Butter and insulin

In a previous post, Atkins Diet: Common Errors, I commented on butter's unusual ability to provoke insulin responses. I offer this as a possible reason why, after a period of effective weight loss on a low-carbohydrate program, inclusion of some foods, such as butter, will trigger weight gain or stall weight loss efforts.

This develops because of butter's insulin-triggering effect, doubling or tripling insulin responses (postprandial area-under-the-curve). If insulin is triggered, fat gain follows.

Here's one such study documenting this effect: Distinctive postprandial modulation of ß cell function and insulin sensitivity by dietary fats: monounsaturated compared with saturated fatty acids

López et al 2008


From Lopez et al 2008. Mean (± SD) plasma glucose, insulin, triglyceride, and free fatty acid (FFA) concentrations during glucose and triglyceride tolerance test meal (GTTTM) with no fat (control), enriched in monounsaturated fatty acids (MUFAs) from refined olive oil (ROO meal), with added butter, with a mixture of vegetable and fish oils (VEFO) or with high-palmitic sunflower oil (HPSO). N = 14.

The postprandial (after-eating) area-under-the-curve is substantially greater when butter is included in the mixed composition meal. This effect is not unique to butter, but is shared by most other dairy products.

Fat, in general, does not make you fat. But butter makes you fat.

Comments (83) -

  • Miki

    3/19/2010 5:48:56 PM |

    I wander if the effect is due to the milk solids or the type of fatty acids. If it is the milk solids making ghee will solve the problem.

  • Anonymous

    3/19/2010 5:54:39 PM |

    So the low fat control meal of pasta and bread gives the LEAST amount of insulin response!

    So, to avoid insulin spikes you must minimize all types of fats.

    Fat+Pasta seem to trigger the insulin.  The glucose response does not seem to matter all that much.

  • jd

    3/19/2010 5:54:39 PM |

    Thanks for the great info as always.

    Is it correct to say, in view of the graphs, that this type of dairy-induced insulin elevation is not mirrored by blood glucose readings, so we couldn't check for it at home with a glucose meter?

  • John

    3/19/2010 5:56:08 PM |

    butyric acid causes an insulin response, as does casein...interestingly, although i can't find it, i saw a paper that showed the insulin response to white bread was actually less when combined with butter...

  • daniel the smith

    3/19/2010 6:06:21 PM |

    What if you eat it without any carbs (e.g., like I do with my eggs in the morning)? If there's nothing to trigger the insulin in the first place, butter can't make it worse, right? Or am I wrong?

  • Lucy

    3/19/2010 6:16:20 PM |

    That's an interesting study indeed.  It seems to indicate that eating no fat at all (the control meal) provided better results in every category except glucose rise, and then it was only with the rest of a fairly tight pack.  Adding any fat at all spiked the insulin significantly higher.   This is consistent with the charts in your post "The Timing of Blood Sugars".  Yet you concluded there that carbohydrates should never be consumed without fat.  Based on these studies, it sure looks like a person is trading a little glucose rise for a larger insulin spike when consuming fat.  Which begs the question, which is worse?  Does insulin cause more problems than glucose?   You did say it was the insulin that triggered weight gain...

    I remain unconvinced that I should rush out and follow Ornish.

  • Diana Hsieh

    3/19/2010 6:34:54 PM |

    Interesting post -- and my experience confirms it.  Here's something that I recently posted to the OEvolve e-mail list:

    As folks might know, I've been struggling with my weight due to my hypothyroidism.  Even though many of my symptoms have improved, I continued to gain weight at the very consistent rate of 3 pounds per month.  Sometimes, mostly due to a bit of fasting, I'd be down a pound or two, but then I'd suddenly gain back all that weight plus more within a day or two, so that I'd be on that steady upward slope again.  

    In late February, I was up to just over 150 pounds; that was my pre-paleo weight.  That's not so terrible in and of itself -- although I hated it -- but the continued upward progression was really alarming.  Plus, I'd outgrown almost all my pants!

    After listening to Robb Wolf talk about the growth-promoting, insulin-spiking effects of dairy, I realized that I'd been eating a huge amount of dairy lately -- far more than ever before.  I've been buying those huge blocks of cheese from Costco, not to mention those delectable half gallons of cream.  So instead of eating meat-and-veggie leftovers for lunch, I was usually eating some high-fat dairy.  And for breakfast, I would eat cheese rather than meat with my eggs.  

    A few weeks ago, I decided to cut my dairy down dramatically -- to basically just one serving per day at most.  So I'll have a cup of raw milk kefir or cheese on meatza, but not much more than that.  That was really hard for me to do for the first week, as I really was used to eating it as a staple.  I'm also not eating nuts, absent some "must have food as I run out the door" emergency, as I know they can hamper weight loss for me.

    The results have been good so far.  I've not gained any more weight in the last two weeks.  Instead, I've lost four pounds.  Given what I had been experiencing, that's pretty remarkable.

    I'm not sure how much more weight I'll lose just due to cutting back the dairy.  I definitely think my metabolism isn't quite up to speed yet due to the hypothyroidism. However, my experience suggests that eating boatloads of dairy -- even good-quality, high-fat dairy -- is an excellent way to gain weight.

    That being said, I don't think that it's necessary to cut out all dairy to lose weight.  I'm still eating some dairy, and I'm losing weight.  Plus, I lost my original 18 pounds with my 1.5 shares of raw milk -- that's 1.5 gallons per week.  (I'm now down to just 1/2 shares, meaning 1/2 gallon per week.)  I just think dairy is something to consider reducing if you're not meeting your weight loss goals.

    ***

    I've not lost much more weight since writing that, but I'm definitely not gaining any weight.  That's huge: I was petrified that I'd be 200 pounds by next summer.  

    I've probably stalled in that weight loss because my metabolism is still screwy due to my not-yet-fully-managed hypothyroidism.  Plus, I'm not seriously trying to lose weight right now: I don't want to stress my already over-stressed body.  But perhaps cutting out dairy entirely would make a difference.

    Anyway, thanks for putting some science behind my experience, Dr. Davis!  I'll definitely add a link to it in the discussion of dairy on the principles page of Modern Paleo.

    -- Diana Hsieh (Modern Paleo)

  • StephenB

    3/19/2010 6:40:08 PM |

    My working assumption has been that I don't need to worry about any increased insulin resistance with high saturated fat intake since I don't eat foods which spike my glucose. Am I correct?

  • Darrin Carlson

    3/19/2010 6:47:03 PM |

    Yikes! Never would have thought butter could do this. Are there any other non-carbohydrate foods that are known to cause insulin secretion?

  • Christian W

    3/19/2010 6:47:03 PM |

    If anything, it seems like the study supports the idea that all fats are bad, doesn't it?

    The zero fat control meal does better than all the fatty meals. Look at insulin for instance.

  • howardh

    3/19/2010 7:54:46 PM |

    I notice that you conveniently ignored the pasta (sugar/gluten) in the study, and attributed ALL of the negative effects to butter. Try again, this one failed.

  • Anonymous

    3/19/2010 8:35:11 PM |

    Hmmmm, Wheat Pasta and Wheat Bread?
    All bets are off. Would be curious to have conducted tests without either of those included.

  • Andrew

    3/19/2010 8:46:58 PM |

    Could butter still make you fat if you're eating below BMR?  It seems to me that if you were eating 1000 calories per day consisting of only butter, and your BMR was 1800, you would still lose weight.  Is there anything that scientifically proves this to be false?

  • Nostril Damus

    3/19/2010 9:00:35 PM |

    Any ideas why ?

    I believe insulin drives the rate of ageing, and this would certainly make me scale back my butter consumption.  

    But what part of butter causes this ?

  • Marielize

    3/19/2010 9:02:16 PM |

    Dear Dr Williams, I find this topic very interesting, but being a lay person would like to know a bit more. What would the "meal" they talk about be? Would that be grains? Is the resuls they got from combining grains with cream or butter? Would butter or dairy products have the same effect in the absence of grains?

  • Donald Duck

    3/19/2010 9:35:38 PM |

    Doesn't this study mainly show that butter is a bad idea when eaten together with lots of carbs?

    Is it really likely you would get the same insulin response if the butter was eaten without all that carbs?

  • Mark

    3/19/2010 9:44:04 PM |

    After removing dairy, grains, and anything else processed. I'd imagine it would be hard to eat too many calories when all you're left is meat, veggies, and fruit but not too much. Just curious, is that all we have to choose from?

  • K Walt

    3/19/2010 10:26:25 PM |

    Interesting.

    But the meals were carb-heavy, too.

    "The subjects then ingested, within 15 min, a fat-rich meal consisting of dietary fat [50 g/m2 body surface area of butter, refined olive oil (ROO), high-palmitic sunflower oil (HPSO) or a mixture of vegetable and fish oils (VEFO) along with a portion of plain pasta (30 g/m2 body surface area), one slice of brown bread, and one container of skim yogurt.

    I wonder if the same effect would be noted if were JUST butter, or oil.

    Is it the butter? Or the wheat pasta, brown wheat bread and lactosey yogurt?

  • sonagi92

    3/19/2010 10:26:26 PM |

    Thanks for taking the time to post a response to inquiring commenters.

  • pyker

    3/19/2010 10:26:26 PM |

    Interesting. Here are the numbers from the study for insulin AUC:

    19960 +- 2766 control
    27970 +- 2107 VEFO
    29619 +- 4975 MUFA
    34749 +- 1167 HPSO
    37582 +- 4364 SFA (butter!)

    Unless I've misread the study, the "control" meal has no fat at all, and is not isocaloric with the test meals. "the macronutrient profile was as follows: 72% fat, 22% carbohydrate, and 6% protein (see Table S1 under "Supplemental data" in the online issue). The subjects also consumed the same test meal containing no fat as a control meal". So the butter test meal has nearly 4x as many calories as the control meal. The AUC for insulin between the two is about double for the butter, but that seems like a useless measure.

    Comparing like-for-like, the spread between average insulin AUC for butter meal and the isocaloric alternate fat meals  shows the butter to be about 34% higher than VEFO and only 8% higher than HPSO. (I have to be pedantic here and point out the spread between averages is not as good as would be the average spread, but I can't get that unless I have the raw data from the study.)

    If you want to claim that butter has some unique ability to raise insulin vs. other fats, this is not strong support.

    You say "butter's insulin-triggering effect, doubling or tripling insulin responses", and "butter makes you fat". I don't see support for either claim when I read that study.

  • Neonomide

    3/19/2010 10:44:24 PM |

    Why ?

    How about cream and fatty milk, or other dairy products ?

    I guess coconut is again the safest bet here...

  • Beth@WeightMaven

    3/19/2010 10:58:06 PM |

    I'm not an MD nor a research scientist. But decades ago, I was a math major. If I read the study and do my math right, the subjects ate an 800 kcal meal of which 72% was fat, for 576 kcals worth of fat (the other control meal components were pasta, bread, and skim milk yogurt).

    576 kcals worth is nearly 6T of butter -- or 3/4 of a stick! To me, that is important additional context for the increased AUC for both the insulin and the triglycerides.

    Considering my typical use (~1T/meal) and considering the potential downside of replacing carb calories with more PUFAs (and omega 6s -- even 1T of EVOO has over 1g of omega 6), I'm not ready to throw out my ghee just yet.

  • Cheryl

    3/19/2010 11:43:30 PM |

    Is it the milk solids that do it?  if so, then ghee may be an alternative.

  • Anonymous

    3/20/2010 12:52:10 AM |

    as a  personal anecdote - eating butter (even in amounts of 200 g. a day) speeds up my fat loss - i feel as if i'm burning inside (elevated metabolism?)...

  • Dr. William Davis

    3/20/2010 12:56:53 AM |

    I see that I touched a nerve.

    This study is not meant to stand on its own, but taken in the context of other studies.

    I think that you should eat butter . . . in small quantities and occasionally. I do not believe that the data argue for liberal use every day, or else you chance triggering insulin. Remember: It's the interpretation of the data in the context of the broader experience that leads you to practical conclusions.

  • Catherine

    3/20/2010 1:39:53 AM |

    What about coconut oil as a butter substitute? There is a lot of hype and hoopla about it being a "safe" medium-chain saturated fat to use as a butter substitute.  Anyone tested if it spikes glucose?

  • zach

    3/20/2010 3:57:00 AM |

    Pastured butter rocks. My belief with butter is "a stick a day keeps the doctor away."

    It's as though the more butter I eat the leaner I get!

    The anthropological evidence really contradicts the data you and loren cordain cite. The pancreases of many people in traditional cultures carried them toward 100 years old, reacting to dairy every day, multiple times per day.

    Here is a 112 year old woman from a very long lived people who use dairy as a staple.

    http://news.bbc.co.uk/2/hi/europe/8550374.stm

  • Sue

    3/20/2010 7:49:50 AM |

    "Fat, in general, does not make you fat. But butter makes you fat."

    Why make such a comment in regards to butter?

  • Adam

    3/20/2010 8:18:10 AM |

    Dr Davis.

    First of all, thank you for your wonderful site and your willingness to impart life changing and saving advice for anyone to access.

    Peter at hyperlipid has written a counter on this particular blog entry of your.

    Would you care to comment?

    http://high-fat-nutrition.blogspot.com/2010/03/butter-insulin-and-dr-davis.html

  • CK

    3/20/2010 8:42:10 AM |

    So let me get this straight: Ingesting carbohydrates including the bad guy wheat does not do much to blood glucose levels and insulin response. But adding fat to the mix at least doubles, or, in the case of butter, quadruples the peak insulin response? That seems like the best refutation of all the low carb/paleo/primal/ef approaches I've ever seen. So where is the catch?

  • Anonymous

    3/20/2010 9:15:05 AM |

    The last sentence made me cry.

  • Donald Duck

    3/20/2010 9:54:54 AM |

    It seems like butter (or cream) without carbs does not create insulin spikes according to the study that Peter at Hyperlipid discusses here:

    http://high-fat-nutrition.blogspot.com/2010/03/butter-insulin-and-dr-davis.html

  • Anonymous

    3/20/2010 10:39:02 AM |

    If you eat fat, ASP levels will rise, which will make you gain fat. ASP levels increase in response to an oral fat load, and ASP is one of the most potent stimulant of triglyceride synthesis.

    So, if you eat carbs, insulin secretes and you store it as fat, if you eat fat, ASP levels rise and you store it as fat. Why is it only the insulin's fault?

    http://www.jlr.org/cgi/content/abstract/30/11/1727

  • But I thought...

    3/20/2010 11:03:43 AM |

    The oracle's take on your post doc:

    http://high-fat-nutrition.blogspot.com/2010/03/butter-insulin-and-dr-davis.html

  • Lori Miller

    3/20/2010 2:08:13 PM |

    I don't know about the effect of butter, but when I eat a fatty meal (like a cheesy omelet with an avacado), my BG goes down several points.

  • kilton9

    3/20/2010 2:23:42 PM |

    Here's a study that isolates cream and shows a very small insulin response: http://drbganimalpharm.blogspot.com/2009/12/insulin-and-aging-how-paleo-works.html

  • Alfredo E.

    3/20/2010 3:01:02 PM |

    This is becoming more confusing by the minute. First, no carbs,only fats and protein.

    Now, no butter, no dairy, no, carbs, just a few drops of fat and protein.

    I am going to cry, like the previous poster.

  • Hilary

    3/20/2010 3:05:41 PM |

    "Fat, in general, does not make you fat. But butter makes you fat."

    This seems wrong. When I eat more butter, I lose fat/weight. Eat more carbs, gain fat/weight. Been noticing this for years. Sure, put a load of butter on noodles or rice, and you'll gain plenty, but just keep the carbs low and there's no problem. This seems like a case of being blinded by science. Maybe the science isn't exactly wrong, but just incomplete or misapplied.

  • pmpctek

    3/20/2010 3:05:41 PM |

    I think I fugured it out...

    The AMA or AHA has kidnapped Dr Davis and they are forcing him to post these confusing refutations.

    What will we see next?  Studies that show how Cocoa Puffs actually will help reach our 60-60-60 goal after all?

  • Joseph

    3/20/2010 3:07:15 PM |

    After reading your post and the hyperlipid post I'm left with a few questions.

    1.The big one, why is butter raising insulin so much? I had previously thought it was only high GI carbs that did that. Hyperlipid seems to think it was the small amounts of casein.

    2.Is it right to say that since the control carb meal only contained 174 calories compared to the butter meal which contained 800 this study is fairly useless? It raises some interesting questions but you can't conclude anything until you have a proper control containing the same amount of calories.

    3. Are there any studies which measure insulin secretion after a pure butter meal with no carbs?

    Even though the study is inconclusive, I'm lowering my butter consumption until I'm sure it isn't causing an agrovated insulin response. Even though butter causes much higher levels of FFA's which mean more of the fat is being burned, insulin levels that high can't be healthy

  • Miles

    3/20/2010 3:52:22 PM |

    All this information hurts my brain...ugh. All I know is when I eat low carb... I lose weight... feel better and more energetic. Sometimes there's just too much analysis and information about what constitutes a healthy diet. It's all opinion and based on research. Then other research refutes that idea.

    My Grandma used to say, "Eat when you're hungry and drink when you're dry."

    BTW... Grandma lived to be 95.

  • Helen

    3/20/2010 3:54:17 PM |

    Dr. Davis,

    I'm not too sure this is right.  I don't have the time to hunt down the links right now, but there was a study on Swedish children recently that showed those eating full-fat dairy (butter fat) were leaner than those who ate low-fat dairy.  Also, butter contains a lot of CLA, which is now being sold as a fat-loss supplement.  I can't parse this study on its own merits like Peter or Pyker (though I thank them for doing so), but I remain unconvinced.  

    I also agree with other posters about the in-vivo, long-term evidence of dairy-reliant cultures and their longevity.  

    Again, with so many cautions of what not to eat, I'd love to see a Dr. Davis-approved diet plan.  If I were just following all the Don'ts, I'd go crazy (and hungry).

  • Anonymous

    3/20/2010 5:39:12 PM |

    The palmitic acid content of the butter would probably trigger  insulin when there is an abundant source of glucose in a meal.  But, if you look at this post by Stephan you will see that the body stores dietary fats when there is a glucose source of energy available.  

    http://wholehealthsource.blogspot.com/search/label/fats

    As the glucose is depleted the fat is released to be used as energy.  The graph in Stephan's post clearly shows the cycling that occurs in normal metabolism.


    The information Dr. Davis presented showed an insulin spike, not continual high levels of insulin that would inhibit the release of FA as an energy source.
    I believe it was Dr. Eades who recently posted about the constant exchange of fats in and out of storage, and the implication is that storage is only a problem when cells remain saturated with glucose.  The fat never comes out because it isn't needed.  In this scenario insulin resistance and fat storage is protective.

    http://high-fat-nutrition.blogspot.com/2010/03/getting-fat-is-good-official.html

    My understanding of this subject is, by limiting carbs, especially the sugar surrogates that are refined grain products, you can keep the normal cycling of energy sources going.

    When everything is working right, your body signals hunger and satiety appropriately, and the body runs at an equilibrium level of energy intake and energy expenditure.

    I suspect that the FA composition of butter makes it available as an energy source sooner than the other FA's tested in the study.  Hence the higher insulin level.


    I don't see where a moderate amount of butter, when there is a limited or low availability of glucose sources will make you fat, expecially if you are VLC or on a ketogenic diet.  I can see where it could be a problem if you were eating 150 or more grams of carbs per day and have metabolic syndrome.  Then high levels of insulin would spike even higher prompting the liver to pump out more glucose, and the fat just has no where to go except into storage.

    Take your vitamin D3 to get your adiponectin levels up.  Take fish oil while limiting Omega-6's to normalize inflammatory responses. Limit carbs, and get the glucose-FA cycle working for you.

  • Nigel Kinbrum

    3/20/2010 6:19:20 PM |

    Eating carbs with butter produces a big insulin response because butter induces temporary insulin resistance (IR) which means that more insulin has to be secreted to get the same net effect. Looking at the blood glucose response, the net effect is the same. So stop panicking. The temporary IR lasts for only a few hours.

  • Gretchen

    3/20/2010 7:49:28 PM |

    "Fat, in general, does not make you fat. But butter makes you fat."

    If you based your conclusion on the graph in this study, all fats make you fat.

    Protein also stimulates insulin, so protein makes you fat.

    Carbs stimulate insulin, so carbs make you fat.

    Conclusion: Food makes you fat.

    It's known that fatty acids acutely stimulate insulin synthesis. With chronic exposure to fatty acids (as occurs in obesity), insulin synthesis is blunted.

    I've never understood the body's rationale for this, unless a sudden infusion of fat makes it think it had better store the fat for the future, but with chronic stimulation it figures it has enough.

    I don't know how ingested fat is related to fatty acids in the blood, whether or not this is linear.

    Whatever, it doesn't look to me as if butter is much different from the other fats, and as others have pointed out, the amounts used in this study (on top of about 44 g of carb, which I wouldn't call a low-carb meal) were enormous.

    The other odd thing is that usually fats slow down a carb-stimulated blood sugar peak, and they didn't in this study.

  • Neil

    3/20/2010 10:33:31 PM |

    This is what is considered 'butter' in the study you refer to above Dr Davis and ultimately what this study uses to prove its point:

    "The subjects then ingested, within 15 min, a fat-rich meal consisting of dietary fat [50 g/m2 body surface area of butter, refined olive oil (ROO), high-palmitic sunflower oil (HPSO) or a mixture of vegetable and fish oils (VEFO) along with a portion of plain pasta (30 g/m2 body surface area), one slice of brown bread, and one container of skim yogurt]."

    Yep, that would be my definition of 'butter' as well!

    If that pile of c**p didn't raise your insulin levels what would?

    In addition: "The average total energy provided by the meals was 800 kcal (10 kcal/kg), and the macronutrient profile was as follows: 72% fat, 22% carbohydrate, and 6% protein"

    Only 22% carbohydrate, no chance of that increasing insulin levels either I suppose!

    It has to be the 'butter'

  • Peter

    3/21/2010 12:02:51 AM |

    @Helen: I couldn't have said it any better myself. I too remain unconvinced.

    You get fat from pasta, bread and butter in combination? Not really groundbreaking work.

  • Peter

    3/21/2010 12:19:14 AM |

    @Helen: I found the study you are referring to I believe.

    "BMI correlated strongly to fat mass and leptin was the best marker of overweight and fat mass in 8-year-olds. Food choice was similar to that at 4 years of age. An intake of fat fish once a week was associated with higher serum concentrations of n-3 fatty acids. The intake of saturated fat and full fat milk were inversely associated with BMI."

    The study was made at the University of Gothenburg.

    http://gupea.ub.gu.se/dspace/bitstream/2077/20457/2/gupea_2077_20457_2.pdf

  • Sue

    3/21/2010 12:51:41 AM |

    I'm sorry Dr Davis but you really didn't analyse this study properly before jumping to conclusions.

  • Anonymous

    3/21/2010 2:24:49 AM |

    Just wondering if you had seen this recent study about higher levels of Vit D being associated with increased arterial calcification in the African American population: http://www.eurekalert.org/pub_releases/2010-03/wfub-vdl031110.php

  • Mike

    3/21/2010 3:44:28 AM |

    Looking at insulin alone can be very misleading. If glucagon is released along with the insulin ,as happens when eating protein, then the fat storing effects of insulin are negated.

    For low carbers, the study is meaningless as it was done with lots of carbs. I will continue to eat butter and cheese until I see a meaningful study that shows that they cause a real problem.

  • PRIDE MAFIA

    3/21/2010 6:02:42 AM |

    Maybe DR Davis saw something on that "low carb cruise" that didn't sit well with him and he's rethinking certain principles?

  • W. Bacon

    3/21/2010 8:19:58 AM |

    Dr. Davis' goof is discussed here:

    http://high-fat-nutrition.blogspot.com/2010/03/butter-insulin-and-dr-davis.html

  • Anonymous

    3/21/2010 5:25:38 PM |

    No, Neil, the 'butter' was just butter. They didn't have "that pile of c**p" at one time: each item in the list was a separate meal & separate data point. Unfortunately, the wording of the paper is in places not very good.

  • Helen

    3/21/2010 8:28:26 PM |

    "Anonymous said...

    Just wondering if you had seen this recent study about higher levels of Vit D being associated with increased arterial calcification in the African American population: http://www.eurekalert.org/pub_releases/2010-03/wfub-vdl031110.php"

    I saw it, and was hoping to discuss it in the pro-D blogosphere.

    I have two ideas why this might be the case.

    (1)  Because people of African descent are adapted to live nearer the equator, where the sun is all you need for enough vitamin D, they may not be as adapted as Europeans to use dietary vitamin D (supplements being an analogue), which Europeans probably relied on during winter months.  Thus, too much supplemental vitamin D may be harmful to African Americans, at least in the case of arterial calcification.  (I hedge, because I've also read recently that African American children with low D status have higher rates of asthma. http://www.sciencedaily.com/releases/2010/03/100317112055.htm)

    (2) There is also the possibility that somewhat different dietary patterns between European Americans and African Americans may offer some explanation.  I can't imagine what this might be, but maybe something having to do with vitamin K2, which helps prevent calcium deposits in the arteries?  There are two possibilities here:

    (a) Maybe African Americans consume (or produce in the gut - from eating greens, a traditional part of the African American diet) more K2 than European Americans, and this is why they have less arterial calcification with lower D status - they don't need the D as much for arterial health, and more dietary D just upsets the balance.

    (b) Maybe they eat less K2 than European Americans (maybe eat less hard cheeses?), and thus vitamin D supplementation, which may require a certain level of K2 to be beneficial, might be harmful instead.

    This sentence leads me to believe it's more likely to be (a):  "Despite these lower vitamin D levels and dietary calcium ingestion, blacks naturally experience lower rates of osteoporosis and have far less calcium in their arteries."  The strong bones and clear arteries make me think African Americans may have better K2 status.  

    It's possible that vitamin A status also plays a role.

  • Helen

    3/21/2010 8:56:30 PM |

    Another thought on the question of African Americans and vitamin D - perhaps *because* they consumed less calcium their vitamin D requirements were lower, so the supplemented amounts were excessive.

  • Dr. William Davis

    3/21/2010 9:55:55 PM |

    The point is not whether glucagon is stimulated. That is, in my view, immaterial.

    The point is that your poor, tired pancreas, likely operating at a fraction of its original beta cell capacity from the years of the beating it took while you ate Cheerios and Cocoa puffs, ate sandwiches, and drank Coca Cola with your pizza, is being stimulated to produce more insulin.

  • Nigel Kinbrum

    3/22/2010 9:05:25 AM |

    Regarding calcification, I think that Helen has hit the nail well & truly on the head regarding Vitamin K2. "If it calcifies, think K2" is what I always say (along with "If it spasms, think Magnesium").

    Taking large amounts of Vitamin D3 and nothing else probably exposes deficiencies in the other fat-soluble vitamins A, E & K2.

    Having cured Lumbar osteoporosis in three years using Ca, Mg, D3 & K2 (and no Alendronate), I will never stop taking Ca, Mg, D3 & K2.

  • Anonymous

    3/22/2010 8:15:10 PM |

    Why eat carbs together with fat?
    They ate 44 g glucose which means the P-glucose could reach >48 mM without insulin i 70 kg person. Of course the disaster hormone insulin increases to block all lipolysis as well as proteinolysis to try to burn off all the totally unnecessary carbohydrates they added.
    If contol diet (gluose) did not change glucose and thus insulin level it must be fake.

    Just another totally stupid study.

  • Anonymous

    3/22/2010 8:53:10 PM |

    I guess I am going to become a breatharian....someone who survives only on air.....since I have learned that butter and fat stimulates my insulin, protein stimulates my insulin, carbs stimulate my insulin and thus I am doomed to be fat....and leptin is stimulated by all three but my brain doesn't register that I am full.  

    Ingesting air is the only thing that will not make me fat.

    Go here to be a Breathairian http://www.breatharian.com
    You can even go to a $1 million dollar seminar that must be completed prior to Dec 21, 2012.

  • Dana Seilhan

    3/22/2010 10:20:44 PM |

    When I'm low-carbing, a favorite meal is a tenderloin cooked medium-rare, sliced thin, and dipped in butter.

    I lose weight anyway.

    Also, what kind of butter was used in the study?  Was it regular grocery-store butter, or was it organic and/or grass-fed butter?  The FDA claims there's no difference between dairy produced with rBGH and dairy produced without, but I'm given to understand that rBGH-produced dairy has higher levels of IGF-1.  What would be the effect on insulin of all that exposure to insulinlike growth factor?

    And I'll second Miki's question of whether the milk solids wouldn't make a difference.

    And to the person who mentioned "all that lactose-y yogurt"--if you make yogurt correctly, it should have hardly any lactose in it at all.

  • Dana Seilhan

    3/22/2010 10:22:01 PM |

    I suspect that the FA composition of butter makes it available as an energy source sooner than the other FA's tested in the study. Hence the higher insulin level.

    Fatty acids by themselves don't prompt insulin release.  Protein does (but the insulin is balanced out by glucagon), and of course carbs do, but there's nothing inherently dangerous in a fatty acid that would prompt the body to store it away immediately.

  • Anonymous

    3/23/2010 7:02:21 PM |

    It seems like no one has a handle on how the metabolic parts fit together to make the whole. My experience from converting from whole grains and no-fat dairy to full-fat dairy has been weight loss and increased energy, particularly after eating a selection of artisan cheese. I often get up, have a bowl of full-fat yoghurt or kefir with 100% chocolate nibs and fresh-roasted nuts, then sample several artisan cheeses, and go cycling 44 km before getting back to make everyone else breakfast. My body seems geared to fat as fuel and I never get blood sugar lows. If this is raising my insulin, it apparently does not affect my blood sugar.

    Murray

  • Apolloswabbie

    3/25/2010 7:38:15 PM |

    Usually, I learn all I need to from Dr. Davis' posts.  My thanks to the other contributors today for illustrating that context is everything.  We have reason to believe that dairy from the industrial food chain would not be as good a food as if we could get true grass fed dairy cow products - but this seems out of context with other info I've seen which shows only moderate insulin response to dairy fats.  Bottom line: measure the markers which indicate insulin levels over time as a gauge of whether your diet does/doesn't work (unless you are losing weight - in which case, you know it is working).

  • Anna Delin

    3/26/2010 9:42:22 AM |

    It seems that whatever butter does to my insulin levels, this does not curb the very positive effects I experience from eating butter. When I cut carbs and replaced them with generous amounts of cream and butter (organic preferably) I lost 14 kg. Moreover, when in "carb country", i.e. airports, airplanes, trains and the like, I can keep my energy up by eating the small amounts of butter and cheese available. Butter also has a way of keeping me feeling full for a very long time. This implies that the fat is not stored away in my fat cells but instead made available for burning. Perhaps other people are more sensitive.

  • ET

    3/26/2010 11:46:15 AM |

    While I often disagree with the conclusions you post, I always enjoy the discussions and research raised by your blogs.  It's one reason I keep coming back for more.  It's keeps me searching for answers.

  • Star Trek TNG

    3/28/2010 6:13:00 PM |

    I still prefer coconut oil for fat loss used in a no-carb diet. I'll find that ghee, which I've also tried, isn't so effective for weight-loss perhaps because it's not so fatty. But it does have to be in a no-carb diet, not a low-carb one. Everyone's got a switch which is triggered by carbs, but no-one knows where it is, not exactly. So unless a study is rabidly no-carbs, none at all, I don't really see what can be learned.

    BB

  • Nancy

    4/8/2010 12:53:02 AM |

    Dr William
    your response to the commentors seems to indicate that butter will make you fat IF you have abused your body with carbohydrates because of a compromised pancreas.  I am willing to suppose this could be true, but what about people who his ave not abused their bodies, what about children being raised low carb from the start, would butter be fattening for them?  Your response would lead me to believe your answer will be no.  I really appreciate your blog and recommend it to all, but please clarify this issue.  Maybe a whole new blog on this would be a good idea, since the entire low carb community is talking about it.

    To everyone else I have to say there is nothing like testing something for yourself.  If you have an insulin tester, have some butter and test yourself and make a chart.  See how YOU are affected.

  • Alejo Hausner

    4/9/2010 1:28:50 PM |

    The work was funded by the Fundación Centro de Excelencia en Investigación sobre Aceite de Oliva y Salud (“Center of excellence for research on olive oil and health”).

    Notice that they end up concluding that olive oil raised glucose and insulin less than butter. Had this study been done by French researchers and not Spanish researchers, it would have found that butter is better for you than olive oil!

    Alejo

  • jpatti

    5/7/2010 7:58:00 AM |

    Pasture-raised butter is a good source of vitamins A, D and K2 plus CLA.

    And it makes veggies yummy.  

    As Julia Child said... butter is better.

  • info

    5/16/2010 6:10:09 AM |

    Little test
    I'm a very low carber. 80% of my calory intake come from fat. I eat less than 20 grams of carbs. I did a little test. For a week I took tallow and coconut oil instead of butter. In that week I lost three pounds. Conclusion: Butter seem to have a sort of effect.

  • kimberly

    9/16/2010 1:46:12 AM |

    I love to prepare some recipe that contain many cream.  although i know that a person can gain weight I don´t matter because i love the taste, Simply delicous. And when i cook, my husband usually is very happy.
    Actually i was looking information about how tobuy viagra  but i reached this blog, i really enjoyed reading.

  • buy jeans

    11/2/2010 8:24:56 PM |

    The postprandial (after-eating) area-under-the-curve is substantially greater when butter is included in the mixed composition meal. This effect is not unique to butter, but is shared by most other dairy products.

  • Chester The Bear

    1/19/2011 10:55:45 PM |

    Um... Sorry... I see the data differently.
    In the fat meals in the study, the amount of fat intake was the same, yet butter delivers higher serum FFAs, indicating that fat might stimulate lipolysis, even though it appears to induce a short term insulin spike.
    Carbohydrate might promote a lower insulin response, but it blocks lipolysis.
    Finally, there's a lot more going on here than just insulin.  To take it out of context is meaningless.

  • racing games

    1/20/2011 11:15:13 AM |

    but my question is what is the reason behind this insulin triggering effect of butter? can anyone answer this?

  • liposculpture guide

    1/26/2011 7:18:57 AM |

    It's always good to challenge deeply held beliefs in case we are wrong. I do have a soft spot for butter and hope it is an outlier as far as blood glucose.

  • francisco camps

    2/5/2011 8:41:02 PM |

    I am scary with butter now...lol

  • ABBEY

    3/5/2011 6:27:47 AM |

    As people know, I've been struggling with my weight due to my hypothyroidism. Although many of my symptoms have improved, I kept the weight gain in very consistent rate of 3 pounds per month. Sometimes, mostly due to a little fast, would be a pound or two, but then suddenly I would like to recover all that weight plus more than a day or two, so it would be in this constant uphill again.

    people searches

  • Matt Titus

    5/6/2011 3:42:50 AM |

    I wonder if the results would be the same with raw butter?

  • Paula Nedved

    10/3/2011 2:30:40 AM |

    Peter over at Hyperlipid has done a critique of this post of your, Dr. Davis.
    Entitled "Butter insulin and Dr. Davis"    He dunna believe you.

  • Nancy

    10/20/2011 4:57:58 PM |

    I'm stunned by your absolute condemnation of butter based on this one study.  Geez, have you been paid off by Wesson or Crisco?   You need to consider all the confounding variables in this study.  Your blog post should be retracted and/or rewritten.  This is very disappointing after your carefully researched examination of wheat.

    In my experience, butter and butter fat are good for you.  I have lost considerable body fat and gained much muscle this year on an eating plan that involves a lot of raw milk and cream from grass-fed cows, 3 to 4 glasses of milk and up to a cup of cream per day.  Butter fat is not making ME fat, quite the opposite.

  • Karl Schmidt

    9/27/2012 6:35:46 PM |

    Insulin goes down faster because the vegetable fats are stored in the fat tissue faster..

    A better understanding of butter is here :

    http://high-fat-nutrition.blogspot.com/2012/09/protons-pancreas.html

  • Karl Schmidt

    12/1/2012 9:41:46 PM |

    There is another problem with that study - people do not keto adapt in 8 hours - it takes 4- 6 weeks to fully adapt to a low carb diet.

    Once adapted, low-carbers are BETTER able to clear FA as the liver revs up it's fat metabolic capabilities.  Low carbers also tend to eat less frequently - reducing the exposure to both BG and FA - only when both are elevated do we see the pronounced toxic effects of the fats.

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Track Your Plaque and non-commercialism

If you're a Track Your Plaque Member or viewer, you may know that we have resisted outside commercial involvement. We do not run advertising on the site, we do not allow drug companies to post ads, we do not covertly sponsor supplements. We do this to main the unbiased content of the site.

We've seen too many sites be tempted by the money offered by a drug company only to see content gradually drift towards providing nothing more than cleverly concealed drug advertising. I personally find this deceptive and disgusting. Ads are ads and everyone knows it. But when you subvert content, secretly driven by a commercial agenda, that I find abhorrent.

That said, however, I do wonder if we need the participation of some outside commercial interests to help our members. In other words, many (over half) of the questions and conversations we have with people is about what supplement to take, or what medication to take. While we cannot offer direct medical advice online (nor should we) because of legal and ethical restrictions, I wonder if could facilitate access to products.

Many people struggle, for instance, with trusted sources for l-arginine, vitamin D, fish oil. Other people struggle with finding a heart scan center because of the changing landscape of the CT scanning industry. Could we somehow provide a clear-cut segment of the website that clearly demarcates what is commercial and non-Track Your Plaque-originated, yet at least provides a starting place for more info?

Ideally, we would have personally tried and investigated everything there is out there applicable to the program. But that's simply impossible at this stage.

I feel strongly that we will never run conventional ads on the site. Nor will we ever permit any outside commercial interest to dictate what and how we say something. The internet world is full of places like that. Look at WebMD. I find the site embarassing in the degree of commercial bias there. We will NEVER sell out like that, regardless of the temptation. People with heart disease are all conducting a war with the commercial forces working to profit from them--hospitals, cardiologists, drug companies, medical device companies (yes, even they advertise to the public, e.g., implantable defibrillators--no kidding). Genuine, honest, unbiased information is sorely needed and not from some kook who either knows nothing about real people with real disease, or has a hidden agenda like selling you chelation.

I'd welcome any feedback either through this Blog or through the contact@cureality.com.

The nattokinase scam

A conversation about vitamin K2 commonly leads to confusion. Several people have asked about something called nattokinase.

The scientific data on the potential role of vitamin K2 deficiency in causing both osteoporosis and vascular calcification is fascinating. Along with vitamin D3, vitamin K2 may be an important factor in regulation of calcium metabolism. Supplementation may prove to be a major strategy for inhibition of vascular calcification.

Obtaining K2 in the diet is tricky, since it's present in just a handful of foods: egg yolks, liver, traditional cheeses, and natto. This is where the confusion starts.

Natto is a Japanese fermented soy product. I've had it and it's quite disgusting. Nonetheless, Japanese who eat natto experience less fracture. (A parallel study in heart disease has not been performed.) Natto is also a source of another substance called nattokinase.

Advocates (otherwise often known as supplement distributors) claim that nattokinase is a "fibrinolytic", or blood clot-dissolving, preparation that "improves blood flow, protects from blood clots, and prevents heart attacks and strokes."

Don't you believe it. This is patent nonsense. There are several problems with this rationale:

--Any oral fibrinolytic agent is promptly degraded in the highly acid environment of the stomach. That's why all medically used fibrinolytics are given intravenously. Drug companies have struggled for years to encapsulate, modify, or somehow protect protein (or polypeptide) products taken orally from degrading this way. They've never succeeded. That's why, for instance, growth hormone (a polypeptide) remains an injection, not an oral agent. An oral growth hormone, by the way, would sell like mad, so the drug companies would very much like to figure out how to bypass the degradative effects of stomach acid. One of the "researchers" behind the nattokinase claims boasts that he has single-handedly figured out how to protect the nattokinase molecule in the gastrointestinal tract. However, he won't tell anybody how he does it. Right.

--Fibrinolytic agents are extremely dangerous. In years past, we used to treat heart attacks with intravenous fibrinolytic agents like tissue plasminogen activator, urokinase, streptokinase, and others. They have fallen by the wayside, for the most part, because of limited effectiveness and the unavoidable dangers of their use. Fibrinolytics are "dumb": they dissolve blood clots in both good places and bad. While they might dissolve the blood clot causing your heart attack, they also degrade the tiny clot in your cerebral (brain) circulation that was protective. That's why fatal brain hemorrhages, bleeding stomach ulcers, and blood oozing from strange places can also occur with fibrinolytic administration. Believe me, I've seen it happen, and I've watched people die from them.

The idea that a small dose taken orally is healthy is ridiculous. Even if nattokinase worked, why the heck would you take an agent that has known dangerous and very real consequences?

Don't let this idiocy reflect poorly on the K2 conversation, which, I believe, holds real merit and is backed by legitimate science. This is symptomatic of a larger difficulty with the supplement industry: Insane and unfounded claims about one supplement erodes credibility for the entire industry. It gives regulation-crazed people like the FDA ammunition to go after supplements, something none of us need. You and I have to sift through the nonsense to uncover the real gems in this rockpile, real gems like vitamin D3, omega-3 fatty acids from fish oil, and, perhaps, vitamin K2. But not nattokinase.

Blood pressure with exercise

Here's a frequently neglected cause for an increasing CT heart scan score: High blood pressure with exercise. Let me explain.

Paul's blood pressure at rest, sitting in the office or on arising in the morning, or at other relatively peaceful moments: 110/75 to 130/80--all in the conventional normal range.

We put Paul on the treadmill for a stress test. At 10 mets of effort (on the protocol used, this means 3.4 mph treadmill speed at 14 degree incline), Paul's blood pressure skyrockets to 220/105. That's really high.

Now, blood pressure is expected to increase with exercise. If it doesn't rise, that's abnormal and may, in fact, be a sign of danger. Normally, blood pressure should rise gradually in a stepwise fashion with increasing levels of exercise. But any blood pressure exceeding 170/90 is clearly too high with exercise. (Not to be confused with high blood pressures not involving exercise.) A handful of studies have suggested that a "breakpoint" of 170/90 also predicts heightened risk of heart attack over a long period.)

I see this phenomenon frequently--normal blood pressure at rest, high with exercise. This also suggests that when Paul is stressed, upset, in traffic congestion, under pressure at work, etc., his blood pressure is high during those periods, as well. I wouldn't be surprised to see other phenomena of underappreciated high blood pressure, like abnormally thick heart muscle (left ventricular hypertrophy), an enlarged thoracic aorta (visible on your heart scan), left atrium, perhaps even an abnormal EKG or abnormal kidney function (evidenced by an elevated creatinine on a standard blood panel).

Unfortunately, the treatments that reduce blood pressure are "stupid," i.e., they have no appreciation for what you are doing and they reduce blood pressure all the time, whether or not you're stressed, exercising, or sleeping.

Blood pressure reduction should begin with weight loss, exercise, reduction of saturated fats and processed carbohydrates (esp. wheat), magnesium replacement, vitamin D replacement. Think about CoQ10. After this, blood pressure medication might be necessary.

The message: Watch out for the blood pressures when you have a stress test. Or, if you have a friend who is adept at getting blood pressures, get a blood pressure immediately upon ceasing exercise. It should be no higher than 170/90.

Vitamin D2 vs. vitamin D3

An interesting question came up on the Track Your Plaque Member Forum about vitamin D2 vs. vitamin D3. This often comes up among our patients, as well.

Vitamin D is measured in the blood as 25-OH-vitamin D and is distinct from 1,25-diOH-vitamin D, a kidney measure, a test you do not need unless you have kidney failure.

The human form of vitamin D is cholecalciferol and is usually obtained via activation of a precursor molecule in the skin on activation by the sun. You can also take cholecalciferol and it increases blood levels of 25-hydroxy vitamin D reliably.

However, there is a cheap, plant-sourced, alternative to vitamin D3, called vitamin D2, or ergocalciferol. D2 has far less effect in the body. Taking D2 or ergocalciferol orally is an extremely inefficient way to get D. Unfortunately, it's the form often used in milk and many supplements, even the prescription form of D. About half the multivitamins and calcium supplements I've looked at contain ergocalciferol rather than cholecalciferol.

Taking vitamin D2 yields very little conversion to the effective D3. This particular issues is maddening, as the USDA requires dairy farmers to add 100 units of vitamin D to milk, and D2 is often used. In other words, the D in many dairy products barely works at all. There are many children who rely on D from dairy products who are at risk for rickets and are not getting the D they need from dairy products because of this cost-saving switch. Do not rely on milk for vitamin D for your children.

D2 or ergocalciferol is often included in the blood measures of vitamin D along with vitamin D3. The only reason it's checked with blood work is to ensure "compliance,", i.e., see whether or not you're taking a prescribed ergocalciferol. Beyond this, it has no usefulness.

25-OH-vitamin D3, or cholecalciferol, is both the blood measure and the supplement you need. This is the one that packs all the punch. Keep in mind also that it is the oil-based gelcap you want, with more consistent and efficient absorption. Tablets usually barely work at all, even if it contains cholecalciferol. Most people who take calcium tablets with D, or multivitamin with D, not only are getting a powdered form of D, but also in trivial doses. It's the pure vitamin D3, cholecalciferol, in gelcap form you want if you desire all the spectacular benefits of vitamin D.

World record heart disease reversal

A quick but important note.

Track Your Plaque Members:

Keep your eyes on the Track Your Plaque Member website for details and images of our most recent huge success story. Track Your Plaque participant, Neal, dropped his score more than anyone else before.

Although reduction of heart scan score is an everyday event around here, a 51% drop in score deserves to make news!

We will post the images of Neal's heart scans on the www.cureality.com Member website in the coming days.

Dose of fish oil

Dosing for fish oil is a perennial point of confusion. However, it's quite simple.

The active ingredients in fish oil are DHA and EPA, the so-called omega-3 fatty acids. Of course, if there's anything else in your capsules, such as omega-6, omega-9, or linolenic acid, these should not count towards the sum of EPA + DHA, since they do not exert the same benefits as the omega-3s.

The basic suggested starting dose for the Track Your Plaque program is 1200 mg of EPA+DHA. This is usually provided by taking 4 x 1000 mg capsules of fish oil, providing 180 mg EPA, 120 mg DHA per capsules, for a total of 1200 mg EPA+DHA.

About a third of people, however, will require greater doses of omega-3s to reduce triglycerides, VLDL, and/or intermediate-density lipoprotein (IDL). Most people will do fine with an increase to 1800 mg EPA+DHA, usually provided by 6 x 1000 mg standard capsules. A very occasional person (about 1 in 100) will require even higher doses.

If you ever decide to change your fish oil preparation, or if you change to a more concentrated form or another form such as liquid fish oil (e.g., Carlson's), paste (e.g., Coromega), or syrup (e.g., Pharmax Frutol), then you will need to examine the label to determine the dose of EPA+DHA. If, for instance, a teaspoon of liquid fish oil provides 360 mg EPA and 240 mg DHA, that's a total of 600 mg omega-3s per teaspoon. If your EPA+DHA dose is 1200 mg per day, then two teaspoons a day should provide it. Always adding up the EPA+DHA content of whatever preparation you choose will therefore allow you to mix, match, or change your dose whenever you like.

Niacin scams

As most of you know, niacin (vitamin B3) is an important tool for many in the Track Your Plaque program.

Niacin:

--raises HDL cholesterol
--reduces small LDL
--reduces lipoprotein(a)

And it's the most potent agent we have for all three patterns, despite just being a vitamin. Niacin also reduces LDL cholesterol, VLDL, IDL, triglycerides; reduces heart attack risk dramatically either alone or in combination with other agents.

Unfortunately, some people who are either afraid of the "hot flush" side effect, or experience excessive degrees of it, have resorted to two preparations sold in stores that have none of these effects.

Most notorious is "No-flush" niacin, also known as inositol hexaniacinate. This compound is an inositol sugar molecule complexed with 6 ("hexa-") niacin molecules. Unfortunately, it exerts none of niacin's effects in the human body. No-flush niacin has no effect on HDL, small LDL, or Lp(a), nor on LDL or heart attack.

In short, no-flush niacin is a scam. It's also not cheap. I've met people who have spent hundreds of dollars on this agent before they realize that nothing is happening, including a flush.

Likewise, nicotinamide does not work. It sounds awfully close to the other name for niacin, nicotinic acid. But they are two different things. Like no-flush niacin, nicotinamide has no effect on HDL, small LDL, Lp(a), etc.

Though I've discussed this issue in past, somehow these two "supplements" seem to sneak back into people's consciousness. You walk down the health food store aisle and spy that bottle of X-brand No-flush niacin, promising all the benefits of niacin with none of the bother. Then you remember that rough night you spent a few months back when the hot flush lasted longer than usual. That's when some people end up buying this agent making extravagant--and false--promises.

For now, for all its imperfections, niacin is still a pretty darn good agent for these patterns. Remember that the best strategy to minimize the hot flush effect is to drink plenty of water. We generally recommend taking the dose at dinner along with water. If the hot flush occurs, drink two large glasses of water (total volume 16-24 oz). Nine times out of ten, the flush is gone. It also dissipates the longer you take niacin.

Media mis-information

This is an excerpt from a popular health website, EverydayHealth.com:


A Cholesterol-Busting Vitamin?
Did you know that niacin, one of the B vitamins, is also a potent cholesterol fighter? Find out how niacin can help reduce cholesterol…

Niacin is safe — except in people with chronic liver disease or certain other conditions, including diabetes and peptic ulcer. It is also inexpensive. However, it has numerous side effects. It can cause rashes and aggravate gout, diabetes, or peptic ulcers. Early in therapy, it can cause facial flushing for several minutes soon after a dose, although this response often stops after about two weeks of therapy and can be reduced by taking aspirin or ibuprofen half an hour before taking the niacin. A sustained-release preparation of niacin (Niaspan) appears to have fewer side effects, but may cause more liver function abnormalities, especially when combined with a statin.

Many people begin treatment at low doses (250 mg twice a day, for example) and, over six weeks or so, gradually build up to an amount that lowers lipid levels, anywhere from 1,000 to 2,500 mg split between two doses during the day. This gradual approach may help build tolerance to side effects such as facial flushing. Although niacin is available over the counter, you should not use it in quantities sufficient to lower cholesterol without a physician’s supervision. It is important to test liver function and levels of blood sugar and uric acid before beginning niacin therapy and during the course of treatment.


(Bold emphasis mine.)

At http://www.everydayhealth.com/publicsite/index.aspx?puid=548e8630-32d6-41dd-91a7-48e1cbac65ad&p=4




After an enticing headline, the article goes on to scare the pants off you. It also sounds like accurate information, delivered in an unbiased way, cold and straight.

If we were to use niacin this way, it would indeed be intolerable for most. Do not follow the above nonsensical advice. But that may have been the intention from the start.


Very telling are the fact that, both above and below the article were colorful advertisements for Lipitor, complete with Dr. Robert Jarvik’s (inventor of an implantable mechanical heart) soothing, professorial image.

Did they want to bait us with promising information about cholesterol and niacin, only to throw water on our fire and steer us towards something else?

That would be typical drug company marketing.

All in all, I’m grateful for the attention the media provides for health issues. Perhaps many people wouldn’t even be aware of niacin and other healthy strategies if some website, newspaper, or magazine article hadn’t talked about it.

But I do worry about bias. Was this an unbiased report? Or was it more like much of the physician-directed mail I receive, cleverly concealed propaganda from the drug manufacturers? Who wrote it? No author is listed. Could it have been ghost written by someone in the drug company itself, or an arm of the drug company? That’s a very common practice for the literature physicians receive, glossy, high-class materials paid for by drug companies, written by drug company-owned companies, but no company logo or name listed.

My point: Be skeptical of what the media tells us. There’s usually a good deal of truth in the reporting, but there’s also often just enough mis-information or slanting of content to make you behave or believe a certain way. “If niacin is this dangerous, maybe I really should take the Lipitor.”

A dirty little secret

Here's a dirty little secret many people don't know about.

If I implant a stent, I might get paid somewhere around $2000 for the heart catheterization, stent implantation, femoral artery closure device, hospitalization charges. That's not too bad.

But what if I'd like more? What if I'd like to squeeze this unsuspecting patient for more, or actually his/her insurance company?

Easy: Add on complex procedures to the basic procedure that yield more professional charges. For instance, I could perform laser angioplasty, a procedure that adds another couple thousand dollars. I might pull out the old rotational atherectomy device, a high-speed diamond tipped drill that also adds substantial professional charges. I might also use the intracoronary ultrasound device, an otherwise helpful device, but I might pull it out to use on everybody.

With the exception of ultrasound, all the "add-on" procedures were more popular in the early and mid-1990s--before they were shown in clinical studies to provide no advantage, perhaps even add to procedural risks.

Thus, a patient might undergo a heart catheterization, balloon angioplasty with stent implantation into the proximal left anterior descending coronary artery (LAD), followed by laser angioplasty of the mid-LAD, followed by intracoronary ultrasound of the vessel. Next, rotational atherectomy of the circumflex, followed by stent and ultrasound. Total charges for this 2-3 hour procedure? Somewhere around $8000 to the cardiologist. Of course, hospital charges are far more.

Ironically, patients are invariably impressed. Hearing that they went through all sort of high-tech procedures makes them grateful for receiving the benefits of the skills of their cardiologist. Of course, they would like have done as well with a far simpler procedure. Perhaps they didn't need the procedure at all.

If the excessive use of procedures and devices fails to benefit patients, why don't hospitals discourage it? Two reasons: 1) It's difficult to legislate or regulate decisions made on judgement, which can be a tough issue with many fuzzy edges, and 2) hospitals made oodles more money from the practice.

If you have a salesman in your new car lot and he outsells all his colleagues by 30-50% and makes you a couple hundred thousand a month more in sales. You've watched him at work and he's clearly good at it. But you suspect that he pushes the envelope of propriety frequently--badgering customers, add rustproofing to a little grandmother's car that will be driven 3000 miles a year, selling cars for prices far above what they would have sold for had the customer bargained more vigorously.
do you put a stop to it at the risk of pushing your star salesman away? Few would.

Only a minority of my colleagues are guilty of this despicable practice. I only know of a few who openly do it. Hopefully, you're not among their patients.

The party’s over

A good number of cardiology colleagues are vigorously bashing the outcome of the COURAGE Trial. Recall that COURAGE is the large clinical trial recently released that showed that, in people with stable angina (chest pains), people did equally well with “optimal medical therapy” as with stents.

The problem is that many of my colleagues wouldn’t know what to do in a world deprived of implanting 10 stents a day. Giving people nitroglycerin/statin drug/aspirin/beta-blocker day after day, week after week, would be an awfully dull world. All the excitement of the cath lab would be a lot more rare. We’d actually have to wait for a heart attack from some dumb smoker! All the money would disappear, too. After all, seeing a patient in the office pays, at best, $200 (and has to be stretched to cover overhead expenses like staff, malpractice insurance, and rent). Putting a stent in can pay $2000, $3000, $4000, often more. Put in several a day and—Wow! Now we’re talking money.

You can understand how upsetting it is to my colleagues who feel like the rug may be pulled out from underneath their practices and lives. Feel as sorry for them as you do for people who lose their jobs on an assembly line because of robotic technology. Or travel agents because everyone makes travel arrangements over the internet. Technology, in this information technology, marches on.

Cardiologists, cath labs, stent manufacturers, and the huge industry built around heart disease had their party. Now it’s time to clean the room and sober up. The party’s over.

The broader acceptance of “optimal medical therapy,” as lame as it is, will eventually open the door for many to demand for something even better. Ever hear of Track Your Plaque?