High blood pressure vanquished

19. January 2011 William Davis (28)
Heart Scan Blog reader, Eric, related his blood pressure success story to me:

I'm 34 and have been battling chronic hypertension (systolic 150-200, depending on my anxiety levels) even with multiple prescriptions for over a decade now. I've seen four different cardiologists, all stumped as to what is causing my hypertension. First, they suspected coarctation of my aorta [a constriction in the aorta], but an angiogram determined blood pressure readings were the same on both sides of the narrowing.

The second angiogram performed last year to determine if my coarct had worsened determined that it had not, but that my aorta had calcium build up. The cardiologist was stumped because he told me he hasn't seen calcium in a patient so young. Needless to say, this scared me to death, with my wife being pregnant with our first child. I asked if it could be reversed and he didn't know so he sent me to get a Berkeley lab.

The Berkeley came back with LDL 91, HDL 41, Triglycerides 73, CRP 4.1, vit D 26. The doctors weren't very knowledgeable about explaining to me what these meant and how I could correct the low vit D and high CRP. They told me to follow the low-fat diet recommended by Berkeley. Well I've already tried the DASH diet and didn't like how I felt or my energy levels, so I didn't transition.

I was at a loss until I encountered your blog and it was truly a gift. It was a refreshing feeling to meet a knowledgeable Dr. who knew what I was going through and seems to truly care about reversing calcium in the heart (something I never got from my any of my cardiologists). With your blog I have an appointment to get a heart scan here in CO and take that number along with my Berkeley results and join Track Your Plaque.

For the past 2 weeks I've been following your advice by taking a D3+K2 supplement with Omega3 Fish oil and avoiding all grain, wheat, sugar and I'm already down 4lbs to 223.5lbs at 6'5" tall and my blood pressure readings have been 128/54 and 129/60 the past 2 days! With your help I may not have the dark future my father had: dead at 48 with a massive heart attack.

Stay on the look out because I look forward to telling you how I'm one of your top calcium losers!

Eric, Colorado

Conventional medical care fails at so many levels for so many people. While Eric's doctors were busy contemplating the next angiogram, they were neglecting several crucial aspects of his health.

It's really not that tough. But it can mean doing the opposite of what conventional "wisdom" tell us.
Tags :

Comments (28) -

  • Kurt

    1/19/2011 3:40:59 PM |

    Slightly off topic, but I'm wondering if you've had patients complain of sleeplessness when they take Vitamin D. I take 1000iu in the morning; if I take more, I can't get to sleep at night.

  • Patty

    1/19/2011 3:51:39 PM |

    Congratulations to Eric! That is an incredible improvement in your blood pressure.  And I am very happy for you and your family.  

    Thanks Dr. Davis,  for continuing to share these amazing stories.

  • Anonymous

    1/19/2011 4:35:03 PM |

    I've just learned the hard way that HTN in someone young, that has to be treated with multiple meds, can sometimes be caused by a condition called primary aldosteronism.

    Eric, if your docs have not tested your plasma aldosterone and plasma renin activity, *please* ask them to.

  • Anonymous

    1/19/2011 5:06:59 PM |

    Blood pressure is related to the relative tension of the blood vessels.  So, how does that relate to the buildup of plaque?

    Is it that relaxed cells are less likely to allow plaque to adhere/incorporate?

    I have low blood pressure; sometimes 90/60.  However, I don't feel that means my risks of plaque buildup can be ignored or can it?

  • Eric

    1/19/2011 5:16:21 PM |

    Thanks for the super kind words Patty- I'm feeling better than I have in a long time!

    I'll have to see if my plasma aldosterone and plasma renin have been tested. I know my potassium levels get low, but not sure if it's related to the HCTZ Rx or not. Thanks for the heads up though!

    As far as blood pressure and plaque- I was advised that the many years my BP was uncontrolled it caused calcification of my aorta (plaque). Not sure if this is correct, Dr. D would be the expert on this. I am getting my calcium score done on Tuesday, but I know I have calcium build up based on the angiogram images.

  • Anonymous

    1/19/2011 6:50:10 PM |

    Eric, low potassium combined with HTN is often the first indicator of an aldosterone problem. They thought my low K was related to the HCTZ that I took for some 5 years, but it turned out that the other med I was on - Diovan - masked the issue.

    Most primary care docs haven't even heard of primary aldosteronism (or they don't remember the five minutes they spent on it in med school) so they don't routinely order the test. Which is a shame, because some of us spend years misdiagnosed with primary HTN when our HTN is really secondary to the aldosterone issue.

  • Eric

    1/19/2011 7:03:30 PM |

    That is crazy- during the years I have researched many secondary causes and don't remember even reading about Primary Aldosteronsim.

    How did they finally determine it was this and what treatment did you receive for it? Thanks for the info.

  • Bean

    1/19/2011 8:23:05 PM |

    Hey Doc
    Can you bring us up to speed on K2 supplementation.  I saw your "nasty natto" post from a few years ago about how it might be promising treatment but back then it was still too early to tell.. What have you learned since then? How/when do you prescribe it?  Are there particular brands you recommend?
    Thanks for this great blog and for your tenacity in speaking truth to power.

  • Apolloswabbie

    1/19/2011 9:30:49 PM |

    Awesome work and inspiring for many who no doubt also felt as thought they had no option to restore their health.  I meet these people all the time, and many are so frustrated they are no longer taking in new information; but for the ones who will try, transformation awaits.

  • Anonymous

    1/19/2011 10:26:22 PM |

    Hi Eric - regarding primary aldosteronism, I'm only in the first stage of being diagnosed, but here's what I know. The causes are most often an adrenal tumor (in which case they remove the entire gland, at least in the U.S.) or less commonly, a condition known as bilateral hyperplasia, which affects both adrenals. For the latter, they can't do surgery; usually the protocol is spironolactone and a low-salt diet for life. There's also a third possibility, a very rare condition known as GRA that requires meds. I don't know which of these I am yet - I'm waiting for the insurance company to approve further testing.

    In over 9 years of unexplained HTN, I hadn't heard of it either despite lots of research (hey, I'm a trained librarian!). I got lucky - in October I changed primary care doctors and the new doc immediately referred me to a specialist. Both recognized the high BP/low K as symptoms of PA. The high aldosterone/low renin was confirmed by a blood test. Next test is a CT scan to see if there is a tumor.

  • Andrew

    1/19/2011 11:30:28 PM |

    From Wikipedia:

    "CRP is a general marker for inflammation and infection, so it can be used as a very rough proxy for heart disease risk. Since many things can cause elevated CRP, this is not a very specific prognostic indicator. Nevertheless, a level above 2.4 mg/l has been associated with a doubled risk of a coronary event compared to levels below 1 mg/l"

    also:

    "CRP is associated with lipid responses to low-fat and high-polyunsaturated fat diets."

    Hopefully, your CRP levels have fallen along with the blood pressure.

  • Dr. William Davis

    1/19/2011 11:30:43 PM |

    Hi, Kurt--

    Yes, some people are very sensitive to the effect.

    The only way I know to deal with it is to increase dose to the desired level very, very gradually, e.g., additional 1000 units every 3-6 months.

  • Anne

    1/20/2011 11:23:00 AM |

    Slightly off topic here too - has anyone info on Hyperalphalipoproteinemia. That is high cholesterol due to high HDL. Does anyone know the figures for a typical lipid profile for a diagnosis of Hyperalphalipoproteinemia ?

    Many thanks in advance

  • Davide

    1/20/2011 2:00:25 PM |

    I'm just curious what exactly caused Eric's BP to drop in such a short period of time. Obviously, the diet changes and supplementation lead to it, but what did those things do to cause the change?

  • Gillian

    1/20/2011 2:30:56 PM |

    Dr Davis,
    I also would like to know what K2 supplement you recommend nowadays..?

  • Eric

    1/20/2011 4:25:45 PM |

    Bean & Gillian-

    Dr. Davis advised me on Track Your Plaque that he is recommending 1,000mg/day of K2 that has a mix of short acting MK4 and long acting MK7. He suggested Life Extension "Super K". Hope this helps.

    http://www.lef.org/Vitamins-Supplements/Item01224/Super-K-with-Advanced-K2-Complex.html

  • Eric

    1/20/2011 4:29:44 PM |

    Davide- I think it was a combination of diet, supplementation and reduced anxiety.

    When you have a cardiologist tell you he's never seen something like calcium in an aorta, made my anxiety level sky rocket. Especially when they had no clue how to stop or reverse the build up.

    Reading Dr. D's blog and info on Track Your Plaque put control back in my court and that was extremely beneficial to my mental stress.

    It's amazing the biological affects the mind can create.

  • Dream_Puppy

    1/20/2011 6:21:34 PM |

    Dr. Davis,

    Thank you so much for your blog. After your comment on Atenolol I have been inspired to once and for all conquer my insane hypertension. I have a blog to track my progress. I am doing low carb, real food, exercise and a shitload of supplements.

    I'll let you know how it goes.

  • Might-o'chondri-AL

    1/20/2011 7:40:37 PM |

    Hyper-alpha-lipo-proteinemia is an uncommon genetic trait detected mostly(?)among the
    Japanese, French Quebequois and South African Boers. One curious
    peculiarity is a thick Achilles tendon; another is women with HDL over 70 mg/dl (men's HDL is more confusing if they drink alcohol).

    Their cholesterol ester transport protein (CETP)is less active. Instead of HDL being able
    to pass cholesterol fractions over to lipoprotein B those esters stay "stuck" in the HDL.

    Person's HDL gets large as it fills with re-cyclable cholesterol. This only becomes problematic when their
    macrophages become overloaded with LDL it (the macrophage) picked up. Those LDL laden macrophages can, in certain individuals, go on to become the
    nefarious foam cells.

    In this case, the "full up" HDL can't "snatch" up much LDL from the "filling up" macrophage. Sure, HDL is around, but there's diminished capacity to "unload".
    I can't say if (or how) CETP can "break down" in a "normal"
    person and cause them to develop
    clinical hyper-alpha-lipoproteimenia.

  • Anne

    1/20/2011 7:51:24 PM |

    Thanks Might-o'chondri-Al ! Most interesting. My HDL is 116 so am wondering if my 'hypercholesterolemia' is due to Hyperalphalipoproteinemia as my trigs are only 36 but total is high at 333. Trying to find out as much as I can....and there isn't much info around.

  • Tami

    1/20/2011 7:57:48 PM |

    @  Might-o'chondri-AL :

    Does that mean japanese people could do bad on a high fat- low carb diet?

  • Might-o'chondri-AL

    1/21/2011 12:48:34 AM |

    Hi Tami,
    Blog being Doc Davis' I won't presume to give dietary advice.
    If you lay out your reasoning maybe readers will try to work  out a good theory with you.

    Hi Anne,
    My favorite cousin's total cholesterol ran over 300 for years; she's 76 - with  medical "help". I think, in the post before this one's comments thread, Doc Davis gives his office phone for arranging paid consultations (a man asked for it). Free internet advice has it's limitations.

  • Anne

    1/21/2011 9:05:59 AM |

    Hi Might-o'chondri-AL,
    Unfortunately (or perhaps fortunately !) I live in the United Kingdom so a telephone consult to the US is out, especially as we can't get the same kinds of tests done in the UK that people in the US can get done - believe me I've tried asking for particle size tests and Lp(a) and asked privately, rather than NHS, and still not been able to get them. Ideally I should be able to ask these questions on a UK forum or blog devoted to heart health, but such a forum doesn't exist so I have to rely on the good will of people like you or Dr Davis. If I can get sufficient information to present to my cardiologist then he will do the necessary, I'm absolutely sure of that, I just need a little bit more info !

  • Anonymous

    1/21/2011 1:08:35 PM |

    @ Anne:

    I'd suggest looking for a private lab that tests for as many of the tests as Dr Davis recommends. If Claymon Biominis has branches in the UK, they can do most tests, excluding the advanced lipoprotein testing.

    In the meantime, join the Track Your Plaque site, it costs very little and has wonderful resources, an almost overwhelming array, in fact!

    When you've got your basic tests done, book a cheap flight to the USA and schedule advanced lipoprotein testing, an appt and a heart scan with Dr Davis. That's my plan.

    Good luck!

  • Anne

    1/21/2011 1:53:01 PM |

    Hi Anonymous,

    Private labs in the United Kingdom won't do any of the tests unless a doctor does a bona fide request form. I have private medical care as well as NHS and I cannot get those tests because even though they would be done privately the doc is not prepared to ask for those tests considering them unnecessary.

    Medicine is very different in the UK. Patients are unable to self refer to doctors or to private labs for tests. However, once I have just a little more info - I'm not asking for medical advice at all but just info on how Hyperalphalipoproteinemia is diagnosed - to present to my doctor he will be more likely to look into this.

    Doing phone consults to the US or even flying out there and seeing a US doc would not go down at all well with a doc here in the UK - they are unlikely to take any consultation or tests I have in the US seriously. I know that's a pain, but medicine is more tightly regulated here.

    The internet is great but it has its limitations :-( Sorry for wasting peeps time.

  • Might-o'chondri-AL

    1/21/2011 6:11:43 PM |

    O.K. Anne,
       I don't want to detail how my cousin's life has gone; there is no way to guess it relates to you. If you are young,around 30, you should consider seeking out a medical opinion now; I hear in U.K. you'll get on a waiting list.

    You asked for a symptom for a doctor to look into - your HDL reading is it. IF you already had one who said "never mind & go away" try to see a different doctor for your peace of mind. You can not conclude that you have hyperalphalipoproteinemia just because it might explain your data.  
        
    High HDL in Japanesse was originally seen as a sign of longevity. So researchers figured more of a good thing should mean it's even better. Then the genetics of hyperalphalipoproteinemia was found - in some, not all.

  • Anne

    1/21/2011 6:47:36 PM |

    Yes..I guess I should just go back and ask the doctor to explain the high HDL then and see what he comes up with then...before I start a stain that is !

  • peter

    1/19/2012 8:29:49 AM |

    very helpful: http://itunes.apple.com/pl/app/bloodnote-blood-pressure-control/id493849490?mt=8

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Who knows what

4. September 2008 William Davis (4)
You know that cynical old saying:


It’s not what you know, it’s who you know.

In other words, knowing the right person provides you strategic advantage in business, social advancement, etc.

In health, it was often true. Knowing who the better doctors were, for instance, in your city might provide you with access to better care.

Enter the Information Age. You now have access to medical information equal to that of your doctor. You now have access to patient discussions about doctors, their practices, their performance records. There is now a depth and breadth of information on health that was never available before.

I’d therefore turn the old saying into the new Health 2.0 version:


It’s not who you know, it’s what you know.


In health, information now reigns supreme, not knowing somebody else who has the right connections.

Positive: Everybody now theoretically has access to an equal amount of information, since you can access information on any topic just as easily as I can.

Negative: It puts more of the burden on you. If you screw up in health, perhaps you didn’t try to get the best information hard enough.

I love this new development, this emergence of empowerment in health. I call it self-directed health, the individual capacity to exert enormous influence over the quality of your healthcare.

This is obviously a work in progress. All the answers and tools for self-directed care, self-empowerment are not yet available, some haven’t even yet been imagined.

But they are coming.

“Too many false positives”

4. September 2008 William Davis (6)
“Do you really think I need a heart scan?” asked Terry.

“My doctor said that heart scans show too many false positives. He says that many people end up getting unnecessary heart catheterizations because of them.”

At age 56, Terry was becoming increasingly frightened. His father had suffered his first heart attack at age 53, Terry’s paternal uncle had a heart attack at age 56, his paternal grandfather a heart attack at age 50.

Is this true? Do heart scans yield too many false positives, meaning abnormal results when there really is no abnormality?

No, it is not. What Terry’s doctor is referring to is the fact that, in the decades-long process that leads to heart attack, heart scans have the ability to detect early phases of developing coronary atherosclerotic plaque.

Let’s take Terry’s case, for example. Given his family history, it is quite likely that he does indeed have coronary atherosclerotic plaque. Will it be detectable by performing a stress test? Probably not. In fact, Terry jogs and feels well while doing so. While a stress test abnormality that fails to reach conscious perception is possible, it’s fairly unlikely given his exercise routine.

Will Terry’s coronary atherosclerotic plaque be detectable by heart catheterization? Very likely. But why perform an invasive hospital procedure just as a screening test? Should a woman wishing to undergo a screening test for breast cancer undergo breast removal? Of course not.

Is waiting for symptoms a rational way to approach diagnosis of heart disease? Well, when symptoms appear, it means that coronary blood flow is reduced. Stents and bypass surgery may be indicated. The risk of heart attack and death skyrocket. Sudden death becomes a real possibility.

In the 30 or so years required to establish sufficient coronary plaque to permit the appearance of symptoms or the development of an abnormality detectable by stress testing, there were many years when the disease was early--too early to generate symptoms, too early to be detectable by stress testing.

That’s when heart scans uncover evidence for silent coronary atherosclerotic plaque.

Should we call this a “false positive” just because it doesn’t also correlate with “need” for a catheterization, stent, bypass operation or result in heart attack within the next few weeks?

The detection of early plaque is just that: early disease detection.

Imagine, for instance, that the breast cancer that will grow into a palpable nodule or mass detectable by mammogram is detectable by a special breast scan 15 years before it becomes a full-blown tumor, metastasizing to other organs. What if effective means to halt that earliest evidence of cancer could put a stop to this devastating disease decades ahead of danger? Is this a “false positive” too?

In my view, this is the knuckleheaded thinking of the conventional practitioner: “Don’t bother me until you’re really sick.” Prevention is a practice that has become fashionable only because of the push of the drug industry. Nutrition is an afterthought, a message conceived through consensus of “experts” with suspect motivations and allegiances.

So, no, heart scans do not uncover “false positives.” They uncover early disease--true positives--years before it is detectable by standard tests or by the appearance of catastrophe. But that is the whole point: Early detection means getting a head start on prevention.

Do heart scans lead to unnecessary heart catheterizations? Yes, sadly they do. But not because heart scans are false positive. It happens because of unscrupulous or ignorant cardiologists who use the information wrongly. In my view, heart scans should NEVER lead directly to heart catheterization in an asymptomatic patient. Heart scans, as helpful as they are, do not modify the standard reasons for performing heart procedures.

If a car mechanic is dishonest and fixes a carburetor that didn't need fixing, should we condemn all car mechanics? No, of course not. We only need to develop the means to weed out the bad apples. The same applies to heart scans.

Triglycerides divided by five

3. September 2008 William Davis (8)
Here's a bit of lipid tedium that might nonetheless help you one day decipher the meaning of shifts in your cholesterol panel.

Recall from prior discussions that conventional LDL cholesterol is a calculated value. Contrary to popular opinion, LDL is usually not measured, but calculated from the Friedewald equation:

LDL cholesterol = Total cholesterol - HDL cholesterol - triglycerides/5

For the sake of simplicity, let's call total cholesterol TC; HDL cholesterol HDL, and triglycerides TG.

We've also talked in past how a low HDL makes calculated LDL inaccurate, sometimes wildly so. (See Low HDL makes Dr. Friedewald a liar.)

Here's yet another source of inaccuracy of the Friedewald-calculated LDL: any increase in triglycerides.

Let's say, for instance, that starting lipid panel shows:

TC 170 mg/dl
LDL 100 mg/dl
HDL 50 mg/dl
TG 100 mg/dl


You're advised to follow a standard low-fat, whole grain-rich diet advocated by "official" agencies (the diet I bash as knuckleheaded). Another panel a few months later shows:

TC 230 mg/dl
LDL 140 mg/dl
HDL 50 mg/dl
TG 200 mg/dl


(Obviously, I've oversimplified the response for the sake of argument. HDL would likely go down, LDL would change more depending on body weight, small LDL tendencies, and other factors. You'd also likely get fat.)

Now your doctor declares that your LDL has gone up and you "need" a statin agent.

Nonsense, absolute nonsense.

What has really happened is that the increased dietary intake of wheat and other "healthy whole-grain foods" has caused triglycerides to skyrocket. LDL increases, in turn, by a factor of TG/5, or 40 mg/dl. Thus, LDL has been inflated by the triglyceride-raising effect of whole grains.

This is yet another reason why the standard lipid panel, full of hazards and landmines, needs to be abandoned. But calculated LDL in particular is an exercise in frustration.

Though the example used is hypothetical, I've witnessed this effect thousands of times. I've also seen many people placed on statin drugs unnecessarily, due to the appearance of a high LDL cholesterol that really represented increased TG/5, usually induced by an excessive carbohydrate intake, including those commonly misrepresented as healthy such as whole grains.

Who reads The Heart Scan Blog?

2. September 2008 William Davis (0)
In the Heart Scan Blog, I am often guilty of speaking out loud of my varied thoughts on this crazy thing that we've created called the cardiovascular healthcare machine. But I discuss it in the context of asking "How could this be done better--better outcomes, more patient-friendly, more accessible . . . more do-it-yourself?

The last part is the part that throws most people. Do-it-yourself? My colleagues would claim I'm nuts, suggesting that coronary heart disease is something manageable by yourself. In the conventional pathway, after all, coronary disease is that unpredictable, poorly detected by standard tests, condition that then leads to heart catheterization, stents, bypass , and the like.

Several factors distinguish the readers of The Heart Scan Blog that surprised me:

--Nearly 60% are women
--There are a disproportionate number of Asian people. (Can someone explain this to me?)
--A great number have graduate degrees

I believe this tells me that The Heart Scan Blog appeals to a somewhat more sophisticated audience. This, to some degree, warms my heart, since it means that I've captured the attention of some people who may be more discriminating and thoughtful in their Internet surfing.

However, I also lament the fact that these conversations are not achieving the mainstream. After all,

Kitchen sink approach for Lp(a)

29. August 2008 William Davis (12)

Lipoprotein(a), Lp(a), can be a tough nut to crack.

Having struggled and wrestled with this genetic pattern for the last 12 years or so in hundreds of patients, I have gained great respect for this difficult to control pattern.

I regard lipoprotein(a) as the number one most aggressive cause for heart disease and coronary plaque known. It can account for heart attacks in men in their 40s, women in their 50s. It can cause heart disease and heart attacks in even the ultra-fit like marathon runners. It accounts for both excessive coronary risk and misleading cholesterol values in slender, healthy-appearing people.

Niacin is the number one treatment choice for Lp(a), followed by testosterone for men, estrogens (preferably human, not horse or other non-human mammal) for women. I then often resort to DHEA, along with adjunctive nutritional agents like raw almonds, ground flaxseed, and others.

Our most recent addition to the Lp(a) treatment list is high-dose fish oil, which appears to exert a significant effect in about 40% of people with Lp(a).

Even with this multi-agent approach, not everybody gains control over Lp(a).

That makes me wonder if someone has Lp(a) at a substantial level of, say, 200 nmol/L or 70 mg/dl (values can differ tremendously, depending on the method of measurement), should we throw everything but the kitchen sink at Lp(a) from the start? Right now, by adding an agent one at a time, it often takes two years to gain control over Lp(a) (if we are going to get it at all).

While many people might find this unpalatable and overwhelming from the starting gate of their program, I do believe it may be a strategy we should consider adopting for full and more immediate plaque control in the Track Your Plaque program. Something to chew on.

Clearly, we need better answers for Lp(a). A "kitchen sink," full-frontal assault might be a way to gain faster control, though not necessarily a superior approach with regards to efficacy and potency.

There are a number of unique, potentially effective therapies for Lp(a) that are worth examining. Given the difficulty of performing clinical trials with non-drug agents (largely a lack of financial support, since nobody gets a financial return with non-patent-protectable agents), I am anxious to put these potential treatments to a test in the Track Your Plaque program Virtual Clinical Trail (VCT). The VCT gives us a quick and relatively easy method to test various potential treatments, with feedback generated in months, rather than years.

Any suggestions on promising agents to test? Of course, they must be widely available nutritional agents, not drugs.

Making Dr. Friedewald an honest man

28. August 2008 William Davis (3)
Colleen started with the usual discrepancy between conventional calculated LDL cholesterol of 121 mg/dl and the far more accurate LDL particle number (NMR) of 1927 nmol/L.

Those of you following this conversation or our many conversations on the Track Your Plaque Forum know that a useful and highly reliable rule-of-thumb for converting NMR LDL particle number to LDL is to drop the last digit: 1927 nmol/L becomes 192 mg/dl. (This is, admitttedly, arrived at empirically, not by design. However, it has held up through thousands of NMR analyses and plays out reasonably when you compare distributions of Friedewald LDL and LDL particle number on a population basis.)

In other words, by this simple manipulation, Colleen's Friedewald calculated LDL is off by 58%. This is very common, a phenomenon I witness several times every day.

By LDL particle size, 75% of all Colleen's LDL particle were abnormally small (small LDL particle number 1440 nmol/L). This is a moderately severe small LDL tendency.

So we took all the steps for reduction of small LDL/LDL, including elimination of wheat and cornstarch, exercise, weight loss (which happens inevitably when wheat and cornstarch are eliminated), fish oil, vitamin D, etc.

Another NMR lipoprotein panel showed an LDL particle number of 882 nmol/L and a Friedewald calculated LDL of 87 mg/dl. Using our rule-of-thumb, LDL by particle number is virtually the same as the calculated LDL. This time, small LDL numbered only 237 nmol/L, or 26.8% of the total, a marked reduction.

Isn't that interesting? As small LDL is corrected, the crude Friedwald calculated LDL approximates the more accurate LDL particle number.

It assumes that accuracy of the Friedewald calculation may be more likely to occur as LDL size approaches normal. However, when LDL size is abnormally small--a condition shared by at least 70% of people with coronary heart disease--then the Friedewald LDL becomes increasingly inaccurate.

The opposite can also happen: When all or nearly all LDL particles are large, Friedewald calculated LDL can markedly overestimate LDL particle number. Yesterday, for instance, a patient had a Friedewald calculated LDL of 183 mg/dl, but an NMR particle number of 1110 nmol/L--drop the zero . . . LDL 110 mg/dl. This woman was advised to take a statin drug by her primary care physician, based on the Friedewald LDL. Instead, she proved to have a far lower LDL. She would not have benefitted from taking a statin drug.

As I've warned many times before: Beware the Friedewald calculated LDL.

Some basic vitamin D issues

24. August 2008 William Davis (7)
The last post on vitamin D raised a number of basic questions among readers. So let me discuss some of these questions one by one. All of them raise important issues surrounding the practical aspects of managing vitamin D in your health.

Anne said:

I think it is important to stress that vitamin D supplementation needs to be continued long term.

I have met too many people who have been prescribed 50,000 IU of D2 for 8-12 weeks and then told to stop because their 23(OH)D went over 30ng/ml. I know one person who's doctor stopped and started the D2 3 times.

Thanks for pointing that out, Anne. Excellent point. I also see doctors do this with statin drugs: start it, check a LDL level which is lower, then think that you're done and stop the drug. What the heck are they thinking?

If vitamin D is not being produced by sun exposure and not obtainable through diet, continued supplementation is necessary, essentially for life.


Twinb asked:

How often you think Vit. D levels should be tested after the initial test is done, especially if the levels are drastically low?

We have used every 6 months in the office. Ideally, levels are in mid-summer and mid- to-late winter in order to gauge the extremes of your seasonal fluctuations. While most adults over 40 fail to fluctuate more than 10 ng/ml in the Wisconsin climate (and this summer, after an initial rainy season early, has been flawlessly bright and sunny, in the high-70s and 80s every single day for months), an occasional person fluctuates more widely. The only way to judge is to check a blood level.


Rich said:

Vitamin D dosage effects appear to be quite idiosyncratic.

Yes, indeed it is. Despite using crude rules-of-thumb, like taking 1000 units of vitamin D per 10 ng/ml desired (a rule I learned from Dr. John Cannell, which he offered fully aware of its inaccuracy), many people will surprise you and have levels that make no sense. Testing is crucial to know your vitamin D level.


Richard asked: Where do we get enough vitamin D wihout worring about laboratory tests?

Well, the entire point of the post was that you absolutely, positively cannot just take vitamin D blindly at any dose and hope that your level is ideal, no more than you can blindly take a dose of thyroid and know you have achieved normal thyroid levels. In my view, vitamin D blood levels are an absolute.


Another simple issue: Don't be afraid of vitamin D. It is, in all practicality, no more dangerous than getting a dark tan. (But, as many of you realize, getting a tan is no assurance of raising vitamin D if you are over 40 years old.)

Wouldn't it be great if someone developed a do-it-yourself-at-home skin test for vitamin D? I know of no effort to develop this, but it would be a huge advantage for all of us.

“How much vitamin D should I take?”

22. August 2008 William Davis (17)
It’s probably the number one most common question I get today:

“How much vitamin D should I take?”

Like asking for investing advice, there are no shortage of people willing to provide answers, most of them plain wrong.

The media are quick to offer advice like “Take the recommended daily allowance of 400 units per day,” or “Some experts say that intake of vitamin D should be higher, as high as 2000 units per day.” Or “Be sure to get your 15 minutes of midday sun.”

Utter nonsense.

The Food and Nutrition Board of the Institute of Medicine has been struggling with this question, also. They have an impossible job: Draft broad pronouncements on requirements for various nutrients by recommending Recommended Daily Allowances (RDA) for all Americans. The Food and Nutrition Board has tried to factor in individual variation by breaking vitamin D requirements down by age and sex, but what amounts to a one-size-fits-nearly-all approach.

Much of the uncertainty over dosing stems from the fact that vitamin D should not be called a “vitamin.” Vitamins are nutrients obtained from foods. But, outside of oily fish, you'll find very little naturally-occurring vitamin D in food. (Even in fish, there is generally no more than 400 units per 4 oz. serving.) Sure, there’s 20 units in an egg yolk and you can activate the vitamin D in a shiitake mushroom by exposing it to ultraviolet radiation. Dairy products like milk (usually) contain vitamin D because the USDA mandates it. But food sources hardly help at all unless you’re an infant or small child.

It all makes sense when vitamin D is viewed as a hormone, a steroid hormone, not a vitamin. Vitamin-no, steroid hormone-D exerts potent effects in tiny quantities with hormone-like action in cells, including activation of nuclear receptors.

It is the only hormone that is meant to be activated by sun exposure of the skin, not obtained through diet. But the ability to activate D is lost by the majority of us by age 40 and even a dark tan is no assurance that sufficient skin prohormone D activation has taken place.

As with any other hormone, such as thyroid, parathyroid, or growth hormones, dose needs to be individualized.

Imagine you developed a severely low thyroid condition that resulted in 30 lbs of weight gain, lose your hair, legs swell, and heart disease explodes. Would you accept that you should take the same dose of thyroid hormone as every other man or woman your age, regardless of your body size, proportion of body fat, metabolism, genetics, race, dietary habits, and other factors that influence thyroid hormone levels? Of course you wouldn’t.

Then why would anyone insist that vitamin D be applied in a one-size-fits-all fashion? (There’s another world in which a one-size-fits-all approach to hormone replacement has been widely applied, that of female estrogen replacement. In conventional practice, there’s no effort to identify need, estrogen-progesterone interactions, nor assess the adequacy of dose, not to mention the perverse non-human preparation used.)

With thyroid hormone, ideal replacement dose of hormone ranges widely from one person to another. Some people require 25 mcg per day of T4; others require 800% greater doses. Many require T3, but not everybody.

Likewise, vitamin D requirements can range widely. I have used anywhere from 1000 units per day, all the way up to 16,000 units per day before desirable blood levels were achieved.

Vitamin D dose needs to be individualized. Factors that influence vitamin D need include body size and percent body fat (both of which increase need substantially); sex (males require, on average, 1000 units per day more than females); age (older need more); skin color (darker-skinned races require more, fairer-skinned races less); and other factors that remain ill-defined.

But these are “rules” often broken. My office experience with vitamin D now numbers nearly 1000 patients. The average female dose is 4000-5000 units per day, average male dose 6000 units per day to achieve a blood level of 60-70 ng/ml, though there are frequent exceptions. I’ve had 98 lb women who require 12,000 units, 300 lb men who require 1000 units, 21-year olds who require 10,000 units. (Of course, this is a Wisconsin experience. However, regional differences in dosing needs diminish as we age, since less and less vitamin D activation occurs.)

Let me reiterate: Steroid hormone-vitamin D dose needs to be individualized.

There’s only one way to individualize your need for vitamin D and thereby determine your dose: Measure a blood level.

Nobody can gauge your vitamin D need by looking at you, by your skin color, size, or other simple measurement like weight or body fat. A vitamin D blood level needs to be measured specifically-period.

Unfortunately, many people balk at this, claiming either that it’s too much bother or that their doctor refused to measure it.

I would rank normalizing steroid hormone-vitamin D as among the most important things you can do for your health. It should never be too much bother. And if your doctor refuses to at least discuss why he/she won’t measure it, then it’s time for a new doctor.

If you’re worried about adding to rising healthcare costs by adding yet another blood test, think of the money saved by sparing you from a future of cancer, heart disease, osteoporosis, diabetes, etc. The cost of a vitamin D blood test is relatively trivial (around $40-50, a fraction of the cost of a one month supply of a drug for diabetes.)

So how much vitamin D should you take? Enough to raise your blood level of 25-hydroxy vitamin D to normal. (We aim for a normal level of 60-70 ng/ml.)

You probably don't take enough fish oil

20. August 2008 William Davis (17)
The results of the recent Heart Scan Blog survey in response to the question: MY DAILY DOSE OF EPA + DHA FROM FISH OIL IS revealed:


Zero--I don't take any
17 (7%) of respondents

Less than 1000 mg per day
24 (10%) of respondents

1000-2000 mg per day
91 (38%) of respondents

2000-3000 mg per day
44 (18%) of respondents

3000-4000 mg per day
40 (16%) of respondents

More than 4000 mg per day
20 (8%) of respondents



Based on the above results, I would say that only a minority of respondents are taking an ideal dose of omega-3 fatty acids. Nearly all of us should consider taking more.

Benefits of omega-3 fatty acids (EPA + DHA) from fish oil begin around a dose of 840 mg per day, according to the GISSI Prevenzione Trial of 1999, an 11,000-participant trial. This dose also corresponds to a quantity of omega-3s that have been shown to raise EPA + DHA blood levels and thereby reduce the notoriously high AA:EPA ratio of Americans.

But what dose is sufficient? What dose is ideal?

Well, the answer to a great degree depends on what you are taking the fish oil for. If being taken to reduce triglycerides and triglyceride-containing lipoproteins, like VLDL and the after-eating (postprandial) IDL, then a higher dose will be necessary. (Triglyceride reduction for the genetically-determined very high triglyceride level of familial hypertriglyceridemia is the FDA-approved indication for prescription Lovaza.)

If you are taking fish oil for treatment of ADHD, depression, or bipolar illness, very high doses are often necessary.

But how about maximal reduction of cardiovascular risk and for control or reversal of atherosclerotic plaque?

This conversation is still evolving. But we can learn some important lessons from three populations of the world that are vigorous consumers of fish:

--The Inuits (aka Eskimos) of Greenland and northern Canada
--The Japanese
--The Bantus of Tanzania who live along Nyasa Lake

All three indigenous populations have several-fold greater intakes of fish and omega-3 fatty acids, have higher blood levels of omega-3 fatty acids, and have enjoyed reduced cardiovascular events, reduced atherosclerotic plaque, or improvement in various surrogates of cardiovascular risk (e.g., Lp(a)).

The most recent addition to this conversation is the ERA JUMP Study, discussed in a previous Heart Scan Blog post. In ERA JUMP, despite being heavy smokers and having other markers for greater risk for heart disease, Japanese men living in Japan had markedly less carotid and coronary plaque, as compared to Caucasian men living in PIttsburgh or Hawaiian men of Japanese descent. The difference appeared to be attributable to serum levels of omega-3 fatty acids.

I believe that the trend is here is to increase the amount of omega-3 fatty acids that most of us take. In the Track Your Plaque program, we have been advocating a rock-bottom starting dose of EPA + DHA of 1200 mg per day. However, I believe that this is due for a change.

We will be increasing the minimum dose for plaque regression and control. Please attend our Webinar this evening for a full, in-depth discussion of the rationale behind this important change.

As always, let me remind you that I am not selling, nor ever have sold, fish oil supplements. If I advocate a specific dose, a higher dose, I do so based on my interpretation of the data and experience with patients, not because I am interested in selling brand X of fish oil.

Vitamin D and HDL

19. August 2008 William Davis (23)
Despite the paucity of scientific documentation of this phenomenon, I am continuing to witness extraordinary increases in HDL cholesterol levels with vitamin D supplementation.

I've touched on the interaction of vitamin D supplementation with HDL in The Heart Scan Blog previously:

Vitamin D: Treatment for metabolic syndrome?

HDL for Dummies


At first, I thought it was attributable to other factors. In real life, most people don't modify one factor at a time. They reduce
processed carbohydrates/eliminate wheat and cornstarch, lose weight, add or increase omega-3 fatty acids from fish oil, begin niacin, increase exercise and physical activity. All these efforts also impact on HDL.

Among the many things I do, I consult on complex lipid (cholesterol) disorders (complex hyperlipidemias) in my office. A substantial number of these people carry a diagnosis of hypoalphalipoproteinemia, a mouthful that simply means these people are unable to manufacture much apoprotein A1, the principal protein of HDL cholesterol particles. As a result, people with hypoalphalipoproteinemia have HDL cholesterol levels in the neighborhood of 20-30 mg/dl--very low. They are also at high risk for heart disease and stroke.

Encourage these people to exercise, attain ideal weight, eliminate wheat and cornstarch: HDL increases 5 mg/dl or so.

Add niacin, HDL increases another 5-10 mg/dl.

Perhaps we're now sitting somewhere around an HDL of 35-40 mg/dl--better, but hardly great.

Add vitamin D to achieve our target serum level . . . HDL jumps to 50, 60, 70, even 90 mg/dl.

The first few times this occurred, I thought it was an error or fluke. But now that I've witnessed this effect many dozens of time, I am convinced that it is real. Just today, I saw a 40-year old man whose starting HDL was 25 mg/dl increase to 87 mg/dl.

Responses like this are supposed to be impossible. Before vitamin D, I had never witnessed increases of this magnitude.

Not all therapies for raising HDL raise the important large (also known as HDL2b) fraction. With lipoprotein analyses, it appears that is principally the large fraction of HDL that rises with vitamin D supplementation.

Why? How?

That I can't tell you. But for those of you struggling with low HDL cholesterols despite your best efforts, vitamin D can make a world of difference.

An interesting corollary: If super-high HDL cholesterols are associated with extreme longevity, as they are with centenarians, does raising HDL to extraordinary levels with vitamin D lead to longer, healthier life, all the way up to age 110 years?

Again, no answers, but an interesting thought. And one I'd bet on. (And I'm not selling vitamin D.)