Overweight, hungry, diabetic, and fat-free

15. December 2009 William Davis (52)

Let me tell you about my low-fat experience from 20 years ago.

At the time, I was living in Cleveland, Ohio, and served on the faculty at a large metropolitan university-affiliated hospital, supervising fellows-in-training and developing high-tech cath lab procedures like directional athererectomy and excimer laser coronary angioplasty. (Yes, another life.)

I was concerned about personal heart disease risk, though I knew next to nothing about lipids and coronary risk prediction outside of the little I learned in training and what the drug industry promoted.

I heard Dr. Dean Ornish talk while attending the American College of Cardiology meetings in Atlanta. Dr. Ornish spoke persuasively about the dangers of fat in the diet and how he "reversed" coronary disease using a low-fat, no added oils, no meat, vegetarian diet that included plenty of whole grains. So I thought I'd give it a try.

I eliminated all oils; I removed all meat, eggs, and fish from my diet. I shunned all nuts. I ate only low-fat products like low-fat yogurt and cottage cheese; and focused on vegetables, fruit, and whole grains. Beans and brown or wild rice were a frequent staple. I loved oatmeal cookies--low-fat, of course!

After one year of this low-fat program, I had gained a total of 31 lbs, going from 155 lbs to 186 lbs. I reassessed some basic labs:

HDL 28 mg/dl
Triglycerides 336 mg/dl
Blood sugar 151 mg/dl (fasting)

I became a diabetic. All through this time, I was also jogging. I ran on the beautiful paths along the Chagrin River in suburban Cleveland for miles north and south. I ran 5 miles per day most days of the week.

It was diabetes that hit me alongside the head: I was eating low-fat meticulously, exercising more than 90% of the population, yet I got fat and diabetic!

I have since changed course in diet. Last time I checked, my lipid values on NO statin agent:

HDL 67 mg/dl
Triglycerides 57 mg/dl
Blood sugar 91 mg/dl

That was my lesson that fat restriction is a destructive, misguided notion. The data since then have confirmed that restricting total fat is unnecessary, even undesirable, when fat calories are replaced by carbohydrate calories.

This is your brain on wheat

10. December 2009 William Davis (32)

Here's just a smattering of the studies performed over the past 30 years on the psychological effects of wheat consumption.

Oddly, this never makes the popular press. But wheat underlies schizophrenia, bipolar illness, behavioral outbursts in autism, Huntington's disease, and attention deficit hyperactivity disorder (ADHD).

The relationship is especially compelling with schizophrenia:

Opioid peptides derived from food proteins: The exorphins.
Zioudrou C et al 1979
"Wheat gluten has been implicated by Dohan and his colleagues in the etiology of schizophrenia and supporting evidence has been provided by others. Our experiments provide a plausible biochemical mechanism for such a role, in the demonstration of the conversion of gluten into peptides with potential central nerovus system actions."

Wheat gluten as a pathogenic factor in schizophrenia
Singh MM et al 1976
"Schizophrenics maintained on a cereal grain-free and milk-free diet and receiving optimal treatment with neuropleptics showed an interruption or reversal of their therapeutic progress during a period of "blind" wheat gluten challenge. The exacerbation of the disease process was not due to variations in neuroleptic doses. After termination of the gluten challenge, the course of improvement was reinstated. The observed effects seemed to be due to a primary schizophrenia-promoting effect of wheat gluten."

Demonstration of high opioid-like activity in isolated peptides from wheat gluten hydrolysates
Huebner FR et al 1984

Is schizophrenia rare if grain is rare?
Dohan FC et al 1984
"Epidemiologic studies demonstrated a strong, dose-dependent relationship between grain intake and the occurrence of schizophrenia."

Small LDL: Perfect index of carbohydrate intake

8. December 2009 William Davis (15)

Measuring the number of small LDL particles is the best index of carbohydrate intake I know of, better than even blood sugar and triglycerides.

In other words, increase carbohydrate intake and small LDL particles increase. Decrease carbohydrates and small LDL particles decrease.

Why?

Carbohydrates increase small LDL via a multistep process:

First step: Increased fatty acid and apoprotein B production in the liver, which leads to increased VLDL production. (Apoprotein B is the principal protein of VLDL and LDL)

Second step: Greater VLDL availability causes triglyceride-rich VLDL to interact with other particles, namely LDL and HDL, enriching them in triglycerides (via the action of cholesteryl-ester transfer protein, or CETP). Much VLDL is converted to LDL.

Third step: Triglyceride-rich LDL is "remodeled" by enzymes like hepatic lipase, which create small LDL.

Carbohydrates, especially if they contain fructose, also prolong the period of time that triglyceride-rich VLDL particles persist in the blood, allowing more time for VLDL to interact with LDL.

Many people are confused by this. "You mean to tell me that reducing carbohydrates reduces LDL cholesterol?" Yes, absolutely. While the world talks about cutting saturated fats and taking statin drugs, cutting carbohydrates, especially wheat (the most offensive of all), cornstarch, and sugars, is the real key to dropping LDL.

However, the effect will not be fully evident if you just look at the crude conventional calculated (Friedewald) LDL cholesterol. This is because restricting carbohydrates not only reduces small LDL, it also increases LDL particle size. This make the calculated Friedewald go up, or it blunts its decrease. Conventional calculated LDL will therefore either underestimate or even conceal the real LDL-reducing effect.

The reduction in LDL is readily apparent if you look at the superior measures, LDL particle number (by NMR) or apoprotein B. Dramatic reductions will be apparent with a reduction in carbohydrates.

Small LDL therefore serves as a sensitive index of carbohydrate intake, one that responds literally within hours of a change in food choices. Anyone following the crude Friedewald calculated LDL will likely not see this. This includes the thousands of clinical studies that rely on this unreliable measure and come to the conclusion that a low-fat diet reduces LDL cholesterol.

Fat "conditioning"

4. December 2009 William Davis (0)

Here's a great study from the prolific laboratory of Dr. Jeff Volek from the University of Connecticut. (Full text here.)

http://jn.nutrition.org/cgi/content/full/134/4/880

Video Teleconference with Dr. William Davis

2. December 2009 William Davis (0)

Dr. Davis is available for personal

one-on-one video teleconferencing

to discuss your heart health issues.

You can obtain Dr. Davis' expertise on issues important to your health, including:

Lipoprotein assessment

Heart scans and coronary calcium scores

Diet and nutrition

Weight loss

Vitamin D supplementation for optimal health

Proper use of omega-3 fatty acids/fish oil

Each personalized session is 30 minutes long and by appointment only. To arrange for a Video Teleconference, go to our Contact Page and specify Video Teleconference in your e-mail. We will contact you as soon as possible on how to arrange the teleconference.

The cost for each 30-minute session is $375, payable in advance. 30-minute follow-up sessions are $275.

(Track Your Plaque Members: Our Member cost is $300 for a 30-minute session; 30-minute follow-up sessions are $200.)

After the completion of your Video Teleconference session, a summary of the important issues discussed will be sent to you.

The Video Teleconference is not meant to replace the opinion of your doctor, nor diagnose or treat any condition. It is simply meant to provide additional discussion about your health issues that should be discussed further with your healthcare provider. Prescriptions cannot be provided.

Note: For an optimal experience, you will need a computer equipped with a microphone and video camera. (Video camera is optional; you will be able to see Dr. Davis, but he will not be able to see you if you lack a camera.)

We use Skype for video teleconferencing. If you do not have Skype or are unfamiliar with this service, our staff will walk you through the few steps required.

Track Your Plaque challenges

1. December 2009 William Davis (31)

Of all the various factors we correct in the Track Your Plaque program in the name of achieving reversal of coronary plaque, there are two factors that are proving to be our greatest challenges:

1) Genetic small LDL

2) Lipoprotein(a)

More and more people are enjoying at least marked slowing, if not zero change or reduction, in heart scan scores following the Track Your Plaque program. We achieve this by correcting a number of factors. Some factors, like vitamin D deficiency, are easily corrected to perfection--supplement sufficient vitamin D to achieve a blood level of 25-hydroxy vitamin D of 60-70 ng/ml. Correcting standard lipid values--LDL cholesterol, HDL cholesterol, and triglycerides--child's play, even to our strict targets of 60-60-60.

However, what I call "genetic small LDL" and a subset of lipoprotein(a) are proving to be the most resistant of all.

Let's first consider genetic small LDL. Small LDL is generally the pattern of the carbohydrate-ingesting, overweight person. It has exploded in severity over the past decade due to overconsumption of carbohydrates due to the ridiculous low-fat notion. Reduce or eliminate carbohydrates, especially wheat, which permits weight loss, and small LDL drops like a stone. But there is a unique subset of people who express the small LDL pattern who start at or near ideal weight. Take Chad, for instance. At 6' 2" and 152 lbs and BMI of 19.6, there's no way excess weight could be triggering his small LDL. Yet he starts with 100% small LDL particles. All efforts to reduce small LDL, such as wheat, cornstarch, and sugar elimination; niacin; vitamin D normalization; thyroid normalization; and several supplements that yield variable effects, such as phosphatidylcholine, all leave Chad with more than 90% small LDL.

Lipoprotein(a) is a bit different. Over the past 5 years, our choices in ways to reduce Lp(a) expression have improved dramatically. Beyond niacin, we now have high-dose EPA + DHA, thyroid normalization that includes use of T3, and hormonal manipulation. In the Track Your Plaque experience, approximately 70% of people with Lp(a) respond with a reduction in Lp(a). (In fact, the 4 out of the 5 record holders for reduction of heart scan scores have Lp(a) that was successfully treated.) But about 30% of people with Lp(a) prove resistant to all these treatments--they begin with a Lp(a) of, say, 260 nmol/L and, despite niacin, high-dose EPA + DHA, and various hormones, stay at 260 nmol/L. It can be frustrating and frightening.

So these are the two true problem areas for the Track Your Plaque program, genetic small LDL and a subset of Lp(a).

We are actively searching for better options for these two problem areas. Given the collective exploration and wisdom that develops from such collaborative efforts as the Track Your Plaque Forum, I am optimistic that we will have better answers for these two stumbling blocks to plaque reversal in the future.

I'll supply the tar if you supply the feathers

30. November 2009 William Davis (13)

The results of the latest Heart Scan Blog poll are in.

DIRECT-TO-CONSUMER PHARMACEUTICAL ADVERTISING HAS:

Increased public awareness of medical conditions and their treatment
19 (11%)

Has had little overall effect on health and healthcare
29 (18%)

Needlessly increased healthcare costs
81 (50%)

Further empowered the revenue-obsessed pharmaceutical industry
130 (81%)

Clearly, there's a lot of negative sentiment against direct-to-consumer (DTC) drug advertising.

It looks as if a small minority believe that good has come from DTC advertising, judging by the meager 11% who voted for increased awareness. In fact, the poll results are heavily weighed towards the negative: 50% voted for "needlessly increased healthcare costs," while an astounding 81% voted for "empowered the revenue-obsessed pharmaceutical industry."

It is, indeed, an odd situation: Pharmaceutical agents available only by prescription being hyped directly to the consumer.

Personally, I would vote for choices 1,3, and 4. While awareness has increased, it has come with a hefty price, not all of it well spent. I believe the pharmaceutical industry still adheres to the rule that, for every $1 spent on advertising, $4 is made in revenue. They are, in effect, printing money.

What goes up can't come down

28. November 2009 William Davis (13)

According to conventional wisdom, heart scan scores cannot be reduced.

In other words, say you begin with a heart scan score of 300. Conventional wisdom says you should take aspirin and a statin drug, eat a low-fat "heart healthy" diet, and take high blood pressure medications, if necessary.

If your heart scan score goes up in a year or two, especially at an annual rate of 20% or more, then you are at very high risk for heart attack. If the heart scan score stays the same, then your risk is much reduced. These observations are well-established.

But more than 99% of physicians will tell you that reducing your heart scan score is impossible. Don't even try: Heart scan scores can go up, but they can't go down.

Baloney. Heart scan scores can indeed go down. And they can go down dramatically.

It is true that, following conventional advice like taking a statin drug, following a low-fat diet, and taking aspirin will fail to reduce your heart scan score. A more rational approach that 1) identifies all causes of coronary plaque, 2) corrects all causes while including crucial strategies like omega-3 fatty acid supplementation, vitamin D supplementation, and thyroid function normalization, is far more likely to yield a halt or reduction in score.

While not everybody who undertakes the Track Your Plaque program will succeed in reducing their heart scan score, a growing number are enjoying success.

A small portion of our experience was documented this past summer. (I collected and analyzed the data with the help of Rush University nutrition scientist, Dr. Susie Rockway, and statistician, Dr. Mary Kwasny.)

Effect of a combined therapeutic approach of intensive lipid management, omega-3 fatty acid supplementation, and increased serum 25 (OH) vitamin D on coronary calcium scores in asymptomatic adults.

Davis W, Rockway S, Kwasny M.

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

Gretchen's postprandial diet experiment

27. November 2009 William Davis (11)

Gretchen sent me the results of a little experiment she ran on herself. She measured blood glucose and triglycerides after 1) a low-fat diet and 2) a low-carb diet.

Gretchen describes her experience:

Several years ago I received a windfall of triglyceride strips that would expire in a week or so. I hated to waste them, so I decided to use them to test my triglyceride and BG responses to two different diets: low carb and low fat.

The first day I followed a low-fat diet. For breakfast I ate a lot of carbohydrate, including 1 oz of spaghetti cooked al dente and ¾ cup of white rice. For the rest of the day I ate less carbohydrate but continued to eat low fat.

The second day I followed a low-carb diet. For breakfast I ate a lot of fat, including a sausage, mushrooms fried in butter, 2 slices of bacon, and ¼ cup of the creamy topping of whole-milk yogurt. For the rest of the day I ate less fat, especially less saturated fat, but continued to eat low carb.

Both days I measured both BG and triglyceride levels every hour until I went to bed. On the low-carb day I had 3 meals. On the low-fat day, I was constantly hungry, had 4 meals, and kept snacking.

You can see the results in Figure 1. On the low-fat diet, after a “healthy” low-fat breakfast of low-glycemic pasta with low-fat sauce, my BG levels shot up to over 200 mg/dL and took more than 6 hours to come down. My triglycerides, however, remained low, and at first I thought perhaps the low-fat diet might be better overall. However, after about 6 hours, the triglyceride levels started to increase steadily, and by the next morning, they were higher than they had been the day before.
On the low-carb diet, my BG levels stayed low all day. However, after meals, the triglyceride levels skyrocketed. After meals they came down, and by the next morning they were lower than they had been the day before.

As I interpret these results, the high triglyceride levels after eating the high-fat meals represent chylomicrons, the lipoproteins that transport fat from your meals to the cells of your body. The high triglyceride levels the morning after eating the low-fat meals represent very low density lipoprotein, which takes the cholesterol your liver synthesizes when your intake of dietary cholesterol is low and distributes it to cells that need it, or again, to the fat for storage.

There are several interesting factors to consider here. First, when you have a lipid test done at the lab, it’s usually done fasting, which means first thing in the morning after not eating for 8 to 12 hours. It tells you nothing about what your triglyceride levels were all day.

Second, the low-carb diet resulted in lower fasting triglyceride levels, but much higher postprandial triglyceride levels. Which are more dangerous? I’m afraid I don’t know. You should also note that the high-fat, low-carb breakfast was extremely high in fat, including saturated fat. I don’t normally eat that much fat but wanted to test extremes.

Third, although the low-fat diet didn’t produce the very high postprandial triglyceride levels that the high-fat diet did, it produced extremely high BG levels that persisted for 6 hours. Some people think that it’s oxidized and glycated lipids that are the dangerous ones, so high BG levels and normal triglyceride levels might be more dangerous than very high triglyceride levels and normal BG levels. Note that high BG levels also contribute to oxidation rates.

Fourth, this shows the results of an experiment with a sample size of one. My physiology might not be typical. If you want to know how your own body’s lipids respond to different types of diets, you should get a lipid meter and test yourself. Unfortunately, your insurance is unlikely to want to pay for this, so it will be an expensive experiment.

The main point of this is that the results of different diets are complex. We have to eat. And what we eat can affect many different systems in our bodies. Finding the ideal diet that matches our own physiology and results in the best lipid levels as well as BG levels is a real challenge.

This was a lot of effort for one person. Thanks to Gretchen for sharing her interesting experience.

Gretchen makes a crucial point: Some of the effects of diet changes evolve over time, much as triglyceride levels changed substantially for her on the day following her experiment. Wouldn't it be interesting to see how postprandial patterns develop over time if levels were observed sequentially, day after day?

The stark contrast in blood sugars is impressive--Low-carb clearly has the advantage here. Are there manipulations in diet composition in low-carb meals that we can make to blunt the early (3-6 hour) postprandial lipoprotein (triglyceride) peak? That's a topic we will consider in future.

More of Gretchen's thoughts can be found at:

http://wildlyfluctuating.blogspot.com
http://www.healthcentral.com/diabetes/c/5068

After-eating effects: Carbohydrates vs. fats

25. November 2009 William Davis (17)

In the ongoing debate over whether it's fat or carbohydrate restriction that leads to weight loss and health, here's another study from the Oxford group examining the postprandial (after-eating) effects of a low-fat vs. low-carbohydrate diet. (Roberts R et al, 2008; full-text here.)

High-carbohydrate was defined as 15% protein; 10% fat; 75% carbohydrate (by calories), with starch:sugar 70:30.

High-fat was defined as 15% protein; 40% fat; 45% carbohydrate, with starch:sugar 70:30. (Yes, I know. By our standards, the "high-fat" diet was moderate-fat, moderate-carbohydrate--too high in carbohydrates.)

Blood was drawn over 6 hours following the test meal.

Roberts R et al. Am J Clin Nutr 2008

The upper left graph is the one of interest. Note that, after the high-carbohydrate diet (solid circles), triglyceride levels are twice that occurring after the high-fat diet (open circles). Triglycerides are a surrogate for chylomicron and VLDL postprandial lipoproteins; thus, after the high-carbohydrate diet, postprandial particles are present at much higher levels than after the high-fat diet. (It would have been interesting to have seen a true low-carbohydrate diet for comparison.) Also note that, not only are triglyceride levels higher after high-carbohydrate intake, but they remain sustained at the 6-hour mark, unlike the sharper decline after high-fat.

It's counterintuitive: Postprandial lipoproteins, you'd think, would be plentiful after ingesting a large quantity of fat, since fat must be absorbed via chylomicrons into the bloodstream. But it's carbohydrates (and obesity, a huge effect; more on that in future) that figure most prominently in determining the pattern and magnitude of postprandial triglycerides and lipoproteins. Much of this effect develops by way of de novo lipogenesis, the generation of new lipoproteins like VLDL after carbohydrate ingestion.

We also see this in our Track Your Plaque experience. Rather than formal postprandial meal-testing, we use intermediate-density lipoprotein (IDL) as our surrogate for postprandial measures. A low-carbohydrate diet reduces IDL dramatically, as do omega-3 fatty acids from fish oil.

All posts by william-davis

Why health care costs are ballooning

28. March 2008 William Davis (7)

Have you ever wondered to what degree health care is driven by a profit motive?

A doctor advises you to undergo a procedure. Is that advice motivated solely by concern for your health and welfare? Or, does the generous financial compensation peculiar to procedures bias your doctor’s decision?

The billboard on the highway advertises a hospital heart program. Is it meant to raise awareness of lifesaving services? Or, is it the same as an ad for a casino or hotel chain, a marketing tool for generating business?

At one time or another, we’ve probably all shared a suspicion that healthcare is occasionally motivated by money: over-priced prescription drugs, hospitals charging higher prices to the uninsured, the three-minute doctor’s visit for $200.

Direct-to-consumer drug advertising has brought aggressive drug sales tactics front and center to the public’s attention. “Ask your doctor about . . .” is the mantra of countless 30-second spots appearing several times an hour on national television. Direct-to-consumer drug advertising has provided the American public with a $4.5 billion reminder that there’s money to be made in the world of prescription drugs (U.S. Government Accountability Office). And there’s certainly a load of money to be made. A 2003 Harvard and Massachusetts Institute of Technology study showed that, of every dollar spent on consumer drug advertising, $4.20 was recovered through increased sales (Impact of Direct-to-Consumer Advertising on Prescription Drug Spending; Henry J Kaiser Family Foundation). A $53,000 ad run three times during the Oprah Winfrey Show is money well invested for a drug manufacturer.

The knotty issue of medical errors has recently captured attention. Unintentional medical errors—-nurses administering the wrong medication, doctor misdiagnoses or amputating the wrong leg, unrecognized medication interactions—-are an estimated $29 billion headache. Former Secretary of Health and Human Services, Tommy Thompson, reported that up to 98,000 lives are lost every year as a result of errors in healthcare delivery.

No doubt, these are all enormous problems that plague our healthcare system.

But I am going to make the case for a much larger problem. The magnitude of this problem dwarfs that of medical errors. It’s not an issue of neglect, nor is it committed in error. It is built on intentionally committed acts, systematically conducted on a massive scale, and sustained by the participation of many. It is a plague of unprecedented proportions on the health care system. It requires the willing participation of parties at multiple levels, from lone medical practitioners, to hospitals, to multi-billion dollar medical device and drug manufacturers, even to institutions like the FDA and American Heart Association.

The problem is the bizarre situation that has evolved in health care for the heart. I specify health care for the heart, not heart disease, because actual disease is not always part of the equation. Astonishingly, much of the inflated cost of heart care is based on the feared specter of heart disease, the implied threat of heart disease, the possibility, sometimes vanishingly remote, of heart disease based on some harbinger of risk. Sometimes the disease itself is nowhere in sight.

The system thrives on a culture of fear, an open ticket to over-testing and profligate spending. Ads cleverly admonish you to “Do it for your family”. Nuclear stress testing alone generates $18 billion of costs. Yet this test is normal in 80% of people tested. Worse, the 20% of “abnormal” stress test results are not always indicative of genuine disease, they are “false positive,” and are a big part of the reason that 30% of heart catheterizations fail to show disease. “My arteries checked out okay!” relieved patients will declare?-but there may have been no reason to have pursued a costly test like catheterization in the first place. But the system makes far better sense when you understand that nuclear stress tests and heart catheterizations are the bread and butter of cardiologists and hospitals, and the ticket to more financially rewarding procedures.

This approach evolved in the 1960s, when coronary heart disease itself was impossibly difficult to diagnose until a catastrophe like heart attack declared itself. But in the 21st century, coronary heart disease is easily, inexpensively, and safely detectable, decades before heart attack risk looms over your life. Yet murky, risk-based tests like stress tests and cholesterol testing continue to dominate the practice of “heart disease detection” in real-life practice.

Make no mistake: This problem is huge. The cardiovascular health care system has mushroomed into a gargantuan profit-generating mechanism, far larger than is required to deliver essential heart care. In 2003, over $431.8 billion was spent in the U.S. on cardiovascular health care, $151.6 of this on coronary disease alone (American Heart Association, Heart Disease and Stroke Statistics—2007 Update). The U.S. Department of Health and Human Services projects that total health care spending will double to $3.6 trillion by 2014, consuming 18.7 percent of the nation's economy, much of the increase due to expanding cardiovascular costs.

Most tragically, the system has grown through the exploitation of trust. The faith we have in doctors, hospitals, and the institutions and people associated with healthcare has been subverted into the service of profit. Many practitioners and institutions have chosen to operate under the guise of doing good but instead capitalize on the public’s willingness to accept as fact the need for a major heart procedure and all its associated costly trappings.

Copyright 2008 William Davis, MD

Heart scans know no race

27. March 2008 William Davis (0)

The New England Journal of Medicine just published a new analysis of the Multi-Ethnic Study of Atherosclerosis (MESA) database authored by Dr. Robert Detrano of University of California-Irvine.

As we would expect, the study confirmed the ability of heart scans and coronary calcium scoring to predict heart attack. This study is unique, hovever, in including Hispanics, Chinese Americans, and African Americans in its 6722 participants.

The analysis confirmed that coronary calcium scores yielded similar information, regardless of race. It confirmed that people with a zero heart scan score had a nearly zero risk of cardiovascular events; it also confirmed that higher scores (e.g., >300) yielded much greater risk over the 4 years of observation: 7.73-fold greater risk for people with scores 101-300; 9.67-fold greater for scores >300.

One of the media reports on the study can be viewed on HeartWire

Bill Sardi's Knowledge of Health website and blog also has an insightful commentary.

To those of us who have used heart scans in thousands of people, the MESA results come as no surprise, having seen these phenomena played out every day in real life. Although similar results have been previously shown in a number of other smaller studies, Detrano's analysis of MESA does serve to further validate these concepts. It also serves to deliver the message more broadly into the mainstream media message.

No surprise whatsoever: Coronary calcium scores obtained through heart scans represent a measure of the disease--coronary atherosclerosis--itself. It is not a risk factor that may or may not be associated with development of coronary atherosclerosis. Thus, when heart scan scores are held up in comparison the cholesterol, LDL cholesterol, c-reactive protein, or any other risk measure, heart scan scores outshine all these measures by enormous margins as predictors of your future.

Want to know what your uncorrected heart disease future could be? Consult your heart scan score. Not your cholesterol panel.

Copyright 2008 William Davis, MD

Heart Scan Frustration

27. March 2008 William Davis (4)

Ideally, you get a heart scan and your doctor sits down with you and provides a rational, insightful discussion on what the results mean.

Is heart attack in your future? If so, when? Are blockages present? What is the role of other tests like stress tests and heart catheterizations? Do CT coronary angiograms add any important information? What is the role of cholesterol? Can diet or nutritional supplements impact on heart scan score?

But what happens if you are unable to get the answers you desire? What if you get brusque responses, or your doctor just doesn't know? Or what if there is a clear conflict of interest or the possibility of financially-tainted advice? ("You need a heart catheterization right away or you'll die of a heart attack!")

One example of this process was posted by a frustrated Member of Track Your Plaque who found that answers were virtually unobtainable from his/her doctors:

I underwent a heart scan a few weeks ago, based on a recommendation from a doctor. I assumed that, since I was paying for it, and I requested it, the results would be fully explained to me.

Late on a Friday afternoon, the radiologist who intrepreted it called me and said I would be receiving a report, and so would the doctor. I asked that she explain them to me. She said their policy was to give the report to the doctor and let him explain them. She did say I was in the 90th percentile for my age--and that 10% had a worse score. I asked where do we go from here, and she said, if you're not having symptoms, maybe lifestyle changes, but YOUR DOCTOR will let you know. I asked for a copy of the films and reports, and was told YOUR DOCTOR can request them. I called back a little later and she was gone. It was starting to sink in that I must have a terrible score. In the meantime, I did what I should have done before I went for the scan---looked up information on the internet, and read about calcium scoring. This website [Track Your Plaque] hadn't showed up in my Google search, so a lot of the information was useless.

I did manage to get the score of 186, with the breakdown per artery from someone at the clinic, but only after I insisted I paid for the test, I have a right to the information. 'Course having a score per artery didn't really help---what did it mean? ie: if a 72, how did that correlate to any blockages? Was it a big lump...or spread along the wall throughout the artery.

I had an appt. the following Tuesday with THE DOCTOR---a very busy doctor. After an hour and 1/2 wait in a crowded waiting room, I got to see him. We discussed briefly another issue, and he started walking out. I followed him out and said I wanted my full l5 minutes of time allotted in their scheduling, which seemed to irritate him.

I followed him into his office and said, WHAT ABOUT THE HEART SCAN? What do the numbers mean? He responded that he didn't know, he'd have to see the films, but don't worry--you're probably ok, and I should get a thallium stress test anyway. He said he couldn't intrepret the numbers, or give an opinion on where the plaque was or how it was configured.

I then went to the interventional cardiologist that afternoon and the thallium stress test was scheduled. I asked about the HEART SCAN, and again, no acknowledgment. I asked if he would get the films and explain the results, and again no acknowledment as he was walking out the door.

After this lengthy saga.....MY QUESTION IS....since this is a test you can order yourself (literature at center made mention of the tests you can get without a doctors request)......WHO IS THEIR FIDUCIARY RESPONSIBILITY TO WHEN IT COMES TO EXPLAINING THE RESULTS?

I learned more on this website [Track Your Plaque], and the emailed book then I did dealing with two doctors and the center itself. Thinking back, there was nothing but a brochure on the test at the center. No "Track your Plaque" stuff.

Day 2
I called the scanning center and relayed my dilemma. I was put in touch with another radiologist--a very informative one, who appeared passionate about heart scans as a preventive test. He compared them to mammograms. He hadn't heard about the "Track Your Plaque" program but was going to check it out. He said people varied in their responses to the test results, as well as doctors/cardiologists as to the next step. (ie: lifestyle changes..the next test, etc). He seemed to feel blockages of more than 50% for many cardiologists would indicated angioplasty and stenting.

I'm going back to review the films with him later this week. He wasn't that concerned with the 101 reading on the right artery. The 72 on the left he had concerns with and indicated the CAT test [CT angiography] would offer more as far as how much was there, and approx. blockage, and could be a baseline to compare to in the future. He said some cardiologists would go right to angioplasty...some to a CAT which is more conservative...some might watch and encourage lifestyle changes. He said the Heart Scan doesn't show soft plaque. He also said the internist who referred me was one of only a few in the city that felt strongly about the heart scan---and probably used it to take further action via a referral, and just didn't have time to discuss it, with the way medicine is run these days.

This Member's frustrated post pretty much sums it up:

1) Doctors don't seem to have the time nor motivation to be bothered about offering advice that leads to prevention of disease.

2) The tendency is to always ask, "Are heart procedures necessary?", not "How did this happen?" or "What can we do about this to keep it from getting worse?" How about diet, supplements, and other tools to use at home?

The obvious uneasiness of the radiologist, the last physician this Member spoke with, can just as easily lead to boneheaded advice: Maybe getting a stent isn't such a bad idea. Maybe a CT angiogram is an absolute necessity.

I hear comments like this every day. It is the reason why I continue to plug away at this program and try to set things straight.

By the way, subscribers to our Track Your Plaque Newsletter just heard about our latest success story, Roy, who dropped his heart scan score over 500 points. If you are yet not a newsletter subscriber, click here.

Copyright 2008 William Davis, MD

Dr. Nieca Goldberg and heart healthy

23. March 2008 William Davis (1)

In January, 2007, $11.6 billion (2006 net sales) cereal manufacturing giant General Mills rolled out three million boxes of Wheat Chex and Multi-Bran Chex, each boasting a picture of cardiologist, Dr. Nieca Goldberg's face on the box.

Dr. Goldberg has been a frequent national spokeswoman for the American Heart Association (AHA). In a media interview, American Heart Association President, Dr. Alice Jacobs, stated that she supports Dr. Goldberg's work with the General Mills’ products. "The AHA is always in favor of educating the public on how to make heart-healthy lifestyle choices." Dr. Jacobs added that the AHA doesn't consider Goldberg's appearance on the cereal boxes ‘an endorsement’ of the products. "The content on the box is basic heart health information," she said.

Putting images of someone like Dr. Goldberg on cereal boxes appeals to a certain audience, mothers worried about health in this instance. Manufacturers recognize that the perceptions of their food need to be created and nurtured.

Eerily reminiscent of tobacco company tactics of the 20th century? Recall the Brown and Williamson claim that Kool cigarettes keep the head clear and provide extra protection against colds? Lucky Strike, Chesterfield, and Camels all promoted the health benefits of cigarettes, including prominent endorsements by physicians.

How about Philip Morris’ ads for Virginia Slims cigarettes: "You've come a long way, baby"? Interestingly, food manufacturing behemoths Kraft and Nabisco were both majority-owned by Philip Morris, now renamed Altria.

Take a look at the composition of these two "heart healthy" breakfast cereals endorsed by Dr. Nieca Goldberg and the American Heart Association:

Products like this:

--Make people fat--abdominal fat (wheat belly)
--Reduce HDL cholesterol
--Raise triglycerides
--Dramatically increase small LDL
--Increase inflammatory responses
--Increase blood pressure
--Increase likelihood of diabetes

These products are sugar and sugar-equivalents with a little fiber thrown in and a lot of marketing propaganda, aided and abetted by the misguided antics of the American Heart Association and Dr. Goldberg. It's hard to believe that Dr. Goldberg would sell her soul on something so knuckleheaded for a moment of notoriety.

As I've often said, if a product bears the AHA Check Mark of approval, be sure not to buy it.

Bait and switch

23. March 2008 William Davis (5)

“When banks compete, you win.”

The TV ad opens with a 60-something man sitting in his living room, talking to a three-piece suit-clad, 30-something banker. The older man is explaining to the dismayed younger man why he’s going to use Lending Tree loan service for a home loan.

“But Dad, I’m you’re son!” the younger whines.

Many of Lending Tree’s clients have collaborated in filing a multi-million dollar class action suit against the company, claiming “bait and switch” tactics. They claim that home buyers are lured by low interest rates or low closing costs on a home loan. Once the buyer concludes the hassle of filling out numerous forms, the suit accuses Lending Tree of making a switch to a costlier loan.

Bait and switch is among the oldest con games around. If you’ve ever bought a car from a car dealer, chances are you’ve had your own little brush with this deception. The ad promises the SUV you’ve wanted for only $299 per month. Only, once you get there, the salesman informs you that only a limited number of special deals were available and they’ve run out. But he’s still got a really good deal right over here!

Most of us recognize that we’ve been hookwinked. Yet we still go along and buy a car from the dealer.

What if it’s not a sleazy salesman behind the pitch, but a physician. If it’s hard to resist the sales pitch at the car dealership, it can be near impossible to ignore the advice of your doctor. But the truth is often loud and clear: in many instances, it is a genuine, bona fide, and fully-certified scam.

Among the most common bait-and-switch heart scams: Your cholesterol is high. The sequence of subsequent testing is well-rehearsed. “Gee, Bob, I’m worried about your risk for heart disease. Let’s schedule you for a nuclear stress test.” The stress test, like 20% or more of them, is “falsely positive,” meaning abnormal even though there’s nothing wrong with you. Another 30% are equivocal, not clearly abnormal but also not clearly normal. Now up to 50% of people tested “need” a heart catheterization in the hospital to clarify this frightening uncertainty. You might end up with a stent or two, even bypass surgery. Your simple $20 cholesterol panel has metamorphosed into $100,000 in hospital procedures. That familiar sequence is followed thousands of times, seven days a week, 365 days a year.

There are times when these heart tests are valuable and provide meaningful answers. Then there's the other half of the time when they provide murky information that can be used for a practitioner's economic advantage.

Copyright 2008 William Davis, MD

A fictional tale of medical economics in heart disease

23. March 2008 William Davis (2)

Dr. Robert Connors is the hospital’s most prized cardiologist.

Practically a fixture in the cath lab, he generates more revenues for the hospital than any of his colleagues. Last year alone, he performed over 1500 procedures, bringing in $18 million dollars to the cath lab, $27 million to the hospital. Dr. Connors is very good at what he does: 55-years old, he has been involved in high-tech heart care since the “early days,” 25 years ago, when hospital procedures really began to take off.

Over his career, he has personally performed over 25,000 heart procedures and has built a reputation as a skilled operator of complex coronary procedures. Because of his skills, he enjoys a vigorous flow of referrals for procedures from dozens of primary care physicians. His skill has also earned him referrals from cardiologist colleagues who seek his abilities for difficult cases.

On any day, Dr. Connors typically schedules up to 12 procedures. His entire day is spent in the cath lab, usually from 7 am until 6 pm. He meets many patients for the first time on the catheterization laboratory table as staff shave their groin, preparing for the procedure. Much of the procedure itself is not even performed by Dr. Connors, but by one or another cardiologists-in-training, a “fellow,” or member of the fellowship the hospital proudly maintains as a clinical teaching institution. Nor will Dr. Connors talk to most patients at the close of the procedure. He leaves that to either the fellow or a nurse. Dr. Connors views himself as a procedural specialist, not someone who has to take care of patients. He gave up seeing patients in his office over 10 years ago.

Dr. Connors’ procedural enthusiasm gained him the attention of drug and medical device manufacturers. Because Dr. Connors lectures widely and advises colleagues, his comments can dramatically alter perceptions of the value of a technology. He has, on many occasions, catapulted an unpopular device to most-asked-for among colleagues, bringing millions of dollars in revenues to the manufacturer. One particularly lucrative arrangement he made around 10 years ago involved a “closure” device, a $400 single-use plug used to close the access site made during heart catheterizations. By swaying his colleagues at _______ Hospital, 50 orders per day (one per procedure) tallied $20,000 every day, $7.1 million dollars per year for the manufacturer. Although he’d used other devices on the market, the 5,000 shares of stock he was offered encouraged him to issue glowing comments to colleagues on the superiority of this specific brand of closure device. Now over 90% of all catheterizations at _______ Hospital conclude with the device manufactured by the company in which Dr. Connors maintains partial ownership.

Negative comments, on the other hand, topple other products when Dr. Connors sees fit to pan them. For this reason, device and drug manufacturers run straight to Dr. Connors to gain his good graces as soon as possible after a product is released into the market. Because the competition is just as likely to do the same, it has often come down to a bidding war, the company providing the most lucrative arrangement most likely to win.

Thus, Dr. Connors proudly boasts of how many times he has flown to Hawaii, Europe, and other exotic locations at industry expense. He also boasts of how, for $100,000 paid to him for a “consulting fee,” he can overturn the choice of products lining hospital shelves. As the hospital’s annual budget for coronary devices will top $84,000,000 this year, device manufacturers regard the sum paid Connors as a profitable investment.

Despite his lofty status in the hospital, Dr. Connors has long expressed a love-hate relationship with ________ Hospital. While he enjoys his work and has made a more than comfortable income, he has long felt that the hospital administration didn’t truly appreciate his contributions. Five years ago, he therefore demanded that he be made “Director of Research.” After all, he had hired a nurse to help him coordinate enrollment of patients into several device trials brought to him by medical device manufacturers. When he encountered an initial lukewarm response from hospital administrators, he threatened to take his “business” elsewhere to a competing hospital. Hospital administrators gave in. They provided him with the title he wanted, along with $100,000 annual “stipend.”

Just fiction? Make no bones about it: Cardiac care is business, big business. And there's money to be made, lots of it.

Copyright 2008 William Davis, MD

Disease engineering

21. March 2008 William Davis (10)

Imagine you catch pneumonia.

You have a fever of 103, you’re coughing up thick, yellow sputum. Breathing is getting difficult. You hobble to the doctor, who then fails to prescribe you antibiotics. You get some kind of explanation about unnecessary exposure to antibiotics to avoid creating resistant organisms, yadda yadda. So you make do with some Tylenol®, cough syrup, and resign yourself to a few lousy days of suffering.

Five days into your illness, you’ve not shown up for work, you’re having trouble breathing, and you’re getting delirious. An emergency trip to the hospital follows, where a bronchoscopy is performed (an imaging scope threaded down your airway) and organisms recovered for diagnosis. You’re put on a ventilator through a tube in your throat to support your breathing and treated with intravenous antibiotics. Delayed treatment permits infection to escape into the fluid around your lungs, creating an “empyema,” an extension of the infection that requires insertion of a tube into your chest through an incision to drain the infection. You require feeding through a tube in your nose, since the ventilator prevents you from eating through your mouth. After 10 days, several healing incisions, and a hospital bill totaling $75,000, you’re discharged only to be face eights weeks of rehabilitation because of the extreme toll your illness extracted. Your doctor also advises you that, given the damage incurred to your lungs and airways, you will be prone to more lung infections in the future, and similar situations could recur whenever a cold or virus comes long.

A disease treatable by taking a 10-day, $20 course of oral antibiotics at home was converted into a lengthy hospital stay that generated extravagant professional fees, testing, and costly supportive care. You’ve lost several weeks of income. You’re weak and demoralized, frightened that the next flu or virus could mean another trip to the hospital. You are susceptible to repeated bouts of such episodes in future.

Such a scenario would be unimaginable with a common infection like pneumonia, or it would be grounds for filing a malpractice lawsuit. But, as horrific as it sounds in another sphere of health care, it is, in effect, analogous to how heart disease is managed in current medical practice.

First, you’re permitted to develop the condition. It may require years of ignoring telltale signs, it may require your unwitting participation in unhealthy lifestyle practices, like low-fat diets, "eat more whole grains," and "know your numbers."

It then eventuates in some catastrophe like heart attack or similar unstable heart situation, at which point you no longer have a choice but to submit to major heart procedures. That’s when you receive your heart catheterization, coronary stents, bypass, defibrillators, etc.

Of course, none of these procedural treatments cures the disease, no more than a Band Aid® heals the gash in your leg. The conditions that were present that created heart disease continue, allowing a progressive disease to worsen. At some point, you will need to return to the hospital for yet more procedures when trouble recurs, which it inevitably does.

A coronary bypass operation costs, on average $67,823. That includes the cost for the heart catheterization performed by a cardiologist to provide the surgical roadmap of your coronary arteries, the surgeon’s fees, the hospital charges. If there are any complications of your procedure, then your hospital bill may total a substantially higher figure.

$67,823 is just the upfront financial pay-off. Over the long run, your life is actually worth far more to the cardiovascular health care system because no heart procedure yields a permanent fix. In fact, repeated reliance on the system is the rule.

In fact, over 90% of people who enter the American cardiovascular health care system do so through a revolving door of multiple procedures over several years. It is truly a rare person, for instance, who undergoes a coronary bypass operation, never to be seen again the wards of the hospital because he remains healthy and free of catastrophe. A much more familiar scenario is the man or woman who undergoes two or three heart catheterizations, receives 3,4, or 6 stents, followed a few years later by a heart bypass, pacemaker, defibrillator, as well as the tests performed for catastrophe management, such as nuclear stress test, echocardiogram, laboratory blood analysis, and consultation with several specialists. The total revenue opportunity is many-fold higher than the initial 60-some thousand dollars, but instead totals hundreds of thousands of dollars per person.

A heart attack alone is a $100,000 revenue opportunity (Agency for Healthcare Research and Quality, 2004).

Of all coronary bypass procedures performed, 25% are “re-do’s”, or bypasses in people who’ve had a previous one, two, or three bypass procedures.

Perhaps it's excessively cynical to label it "disease engineering." But, whether from benign neglect or purposeful failure to diagnose, the fact remains: Heart disease is, all too often by the standard path, undiagnosed and neglected for years until the procedural payoff strikes.

Copyright 2008 William Davis, MD

Free checking, auto shows, low-cost hotel rooms, and bypass surgery

20. March 2008 William Davis (3)

Of the three major highways that lace the city of Milwaukee, there are at least five, and sometimes as many as ten, billboards that prominently feature one hospital heart program or another.

The passing of former First Lady, Ladybird Johnson in July, 2007, reminds us that, just 30 years ago, billboards were a far more common feature (many called them eyesores), proliferating like a dense forest of trees competing for a sliver of sunlight. Ladybird Johnson played a pivotal role in helping to dramatically reduce the number of billboards permissible on the nation’s highways. Of the relative few that remain today, a premium must be paid to post an advertisement. It costs several thousands dollars every month to maintain these highway commercials. But it’s not just an expense; it’s an investment.

The tens of thousands of eyes that view these billboards every day are potential customers, insured Milwaukeeans who carry health insurance and represent a major heart procedure just waiting to happen. They “need” to be directed to the right place. The billboards don’t feature health and wellness, heart disease prevention, or nutritional advice. They feature surgeons proudly wearing scrubs and masks, nurses, and declarations of the advantages of each hospital program. In effect, they invite you to have your heart attack, heart catheterization, bypass surgery, or other major heart procedure at their hospital. High-tech, high-ticket hospital heart care has become the subject of mainstream marketing, the stuff of flyers, brochures, and billboards.

The excesses of “big heart disease” have created a system that makes procedural heart disease “repair” far more profitable than heart disease prevention. Unfortunately, “repair” has disastrous financial, physical, and emotional consequences for everyone save the “repairman.”

While great good has been achieved by the American health care system, this gargantuan and inefficient system has also cultivated a culture of excess that has made many of its participants—physicians, hospitals, drug and device manufacturers—rich. And at our expense.

This approach was, to a degree, justifiable at a time when nothing better was available. But that's no longer true.

Copyright 2008 William Davis, MD

No-flush niacin kills

20. March 2008 William Davis (18)

Gwen was miserable and defeated.

No wonder. After a bypass operation failed just 12 months earlier with closure of 3 out of 4 bypass grafts, she has since undergone 9 heart catheterization procedures and received umpteen stents. She presented to me for an opinion on why she had such aggressive coronary disease (despite Lipitor).

No surprise, several new causes of heart disease were identified, including a very severe small LDL pattern: 100% of LDL particles were small.

Given her stormy procedural history, I urged Gwen to immediately drop all processed carbohydrates from her diet, including any food made from wheat or corn starch. (She and her husband were shocked by this, by the way, since she'd been urged repeatedly to increase her whole grains by the hospital dietitians.) I also urged her to begin to lose the 30 lbs of weight that she'd gained following the hospital dietitians' advice. She also added fish oil at a higher-than-usual dose.

I asked her to add niacin, among our most effective agents for reduction of small LDL particles, not to mention reduction of the likelihood of future cardiovascular events.

Although I instructed Gwen on where and how to obtain niacin, she went to a health food store and bought "no-flush niacin," or inositol hexaniacinate. She was curious why she experienced none of the hot flush I told her about.

When she came back to the office some weeks later to review her treatment program, she told me that chest pains had returned. On questioning her about what she had changed specifically, the problem became clear: She'd been taking no-flush niacin, rather than the Slo-Niacin I had recommended.

What is no-flush niacin? It is inositol hexaniacinate, a molecule that indeed carries six niacin molecules attached to an inositol backbone. Unfortunately, it exerts virtually no effect in humans. It is a scam. Though I love nutritional supplements in general, it pains me to know that supplement distributors and health food stores persist in selling this outright scam product that not only fails to exert any of the benefits of real niacin, it also puts people like Gwen in real danger because of its failure to provide the effects she needed.

So, if niacin saves lives, no-flush niacin in effect could kill you. Avoid this scam like the plague.

No-flush niacin does not work. Period.

Disclosure: I have no financial or other relationship with Upsher Smith, the manufacturer of Slo-Niacin.

Copyright 2008 William Davis, MD

Breakfast comments

19. March 2008 William Davis (7)

I received some wonderful comments to the What's for breakfast blog post.

Even though comments are viewable by clicking on them, I wanted to be sure these were readily visible, since they were so helpful and augmented the few suggestions I made. I'm impressed with the variety of foods people are willing to introduce into breakfast, particularly foods not traditionally thought to be part of standard American breakfast choices.

I normally eat a handful of almonds, some raw cashews, and occasionally an orange for breakfast. I used to eat cheese with breakfast also, but found once I began eating cheese it was hard for me to stop at one or two pieces.

Anonymous

My favorite breakfast is often left over Thai curry. I omit the rice. I also like making a thai omelet which is simply 2 eggs and some fish sauce and water and serving it with Sirachi sauce or Thai peanut sauce. It is street vendor food in Thailand I hear. Here's a recipe.

I find left over dinners are quite wonderful for breakfast. You just have to get past this notion that you have to eat certain foods at certain times in the day. Where'd that idea come from anyway?

Zute

I’ve tried eating oatmeal throughout my life, really wanting to like it. Until now the mere taste or smell of it made my stomach queasy. The key for me was toasting the oatmeal. Here’s what I generally do:

For Steel-cut oatmeal with the taste and texture of rice pudding-

In a frypan:
Toss 1 TBS of butter or so into a hot pan.
Add 1 cup of steel-cut oatmeal until toasted.
--few minutes
In a saucepan:
Boil 2-1/2 cups water
Add 1 cinnamon stick (or equivalent)
Add toasted Steel-cut oatmeal and cook for 15-20 minutes or so

Add 1-1/2 cups of low-fat milk, yogurt, or some combination, etc…
-Optional- Wisk an egg yolk into the milk.
-Optional- Add ¼ tsp salt.
-Optional- 2 TBS honey or Brown sugar. I use one 1 TBS of each.
Add some lemon or orange zest

Return to a boil for 10-15 minutes and then chill before eating. The oatmeal will congeal, resembling rice pudding.
Sprinkle more cinnamon/sugar on top
Add what you like: raisins, nuts, etc...

Use the cinnamon stick if you can, it really makes the difference. I’m constantly refining this recipe.

Anonymous

Once I decided to give up my (former) love affair with breakfast cereals, I was in a quandary about what to do for breakfast. I don't have much time in the morning to get creative and don't have the inclination at that time of the day to do so either.

I've settled on a routine of 2 hard-boiled (organic free-range) eggs (I boil them up a week in advance and leave them, shells-on, in the fridge), and a home-made protein-berry smoothie (frozen organic unsweetened berries, water-based).

This 8 am combo is easy, fast and tasty (I vary the berries and sometimes add natural flavour extracts for variety). It keeps my blood sugar flat and me full until my 1pm lunchtime. And I don't miss the cereals one bit!

Anonymous

I met an out-of-town friend for breakfast the other morning at a French-style bakery cafe. I ordered the goat cheese and herb omelet, but said I didn't want the potatoes or bread with it. They offered extra fruit or a salad instead. I chose the salad, with olive oil and vinegar. My friend wondered how I could eat a salad so early. Why not?

At home I usually eat 2 or 3 eggs over easy cooked in butter for breakfast most mornings and I am comfortably hungry for lunch about 3-4 hours later. But after my nicely filling cheese omelet and generous romaine salad (with a tiny bit of fruit - I ate the berries/melon and left the super-sweet pineapple), I wasn't hungry again until very late in the afternoon so had a small snack (cheese and half an apple) to hold me off and ate my next meal at dinner time. And it was a slow-developing comfortable hunger, not the powerful, "gotta eat something, anything" hunger that follows carb-heavy food.

Breakfast food, indeed!

Anna

You are absolutely right - breakfast is the most difficult meal to change. When I gave up wheat, I started using brown rice or potatoes mixed with anything interesting - nuts or meat or veges. I have now learned that these carbs make my blood glucose skyrocket. I have dropped the rice and potatoes and my BG has dropped nicely.

My favorite breakfast is sauteed veggies with some leftover meat or even an omelette. Soups are great in the AM. Nuts are for the days I am in a hurry.

Would be a little easier if I were not dairy intolerant.

Anne

Here in South India,it is 'Idli' - steam-cooked Lentil-rice (predominantly lentil) droppings, and 'Dosa' - lentil-rice pancakes. We have altered it a bit by increasing lentil ratio and dropping the rice to a minimum. Tastes good and fills you nice, for 4-5 hours.

Neelesh

I have two or three eggs, usually scrambled, but sunny-side-up and over-easy get thrown in for variety. I cook them using butter made from grass-fed cows. I also make my scrambled eggs using whipping cream instead of the more typical water or milk. I'll put a spoonful of fresh-made salsa over the top for some zing, some sliced cheese on the side and a cup of whole, organic milk to drink.

I'm completely sold on the "high-fat, moderate-protein, low-carb" diet and especially the admonition to start the day with a strong breakfast. My overall energy levels are fantastic, running performance is as good as high-school, and my belly hasn't looked this tight in decades.

Ross