All posts by william-davis

Heart scan book

20. April 2009 William Davis (0)

There are only two books on heart scans available.

One, of course, is Track Your Plaque.

The other is the basic book on heart scans, What Does My Heart Scan Show?

Lost in the navigation column to the left on this blog is the link to get the electronic version of the book. In case you didn't know, we make this available for free.

If you're interested, just go here. This book can provide many basic answers to the questions that often arise regarding heart scans, such as the expected rate of increase in score, how your score compares to other people, when should a stress test be considered. Many heart scan centers use this book for educational purposes to help patients understand the importance of their heart scan scores.

(The sign-up for the book requires that an e-mail address be entered.)

The hard copy of What Does My Heart Scan Show? is available from Amazon, also, for $12.99.

Lies, damned lies, and statistics

18. April 2009 William Davis (8)

In the last Heart Scan Blog post, I discussed the question of whether statin drugs provide incremental benefit when excellent lipid values are already achieved without drugs.

But I admit that I was guilty of oversimplification.

One peculiar phenomenon is that, when plaque-causing small LDL particles are reduced or eliminated and leave relatively benign large LDL particles in their place, conventional calculated LDL overestimates true LDL.

In other words, eliminate wheat from your diet, lose 25 lbs. Small LDL is reduced as a result, leaving large LDL. Now the LDL cholesterol from your doctor's office overestimates the true value.

Anne raised this issue in her comment on the discussion:

I eliminated wheat - and all grains - from my diet nearly three years ago (I eat low carb Paleo). My fish oils give me a total of 1680 mg EPA and DHA per day, and my vitamin D levels since last year have varied between 50 ng/ml and 80 ng/ml. However, my lipid profile is not like either John's or Sam's:

LDL cholesterol 154 mg/dl
HDL cholesterol 93 mg/dl
Triglycerides 36 mg/dl
Total cholesterol 255 mg/dl

My cardiologist and endocrinologist are happy with my profile because they say the ratios are good, no one is asking me to take a statin. My calcium score is 0.

However, if we were to measure LDL, not just calculate it from the miserably inaccurate Friedewald equation, we would likely discover that her true LDL is far lower, certainly <100 mg/dl. (My preferred method is the bull's eye accurate NMR LDL particle number; alternatives include apoprotein B, the main apoprotein on LDL.)

So Anne, don't despair. You are yet another victim of the misleading inaccuracy of standard LDL cholesterol determination, a number that I believe should no longer be used at all, but eliminated. Unfortunately, it would further confuse your poor primary care doctor or cardiologist, who--still believe in the sanctity of LDL cholesterol.

By the way, the so-called "ratios" (i.e., total cholesterol to HDL and the like) are absurd notions of risk. Take weak statistical predictors, manipulate them, and try to squeeze better predictive value out of them. This is no better than suggesting that, since you've installed new brakes on your car, you no longer are at risk for a car accident. It may reduce risk, but there are too many other variables that have nothing to do with your new brakes. Likewise cholesterol ratios.

Aspirin, Lipitor, and a low-fat diet

17. April 2009 William Davis (0)

Despite all the hoopla heart disease receives in the media, I continue to marvel at how many people I meet who still think that aspirin, Lipitor, and a low-fat diet constitute an effective heart attack prevention program.

It doesn't. No more than washing your hands prevents all human infections. It helps, but it is a sad substitute for a real prevention program.

Of course, aspirin, Lipitor, and a low-fat diet is the same recipe followed by the unfortunate Tim Russert and his doctors. You know how that turned out. Mr. Russert's experience is far from unique.

What is so magical about aspirin, Lipitor and a low-fat diet?

There is a simple rationale behind this approach. Aspirin doesn't reduce atherosclerotic plaque growth, but it inhibits the propagation of a blood clot on top of a coronary plaque that has "ruptured," thereby reducing likelihood of heart attack (which occurs when the clot fills the artery). So aspirin only provides benefit if and when a plaque ruptures.

Lipitor and other statin drugs reduce LDL cholesterol, promote a modest relaxation of constricted plaque-filled arteries (normalization of endothelial dysfunction), and exerts other effects, such as inflammation suppression.

A low-fat diet is intended to reduce saturated fat that triggers LDL cholesterol formation and to encourage intake of whole grains that reduce cardiovascular events and LDL cholesterol.

If that is the extent of your heart disease prevention program, you will have a heart attack, bypass surgery, or stent--period. It may not be tomorrow or next Friday, or even next month. Aspirin, Lipitor, and a low-fat diet may delay your heart attack or procedure for a few years, but it will not stop it.

Some flaws in the aspirin, Lipitor, low-fat program:

--Aspirin can only exert so much blood clot-blocking effect. It can be overwhelmed by many other factors, such as increased blood viscosity, increased fibrinogen (a blood clotting protein that also triggers plaque), and plaque inflammation.
--Lipitor reduces LDL, but does not discriminate between the relatively harmless large LDL and the truly plaque-triggering small LDL--it reduces all LDL, but small LDL can still persist, even at extravagant levels since neither aspirin nor Lipitor specifically reduces small LDL, while a low-fat diet increases small LDL.
--Low-fat diet--A diet reduced in fat and loaded with plenty of "healthy whole grains" will trigger increased small LDL (an enormous effect), c-reactive protein, high blood sugar, resistance to insulin, high blood pressure, and an expanding abdomen ("wheat belly").

Aspirin, Lipitor and a low-fat diet do not address:

--Vitamin D deficiency
--Omega-3 fatty acid deficiency and the eicosanoid path to inflammation
--High triglycerides
--Small LDL particles
--Distortions of HDL "architecture"
--Lipoprotein(a)--the worst coronary risk factor nobody's heard of
--Thyroid status

In other words, the simple-minded, though hugely financially successful, conventional model of heart disease prevention is woefully inadequate.

Don't fall for it.

Statin drugs for everybody?

17. April 2009 William Davis (10)

Who is better off?

John takes Crestor, 40 mg per day:

LDL cholesterol 60 mg/dl
HDL cholesterol 60 mg/dl
Triglycerides 60 mg/dl
Total cholesterol 132 mg/dl

Or Sam:

LDL cholesterol 60 mg/dl
HDL cholesterol 60 mg/dl
Triglycerides 60 mg/dl
Total cholesterol 132 mg/dl

who obtained these values through vitamin D normalization (to increase HDL); wheat elimination (to reduce triglycerides and LDL); and omega-3 fatty acids (to reduce triglycerides).

Believe the drug industry (motto: If some statin is good, more statin is better!), then John is clearly better off: He has obtained all the "benefits" of statin drugs. They refer to the "pleiotropic" effects of statin drugs, the presumed benefits that extend outside of cholesterol reduction. The most recent example are the JUPITER data that demonstrated 55% reduction in cardiovascular events in people with increased c-reactive protein (CRP). Media reports now unashamedly gush at the benefits of Crestor to reduce inflammation.

However, on Sam's program, elimination of wheat and vitamin D both exert anti-inflammatory effects on CRP, typically yielding drops of 70-90%--consistently, rapidly, and durably.

So which approach is really better?

In my experience, there is no comparison: Sam is far better off. While John will reduce his cardiovascular risk with a statin drug, he fails to obtain all the other benefits of Sam's broader, more natural program. John will not enjoy the same cancer protection, osteoporosis and arthritis protection, relief from depression and winter "blues," and increased mental and physical performance that Sam will.

If our goal is dramatic correction of cholesterol patterns and reduction of cardiovascular risk, for many, many people statin drugs are simply not necessary.

No BS weight loss

13. April 2009 William Davis (18)

If there's something out there on the market for weight loss, we've tried it. By we, I mean myself along with many people and patients around me willing to try various new strategies.

Maybe you say: "Well that's not a clinical trial. How can we know that there aren't small effects?"

Who cares about small effects? If a weight loss strategy causes you to lose 1.2 lbs over 3 months--who cares? Sure, it may count towards a slight measure of health in a 230 lb 5 ft 3 inch woman. But it is insufficient to engage that person's interest and keep them on track. That little result, in fact, will discourage interest in weight loss and cause someone to return to previous behaviors.

What I'm talking about is BIG weight loss--20 lbs the first month, 40 lbs over 4 months, 50-60 lbs over 6 months.

Right now, there are only three things that I know of that yield such enormous effects:

1) Elimination of wheat, cornstarch, and sugars

2) Thyroid normalization (I don't mean following what the laboratory says is "normal")

3) Intermittent fasting

Combine all three in various ways and the results are accelerated even more.

Self-directed health is ALREADY here

12. April 2009 William Davis (12)

It can't happen.

People are too stupid/ignorant/lazy or simply don't care.

It is irresponsible. People will misuse, abuse, misdiagnose, fail to recognize all manner of medical conditions.

It's all true. Most of the medical establishment believes it. And it is self-fulfulling: If you believe it, it will happen.

But it's not true for everybody. If readers of this blog, for instance, were to view the conversations we have in our Track Your Plaque Forum, you would immediately recognize that we have a following that is more sophisticated and knowledgeable about coronary heart disease than 90% of cardiologists. That is really something. Perhaps they can't put in a stent or defibrillator, but they understand an enormous amount about this disease we are all trying to control and reverse, sufficient to seize control over much of their own healthcare for this process and related conditons.

Anyway, self-directed health is already here. And it's happening on an incredible scale.

Witness:

--Nutritional supplements--Now a $21 billion (annual revenues) phenomenon, booming sales of nutritional supplements are a powerful testimonial to the enthuasiasm of the public for self-directed health treatments. Sure, there are plenty of junk supplements out there, but there are also many spectacularly effective products. Information, not marketing, will help tell the difference. Over the long-run, the truth will win out.

The 1994 Dietary Supplement Health and Education Act has allowed the definition of “nutritional supplement” to be stretched to the limit. "Nutritional supplements" includes obviously non-nutritional (though still potentially interesting) products like the hormones pregnenolone, dehydroepiandrosterone (DHEA), and melatonin to be sold on the same shelf as vitamin C. There are also amino acids, polysaccharides, minerals and trace minerals, herbal preparations, flavonoids, carotenoids, antioxidants, phytonutrients.

In fact, I believe that the nutritional supplement pipeline is likely to yield far more exciting and effective products than the drug research pipeline! And you will have access to all of it--without your doctor's involvement.

--Self-ordered laboratory testing--In every state except New York and California, an individual can obtain his or her own laboratory testing. New services are appearing to service this consumer segment. As more people become frustrated with the silly gatekeeping function of their primary care physician and as more people gain more control over some of their healthcare dollars through medical savings accounts, flex-spending, and high-deductible health insurance, more are shopping for cost-saving, self-ordered lab testing. Even at-home lab tests are becoming available, such as ZRT Lab tests we make available through Track Your Plaque.

(In California, a doctor's order, or an order from a health professional allowed to prescribe, is still required which, for most people, is just a formality. Just ask your doctor to sign the form with the tests you'd like. Only the most cretinous of physicians will refuse, in which case you should say goodbye. New York is the only state in the U.S. that still dunks women to see if they float, divines the entrails of sacrificial cows, and prohibits lab self-testing.)

--Self-ordered medical imaging--Heart scans, full body scans; ultrasound screening for abdominal aneurysms, carotid disease, osteoporosis such as that offered by LifeLine Screening (who does a great job). There's plenty of room here for entrepreneurial types to develop new services, though there will also be battles to fight with hospitals, radiologists, and others invested in the status quo. But it is happening and it will grow.

(By the way, since I've previously been accused of making bundles of money from medical imaging: I have never--NEVER--owned and do not currently own any medical imaging facility.)

So the question is not "will it happen?" It is already happening. The question is how fast will it grow to include a larger segment of the public? How much more of conventional healthcare can it include? How can we develop better unbiased information sources, untainted by marketing, that guide people through the maze of choices?

Fire your stockbroker, fire your doctor

11. April 2009 William Davis (10)

Is it yet time to fire your doctor?

I advocate a model of self-directed health, a style of healthcare in which individuals have the right to direct his or her own healthcare with only the occasional assistance of a physician or healthcare provider.

Healthcare would not be the first industry that converted to such a self-directed model. Remember travel agents? Only 15 years ago, making travel plans meant calling your travel agent to book your arrangements. This was a flawed system, because they worked on commission, thereby impairing incentive to search for the best prices. You were, in effect, at their mercy.

The investment industry is another such example, though on a larger scale.

Up until the 1980s, individual investment was managed by a stockbroker or other money manager. Stockbrokers, analysts, and investment houses commanded the flow of investment in stocks, options, futures, commodities, etc. Individuals lacked access to the methods and knowledge that allowed them to manage their own portfolios. Individuals had no choice but to engage the services of a professional investor. This was also a flawed system. Like travel agents, stockbrokers worked on commission. We've all heard horror stories in which stockbrokers churned accounts, making thousands of dollars in commissions while their clients' portfolios shrunk.

That has all changed.

Today, the process has largely converted to discount brokers and online services used by individuals trading and managing their own portfolios. Stockbrokers and investment houses continue, of course, but are competing for a shrinking piece of the individual investment market. Independent investors now have access to investment tools that didn’t even exist 20 years ago. Companies like E-Trade and Ameritrade now command annual revenues of approximately $2 billion each.

Travel agents, stockbrokers . . . is healthcare next? Can we convert from the paternalistic, “I’m-the-doctor, you’re the patient” relationship to what in which you self-direct your own healthcare and turn to the healthcare system only in unique situations?

I believe that the same revolution that shook the investment industry in the 1980s will seize healthcare in the future. In fact, the transition to self-directed health will dwarf its investing counterpart. It will ripple more broadly through the fabric of American life. Health is a more complicated “product,” with more complex modes of delivery, and more varied levels of need than the investment industry.

I predict that the emergence of health directed by the individual, just as the emergence of self-directed investment, will dominate in the coming years.

While I hope you've already fired your stockbroker, and I doubt that anyone on the internet still uses a travel agent, I wouldn't yet fire your doctor altogether. But I believe that we are approaching a time in which you should begin to take control over your own health and begin to reduce reliance on doctors, drugs, and hospitals.

Blast small LDL to oblivion

4. April 2009 William Davis (21)

Here's a graphic demonstration of the power of wheat elimination to reduce small LDL particles, now the number one cause for heart disease in the U.S.

Lee had suffered a stroke due to an atherosclerotic plaque in a brain artery. She also had plenty of coronary plaque with a heart scan score of 322.

Lee began with an LDL particle number (the "gold standard" for measuring LDL, far superior to conventional calculated LDL) of 2234 nmol/L. This is exceptionally high, the equivalent of an LDL cholesterol of 223 mg/dl (drop the last digit). Of this 2234 nmol/L, 90% were abnormally small, with 1998 nmol/L of small LDL particles.

Lee eliminated wheat products from her diet, as well as cutting out sugars and cornstarch. Six months later, her results:

LDL particle number: 1082 nmol/L--a 52% reduction from the starting value and equivalent to an LDL of 108 mg/dl. Small LDL: zero--yes, zero.

In other words, 100% of Lee's LDL particles had shifted to the more benign large LDL simply with elimination of these foods---NO statin drug. (In addition to wheat elimination, she was also taking vitamin D and omega-3 fatty acids at our recommended doses.)

While not everybody responds quite so vigorously due to genetic variation, nor does everyone try as hard as Lee did to eliminate the foods that trigger small LDL, her case provides a great illustration of the power of this strategy.

Buy local, get a goiter

3. April 2009 William Davis (19)

The notion of buying food locally--"buy local"--i.e., food produced in your area, state, or region, is catching on.

And for good reason: Not only do you support your local economy, buying locally saves energy, since food doesn't have to be transported from South America or other faraway locations.

But what about those of us in the Midwest, particularly around the Great Lakes basin, i.e., the region previously known as the "goiter belt"? In the early 20th century, up to a third of the residents of this region had enlarged thyroid glands, or goiters, due to iodine deficiency. Lack of iodine causes the thyroid to enlarge, or "hypertrophy," in an effort to more efficiently extract any available iodine in the blood.

Well, there's been a resurgence of iodine deficiency nationwide with 11.3% of the population severely deficient, representing a four-fold increase since the 1970s.

Why an iodine deficiency? Because more people are avoiding iodized salt, the principal source of iodine for Americans since the FDA introduced its voluntary program for iodization of table salt back in 1924. Approximately 90% of the patients I ask now declare that they use very little iodized table salt. While a few take multimineral or multivitamin supplements that contain iodine, the majority do not. The globalization of the food supply--eat global--however, has softened the blow, since we eat tomatoes from Mexico, blueberries from Argentina, lettuce from the Salinas Valley of California.

Now, we have the growing trend to eat local. In the Midwest, it means that the vegetables, fruits, and meats grown locally will also be iodine depleted, since the soil is also iodine-poor, being so far from the sea.

Ironically, two healthy trends--avoiding salt and eating local--will be accounting for a surge in unsightly neck bulges in the Midwest, as well as an increase in thyroid disease.

The lesson: Avoid salt, eat local, but mind your iodine.

Self-directed thyroid management

2. April 2009 William Davis (9)

Is there an at-home test you can do to gauge thyroid status?

Yes. Measure your temperature.

Unlike a snake or alligator that relies on the sun or its surroundings to regulate body temperature, you and I can internally regulate temperature. The hypothalamus-pituitary-thyroid glands are the organs involved in thermoregulation, body temperature regulation. While the system can break down anywhere in the sequence, as well as in other organs (e.g., adrenal), the thyroid is the weak link in the chain.

Thus, temperature assessment can serve as a useful gauge of thyroid adequacy. Unfortunately, temperature measurement as a reflection of thyroid function has not been well explored in clinical studies. It has also been subject to a good deal of unscientific discussions.

How should temperature be measured? The temperature you really desire is between 3 am and 6 am, while still asleep. However, this is difficult to do, since it would require your bed partner to surreptitiously insert a thermometer into some body orifice without disturbing you. A practical solution is to measure temperature first upon arising in the morning, before drinking water, coffee, making the bed, etc.--immediately.

While traditionalists (followers of Dr. Broda Barnes, who first suggested that temperature reflects thyroid function) still advocate axillary (armpit) temperatures, in 2009 it is clear that axillary temperatures are unreliable. Axillary temperatures are inconsistent, vary substantially with the clothing you wear, vary from right to left armpit, ambient temperature, sweat or lack of sweat, and other factors. It also can commonly be 2-3 degrees Fahrenheit below internal ("core") temperature and does not track with internal temperatures through the circadian rhythms of the day (high temperature early evening, lowest temperature 3-6 am).

Rectal, urine, esophageal, tympanic membrane (ear), and forehead are other means to measure body temperature, but are either inconvenient (rectal) or require correction factors to track internal temperature (e.g., forehead and ear). For these reasons, we use oral temperatures. Oral temperatures (on either side of the underside of the tongue) are convenient, track reasonably well with internal temperatures, and are familiar to most people.

Though there are scant data on the distribution of oral temperatures correlated to thyroid function, we find that the often-suggested cutoff of 97.6 degrees Fahrenheit, or 36.4 C, seems to track well with symptoms and thyroid laboratory evaluation (TSH, free T3, and free T4). In other words, oral temp <97.6 F correlates well with symptoms of fatigue, cold hands and feet, mental fogginess, along with high LDL cholesterol, all corrected or improved with thyroid replacement and return of temperature to 97.6 F.

But be careful: There are many factors that can influence oral temperature, including clothing, season, level of fitness, "morningness" (morning people) vs. "nightness" (night owls), relation to menstrual cycle, concurrent medical conditions.

Also, be sure that your thermometer can detect low temperatures. Just because it shows low temperatures of, say 94.0 degrees F, doesn't mean that it can really measure that low. If in doubt, dip your thermometer in cold water for one minute. If an improbable temperature is registered, say, 97.0 F, then you know that your device is incapable of detecting low temps.

A full in-depth Special Report on thermoregulation will be coming soon on the Track Your Plaque website.

All posts by william-davis

America: The world’s diet laboratory

23. October 2007 William Davis (14)

Low-fat, low-carb, high-protein, Pritikin, Ornish, Atkins, South Beach, Sonoma, Sugar-Busters, Weight Watchers, vegetarian . . . Have Americans tried them all?

We’ve witnessed the relative success of diet habits in selected regions world-wide: the longevity of the Japanese on a spare soy and fish-based diet; the reduced heart disease incidence of the French despite an indulgent food-centered culture; the extreme heart disease-free lives of the Cretan Greeks.

Contrast this with the startling failure of the American diet experiment: We’re all (speaking for the collective whole) fat, diabetic, and miserably mired in the diseases of obesity. We’ve experimented with every possible iteration of diet from grapefruit or cabbage only, to calorie deprivation (a al Weight Watchers), to restricting this or that element of diet. The “official” organizations have made their contributions, as well: the American Heart Association’s Therapeutic Lifestyle Changes (formerly Step I and II diets), a program eerily similar to what Americans are already eating and resulting in failure; the American Diabetes Association diet, incomprehensibly embracing carbohydrates when they are the root of the nutrition-habit-gone-wrong that caused the disease in the first place; the USDA and their Food Pyramid, encompassing a design that contains the germ of wisdom but is so heavily overweighted in grains that it is a sure-fire way to increase weight and heart disease were you to follow their recommendations.

What have we learned from our grand experiment, our nationwide misadventure in nutrition?

I believe that we’ve learned how not to eat: Processed snack foods, meals delivered in a fast-food setting with the offer to “super-size” your order, make-believe food ingested in your car eaten for the sake of staving off the inevitable hunger pangs. Few would argue that these are certain paths to obesity and poor health.

Certainly, if we’ve learned how not to eat, can we extrapolate just how to eat? And not just for weight loss, since most diets focus just on that, but on health, particularly heart health?

If Americans have so far failed to learn the lessons of the nutritional world, we certainly have not failed at talking about it. From books to blogs, websites, information gurus to infomercials, we certainly celebrate the capacity to share our experiences, our grief over our nutritional “misfortune,” despite a world of plenty.

Yet we swim in a sea of information. Can we sift through the chaff to discover the essential truth?

Let me articulate an extreme (extreme meaning closer to the truth, I hope) interpretation of nutritional wisdom:

--If it requires a label or nutritional analysis, reject it. The wondrous green pepper, or bottle of olive oil, for instance, require no such qualifications. Some exceptions: milk, yogurt, cottage cheese (unless, of course, you purchase straight from a local producer). I am always impressed with the contortions and frustrations people experience trying to decipher labels. Ironically, the healthiest foods don’t even require labels.

--If it is ingested in a rush, it’s likely to add to poor health. True food is meant to be consumed at leisure, not in haste to satisfy some irrational, unthinking impulse.

--Search for natural, whole foods. Natural, whole foods require no marketing. You pay a premium for a company to adorn a product with glitz, glamour, and appeal. Repackage Cocoa Puffs as chocolate flavored, round overly-processed wheat flour, sans marketing spin, and what is left? Processed foods are?intentionally?addictive. They are added to, modified, high-fructose corn syruped, etc. to increase desirability, but also create addiction. Eliminate them just as a smoker eliminates cigarettes.

--A corollary to the above issue: purchase foods that appear as if you had grown it or raised it yourself. If you were to grow corn in your backyard garden, you would eat it on the cob or some similar way. You would not grind it, pulverize, process it, nor serve it as cornstarch and add to a pile of chemicals to make breakfast cereal. Eat foods in their natural state, not the highly processed food-product that requires a colorful package and advertising to sell.

--Don’t keep bags of chips, boxes of breakfast cereal and crackers, frozen dinners, all “just in case.” Don’t allow yourself that opportunity because you will more than likely seize it. An alcoholic who keeps a secret bottle of gin hidden in the cabinet is well aware that it’s there and will eventually give in to impulse.

--When you eat meat, try to find free-range, organic products. Even better, purchase from a local producer who you trust.

--For anyone with patterns like low HDL, small LDL, high triglycerides, and blood sugar >100 mg/dl, following a diet that is as free of wheat products as possible will yield enormous benefits. Wheat is a part of all breads, virtually all breakfast cereals, pretzels, crackers, bagels, cookies, cupcakes, pancakes, waffles, etc. Going wheat-free is also a surprisingly effective weight loss strategy.

That’s just a few thoughts. The approach we use in the Track Your Plaque program helps achieve weight loss, but also helps correct lipoprotein patterns, often dramatically.

Many diets have failed to keep pace with the changing nutritional habits of Americans. In 1960, we ingested close to zero high-fructose corn syrup. We’re now approaching 80 lbs per year per American. Breakfast cereal in 1950 consisted of a handful of products, eaten intermittently; today, it is a staple with enough products to fill a modern supermarket’s entire aisle. Meats have changed, thanks to the factory farm phenomenon feeding its animals corn in inhumanely restricted conditions, a dietary shift for livestock that has modified the fat composition to something far different than 50 years ago, not to mention the antibiotics and other chemicals used to accelerate growth and fight off infection from the artificial, overcrowded conditions.

The American nutritional shift, along with rampant obesity, have also caused a relatively new cause of coronary heart disease to explode: small LDL particles. The contribution of small LDL has been enormously underestimated, since most physicians don’t know what it is, don’t know how to check for it, and don’t know what to do with it. Yet it has emerged as the number one cause for heart attack and heart disease nationwide.

Stay tuned for our rewritten New Track Your Plaque diet to be released as a Special Report on the www.cureality.com website in future.

Dr. Jarvik, is niacin as bad as it sounds?

20. October 2007 William Davis (5)

A popular health newsletter, Everyday Health, carried this headline:

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 choleseterol.

At doses way above the Recommended Dietary Allowance — say 1,000–2,500 mg a day (1–2.5 grams) — crystalline nicotinic acid acts as a drug instead of a vitamin. It can reduce total cholesterol levels by up to 25%, lowering LDL and raising HDL levels, and can rapidly lower the blood level of triglycerides. It does so by reducing the liver’s production of VLDL, which is ordinarily converted into LDL.

I'd agree with that, except that it is rare to require doses higher than 1000-1500 mg per day unless you are treating lipoprotein(a) and using niacin as a tool for dramatic drops in LDL. But for just raising HDL, shifting HDL into the healthy large class, reducing small LDL, and for reduction of heart attack risk, 1000-1500 mg is usually sufficient; taking more yields little or no further effect.

But after that positive comment comes this:

Niacin is safe — except in people with chronic liver disease or certain other conditions, including diabetes and peptic ulcer. . . 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.

Strange. After a headline clearly designed to pull readers in, clearly stating niacin's benefits, the article then proceeds to scare the pants off you with side-effects.

But look to the side and above the text: Ah . . . two prominent advertisements for Lipitor, complete with Dr. Robert Jarvik's photo. "I've studied the human heart for a lifetime. I trust Lipitor to keep my heart healthy."

Niacin bad. Lipitor good. Even celebrity doc says so. Sounds like bait and switch to me. "You could try niacin--if you dare. But you could also try Lipitor."

Who is Dr. Jarvik, anyway, that he serves as spokesman (or at least figurehead) for this $13 billion dollar a year drug? Of course, he is the 1982 inventor of the Jarvik artificial heart, surely an admirable accomplishment. But does that qualify him to speak about heart disease prevention and cholesterol drugs?

Jarvik has never--never--actually prescribed Lipitor, since he never completed any formal medical training beyond obtaining his Medical Doctor degree, nor has he ever had a license to practice medicine. He does, however, continue in his effort to provide artificial heart devices, principally for implantation as a "bridge" to transplantation, i.e., to sustain a patient temporarily who is dying of end-stage heart failure.

So where does his expertise in heart disease prevention come from? It's beyond me. Perhaps it was the thousands of dollars likely paid to him. That will make an "expert" out of just about anybody.

Robert Bazell, science reporter, for CNBC, made this report on the Jarvik-Lipitor connection in his March, 2007 report, Is this celebrity doctor's TV ad right for you?

Mr. Bazell writes:

On May 16, 1988, an editorial in the New York Times dubbed the artificial heart experiments, “The Dracula of Medical Technology.”

“The crude machines,” it continued, “with their noisy pumps, simply wore out the human body and spirit.”

Since then, in a series of start-up companies, Jarvik has continued his quest to make an artificial heart — as have several other firms. One competitor recently won FDA approval to sell its device for implantation in extreme emergencies.

Perhaps Jarvik’s chances of success with another artificial heart account for his willingness to serve as pitchman for Pfizer. I inquired, without success, to find the going rate for a semi- celebrity like Jarvik to appear in such ads. Thomaselli of Advertising Age said whatever it is, it is “infinitesimal” compared to Pfizer’s expenditures of $11 billion a year on advertising, much of it for Lipitor.

Why spend so much marketing Lipitor?

Because Lipitor is only one of six drugs in the class called statins that lower cholesterol. Many cardiologists say that for the vast majority of people any one of these drugs works just as well as the other. Two of them, Mevacor and Zocor, have already lost their patent protection so they cost pennies a day compared to $3 or more a day for Lipitor.

In 2010, when Lipitor loses its patent protection, it, too, will cost pennies a day, and Pfizer will no longer need Dr. Robert Jarvik.

So, is niacin so bad after all? Or is this Everyday Health report just another clever piece of advertising for Pfizer?

Is niacin as bad as it sounds?

20. October 2007 William Davis (0)

A popular health newsletter, Everyday Health, carried this headline:

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 choleseterol.

At doses way above the Recommended Dietary Allowance — say 1,000–2,500 mg a day (1–2.5 grams) — crystalline nicotinic acid acts as a drug instead of a vitamin. It can reduce total cholesterol levels by up to 25%, lowering LDL and raising HDL levels, and can rapidly lower the blood level of triglycerides. It does so by reducing the liver’s production of VLDL, which is ordinarily converted into LDL.

I'd agree with that, except that it is rare to require doses higher than 1000-1500 mg per day unless you are treating lipoprotein(a) and using niacin as a tool for dramatic drops in LDL. But for just raising HDL, shifting HDL into the healthy large class, reducing small LDL, and for reduction of heart attack risk, 1000-1500 mg is usually sufficient; taking more yields little or no further effect.

But after that positive comment comes this:

Niacin is safe — except in people with chronic liver disease or certain other conditions, including diabetes and peptic ulcer. . . 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.

Strange. After a headline clearly designed to pull readers in, clearly stating niacin's benefits, the article then proceeds to share the pants off you with side-effects.

But look to the side and above the text: Ah . . . two prominent advertisements for Lipitor, complete with Dr. Robert Jarvik's photo. "I've studied the human heart for a lifetime. I trust Lipitor to keep my heart healthy."

Sounds like bait and switch to me. "You could try niacin--if you dare. But you could also try Lipitor."

Who is Dr. Jarvik, anyway, that he stands as the spokesman (or at least figurehead) for this $13 billion dollar a year drug. Of course, he is the 1982 inventor of the Jarvik artificial heart, surely an admirable accomplishment. But does that qualify him to speak about heart disease prevention and cholesterol drugs? Jarvik has, never actually prescribed Lipitor, since he never completed any formal medical training beyond obtaining his Medical Doctor degree, nor has he ever had a license to practice medicine. He does, however, continue in his effort to provide artificial heart devices, principally for implantation as a "bridge" to transplantation, i.e., to sustain a patient temporarily who is dying of end-stage heart failure.

So where does his expertise in heart disease prevention come from?

Omega-3 fatty acids: Frequency vs. quantity

20. October 2007 William Davis (8)

I believe I have been observing an unexpected phenomenon: When it comes to fish oil and omega-3 fatty acids, the frequency of dosing may be as important, perhaps more important, than the actual dose.

First of all, why advocate omega-3 fatty acids from fish oil? There’s a list of lipid/lipoprotein reasons, including reduction of triglycerides and triglyceride-containing particles (VLDL, intermediate-density lipoproteins), reduction of small LDL, and increase in HDL. There’s also solid benefit in reduction of heart attack risk, reduction in death from heart attack, and reduction in stroke. There are also anti-inflammatory benefits and improvements in mood, reduction in depression.

Fish oil is a crucial ingredient in the Track Your Plaque program. I am honestly uncertain of just how much success we would give up if fish oil were NOT a part of the program, but I am unwilling to find out. The data are simply too compelling to not include omega-3 fatty acids from fish oil. Of course, supplementation of omega-3 fatty acids assumes greater importance in a modern world in which your food has become terribly depleted of the omega-3 fraction of oils. (Cultures that rely heavily on fish or wild game probably would not benefit to the same extent, since these foods contain omega-3 fatty acids.)

But I believe I have observed a curious effect over the past year or two. With the proliferation of many different preparations of fish oil that provide seemingly endless choices—low-potency fish oil, high-potency fish oil, paste forms of fish oil like Coromega, liquids such as Carlson’s, etc.¾I’ve observed that frequency of dosing may exert as much of an effect as the dose.

For example, someone might take the basic, low-potency preparation like Sam’s Club that contains 180 mg EPA and 120 mg DHA per capsule, four capsules per day. That yields a total of 1200 mg EPA and DHA per day. This is our minimum dose that provides the basic heart attack-reducing effect, though with modest effect on triglycerides and associated patterns.

Say someone switches to a high-potency preparation of 360 mg EPA and 240 mg DHA, providing a total of 600 mg omega-3 fatty acids per capsule, or twice the dose of the low-potency preparation. Would you expect double the effect?

Curiously, no. What I have observed, however, is that more frequent dosing may provide a larger effect. The least effective dosing is once per day; twice per day is far more effective. Three times per day¾though cumbersome¾provides even greater effect.

So, which is more important: dose or frequency?

I can’t say for certain, since my observations are informal and have not been obtained by a formal statistical analysis of our data. That will come with time.

For the present, suffice it to say that, if you are struggling with suppression of patterns like increased triglycerides, IDL, or low HDL, then at least twice- or three-times-per-day dosing might be worth considering, even before you increase the dose further.

Best: Greater dose, or higher-potency preparation, combined with higher frequency.

Lipoprotein testing

19. October 2007 William Davis (5)

This is an update of a post I made about a year ago. However, I'm reposting it since the question comes up so often.

How can I get my lipoproteins tested?
This question came up on our recent online chat session and comes up frequently phone calls and e-mails.

If lipoprotein testing is the best way to uncover hidden causes of coronary heart disease, but your doctor is unable, unknowledgeable, or unwilling to help you, then what can you do?

There are several options:

1) Get the names of physicians who will obtain and interpret the test for you. That’s the best way. However, it is also the most difficult. Lipoprotein testing, despite over a decade of considerable scientific exploration and validation in thousands of research publications, still remains a sophisticated tool that only specialists in lipids will use. But this provides you with the best information on you’re your lipoproteins mean.
2) If you don’t have a doctor who can provide lipoprotein testing and interpretation, go to the websites for the three labs that actually perform the lipoprotein tests: www.liposcience.com (NMR); www.berkeleyheartlab.com (electropheresis or GGE); www.atherotech.com (ultracentrifugation). None of them will provide you with the names of actual physicians. They can provide you with the name of a local representative who will know (should know) which doctors in your area are well-acquainted with their technology. I prefer this route to just having a representative identify a laboratory in your area where the blood sample can be drawn, because you will still need a physician to interpret the results¾this is crucial. The test is of no use to you unless someone interprets it intelligently and understands the range of treatment possibilities available. Don’t be persuaded by your doctor if he/she agrees to have the blood drawn but has never seen the test before. This will be a waste of your time. That’s like hoping the kid next door can fix your car just because he says he fixed his Mom’s car once. Interpretation of lipoproteins takes time, education, and experience.

3) Seek out a lipidologist. Lipidologists are the new breed of physician who has sought out additional training and certification in lipid and lipoprotein disorders. Sometimes they’re listed in the yellow pages, or you can search online in your area. One drawback: Most lipidologists have been heavily brainwashed by the statin industry and tend to be heavy drug users.

4) Contact us. I frankly don’t like doing this because I feel that I can only provide limited information through this method and, frankly, it is very time consuming. I provide a written discussion of the implications and choices for treatment with the caveat to discuss them with your doctor, since I can’t provide medical advice without a formal medical relationship. We also charge $75 for the interpretation. But it’s better than nothing.

5) Make do with basic testing. Basic lipids along with a lipoprotein(a), C-reactive protein, fibrinogen, and homocysteine would provide a reasonable facsimile of lipoprotein testing. You’ll still lack small LDL and postprandial (after-eating) information, but you can still do reasonably well if you try to achieve the Track Your Plaque targets of 60-60-60. It’s sometimes a necessary compromise.

Our discussions on the Track Your Plaque Forum have impressed me with the difficulty many people encounter in getting lipoproteins drawn and interpreted. Some of our Members have been very resourceful identifying blood draw laboratories around the country, such as Lab Safe, that will at least provide the blood draw service.

I wish it was easier and we are working on some ideas to facilitate this nationwide. It will take time.

In 20 years, this will be a lot easier when doctors more commonly use lipoprotein testing. But for now, you can still obtain reasonably good results choosing one of the above alternatives.

Is it exercise or diet?

18. October 2007 William Davis (7)

Wayne, a 61-year old retired school superintendent, had been an exercise fanatic all his adult life. If not running long distances and occasional marathons, he'd bike up to 70 miles a day. He did this year-round. In cold weather, he set his bicycle up on an indoor device and also ran on a treadmill and added weight training.

That's why it was kind of surprising that he sported a large belly. At 5 ft 8 inch and 190 lbs, that put his Body Mass Index (BMI) also high at 28.8 (desirable <25). You'd think that vigorous, almost extreme, exercise like this would guarantee a slender build.

Wayne also had lipoproteins to match: triglycerides 205 mg/dl, LDL 176 mg/dl but LDL particle number much higher at 2403 nmol/l (an effective LDL of 240 mg/dl); 75% of LDL particles were small.

I asked Wayne about his diet. "I eat healthy. Cheerios for breakfast usually. Some days I'll skip breakfast. Lunch is almost always a sandwich: tuna, turkey, something like that on whole wheat bread or a whole wheat bagel. Chips, too, but I guess that's not too healthy. Dinners vary and we eat pretty healthy. Almost never pizza or junk like that."

"Pasta?" I asked.

"Oh. sure. Two or three tiems a week. Always whole wheat. With a salad."

Wayne was well aware of the conventional advice for whole grains and, indeed, had been trying to increase his intake, particularly since his basic cholesterol numbers had been high in past. To his surprise, the more he tried at diet, the more LDL seemed to go up, as did triglycerides.

I see this situation every day: The obsession with processed carbohydrate foods, worsened by the message perpetuated by the American Heart Association, the USDA Food Pyramid, Kraft, Kelloggs, Post, etc. Eat more fiber, eat whole grains.

NY Times columnist, Jane Brody, chronicles her (embarassing) mis-adventure following the same mis-guided advice in Cutting Cholesterol, an Uphill Battle.

According to the USDA Food Pyramid, Wayne is not getting enough grains and whole grains, particularly since he is highly physically active. Consistent with the message given by the food industry: "Eat more!"

The food industry-supported Whole Grain Council advises:

Whole Grains at Every Meal
The US Dietary Guidelines recommend meeting the daily requirement by eating three "ounce-equivalents" of breads, rolls, cereals or other grain foods made with 100% whole grains. A slice of bread or a serving of breakfast cereal usually weighs about an ounce.

Want an easier way to think about it? Just look at your plate at each meal, and make sure you've included some source of whole grains. That's why our slogan is "Whole Grains at Every Meal."

By this scheme, if you are overweight, it's because you lack fiber and you're too inactive. "Get up and go!" It's not the diet, they say, it's you!

See through this for what it is: Nonsense. Wayne was overweight, packing 20 extra pounds in his abdomen from his over-dependence on processsed carbohydrates--"whole grains"--not from inactivity.

Instant heart disease reversal

17. October 2007 William Davis (16)

What if reversal of heart disease--regression of coronary atherosclerotic plaque--were achievable instantly? Just add water and--voila!!

To my knowledge, it is not--yet. But I sometimes play with this idea in my head. I could imagine that such a program would consist of a few essential elements:

--A fast or semi-fast, or at least a very spare diet, over a period like 10 days to promote net catabolism. It is also supremely anti-inflammatory to restrict calories.

--High-dose vitamin D, e.g., 20,000 units per day of D3 to fully replenish depleted stores and achieve all the metabolism-correcting effects of D3 restoration.

--EPA + DHA at a higher than usual dose with frequent throughout-the-day dosing to encourage replacement of cellular lipid constituents with the more stable omega-3 fraction of fatty acids.

Beyond this, I'm uncertain. What role l-arginine, statins, niacin . . . conjugated linoleic acid? ApoA1 Milano infusions?

This is simply whimsical at this point. I don't know if such an approach would work. But if it did, you might imagine that it would offer an opportunity--for the properly motivated--as an alternative treatment for angina, advanced coronary disease, a means to pull someone back from the brink.

With the insights gained from our slow-but-powerful Track Your Plaque approach, perhaps we will also gain insights into how to accelerate such a process of reversal so that it is achievable in days, rather than months or years.

Whole wheat is brown

17. October 2007 William Davis (0)

The small LDL epidemic

16. October 2007 William Davis (24)

Ten years ago, small LDL was fairly common, affecting approximately 50% of the patients I'd see. For instance, an LDL particle number of 1800 nmol/l would be 40-50% small LDL in about half the people.

But in the last few years, I've witnessed an explosion in the proportion of people with small LDL, which now exceeds 80-90% of people. The people who show small LDL also show more severe patterns. 80-90% small LDL is not uncommon.

Why the surge in the small LDL pattern? Two reasons: 1) The extraordinary surge in excess weight and obesity, both of which favor formation of small LDL particles, and 2) over-reliance on processed carbohydrates, especially wheat-based convenience foods.

The constant media din that parrots such nonsense as the report on CNN Health website, Healthful Breakfast Tips to Keep You Fueled All Day, helps perpetuate this misguided advice. The dietitian they quote states:

"If you don't like what you're eating, you won't stick with it. If your choices aren't the most nutritious, small tweaks can make them more healthful. For example, if you have a sweet tooth in the morning, try a piece of nutty whole-grain bread spread with a tablespoon each of almond butter (it's slightly sweeter than peanut butter) and fruit preserves instead of eating foods that offer sweetness but little nutritional benefit, like doughnuts or muffins. If you enjoy egg dishes but don't have time to prepare your favorite before work, try microwaving an egg while toasting two slices whole wheat or rye (whole-grain) bread. Add a slice of low-fat cheese for a healthful breakfast sandwich that's ready in minutes. And don't overlook leftovers. If you feel like cold pizza (which contains antioxidant-filled tomato sauce, calcium-rich cheese, and lots of veggies), have it. It's a good breakfast that's better than no breakfast at all."

It sure sounds healthy, but it's same worn advice that has resulted in a nation drowning in obesity. The food choices advocated by this dietitian keep us fat. It also perpetuates this epidemic of small LDL particles.

If you have small LDL and its good friend, low HDL, it's time for elimination of wheat products, not some politically-correct silliness about increasing fiber by eating whole grains. Whole grains create small LDL! Or, I should say, what passes as whole grains on the supermarket shelves.

For some helpful commentary on this issue, see Fanatic Cook's latest post, Playing with Grains.

Mini-dose CTA?

15. October 2007 William Davis (11)

I caught this little news report in the online edition of Canyon News , an LA paper, under the title Cedars-Sinai Develops Test to Prevent Heart Attacks .

They report that Dr. Daniel S. Berman M.D., chief of Cardiac Imaging and Nuclear Cardiology at Cedars-Sinai, reports that a new method of performing CT coronary angiography, "mini-dose CTA," has been developed that allows both coronary calcium scoring as well as CT coronary angiography (CTA) at a dose as low as 10% of standard dose. No technical details were provided.

Now, that may be worth knowing more about. If this is true, then CTA may indeed be useful as a "screening" procedure. However, we are going to need to know more: What devices are capable of doing this, what settings on the devices were used, etc. It does indeed come from a reputable source in Dr. Dan Berman, who is well known in nuclear cardiology circles.

We will try and dig for info. Stay tuned.

A tan does not equal vitamin D

14. May 2008 William Davis (8)

The sun is getting stronger and the days are getting longer, even here in Wisconsin.

Some people are coming to the office with nice tans obtained by sunning themselves for several hours. Others have come back from winter getaways to Florida, Arizona, or the tropics, also sporting nice, dark tans.

Several people, in fact, were so confident that sunning themselves provided sufficient vitamin D that they reduced their usual dose. Some even stopped their vitamin D altogether.

But, when blood levels of 25(OH) vitamin D were checked, they were virtually all low, sometimes as low as <20 ng/ml. Yet all had nice tans.

Why does this happen? Why would people with dark tans remain deficient in vitamin D?

One big factor is age: Anyone over 40 years old is fooling themselves if they think that a tan ensures raising vitamin D levels to a desirable range. Also, the more you tan, the more melanin skin pigment accumulates, and the more vitamin D activation in the skin is blocked.

Weight is another factor: Heavier people need more vitamin D, sometimes three- or four-fold more than slender people.

Why does aging result in inefficient skin activation of vitamin D? It seems that, once we are beyond our reproductively useful years, this ticking clock of aging gets triggered. The older we get, the less activation of vitamin D occurs in our skin, the less of the youth-maintaining, disease-preventing benefits of vitamin D we obtain with sun exposure.

The message: Don't rely on a tan to gauge the adequacy of vitamin D. Maybe that works when you're 16 years old, but not at age 50 or 60. There's only one way to know your vitamin D status: a blood level of 25(OH) vitamin D.

Copyright 2008 William Davis, MD

Confessions of a former drug company patsy

12. May 2008 William Davis (0)

I admit it: In years past, I spoke for the drug industry.

In retrospect, I now regret it. In fact, I'm downright embarassed by it.

Planned obsolence

12. May 2008 William Davis (1)

In the 1960s, you’d purchase a new car. If you changed the oil, adhered to the maintenance schedule—and were lucky—you might expect to get 100,000 miles out of your automobile. Only an occasional car made it beyond that odometer hurdle. Even if the engine made it past the 100,000 mile milestone, the automobile body would inevitably start to develop rusting decay at the edges of the fenders, signaling body rot that threatened to open gaping holes of metal.

Then along came Toyota and Honda, whose cars easily reached 100,000 miles and well beyond, reliably and with bodies intact. As this realization sunk into the American consciousness, many asked, “Why can’t American automakers accomplish the same sort of trouble-free longevity?” “Buy American” emerged as a mantra to preserve American jobs and prop up an economy vulnerable to the superior automotive products from Detroit’s competitors.

Of course, American automakers have since responded to the challenge posed by the Japanese auto industry and produced automobiles that essentially matched the reliability and longevity of Japanese cars. But, the great unanswered question remains: For years before the onslaught of Japanese competition, did Detroit quietly plot to maintain a policy of planned obsolescence that ensured Americans would have to scrap the old and buy a new car every few years whenever the odometer tipped over 100,000 miles?

We will never know. At worst, it may represent the behind-closed-doors, back-slapping sort of plotting that, for many years, maximized revenues, ensured shareholder returns, and secured executive paychecks. Or, perhaps it wasn’t some evil conspiracy but just complacency, a profitable position of comfort at that. There’s little incentive for industry insiders to reveal such self-incriminating information.

But the example set by the American auto industry presents an unusual learning opportunity for us, a chance to make some useful comparisons to the heart healthcare industry.

Is the American healthcare industry also guilty of practicing a policy of “planned obsolescence,” just like Detroit? The product that helplessly crumbles is, of course, not your rust-riddled automobile, but you.

When someone sees a primary care physician year after year, yet appears one morning in the emergency room, clutching his or her chest in agony from the closed coronary artery responsible for a life-threatening heart attack—prompting the flurry of activity that results in $100,000 in hospital procedures . . .

Perhaps “planned obsolescence” is not the perfect phrase to describe the situation, but the principle still applies: A failure to inform the patient that such an outcome was possible—no, probable—makes you wonder whether such an outcome was predictable and thereby preventable in the first place.

What should we do when planned obsolescence leads us down a path engineered by someone who has something, often substantial, to gain? Even if it's just complacency, or adhering to a beaten, ineffective status quo (can you say "low-fat diet?), it all points in the same direction.

You have a choice: Refuse to buy a 1962 Impala of health care, otherwise known as conventional heart disease management.

Melatonin for high blood pressure?

10. May 2008 William Davis (15)

Melatonin is fascinating stuff.

In addition to its use as a sleep aid, melatonin exerts possible effects on cardiovascular parameters, including anti-oxidative action on LDL, reduction in sympathetic (adrenaline-driven) tone, and reduction in blood pressure.

Several studies document the blood pressure-reducing effect of melatonin:

Daily nighttime melatonin reduces blood pressure in male patients with essential hypertension.

Melatonin reduces night blood pressure in patients with nocturnal hypertension.

Prolonged melatonin administration decreases nocturnal blood pressure in women.

Blood pressure-lowering effect of melatonin in type 1 diabetes.

But blood pressure may be increased when melatonin is added to nifedipine, a calcium channel blocker:

Cardiovascular effects of melatonin in hypertensive patients well controlled by nifedipine: a 24-hour study.

Effects on BP tend to be modest, on the order of 5-8 mmHg reduction in systolic, half that in diastolic.

But don't pooh-pooh such small reductions, however, as small reductions exert mani-fold larger reductions in cardiovascular events like heart attack and stroke. NIH-sponsored NHANES data (see JNC VII), for example, document a doubling of risk for each increment of BP of 20/10. The Camelot Study demonstrated a reduction in cardiovascular events from 23% in placebo subjects to 16.7% in subjects taking amlodipine (Norvasc) with a 5 mm reduction in systolic pressure, 2 mmHg drop in diastolic pressure. Small changes, big benefits.

Many people take melatonin at bedtime and are disappointed with the effects. However, a much better way is to take melatonin several hours before bedtime, e.g., take at 7 pm to fall asleep at 10 pm. Don't think of melatonin as a sleeping pill; think of it as a sleep hormone, something that simply prepares your body for sleep by slowing heart rate, reducing body temperature, and reducing blood pressure. (You may need to modify the interval between taking melatonin and sleep, since individual responsiveness varies quite a bit.)

I also favor the sustained-release preparations, e.g., 5 mg sustained-release. Immediate-release, while it exerts a more rapid onset of sleep, allows you to wake up prematurely, The sustained-release preparations last longer and allow longer sleep.

The dose varies with age, with 1 mg effective in people younger than 40 years, higher doses of 3, 5, even 10 or 12 mg in older people. Sustained-release preparations also should be taken in slightly higher doses.

The only side-effect I've seen with melatonin is vivid, colorful dreams. Perhaps that's a plus!

The forces that shape heatlh care

8. May 2008 William Davis (5)

Thinking about the programs for health care reform proposed by the three Presidential candidates highlights a distinct peculiarity of American style health care.

American health care is shaped to an unprecedented degree by five forces:

1) The drug industry

2) The health insurance industry

3) Hospitals

4) Fear of litigation

5) The uniquely American attitude of refusing compromise in access to health care services or products, regardless of the cost (for those who can afford health insurance)

All five of these unique forces have created this thing (monster?) we call health care. Remove or modify any one of these forces, and the health care landscape would look dramatically different.

The drug industry has recently been on the receiving end of plenty of negative press. This warms my bones. Decades of heavy-handed lobbying, sleazy marketing to physicians (all too willing to be wined and dined), and behind-the-scenes manipulation of clinical data are coming back to bite them. Sadly, the drug industry is so powerful that this bit of fuss is not likely to substantially change their ways.

I am thrilled that all three Presidential candidates agree that reimportation of drugs from outside the U.S. is a good idea. While the shrug of the shoulders federal and state attitude towards importation of drugs from Canada has not resulted in cost savings sufficient to impact on overall costs, it surely will lead to savings when practiced on a broad basis by pharmacies, distributors, and other bulk buyers of pharmaceuticals.

Senator Obama, in particular, has used strong language in his criticism of the health insurance industry, tough talk that is needed in an age in which insurance executives bring home salaries in the hundreds of millions of dollars and stock prices are climbing due to substantial profit gains within the industry, going against the grain of increasingly costly premiums. However, the Clinton experiment of federalizing health care during Bill Clinton's term that caused all the big boys to band together (most notably health insurance companies and drug industry) has tempered enthusiasm for attacking the insurance industry head-on. In both Democrats' health care reform proposals, the option of private insurance is preserved, as it is in the McCain proposal.

How about hospitals? Hospitals, though on a smaller scale than the nationwide reach of the drug and insurance industries, aim to maintain health service delivery in hospitals. For instance, the high-tech bypass service in the hospital gets plenty of local media coverage, as does the newest DaVinci robotic surgery, bariatric surgery, and other revenue-rich services. Many hospitals have forgotten that their mission is delivery of health, of which revenue creation and profiting from disease should only be part.

How big is fear of litigation? Estimates vary, but several have quoted numbers in the neighborhood of 20 to 30% of overall health care costs. At the street level from what I see, I'd say at least that much. Fear of litigation is rampant, often unrestrained, and sometimes leads to the craziest, illogical sequence of testing. Chest pain, for instance, no matter how trivial, will typically trigger around $5000 worth of testing (nuclear stress test, echocardiogram, laboratory work, etc.) Emergency room visit for a minor injury? CT scan of head, chest, abdomen. A formula to minimize this aspect of fear in health care delivery would generate enormous savings.

The last issue, the uncompromising nature of Americans in health--always wanting the latest new drug, new procedure, "best" surgeon--often simply causes the health care consumer to fall victim to marketing. If a hospital advertises the newest procedure, people want it regardless of whether it represents genuine improvement over the older procedure. The newest sleeping pill, antidepressant, antihypertensive, etc. replaces the old yet equivalent product, but at considerably greater cost.

I am optimistic that, regardless of which candidate gains the White House, that some reform is on the way. I do fear, however, that progress will be small and incremental, since major change of the sort that would slash hundreds of billions of dollars in costs would rouse the powers-that-be (drug industry, health insurers, etc.) to once again combine forces and combat the disruption of their franchise.

Until you and I see real change and cost savings coming through either legislation or free market advances, we need to continue to make full use of the self-empowering health information that we gain through venues like the web.

Copyright 2008 William Davis, MD

Lipoprotein(a): Surprising Poll Results

6. May 2008 William Davis (5)

No doubt, our little informal poll asking readers whether they have lipoprotein(a), is skewed towards people inclined to respond because they have this genetic trait.

Nonetheless, the response is telling. Of 82 respondents:

--40 (48%) said they did have Lp(a)

--16 (19%) said that they did not have Lp(a)

--26 (31%) said that they did not know whether or not they had Lp(a)

Though admittedly an informal analysis, I'd draw several conclusions from this simple "experiment".

One, while the proportion of people responding that they have Lp(a) may not be accurate, it is a prevalent genetic risk factor that, according to formal studies, is present in 17% of people with coronary or vascular disease, 11% of the broader population. This number may be even higher if the newer particle number assays (measurements) are used (with results expressed in nmol/L), since an occasional person with a "normal" Lp(a) in mg/dl (weight-based) will prove to have increased Lp(a) by nmol/L (particle number-based). (The reason for this phenomenon is not clear. It may be consequent to variation in apo(a) size, with larger apo(a) varieties of Lp(a) occasionally escaping detection .) As our little poll shows, plenty of people have Lp(a).

Two, readers of this blog tend to be highly motivated, sophisticated, and knowledgeable about health and heart disease. Yet a substantial portion--31%--did not know whether they have this crucial risk factor. That shouldn't be. The unnecessary difficulty of getting this simple blood test performed has been driven home to me repeatedly when I identify this factor in someone and then suggest that their grown children and parents, each of whom have a 50% chance of having Lp(a), be tested. It's not uncommon for a 35-year old son, for instance, to say that his doctor refused, claiming it is an unproven risk marker, or to simply say that he/she doesn't know what it is.

No doubt, just knowing whether you have Lp(a) or not is not the end of the story. Reducing Lp(a) and its associated co-factors is no easy matter. With several hundred patients in my practice with Lp(a), it occupies much of my time and energy. Sometimes it leads to enormous successes , but it can also pose a real challenge.

There should no longer be any doubt that Lp(a) is associated with significantly increased risk of cardiovascular disease. This has been demonstrated conclusively across dozens of studies. Risk from Lp(a) is over and above that posed by other risk factors; it also amplifies the risk posed by other factors, e.g., small LDL, inflammatory phenemena, homocysteine, total LDL, low HDL.

In the world of Lp(a), our two most desperate needs for the future are:

1) Better education of physicians and the public, and

2) More effective treatment options.

Thus, our reasons to form The Lipoprotein(a) Research Foundation. Steps to gain tax-exempt status are being pursued as we speak.

I can't help but wonder whether, like vitamin D, a solution is right beneath our noses. An investment in research to fund the trials to better explore both basic science as well as practical treatment options might yield an answer more readily than we think. Wouldn't that be great?

Are endogenous nutritional supplements better?

4. May 2008 William Davis (6)

Just a muse.

Endogenous substances are those that are already contained within our bodies. They are part of basic human equipment.

Exogenous substances are those that come from outside of our bodies. This includes various substances in foods, drugs (most, though not all), and pesticides.

I often mull over all of the tools we use in the Track Your Plaque program to achieve control over this thing called coronary plaque. It struck me that just about all the supplements we use that seem to provide outsized benefits are all endogenous substances themselves:

--Omega-3 fatty acids from fish oil
--Vitamin D
--l-arginine
--Niacin (vitamin B3)

Many of the other substances, though not directly relevant to our plaque-control efforts, but are among the most effective nutritional supplements, also supplement endogenous levels: calcium pyruvate, creatine, acetylcarnitine, DHEA, testosterone, progesterone, growth hormone, pregnenolone, phenylalanine, tyrosine, melatonin, etc.

Curiously, most drugs are not meant to directly supplement endogenous levels, but are designed either to enhance or block an enzyme (e.g., acetylcholinesterase inhibitors that block breakdown of acetylcholine; HMG CoA reductase inhibitors to block cholesterol synthesis; angiotensin converting enzyme inhibitors to reduce blood pressure), to exert toxic effects on an organism (antibiotics, antivirals), or to exert an entirely unique effect that does not ordinarily occur in the human body (some anti-cancer drugs, for instance). (This is an admitted, vast over-simplification.)

That's not to say that any endogenous substance is desirable or safe when supplemented. Cortisol, thyroid hormone, and estrogens are three examples of endogenous substances that have downsides when administered at slightly more than physiologic concentrations.

Nonetheless, it makes me wonder if the world of endogenous substance supplementation has not been fully explored. Are there other endogenous substances that are as potent and wonderful, for instance, as vitamin D but not yet fully appreciated? I'm sure there are.

Vitamin D Newsletter reprinted

1. May 2008 William Davis (2)

Reprinted here is the unfailingly informative Vitamin D Newsletter from Dr. John Cannell. Although there's little here specifically about heart disease, there's so much great information about vitamin D that I thought most would still appreciate it.

The Vitamin D Newsletter

May, 2008

Yesterday's Washington Post article, Too-Good-To-Be-True Nutrient?, sums up the April 9th vitamin D symposium at UCSD in San Diego, which was nothing short of spectacular. Carole Baggerly outdid herself organizing it and explaining how she got involved. Make no mistake; Carole is both serious and energetic. She told about her efforts to introduce resolutions at upcoming meetings of various professional groups. Then she introduced the volunteers from the San Diego Black Nurses Association who made sure the conference went off without a hitch. Then Carole introduced the four speakers. The slides of each speaker are available at Grassroots Health.

Before I tell you the highlights of the conference, I'd like to tell you about another conference, this one in Germany, this May 17th and 18th. It is the Third International Symposium on Vitamin D Analogs in Cancer Prevention and Therapy. Readers know how I feel about giving analogs to vitamin D deficient patients instead of vitamin D but speakers include Michael Holick, Reinhold Veith, Bill Grant, Tai Chen, Heidi Cross, David Feldman, and Roger Bouillon, all of whom know the importance of the nutrient. Most of this conference is for scientists, not lay people. However, Michael Holick is the first speaker and if you have not heard his latest talk about vitamin D, it might be worth a trip to Germany.

The first San Diego speaker was Dr. William Grant. Since leaving NASA to begin a full-time career as a vitamin D researcher, Bill has published dozens of studies and has another dozen in the works. Using ecological studies (from Greek oikos, house + German -logie, study or studying your own house) of UVB irradiance and cancer, Bill reported that 15 cancers (colon, esophageal, gallbladder, gastric, pancreatic, rectal, small intestinal, bladder, kidney, prostate, breast, endometrial, ovarian, Hodgkin's lymphoma, and non-Hodgkin's lymphoma) are associated with lower UVB light. He concluded that 257,000 cancer deaths in 2007 in the USA were accounted for by inadequate vitamin D levels. Of course the problem with ecological studies is that it easy to be vitamin D deficient in Miami, all you have to do is listen to your doctor's advice and stay out of the sun. Recently, a group from the Arizona Cancer Center found almost 80% of Arizonians had levels below 30 ng/ml. So much for sunny spots.

Jacobs ET, et al. Vitamin D insufficiency in southern Arizona. Am J Clin Nutr. 2008 Mar;87(3):608-13.

The next speaker was Professor Cedric Garland. I found myself wondering how he did it. I became convinced that vitamin D prevents cancer five years ago. Cedric and his brother Frank and his colleague Ed Gorham knew it 30 years ago! I know what it is like to tell someone that vitamin D prevents cancer and see them think, "Here we go again, another miracle vitamin." I know what it is like to try and explain and watch people die unnecessarily. But I've only had that experience for five years. Cedric has dealt with that frustration for thirty years. Almost thirty years ago, Cedric and Frank Garland published evidence that vitamin D prevents cancer. In fact, it was Cedric's first publication. Thankfully, the paper was recently recognized as being so important that it was republished in 2006 by the International Journal of Epidemiology. You can read the entire paper for free by clicking on the second link below and then clicking on "free final text", courtesy of Oxford Journals.

Garland CF, Garland FC. Do sunlight and vitamin D reduce the likelihood of colon cancer? Int J Epidemiol. 1980 Sep;9(3):227-31.

Garland CF, Garland FC. Do sunlight and vitamin D reduce the likelihood of colon cancer? Int J Epidemiol. 2006 Apr;35(2):217-20.

Cedric began by showing the incidence of type-1 diabetes and multiple sclerosis by latitude. I had no idea that the latitudinal data was so strong for type 1 diabetes in children. This disease is almost nonexistent around the equator. Type-1 diabetes is but one of the three modern childhood epidemics caused by the sunlight-hating dermatologists, the other two, I think, are autism and asthma. Next he showed latitude and 25(OH)D levels, which reminded me to be suspicious of high levels, unless they use accurate methods of detecting 25(OH)D. Some methods used, even in this country, are over detecting vitamin D and telling patients their levels are above 50 ng/ml when they are, in reality, much lower. Cedric's data showed Thailand had mean levels of 70 ng/ml, which I doubt and suspect were due to inaccurate 25(OH)D tests. He then reviewed evidence of the 25(OH)D levels needed to prevent numerous cancers. The safest levels are somewhere above 50 ng/ml. Cedric spent most of his time presenting an entirely new theory of carcinogenesis, one dependent on vitamin D maintaining cellular junctions. I suspect this paper will also be reprinted in 20 years. The only disagreement I have is with his recommendation for cancer patients to start at fairly low doses. For reasons I recently explained, the risk benefit analysis indicates cancer patients should take 5,000 to 10,000 IU per day and they may have no time to lose. Why worry about the phantom of vitamin D toxicity if you may be dying of cancer? Just have your calcium checked along with frequent 25(OH)D levels. Get your levels up to 70-90 ng/ml if you have cancer.

Does vitamin D treat cancer?

The next speaker was Professor Bruce Hollis. He reviewed basic physiology of vitamin D and emphasized that the entire system is designed to deal with an excess not with an insufficiency of vitamin D. Numerous mechanisms are available in your body to prevent vitamin D toxicity but few are available to deal with insufficiency. Then he briefly mentioned one of the most important discoveries about vitamin D in the last few years, one where Professor Neil Binkley of the University of Wisconsin was senior author. (In the last four years, Professor Binkley has become a prolific vitamin D expert and I hope Carol Baggerly is able to get him to speak at some of the upcoming conferences she hopes to sponsor.) As I have pointed out before, Hollis and Binkley's crucial discovery was that the body doesn't start storing the parent compound, cholecalciferol, until 25(OH)D levels reach about 50 ng/ml. They showed, using basic steroid pharmacology, that 50 ng/ml should be considered the lower limit of adequate 25(OH)D levels.

Hollis BW, Wagner CL, Drezner MK, Binkley NC. Circulating vitamin D3 and 25-hydroxyvitamin D in humans: An important tool to define adequate nutritional vitamin D status. J Steroid Biochem Mol Biol. 2007 Mar;103(3-5):631-4.

Bruce kept the audience enthralled with a review of all the disease states that indicate 25(OH)D levels need to be much higher than they are now, that is, the multiple biomarkers that suggest the lower limit of 25(OH)D levels should be above 40 ng/ml and closer to 50 ng/ml. Then Professor Hollis spoke of his ongoing study in pregnant women and how he got approval to use 4,000 IU of vitamin D per day back in 2003, quite an accomplishment. He also reviewed another one of his research projects, one that answered an age old question, why is breast milk a poor source of vitamin D? How were prehistoric infants supposed to get their vitamin D, by lying out in the sun where saber tooth tigers would eat them? No, they were hidden in caves and had to have another source or the human race would have died out long ago because rickets destroys a woman's and infant's chance to live through childbirth due to rachitic deformations of the mother's pelvis. Carol Wagner and Bruce Hollis, together with their colleagues, answered that age old question, human breast milk is a poor vitamin D source because virtually all modern mothers are vitamin D deficient. That is, when pregnant women keep their levels where we think prehistoric human levels were, about 50 ng/ml, breast milk becomes a rich source of vitamin D. First Carol and Bruce gave 2,000 IU per day, then 4,000 IU per day and finally 6400 IU of D3 per day to lactating women. Only at 6400 of D3/day did the women maintain both their own 25(OH)D levels and the levels of their breast feeding babies above 50 ng/ml. On 6400 IU/day, the vitamin D activity of the breast milk went from about 80 to 800 IU/L. Quite a discovery, and another reason for all of us to keep our levels above 50 ng/ml.

Wagner CL, Hulsey TC, Fanning D, Ebeling M, Hollis BW. High-dose vitamin D3 supplementation in a cohort of breastfeeding mothers and their infants: a 6-month follow-up pilot study. Breastfeed Med. 2006 Summer;1(2):59-70.

Professor Robert Heaney went last, discussing 74 slides. So much of what we know about vitamin D today is due to Robert's unceasing dedication to vitamin D, the most recent example being his and Joanne Lappe's randomized controlled trial showing that increasing baseline levels from 29 to 38 ng/ml reduced the risk of getting cancer by around 70%. He again pointed out that the body does not begin to consistently store much vitamin D until your levels get to around 50 ng/ml. He also went through multiple biomarkers of vitamin D. That is, what level or intakes do you have to have to reduce the incidence of multiple diseases? He covered calcium absorption, osteoporosis, risk of falling, muscle function, death and disability of the aged, TB, influenza, cardiovascular disease, hypertension, diabetes, cancer, multiple sclerosis, and gum disease. How can one vitamin be involved in so many diseases? Simple said Dr. Heaney, "vitamin D is the key that unlocks the DNA library." He then reviewed toxicity and concluded there is no evidence that it occurs at levels below 200 ng/ml or with intakes (total) below 30,000 IU per day. Of course, we have no reason to think anyone needs 30,000 IU per day or levels of 200 ng/ml, which would be irresponsible. But someone with a serious cancer should consider getting their level up to 70-90 ng/ml and that may take 10,000 IU per day or even more in some people. As a rule of thumb, 1,000 IU will raise 25(OH)D levels by about 10 ng/ml.

Then Professor Heaney addressed a public health question. How much would we have to give all Americans to get 98% of people above 32 ng/ml without causing toxicity in anybody? The answer: 2,000 IU per day. Of course 32 ng/ml is not adequate but it would be a great first step. Furthermore, of the people left out, a high percentage would be African Americans. In fact, Dr. Talwar recently reported that 40% of African American women fail to achieve a level of 30 ng/ml even after taking 2,000 IU/day for a year.

Talwar SA, Aloia JF, Pollack S, Yeh JK. Dose response to vitamin D supplementation among postmenopausal African American women. Am J Clin Nutr. 2007 Dec;86(6):1657-62.

He also discussed his recent study giving healthy adults 100,000 IU as a single dose. If you start with a baseline level of 28 ng/ml and take 100,000 IU as a single dose, mean levels will remain above 32 ng/ml for two months. If you rely on such stoss doses, but you start with a lower level, or want your levels above 50 ng/ml, how often do you need to take 100,000 IU? We don't know the answer to the last question but we know that Grey et al gave 50,000 IU per week for four weeks then 50,000 per month for a year to 21 patients with hyperparathyroidism. Blood levels rose from a mean of 11 ng/ml at baseline to 30 ng/ml at one year and levels did not continue to rise after six months. Remember, that means half the patients had levels lower than 30 ng/ml at the end of the year. Also remember that the metabolic clearance (how quickly you use it up) might be higher in certain disease states.

Grey A, et al. Vitamin D repletion in patients with primary hyperparathyroidism and coexistent vitamin D insufficiency. J Clin Endocrinol Metab. 2005 Apr;90(4):2122-6.

That last point, metabolic clearance, is only one of a number of reasons that patients vary in their response to vitamin D. Remember, a surprising number of patients will tell their physician they are taking vitamin D when they are not, some will be taking preparations that have less in it than the label says, some will not absorb it, and some people weigh more than others. As Dr. Heaney points out, even if you know patients took 100,000 IU, great variably exists in individual response. At the end of two months some will have shown a minimal response and other much more. This is a field where little is known. Do different disease states use up vitamin D quickly? The answer is probably yes. Furthermore, variability also exists in how one metabolizes and catabolizes (breaks down) vitamin D. Also, what is the interactive effect of drugs that use the same liver enzymes for catabolism? We just don't know and that is why vitamin D blood testing is crucial. Remember, the only test to have is a 25-hydroxy-vitamin D. Do not let anyone get a 1,25-dihydroxy-vitamin D; it will not tell you if you are vitamin D deficient and is usually only indicated in evaluating high blood calcium.

As far as 25(OH)D levels go, many of you have written complaining about the high cost of a 25(OH)D levels at some labs. I've got some good news. For the next month, Life Extension Foundation is having a sale on their 25(OH)D blood tests, only $32.25, including the fee for drawing the blood. (No, we don't get funding from Life Extension, I wish we did.) Life Extension uses LabCorp, which, in turn, uses an accurate method to determine 25(OH)D levels, the DiaSorin Laiason method. The only problem is that DiaSorin, LabCorp, and Life Extension all say that 30 ng/ml is acceptable. It is not. Take enough vitamin D or get enough UVB radiation to get your levels above 50 ng/ml. To order the test, call Life Extension at 800 208-3444. Unfortunately, this offer is not available in New York, New Jersey or Rhode Island.

Also, Dr. James Dowd has written a fine book about vitamin D, The Vitamin D Cure. Get this, he is board certified in internal medicine, adult rheumatology, and pediatric rheumatology, an associate professor at Michigan State University, and runs his own Arthritis Institute and the Michigan Arthritis Research Center. He gives a formula for how much vitamin D you need but stresses the importance of testing to know for sure. He uses the formula of 2000 IU for every 100 pounds of body weight, which is as accurate an estimation as one can make without knowing baseline levels. Of course it depends on so many things, as Dr. Dowd points out, such as percentage body fat, latitude, skin type, sun exposure and age. He gives case after case examples of how vitamin D not just prevents disease, but seems to have a treatment effect. He also stresses three other things I've written about before, acid base balance, magnesium and potassium. If you can't get eat enough fruits and green leafy vegetables to obtain your potassium and magnesium and to get rid of low-grade chronic metabolic acidosis, then you should consider magnesium supplements and potassium bicarbonate supplements.

With these four experts and with this month's vitamin D news articles about breast cancer, brain function, artery blockage in the legs, soft skulls in babies, peripheral neuropathy in diabetics, childhood type-1 diabetes, colon cancer, and stress fractures and with the increasing number of scientists around the world jumping on the vitamin D express, why doesn't the government do something? What will it take? Like Carole says it will take a grassroots effort.

The first thing to do is tell your family and friends about vitamin D. Tell your doctor. Get your family's 25(OH)D tested, including your children. Once people begin to see it works, they will get their family and friends to take it. They will feel better and then the word will spread. All the government can do is make vitamin D illegal or limit the amount in each pill. The first is unlikely but not the second. With 5,000 IU capsules widely available, many people give no thought to taking one a day. But if the government limits the sale of anything over 400 IU and people had to take 12 of the 400 IU tablets, instead of one of the 5,000 IU, they might balk at so many pills. Before our officials in Washington take such a step, let's hope they read the Washington Post.

John Cannell, MD
The Vitamin D Council

This is a periodic newsletter from the Vitamin D Council, a non-profit trying to end the epidemic of vitamin D deficiency. This newsletter is not copyrighted. Please reproduce it and post it on Internet sites. We are a nonprofit tax-exempt educational organization and depend on your donations.

The Vitamin D Council
9100 San Gregorio road
Atascadero, CA 93422

Biggest bang for your nutritional buck

29. April 2008 William Davis (13)

Judging by the conversations here, in the Track Your Plaque Forums, and elsewhere, it's clear that many people are searching for the perfect diet.

Should we reconsider the role of saturated fat? Are there fractions of fatty acids in saturated fat that are more or less harmful? How about the role of fats on cancer risk? How about the role of proteins like casein on cancer risk? Are there flavonoid sources, or combinations of flavonoids, that yield outsized health benefits? Is there a ceiling for omega-3 fatty acid supplementation? Is there a role for linolenic acid sources in cardiovascular disease prevention? And on and on.

All important issues, to be sure, ones that we've all zig-zagged through over the past 30 years.

I also see patients every day, however, who are not interested in micro-managing their diet. Their goals are less ambitious: lose 20 lbs, feel good, raise HDL, reduce triglycerides and small LDL, all while meeting all the other responsibilities in their lives, like children, spouses, maintaining a household and jobs.

So, if your interest is not to consider whether we should distinguish myristic acid sources from palmitic, or if epigallocatechin is better when combined with quercetin, then the biggest bang from your nutritional buck can come from one single strategy:

Eliminate wheat flour products

Secondarily, avoiding corn starch products and "goodies" (candy, fruit juices, fruit drinks, cookies, potato chips, etc.--you know what they are) is important, as well.

It means weighing your diet more heavily in favor of vegetables and fruits; lean meats; healthy oils; and raw nuts and seeds, all in unlimited quantities. Dairy products should be limited, however, because of sugar effects.

Of course, this advice clearly contradicts the pronouncements of the USDA Food Pyramid (6-8 servings of grains per day), the American Heart Association, and the diabetes-causing American Diabetes Association diabetic diets.

But, follow this approach, a diet strategy that appears too simple to be effective, and the majority of people lose dramatic amounts of weight, raise HDL, reduce triglycerides, reduce small LDL, reduce C-reactive protein and other inflammatory measures, reduce blood pressure, and raise self-esteem.

It's also a lot easier than it sounds (after habits are broken) because the appetite stimulating effect of wheat is removed. Many, if not most, people also experience increased energy, including elimination of the afternoon "slump," improved sleep, less mood swings, less intestinal problems.

It may not be perfect, but if your interest is to get the most with a modest amount of effort, it works like a charm for the majority of people.

Copyright 2008 William Davis, MD

Can skinny be fat?

29. April 2008 William Davis (6)

You're going to hate this.

Dr. Romero-Corral and colleagues from the Mayo Clinic presented an analysis of the National Institutes of Health-funded National Health and Nutrition Examination Survey (NHANES-3) at the recent American College of Cardiology meetings. (Science Daily also has some coverage on this report.)

Their analysis identified 2127 adults from the NHANES database who had normal body-mass indexes (BMI) between 18.5 and 24.9 units), average age 41 years old. When broken down by percent body fat (measured with bioimpedance, meaning a small electrical current is passed through the body, much like what the store-bought Tanita devices do), with normal-weight obesity defined as >20% body fat in males, >30% body fat in females, 55% of participants met criteria for designation as normal-weight obesity.

Compared to people with similar BMI's but who fell below these body fat percentage cut-offs, the normal-weight obese men had increased ratios of Apo B to Apo A1; were much more likely to have increased blood sugars or be diabetic; have higher C-reactive protein (CRP); were several-fold more likely to meet other criteria for diagnosis of metabolic syndrome; had lower HDL cholesterols; and had higher blood pressure. Women with normal-weight obesity were four-fold more likely to have coronary disease.

While preliminary, this suggests that a substantial number of people with apparently favorable body weights and BMIs are, in actuality, overweight when judged by metabolic parameters. This then probably leads to increased risk for heart disease. We can then fairly readily extrapolate the argument that a reduction in weight to even lower BMIs likely reduces or corrects these patterns.

This argument is similar to that proposed by several others, arguing that BMI is a flawed measure, since it does not incorporate muscle mass or skeletal factors ("big- or small-boned"). Instead, they have argued that waist circumference is preferable.

The normal-weight obesity syndrome was originally identified by Dr. Antonio de Lorenzo and colleagues at the University of Tor Vergata, Rome, Italy, and reported in Normal weight obese (NWO) women: an evaluation of a candidate new syndrome. Their studies of women with this "syndrome" have suggested that heightened measures of inflammation are present despite apparently normal body weight and BMIs. One such report, Normal-weight obese syndrome: early inflammation?, is available in full-text.

Is there a lesson to be learned for the Track Your Plaque program? I believe there is. I believe it means that, if you have any weight-sensitive parameter, such as low HDL, small LDL, high triglycerides, high CRP, high blood sugar, high blood pressure, etc., then further weight loss might be considered, even if BMI is around 25. Obviously, there is a rational limit to how far you can push this concept. (Anorexia is not good for you either.)

I find this a useful concept. It provides yet another potential strategy to pursue when the above patterns are encountered. Perhaps it's also a way to cap reliance on niacin, whose effects closely mimic that of weight loss.

Now that's a lot more preferable to more and more statin drug, isn't it?

Copyright 2008 William Davis, MD

All posts by william-davis

Estrogens and CT heart scan scores

2. July 2007 William Davis (1)

A recent study from the Women's Health Initiative (WHI), the large study that originally showed no reduction in heart attack with use of estrogens in postmenopausal females, has just published a new study.

In this new effort, women who took Premarin (horse estogens) had up to 61% lower CT heart scan scores. This new study was confined to the women from the original WHI study who had entered the study between the ages of 50-59 years (average 55 years old), since this was the significant subgroup of women who actually showed a reduction in heart attack risk, whereas other groups showed no benefit or a slightly increased risk.

For a full discussion of this fascinating result, see the Track Your Plaque report, Can estrogen reduce CT heart scan scores? at http://cureality.com/library/fl_06-017estrogen.asp. (This report is open to both Track Your Plaque Members and non-Members.)

I truly wish that the issues surrounding female hormone replacement were clearer. This new perspective adds just another interesting twist on a strategy that too many people, in my view, dismissed too readily with the initial WHI results.

To add to an already confusing situation, the WHI study was sponsored by Wyeth Pharmaceuticals, the maker of Premarin, and many of the investigators participating in the study obtained financial compensation from Wyeth. On the one hand, we have to give credit to the company and the investigators for publishing the initial study that panned the effects of Premarin. On the other hand, it makes any positive data somewhat suspect, particularly since there is a far less costly and probably superior preparation called human estrogens.

Incidentally, Wyeth is also behind the maddening FDA petition to prevent "compounding" pharmacies from dispensing human hormones like estrogen unless made by a drug manufacturer. They hide behind claims of concerns over safety. Nonsense. This is pure profiteering and protection of their enormously profitable franchise and has nothing to do with public safety. If there were genuine concerns that the compounding pharmacies, around for decades with an excellent reputation, pose safety issues, why not just lobby for improved oversite?

If only we had data like WHI that used human estrogens and human progesterone. I suspect that we'd see bigger, better effects with less of the ill effects peculiar to the cross-species use of Premarin and the synethetic progestin, Provera.

The wheat-free life

30. June 2007 William Davis (10)

"There's nothing else I can do with my diet," declared Whitney, a 53-year old university faculty member.

"I don't eat meat. I never eat fried foods. I can't remember the last time I used butter. My idea of having a treat is a handful of blueberries. What else can I do?"

Whitney was clearly frustrated. With a CT heart scan score of 264, she was worried that trouble was just around the corner. Her lipoprotein panel had demonstrated a severe small LDL pattern, with 70% of all LDL particles in the small category. HDL was also low at 41 mg/dl.

"What did you eat for breakfast?" I asked.

"Same as always: Either Fiber One cereal or Shredded Wheat. No sugar, just skim milk. Sometimes I have some orange juice, fresh-squeezed of course."

"How about lunch?"

"If I brown-bag it, I'll usually have a reduced-fat turkey breast sandwich on whole grain bread. About once a week, I'll have a whole wheat bagel--no cream cheese, of course."

"Dinner?"

"Sometimes I have chicken--skinless--with a vegetable, corn, or salad. I love pasta, but I always use whole wheat."

"How about snacks?"

"I try not to snack. But, when I'm desperate, I usually grab some Triscuits or pretzels."

The problem with Whitney's diet was clear: Too many sugar-equivalents, otherwise known as wheat. I suggested that her diet was far too heavily laden with wheat products. She seemed skeptical. "But this is as low-fat as I can get! Now you're going to take away wheat?"

What happens when you eliminate wheat from your diet?

Several predictable, consistent changes can be observed:

--HDL cholesterol goes up.

--Triglycerides go down.

--Small LDL particles are reduced.

--LDL cholesterol drops (the amount dropped depends on the proportion of small LDL pattern)

--Blood sugar drops.

--Blood pressure drops.

--C-reactive protein (an index of imperceptible inflammation) drops.

In addition to these measurable changes, several perceptible improvements often develop: more energy, less afternoon "slump," better sleep, sometimes less rashes.

Since Whitney was skeptical, I suggested a simple 4 week "experiment": Eliminate wheat products entirely for 4 weeks and see for herself what happens. I also warned her that, while I believe that elimination of wheat is a great strategy, she could negate the benefits by indulging in candy, soft drinks, and other junk products. It would therefore be necessary to maintain an otherwise healthy diet.

So Whitney gave it a try for 4 weeks. To make up for the dropped calories, she increased her reliance on vegetables, fruits, lean proteins, nuts, seeds, and healthy oils.

After losing 6 lbs over the 4 weeks without otherwise trying, she was convinced. She was further convinced when we reassessed her laboratory work: HDL went up 10 mg/dl; triglycerides down 120 mg/dl; blood sugar dropped from 112 mg/dl (pre-diabetic) to 95 mg/dl (normal). Several months later, we checked her lipoproteins. Small LDL had dropped to around 30% of total LDL--a big improvement.

It's contrary to conventional wisdom. It's counter to the USDA Food Pyramid. It's certainly not what the American Heart Association says. It could potentially disrupt the economics and politics of the enormously powerful food industry.

But, more often than not, the results are impressive to phenomenal.

Death of a $7 billion industry

28. June 2007 William Davis (8)

Vitamin D has taken its place as a crucial ingredient for coronary plaque control and control of CT heart scan scores.

Vitamin D replacement is also crucial for bone health, particularly the prevention of osteoporosis. But conversations about vitamin D replacement to true healthy levels is notably absent from the conversation on treatment and prevention of osteoporosis. Yes, you will find a small dose of vitamin D in calcium tablets and in multivitamins. Those of us who check blood levels of 25-OH-vitamin D3 in patients will tell you: They don't work. These are unabsorbable forms of vitamin D and at trivial doses. There was an attempt to give this issue a little cursory attention when a small dose of vitamin D was added to Fosamax (Fosamax D).

There are an estimated 50 million Americans with various degrees of osteoporosis. It's numbers like this that make the drug manufacturers salivate. Osteoporosis treatment is also chronic. This is among the holy grails of the drug industry: developing agents for widespread ailments that require long-term treatment that extends over years. That's a lot more profitable than 10 days of antibiotics that are over and done with in one treament course.

The osteoporosis market now stands at $7 billion per year and is expected to grow 6-7% per year, according to industry analysts. Drugs like Fosamax, Evista, and Actonel will eventually be replaced by Boniva, Eclasta, and bazedoxifene, and later by AMG-172 and balicatib. Monthly costs for these drugs can be $70 or more per month, sometimes several hundred dollars. (Experience has shown that the introduction of new drugs does not necessarily mean that other drugs will drop in price.)

Here's a clinical trial I'd like to see performed: Vitamin D restored to healthy levels of 50-100 ng/ml over an extended period and compared to a group treated with placebo. My prediction is that there will be dramatic differences in bone density. (Small studies have been performed, but no large, long-term trials of the sort that would yield real firepower.) Or, how about vitamin D to true therapeutic levels over 5 years compared head-to-head with one of the drugs. My prediction: little difference.

Vitamin D also provides an enormous panel of health benefits beyond restoration of bone density, like rise in HDL, drop in triglycerides, facilitation of control over CT heart scan scores, drop in fracture risk, drop in blood pressure and C-reactive protein, reduction in risk for colon, prostate, and breast cancer. None of the drugs can hope to provide any of these effects, except a drop in fracture risk.

Vitamin D usually costs around $2 per month. I doubt that such trials will be performed. If I were a manufacturer of osteoporosis drugs and my career success was dependent on the increasing revenues of these drugs, I would be quaking in my shoes, hoping that the public does not learn what a powerful tool good old vitamin D is. But if you are an individual just looking for health tools, vitamin D is, in my view, amongst the most powerful natural, nutritional tools you have available with outsized health benefits.

Lose weight and HDL goes . . . down

27. June 2007 William Davis (2)

Steve started with a miserable HDL cholesterol of 27 mg/dl. As expected, the low HDL was associated with all its evil friends: small LDL, deficiency of healthy, large HDL, high triglycerides, VLDL, and a pre-diabetic blood sugar.

Steve committed to a strict diet of reduced processed carbohydrates like wheat products, reduced meat and saturated fats. He relied on vegetables, fruit, lean proteins, and healthy oils. Over a 6 month period, he lost an impressive 39 lbs. He proclaimed that he hadn't felt this good in 30 years.

We rechecked his HDL: 25 mg/dl.

"I don't get it!" Steve declared, understandably.

There's a curious phenomenon with HDL. If you lose weight, HDL goes up--but not right away. Steve had lost a substantial quantity of weight and was continuing to lose weight when the blood work was obtained. While HDL does indeed rise with weight loss, it doesn't do so immediately. In fact, in the first two or so months after significant weight lost, HDL goes down.

Why? I don't really have an explanation, but it is a very consistent effect.

Losing weight towards ideal weight is truly an effective strategy for raising HDL. But we need to be patient. If you've lost many pounds like Steve did, then waiting at least two months after weight has stabilized may be necessary to fully gauge the effect on raising HDL.

Addictive Foods

25. June 2007 William Davis (3)

Kraft Foods, Inc. is manufacturer of Kool Aid, Oscar Mayer, Kraft Macaroni and Cheese, Velveeta, Honey Maid Grahams, and hundreds of other processed food products. Post cereals also falls under the umbrella of Kraft with products like Raisin Bran, Post Toasties, and Fruity Pebbles. Annual revenues in 2006 for Kraft: $34.4 billion. A big operation with enormous influence over our eating habits.

Nabisco is manufacturer of Oreos, Ritz Crackers, Chips Ahoy and many others. Like Kraft/Post, it is also a big player.

While Nabisco was owned for several years by tobacco giant RJ Reynolds, in 2000 it was acquired by Philip Morris, another big tobacco manufacturer.

More recently in Spring, 2007, Philip Morris (now called Altria--you'd change your name, too, if it was synonymous with dirt) spun off its Kraft subsidiary for a big profit. However, the management structures remain intertwined.

In other words, despite the shuffling of shares, the two industries, big tobacco and big food, are in many respects one and the same.

Is it any surprise that the same industry that made billions of dollars pushing addictive nicotine products responsible for the deaths of hundreds of thousands of people is now intimately involved with addictive products produced and marketed by the processed food industry?

If you believe that food manufacturers are innocently and honestly conducting their businesses, simply think back to the testimony provided in front of Congress during the tobacco industry hearings. Broad deception, concealed truths, and outright lies were commonplace. There was no conscience involved. This was about money--and lots of it.

Why should the processed food industry, intimate with the tobacco industry, be any different?

If you want control over heart disease and your heart scan score, buy produce and buy local. Spend your time in the produce aisle, not the cereal or chip aisle. Unprocessed food, unadorned by bright labels, cartoon animals, American Heart Association endorsements, that's what we should seek.

Heart Scan Curiosities #7

25. June 2007 William Davis (1)

Here's a situation that crops up once in a while, occurring in perhaps 2% of heart scans.

The white within the circled area represents calcium, and thereby atherosclerotic plaque, situated immediately at the "mouth", or opening, of the the right coronary artery. What is somewhat unusual is that this plaque is not principally coronary, but aortic. That is, the plaque is mostly situated in the large vessel called the aorta. The three coronary arteries arise from the aorta.

In this instance, the aortic plaque involves the mouth of the right coronary artery. (In views not shown, the plaque also extends into the artery as well.) I call this a "double whammy" because the same plaque can post risk for heart attack and stroke.

Generally, aortic plaques pose risk for stroke. When aortic plaque fragments, little bits and pieces can travel upward to the brain and block an artery, thus a stroke.

In the coronaries, disrupted ("ruptured") plaques don't generally shower debris, but permit blood clot formation, resulting in heart attack.

This plaque, however, poses the theoretical risk of both heart attack and stroke because of its strategic location.

Should a plaque like this be handled any differently? I don't think so. But it does provide another reason to take atherosclerotic plaque in any artery seriously.

The nutrition counterculture

23. June 2007 William Davis (2)

When we look back over our American nutritional history over the last 50 years, it's hard not to come to the conclusion that much of the innovation in nutrition did not come from official agencies like the Food and Nutrition Board of the Institute of Medicine, the National Academy of Sciences, the FDA, the USDA, or the AMA.

Instead, it came from the popular culture. It came from bold, extravagant claims made by maverick figures like Ancel Keys, Nathan Pritikin, Dean Ornish, and Robert Atkins. Of course, some ideas have now fallen by the wayside, dismissed in a broad American "experiment" as ineffective, impractical, or kooky. But it permitted experimentation on an extraordinary scale with millions of people following a particular strategy at a time.

The advice of the official agencies tended to be reactionary. When nutritional deficiencies (remember those?) of the early 1900s were prevalent, they issued advice on food choices to help alleviate deficiencies. When deficiency transformed into excess after World War II, "smart" food choices from food groups and "sensible eating" became the theme.

Unfortunately, the advice was always adulterated by the enormous influence of various special interests, anxious to protect their national franchise. Powerful groups like the meat industry, wheat producers, and the dairy industry all made sure they had a big hand in crafting and influencing what was told to the American people.

The result: the advice offered by official groups has always represented the compromise of what some agency wished to convey to the people and the very powerful input of industry. What if the government decided to advise us what automobile to buy? Imagine the uproar in the auto industry when Washington tells us to buy Toyota for fuel economy and reliability. How long would that advice last?

That's why almost no knowledgeable adult follows the advice of the USDA, the National Academy of Sciences, or the Food Pyramid. I believe that we all intuitively recognize that the advice is watered-down, sometimes silly, sometimes downright unhealthy.

Nonetheless, the national experiment in diet that has taken place since 1950 has led to a collective wisdom of what is good and what is bad. The most productive conversations on nutrition therefore take place outside of the USDA and Washington. It occurs, instead, in places like bookstores, websites, and the media. Of course, there's lots of misinformation and profiteering in these sectors, as well. But like the enormous force unleashed by the collective wisdom of those contributing to the Wikipedia phemonenon, we've zig-zagged to something closer to the truth than ever uttered by an official agency.

Prescription vitamin D

23. June 2007 William Davis (32)

Niacin:

Over-the-counter: $2-5 per month
Prescription: $120 per month

Fish oil:

Over-the-counter: $3-6 per month
Prescription: $120 per month

Vitamin D:

Over-the-counter: $2 per month
Prescription: $70 per month

With vitamin D in particular, the prescription form is vastly inferior to the over-the-counter preparation. This is because the prescription form is ergocalciferol, or vitamin D2, not the effective human form, vitamin D3 or cholecalciferol.

When you're exposed to sun, what form of vitamin D is activated in the skin? It's all vitamin D3, no vitamin D2 whatsoever. Vitamin D3 is also far more effective than D2. People taking D3 (as long as it's oil-based) easily obtain healthy levels of vitamin D in the blood. People taking 50,000 units per day of D2 (the recommended quantity) remain miserably deficient, with minor increases in vitamin D blood levels. In short, D2 barely works at all. D3 works easily and effectively.

Moreover, D2 is the plant-based form. It is a form not found naturally in humans. D3 is the mammalian form, the same found in humans that exerts all its biologic benefits.

Then why is the prescription form of vitamin D2 (brand names Driscol and Calciferol) more expensive?

It's the same old pharmaceutical industry scam: Look for something patent protectable, regardless of whether it's superior to the non-patent protectable product, then sell it for exagerated profits. Though it is inferior and the science and clinical experience prove that it's inferior, you can still fool lots of people, including prescribing physicians. So what if you only make $50 or $100 million?

Don't fall for it. Prescription doesn't necessarily mean superior. In fact, the prescription form may be significantly inferior, as with vitamin D2. But the pharmaceutical industry carries such power and persuasion, who's going to know?

Nutrition activist Mike Adams

20. June 2007 William Davis (1)

I borrowed the above comic from the website of nutritionist, more properly nutrition activist and author, Mike Adams. His website, www.newstarget.com, was a pleasant surprise.

I was actually looking for some thoughts on pharmaceutical advertising and its pervasive and destructive effects and came across one of Adam's reports, Pharmaceutical television advertising is a grand hoax at http://www.newstarget.com/021526.html. The piece is a rant against the pharmaceutical industry's constant bombardment of the media, who have also been co-opted into their service, enticed by the enormous advertising revenues the drug industry brings.

But I was surprised to find an insightful, informative website on health issues, particularly healthy eating that rejects the manufactured food industry's intensive effort to persuade us to eat their products. While I don't agree with everything Adams has to say, his website provides some great food for thought. He also provides lots of downloadable information.

There's also some great laughs at his poke at the pharmaceutical industry with his Disease Mongering Engine at http://www.newstarget.com/disease-mongering-engine.asp, in which you get to create your own diseases. I got a real kick out of this.

CT scans and radiation exposure

19. June 2007 William Davis (8)

The NY Times ran an article called

With Rise in Radiation Exposure, Experts Urge Caution on Tests at

http://www.nytimes.com/2007/06/19/health/19cons.html?_r=1&adxnnl=1&oref=slogin&adxnnlx=1182254102-vQpytpx6W/Z9gvAaNPDZvA

“This is an absolutely sentinel event, a wake-up call,” said Dr. Fred A. Mettler Jr., principal investigator for the study, by the National Council on Radiation Protection. “Medical exposure now dwarfs that of all other sources.”

Where do CT heart scans fall?

Let's first take a look at exposure measured for different sorts of tests:

Typical effective radiation dose values

Computed tomography Milliseverts (mSv)

Head CT 1 – 2 mSv
Pelvis CT 3 – 4 mSv
Chest CT 5 – 7 mSv
Abdomen CT 5 – 7 mSv
Abdomen/pelvis CT 8 – 11 mSv
Coronary CT angiography 5 – 12 mSv

Non-CT Milliseverts (mSv)

Hand radiograph Less than 0.1 mSv
Chest radiograph Less than 0.1 mSv
Mammogram 0.3 – 0.6 mSv
Barium enema exam 3 – 6 mSv
Coronary angiogram 5 – 10 mSv
Sestamibi myocardial perfusion (per injection) 6 – 9 mSv
Thallium myocardial perfusion (per injection) 26 – 35 mSv

Source: Cynthia H. McCullough, Ph.D., Mayo Clinic, Rochester, MN

If you have a heart scan on an EBT device, then your exposure is 0.5-0.6 mSv, roughly the same as a mammogram or several standard chest x-rays.

A heart scan on a 16- or 64-slice multidetector device, your exposure is around 1.0-2.0 mSv, about the same as 2-3 mammograms, though dose can vary with this technology depending on how it is performed (gated to the EKG, device settings, etc.)

CT coronary angiography presents a different story. This is where radiation really escalates and puts the radiation exposure issue in the spotlight. As Dr. Cynthia McCullough's chart shows above, the radiation exposure with CT coronary angiograms is 5-12 mSv, the equivalent of 100 chest x-rays or 20 mammograms. Now that's a problem.

The exposure is about the same for a pelvic or abdominal CT. The problem is that some centers are using CT coronary angiograms as screening procedures and even advocating their use annually. This is where the alarm needs to be sounded. These tests, as wonderful as the information and image quality can be, are not screening tests. Just like a pelvic CT, they are diagnostic tests done for legimate medical questions. They are not screening tests to be applied broadly and used year after year.

Always be mindful of your radiation exposure, as the NY Times article rightly advises. However, don't be so frightened that you are kept from obtaining truly useful information from, for instance, a CT heart scan (not angiography) at a modest radiation cost.

Detail on radiation exposure with CT coronary angiograms on multidetector devices can be found at Hausleiter J, Meyer T, Hadamitzyky M et al. Radiation Dose Estimates From Cardiac Multislice Computed Tomography in Daily Practice: Impact of Different Scanning Protocols on Effective Dose Estimates. Circulation 2006;113:1305-1310, one of several studies on this issue.