHA). Reduction of processed carbohydrates, eimination of processed foods that contain high-fructose corn syrup, and weight loss to ideal weight are also very effective. "Soft" strategies with modest effects include green tea (>6 cups per day) or theaflavin 600-900 mg/day; raw nuts like almonds, walnuts, and pecans; exercise; soy protein.Reduction of LDL--Lots of alternatives here including oat bran (3 tbsp per day), ground flaxseed (3 tbsp per day), soy protein (25 grams per day), Benecol butter substitute (for stanol esters), soluble fibers like pectin, psyllium, glucomannan; raw nuts like almonds, walnuts, and pecans. In future, should torcetrapib become available (by prescription), this will add to our available tools for these areas when niacin can't be used. Until now, the alternatives to niacin depend on what you and your doctor are trying to achieve. In the vast majority of cases, HDL, small LDL, triglyceride, etc. goals for heart scan score control can be achieved, even when niacin is not well tolerated.
Is flaxseed oil a substitute for fish oil? 9. September 2006 William Davis (3) This question comes up so frequently that it's worth going over. Flaxseed oil is a wonderful oil rich in linolenic acid, which may provide health benefits all by itself. Some authorities have speculated that the substantial reduction in heart attack seen in the Lyon Heart Study, the study that demonstrated the healthy power of the Mediterranean diet, is due to linolenic acid. Flaxseed oil is also rich in monounsaturates and low in saturates, both desirable qualities. Of course, I'm talking here about flaxseed oil, to be distinguished from flaxseed , which are the intact seeds. The seeds themselves also contain the same oils, but contain other components, specifically lignan, a plant fiber with suspected health benefits like reduction in cancer risk. Despite all flaxseed oil's wonderful properties, it is definitely not a substitute for fish oil. Why do we use fish oil for our coronary plaque control program (trying to reduce your heart scan score)? Several reasons. Fish oil:--Dramatically reduces triglycerides, usually by 50% or more. --Dramatically reduces specific lipoprotein classes like VLDL--Dramatatically reduces, often eliminates, abnormal postprandial (after-eating) lipoprotein patterns, like IDL (intermediate-density lipoprotein)--Has been conclusively shown to reduce risk of heart attack and death from heart attack (GISSI Prevenzione Trial).--Has been shwon to reduce risk of stroke.--Modifies blood clotting parameters, particularly a 20% reduction in fibrinogen.Flaxseed oil, or linolenic acid concentrate for that matter, do not accomplish any of these effects, all crucial if you are to gain control over your coronary plaque. Flaxseed oil and flaxseed remain wonderful nutritional agents for their own reasons. But they will not substitute for fish oil in your program. Only fish oil--the real thing--does the job.
If you have coronary artery disease . . . do you know why? 9. September 2006 William Davis (0) This conversation is aimed primarily at non-followers of the Track Your Plaque program, because if you were a follower, you’d already know the answer!I saw a woman in the hospital today. She’d just survived her second heart attack one week earlier. At 51 years old, she was understandably shaken, perhaps terrified. She felt that her future was uncertain and, in fact, had discussed with her husband what he should do to prepare for a future without her. One week earlier, she’d received three stents that successfully aborted her heart attack. But, as is always the case, the modest delays of ambulance transport, the emergency room preliminaries, then of mobilizing an available cardiologist and catheterization laboratory team, totaled nearly two hours before her stent procedure. Inevitably, a moderate amount of damage had been done to her heart. Her first “event” had been very similar: very little warning, then 911 and the flurry of activity. Both times, the cardiologists (two different physicians) complimented the patient on her prompt action. Both also called her heart attacks “close calls”. She defied the odds with two near-death events. So, when I met her a week after her last heart attack, I asked an obvious question: “Has anyone told you why you’re having these heart attacks?”She looked completely puzzled at first. She then said, “No, not really. I just assumed it was genetic. My mother went through the same thing when she was my age. But she didn’t get as far as I have, since they didn’t have these procedures back then.”To me, this seems inexcusable: This woman had experienced two brushes with death and no doctor had established a cause. Could this woman’s belief be true, that it’s just genetic?While there are, indeed, genetic causes for heart disease, the vast majority of these genetic causes are 1) identifiable, and 2) correctable. Genetic does not necessarily mean hopeless. It just means that the usual equation of heart disease risk management (heart disease = LDL cholesterol = need for Lipitor) has limited value. It would be like giving penicillin to people for any and all infections. It will work occasionally, but it will fail miserably in a great many cases. Treating LDL cholesterol with statin drugs is just like that.Perhaps this woman has lipoprotein(a), a serious genetic trait that predicts heart disease at a young age and is largely unaffected by statin drugs. Or, she may have a severe excess of small LDL, only partially suppressed by statins. If she has the combined pattern of lipoprotein(a) and small LDL, that means she has two statin-unresponsive and significant genetic traits. But they respond to niacin, specific nutritional strategies, and several other agents. The message: If you have coronary disease, you need to insist on knowing why. “It’s genetic” is not an acceptable answer. “There’s no proof of any heart disease causes beyond cholesterol” is also nonsense. “Everyone gets heart disease, or “hardening of the arteries”, eventually. You just got it a little before everyone else” is also patently ridiculous. Identifying the causes of your coronary disease (or coronary plaque if you’ve had a CT heart scan) is the first step in developing a program of treatment that provides you with control over this disease.
Have you tried inulin yet? 8. September 2006 William Davis (0) If you haven't yet tried it to facilitate weight loss, it's really worth giving the new inulin-containing product, Fiber Choice "Weight Management", a try. Recall (from a prior Heart Scan Blog) that inulin is a vegetable-based fiber found in celery, green peppers, etc. that, when exposed to water, expands to many times original volume. This simple phenomenon yields satiety--a feeling of fullness. The manufacturer of the product has also added green tea, which has been shown in two small clinical studies to enhance weight loss, though by a different route. We've been advising patients to chew two of the strawberry flavored tablets one hour before every meal (or with breakfast if you eat immediately in the morning). You'll be satisfied with less food and you'll experience less intense food cravings. Though no one so far has achieved a huge drop in weight, it does seem to enhance a slow, gradual weight loss larger than achieved by diet and exercise alone. And it's very safe and inexpensive. If you give it a try to help you lose weight, let us know what kind of results you've obtained.
Fish oil update on Life Extension 6. September 2006 William Davis (1) An article of mine came out in Life Extension Magazine and is available on the online version at: http://www.lef.org/magazine/mag2006/sep2006_report_omega1_01.htmThis is an update on the heart health applications of fish oil. Or, go to to www.lef.org and put fish oil into your on-site search and you'll come back to it in future. Of course, it comes with Life Extension's promotion of its supplements. Although it's not yet available online, the hard copy version of an article I wrote on homocysteine is available in the October, 2006 Life Extension Magazine. If you're not a member of their program, they'll send you a free copy just for signing up for it without obligation. Go to the home page of www.lef.org to do so. Or, Life Extension is available at newstands if you're in a rush or don't want to sign up for a free copy.
More on Vitamin D 6. September 2006 William Davis (0) If you haven't done so already, you should subscribe to Dr. John Cannell's free newsletter on vitamin D issues. His newest issue is available at:http://www.vitamindcouncil.com/newsletter/2006-aug.shtmlA sign-up to subscribe is available on the same page. I continue to be shocked and amazed at the prevalence and magnitude of vitamin D deficiency in the people I see every day. It's been a beautiful summer with very little rain. Most days have been in the 70-80 degree range--very comfortable to be outdoors in the sun and getting skin expoxure to activate vitamin D in the skin. Yet, in the vast majority of people I see, summer blood levels of vitamin D are virtually indistinguishable from winter levels. Both hover around the 30 ng/ml range. Summer levels in Wisconsin people seem to be no more than 10 ng/ml higher than winter levels. This remains true even in people who spend a lot of their day outdoors gardening, walking, etc. wearing shorts and a short-sleeved shirt, i.e. with plenty of skin surface area exposed. I'm at a loss to explain precisely why. Yes, it is Wisconsin. But a direct sun overhead, 75 degree day should be providing plenty of sun. My suspicious is that a combination of factors are at work: people are not spending as much time outdoors as they claim; they often seek shade; use sunscreen; and they're overweight. (Excess weight decreases vitamin D blood levels dramatically, yet another reason not to get fat!)Read more about vitamin D by checking out Dr. Cannell's insightful comments on the unfolding vitamin D story. He holds nothing back.
Near-fatal brush with nattokinase 14. April 2010 William Davis (0) Here is precisely why I have spoken out against nattokinase: People may put faith in this "supplement" when there are virtually no data to support its use in such dangerous conditions as pulmonary embolism. Pulmonary embolism occurs when a large volume of blood clots in the veins of the pelvis, abdomen, and into the legs. A clot breaks off and lodges in the pulmonary arteries of the lungs. This can be fatal within minutes to hours, the victim struggling to breathe, since oxygen is not transferred to the blood and it causes terrible pain in the chest. The treatments are fairly obnoxious: intravenous anticoagulants (blood thinners), followed by oral blood thinners like warfarin. While they carry risk of bleeding and other long-term risks, it's better than dying. Would you bet that a "nutritional supplement" manufacturer's vague claims and lack of data are sufficient proof to treat a life-threatening condition? You're a fool if you are. Anyone reading these pages knows that I am a vigorous supporter of nutritional supplements. I even consult for the nutritonal supplement industry. But I am also an advocate of TRUTH, not BS. Here is a woman from England who inquired whether she should stop her husband's warfarin in favor of nattokinase. This is precisely the sort of thing that can happen because of the campaign of misinformation behind nattokinase. Dr. Davis,Thank you for your very interesting blogs, which I came across searching for natural alternative treatments to warfarin. My husband has been following the low carb, high fat, real food regime over the past few years. He got off all the blood pressure and cholesterol drugs and never felt better. He even got his blood sugar down from a recorded high that we are aware of 13 nmol/L (234 mg/dol) to 6.1 nmol/L 109.8 mg/dl). We were on holiday in the Caribbean. Just before our return home, we did a trip to a neighbouring island that included non-alcoholic fruit punches. They tasted great, but were very sweet. I broke my normal refusal to drink these things, but only had a couple of glasses. (After all, we were on holiday!) My husband believes he consumed around 1.5 litres of the stuff and now realises he was feeding his body a very toxic product – fructose. That night, he had an incredible toxic response and we only got him onto the plane with a visit to the hospital and a pain killer injection. The symptoms of pulmonary embolism only showed 2 weeks later . . . and warfarin treatment was started. We would both like to use an alternative therapy if we can find someone with experience to provide the support.Do you know of any studies that support alternative options?Do you know of any practitioners in the England who support a non-drug approach with an understanding of nutrition who we may be able to receive advice and support?FBYork, England
Glucophobia: The Novel 13. April 2010 William Davis (25) Just kidding: No novel here. However, there is indeed a story to tell that should scare the pants off you. If you haven't yet gathered that carbohydrates are a macronutrient nightmare, let me recount the list:Carbohydrates increase small LDL particlesOr, in the cholesterol-speak most people understand, "carbohydrates increase cholesterol." It's counterintuitive, but carbohydrates increase LDL substantially, far more than any fat. Carbohydrates increase blood sugarEggs don't increase blood sugar, nor do chicken, raw almonds, onions or green peppers. But a bowl of oatmeal will send your blood sugar skywards. Carbohydrates make you fatCarbohydrates, whether in the form of wheat flour in your whole wheat bread, sucrose in your ice cream, fructose in your "organic Agave nectar," or high-fructose corn syrup in your dill pickles. They all provoke de novo lipogenesis, or fat formation. They also stimulate insulin, the hormone of fat storage. Carbohydrates cause glycationHigh blood sugar, like the kind that develops after a bowl of oatmeal, triggers glycation, or modification of proteins by glucose (blood sugar). This is how cataracts, kidney disease, and atherosclerotic plaque develop. Small LDL is 8-fold more glycation prone than large LDL, providing a carbohydrate double-whammy. Your glucose meter remains the single best tool to gauge the quality of your diet. Many people have horror stories of the shocking experiences they've had when they finally get around to checking their postprandial glucose.
Drama with the Dr. Oz Show 11. April 2010 William Davis (27) A producer from the Dr. Oz show recently contacted my office. They asked whether we could supply them with a volunteer patient from either my practice or the Track Your Plaque program who would be willing to appear on the show and discuss heart disease prevention. They needed someone to commit within 24 hours. Despite the short notice, we identified a volunteer. He flew to New York the following week where he was interviewed along with several other men and women, all of whom had heart disease (heart attacks, stents, etc.). However, as this young man is very slender and follows most of the Track Your Plaque principles (e.g., vitamin D and omega-3 fatty acid supplementation; no wheat, cornstarch, or sugars, no restriction of fat, etc.), he apparently received less attention than the overweight, I-know-nothing-about-diet interviewees. Then there was an odd turn of events: Dr. Dean Ornish, apparently a friend of Dr. Oz, will be providing the dietary counseling. The producer had made no mention of Dr. Ornish. Now that's an odd collision of philosophies: Our Track Your Plaque version of low-carb with the guru of low-fat, Dr. Ornish. The following week, Dr. Ornish called me and graciously asked whether I was okay with this. I'm not sure just how much he knew about the philosophy I advocate, nor how much I have bashed his program as a destructive approach to diet, nor whether he knew that I gained 30 lbs on the Ornish diet, along with a drop in HDL to 27 mg/dl, increased triglycerides to 350 mg/dl, and type II diabetes that I've talked about on this blog and the Track Your Plaque book and website. I suspect he knew little to none of this. Anyway, I tried to diplomatically explain that my patient's cause for coronary plaque was small LDL particles that he expressed despite his very slender build, likely from excessive carbohydrates, controlled with carbohydrate restriction. Dr. Ornish maintained his usual arguments: Grains are good, provided they are whole grains, heart disease is "reversed" with his diet program, etc. (I didn't want to challenge him in a phone call and tell him that he never actually reversed coronary plaque, but just reversed endothelial dysfunction. But, as Dr. Ornish is not a cardiologist, I wasn't sure how far his understanding of these issues went.) We agreed to disagree. This leaves my poor patient in an odd position: Being asked by Dr. Ornish and the Dr. Oz show to follow a low-fat program for the sake of entertainment, or adhering to the advice we follow that has so far served him well, given his small LDL particle size tendencies. We'll see where this little drama leads.
Response from Nature Made 10. April 2010 William Davis (31) Here's the response from Nature Made when I emailed them about my concern that there appears to be no vitamin D in their vitamin D gelcaps. It is the usually CYA corporate-speak that says nothing. The grammatical errors make it clear that this was a "canned" response. Date: April 9, 2010From: Marissa Reyes, Consumer Affairs DepartmentSubject: Reference #346236Dear William Davis, MD:We recently received your e-mail regarding Nature Made products. We regret to hear that the quality standards of our company. [?]Our company is called Pharmavite, and we manufacture Nature Made nutritional supplements. We have been in business since 1971. We are committed to quality control, and have very high quality standards. Our Quality Control personnel sample and test all raw materials as they enter our plant, and again assay the finished product, before final packaging. Dietary Supplements are regulated under the FDA through DSHEA (Dietary Supplement Health & Education Act of 1994). The United States Pharmacopoeia (USP) establishes standards for the composition of drugs and nutritional supplements. This voluntary non governmental organization was set up in 1820 and has officially been recognized by federal law since 1906. Standards established by USP for products are legally enforceable by the FDA. At Pharmavite we participate in the USP Dietary Supplement Verification Program (DSVP). Many of our products have earned the DSVP seal and additional products are currently being evaluated. Our DSVP certified products will have the DSVP seal on the product label.Our Nature Made Vitamin D 400 IU tablets have been reviewed by the USP and bears the DSVP symbol on the label. Although the USP has not reviewed all of the Nature Made Vitamin D supplements, all of our products go through the same rigorous quality testing at Pharmavite. The products which have earned the seal help us to demonstrate the high quality of our products. We would like to look into the product(s) your patients have been using. If you could provide the UPC and lot numbers of the product(s), we will be happy to review our records. In addition, if you would like us to test the product(s) that you currently have, we will be pleased to send a prepaid postage mailer so you may return the product(s) to us so that our Quality Control Department can examine it. Please let us know if you would like us to send you the prepaid postage mailer. We thank you for contacting us and hope that you will continue to use and enjoy Nature Made products with complete confidence.Sincerely,Marissa ReyesConsumer Affairs CoordinatorPharmavite, LLCMR:346236-10Patients who come to the office do not provide me with the bottles nor lot numbers. In past, when I've gone to the trouble of doing this (with other companies, not Nature Made), it has come to nothing helpful. The information gets passed on to the company and we hear nothing and never learn if there was a problem, or receive some more corporate-speak letter saying everything was fine. This is obviously a liability-avoidance tactic: Admitting that something was wrong would open them up to legal risk. So, frankly, I can't be bothered. So we are left with the unsatisfying experience of relying on street-level experiences. For now, my advice: Avoid Nature Made vitamin D. Too many people have had blood tests demonstrating that they are not obtaining any vitamin D. By the way, the Nature Made brand of fish oil is among the very few problem brands of fish oil we've encountered. Fish oil should be only mildly fish in smell and generally should not cause stomach upset and excessive belching if properly purified. Nature Made is excessively fishy when you smell it, suggesting oxidation. We've had repeated (dozens) of patients who have experienced difficulties with this brand. Rather than dealing with the frustrating gobbledy-gook of this company, just avoid their products.
What to Eat: The diet is defined by small LDL 9. April 2010 William Davis (15) I approach diet from the perspective of small LDL particles. Small LDL particles have exploded in frequency and severity in Americans. It is not at all uncommon to see 70% or more small LDL particles (i.e., 70% of total LDL particle number or Apo B) on lipoprotein testing. (I saw two people today who began with over 95% small LDL.)Small LDL particles are:--More likely to persist in the bloodstream longer than large LDL particles. --More likely to adhere to components of atherosclerotic plaque. --More likely to gain entry to plaque.--More likely to be taken up by inflammatory white blood cells which, in turn, become the mast cells that fill coronary plaque. --More likely to be oxidized. --More likely to be glycated (8-fold more likely than large)To add insult to injury, foods that trigger small LDL formation--i.e., carbohydrates--also cause high postprandial blood sugars. High postprandial blood sugars, in turn, glycate small LDL. That combination of events accelerates 1) plaque growth, 2) plaque instability, and 3) aging. So carbohydrates trigger this sequence, carbohydrates of all stripes and colors. Not just "white" carbohydrates, but ALL carbohydrates. It's all a matter of degree and quantity. So, yes, even quinoa, bulghur, and sorghum trigger this process. I've only recently appreciated just how bad oats and oatmeal are in this regard--really bad.Foods that trigger small LDL also trigger higher blood sugars; foods that trigger higher blood sugars also trigger small LDL. Small LDL and blood sugar are two different things, but they track each other very closely. So, in the Track Your Plaque approach to diet, we craft diet based on these simple principles:1) Eliminate wheat, cornstarch, and sugars--These are the most flagrant triggers of small LDL, blood sugar, and, therefore, LDL glycation. 2) The inclusion of other carbohydrates, such as oatmeal, quinoa, rye, etc. depends on individual sensitivity. Individual sensitivity is best gauged by assessing one-hour postprandial glucose. Stay tuned for more in this series. Also, Track Your Plaque Members: We will be having an in-depth webinar detailing more on thees principles in the next couple of weeks.
Is it or isn't it vitamin D? 7. April 2010 William Davis (63) Jackie takes 10,000 units of vitamin D(3) per day as a gelcap.Her starting 25-hydroxy vitamin D blood level was 18.1 ng/ml. Severe deficiency, no surprise. On her 10,000 units per day, Vitamin Shoppe brand, her 25-hydroxy vitamin D level was 76.2 ng/ml--perfect. It stayed in this range for about two years. She then changed to the Nature Made brand gelcaps she picked up at Walgreen's. Repeat 25-hydroxy vitamin D level: 23 ng/ml. This has now happened with five different people, all taking the Nature Made brand. If you are taking this brand of vitamin D, please be on the alert. You might consider a 25-hydroxy vitamin D blood level to be sure it actually has the vitamin D it's supposed to have. Or, change brands.
What to eat: Part I 6. April 2010 William Davis (0) I've spent a good number of Heart Scan Blog posts detailing what foods to limit or avoid. The list of unquestionably bad foods to avoid include foods made of wheat, cornstarch, and sugars. Fructose is proving to be an exceptionally bad form of sugar, worse than any other. I've issued warnings about levels of carbohydrates that can be determined by postprandial testing. In response to several requests to clarify what foods to eat, this post begins a series discussing what foods are good to eat. I believe that a strong case can be made for eating vegetables in nearly all its varied forms, from cucumbers to peppers to leafy vegetables to eggplant to alliums like onions. The only form we avoid are red and white potatoes due to the blood sugar-increasing effects. While this seems obvious, I am impressed how many people who follow low-carb diets find themselves following a high-animal product diet with vegetables as the sideline. It should be the other way around: A high vegetable diet with animal products as the sideline. Vegetables are your principal source of:1) Flavonoids and polyphenols--e.g., anthocyanins and catechins. All the recently appreciated effects of flavonoids and polyphenols highlight the wonderful effects of compounds originating in plant foods. This includes the anthocyanins and resveratrol in red wine; the catechins and epicatechins cocoa and green tea; the hydroxytyrosol, phenolic acid, and flavonoids of olive oil. 2) Fiber--Fiber is essentially a plant phenomenon, since there is virtually none in chicken, fish, and beef. The benefits of fiber are, I believe, undisputed. Neglecting fiber can, at the very least, lead to a nasty case of hemorrhoids. At the worst, it is related to various cancers, especially colon cancer. 3) Vitamin C--While vitamin C may be old and boring in light of new, exciting discoveries like flavonoids, neglect leads to bad things. Vegetables are generally classified as carbohydrate foods, since they are low in protein and fat. But this is the source of carbohydrates you do not want to sacrifice in a low-carbohydrate diet. There's just too much good from vegetables. Notice that I didn't say "fruits and vegetables." This is a fundamental mistake made by many: Oveconsumption of fruits. I've even seen people who follow an otherwise good diet develop diabetes--just from too much fruit. Vegetables should be the cornerstone of the human diet. But I'll bet you knew that already.
Carbohydrates and LDL 4. April 2010 William Davis (16) There's a curious and powerful relationship between carbohydrates and LDL particles. Understanding this relationship is crucial to gaining control over heart disease risk. (Note that I did not say "LDL cholesterol"--This is what confuses people, the notion that cholesterol is used as a surrogate marker to quantify various lipoproteins, including low-density lipoproteins, LDL. I'm NOT interested in the cholesterol; I'm interested in the behavior of the low-density lipoprotein particle. There's a difference.)Carbohydrates:1) Increase triglycerides and very low-density lipoprotein particles (VLDL)2) Triglyceride-rich VLDL interact with LDL particles, making them smaller. (A process mediated by several enzymes, such as cholesteryl-ester transfer protein.)3) Smaller LDL particles are more oxidizable--Oxidized LDL particles are the sort that are taken up by inflammatory white blood cells residing in the artery wall and atherosclerotic plaque. 4) Smaller LDL particles are more glycatable--Glycation of LDL is an important phenomenon that makes the LDL particle more atherogenic (plaque-causing). Glycated LDLs are not recognized by the LDL receptor, causing them to persist in the bloodstream longer than non-glcyated LDL. Glycated LDL is therefore taken up by inflammatory white blood cells in plaque. Of course, carbohydrates also make you fat, further fueling the fire of this sequence. The key is to break this chain: Cut out the carbohydrates. Cut carbohydrates and VLDL and triglycerides drop (dramatically), VLDL are unavailable to transform large LDL into small LDL, small LDL is no longer available to become oxidized and glycated, blood sugar is reduced to allow less glycation. Voila: Less atherosclerotic plaque growth. Yet the USDA, American Heart Association, and the Surgeon General's office all advise you to eat more carbohydrates. The American Diabetes Association tells you to eat 70 grams or so carbohydrates per meal. (Yes: Diabetes, the condition that is MOST susceptible to these carbohydrate effects.) Follow their advice and you gain weight; triglycerides and VLDL go up; calculated (Friedewald) LDL may or may not go up, but true measured LDL (NMR LDL particle number or apoprotein B) goes way up; small LDL is triggered . . . You know the rest. The dance between carbohydrates and LDL particles requires the participation of both. Allow one partner to drop out of the dance and LDL particles will sit this dance out.
Strange but true: Part II 4. April 2010 William Davis (0) Here's the second part of the Heart Scan Blog post I wrote a couple of years back describing the wacky origins of this thing that has so changed the face of heart care in the U.S., the cardiac catheterization.
Heart catheterization: Strange, but true 3. April 2010 William Davis (1) It's a couple of years old, but this post from March, 2008, remains relevant. It details the curious origins of heart catheterization, the procedure that has saved some lives, but also been responsible for the proliferation of unnecessary heart procedures.The modern era of heart disease care was born from an accident, quirky personalities, and even a little daring. The notion of heart catheterization to visualize the human heart began rather ignominiously in 1929 at the Auguste-Viktoria Hospital in Eberswalde, Germany, a technological backwater of the day. Inspired by descriptions of a French physician who inserted a tube into the jugular vein of a horse and felt transmitted heart impulses outside the body, Dr. Werner Forssmann, an eager 25-year old physician-in-training, was intent on proving that access to the human heart could be safely gained through a surface blood vessel. No one knew if passing a catheter into the human heart would be safe, or whether it would become tangled in the heart’s chambers and cause it to stop beating. On voicing his intentions, Forssmann was ordered by superiors not to proceed. But he was determined to settle the question, especially since his ambitions captured the interest of nurse Gerda Ditzen, who willingly even offered to become the first human subject of his little experiment.Secretly gathering the necessary supplies, he made his first attempt in private. After applying a local anesthetic, he used a scalpel to make an incision in his left elbow. He then inserted a hollow tube, a catheter intended for the bladder, into the vein exposed under the skin. After passing the catheter 14 inches into his arm, however, he experienced cold feet and pulled it out. One week later, Forssman regained his resolve and repeated the process. Nurse Ditzen begged to be the subject, but Forssmann, in order to allow himself to be the first subject, tricked her into being strapped down and proceeded to work on himself while she helplessly watched. After stanching the oozing blood from the wound, he threaded the catheter slowly and painfully into the cephalic vein, up through the bicep, past the shoulder and subclavian vein, then down towards the heart. He knew that simply nudging the rubber catheter forward would be sufficient to direct it to the heart, since all veins of the body lead there. With the catheter buried 25 inches into his body, Forssmann untied the fuming Ditzen. Both then ran to the hospital’s basement x-ray department and injected x-ray dye into the catheter, yielding an image of the right side of his heart, the first made in a living human. Thus, the very first catheterization of the heart was performed.An x-ray image was made to document the accomplishment. Upon hearing of the experiment, Forssmann was promptly fired by superiors for his brazen act of self-experimentation. Deflated, Forssmann abandoned his experimentation and went on to practice urology. He became a member of the Nazi party in World War II Germany and served in the German army. Though condemned as crazy by some, physicians in Europe and the U.S., after hearing of his experience, furthered the effort and continued to explore the potential of the technique. Forssmann himself was never invited to speak of his experiences outside of Germany, as he had been labeled a Nazi. Many years after his furtive experiments, the once intrepid Dr. Forssmann was living a quiet life practicing small town medicine. He received an unexpected phone call informing him that he was one of three physicians chosen to receive the 1956 Nobel Prize for Medicine for his pioneering work performing the world’s first heart catheterization, along with Drs. André Cournand and Dickinson W. Richards, both of whom had furthered Forssmann’s early work. Forssmann remarked to a reporter that he felt like a village pastor who was made a cardinal. Strange, but true.