All posts by william-davis

Claudia got this letter from her health insurance company:

Dear Ms. ------,

Based on a recent review of your cholesterol panel of January 12, 2011, we feel that you should strongly consider speaking to your doctor about cholesterol treatment.

Reducing cholesterol values to healthy levels has been shown to reduce heart attack risk . . .

Okay. So the health insurer wants Claudia to take a cholesterol drug in the hopes that it will reduce their exposure to the costs for her future heart catheterization, angioplasty and stent, or bypass surgery. This is understandable, given the extraordinary costs of such hospital services, typically running from $40,000 for a several hour-long outpatient catheterization procedure, to as much as $200,000 for a several day long stay for coronary bypass surgery.

So what's the problem?

Here are Claudia's most recent lipid values:

LDL cholesterol 196 mg/dl
HDL 88 mg/dl
Triglycerides 37 mg/dl
Total cholesterol 291 mg/dl

By the criteria followed by her health insurer, both total and LDL cholesterol are much too high. Note, of course, that LDL cholesterol was a calculated value, not measured.

Here are Claudia's lipoproteins, drawn simultaneously with her lipids:

LDL particle number 898 nmol/L
Small LDL particle number less than 90 nmol/L (Values less than 90 are not reported by Liposcience)

LDL particle number is, by far and away, the best measure of LDL particles, an actual count of particles, rather than a guesstimate of LDL particles gauged by measuring cholesterol in the low-density fraction of lipoproteins (i.e., LDL cholesterol). It is also measured and is highly reproducible.

To convert LDL particle number in nmol/L to an LDL cholesterol-like value in mg/dl, divide by ten (or just drop the last digit).

Claudia's measured LDL is therefore 89 mg/dl--54% lower than the crude calculated LDL suggests.

This is because virtually all of Claudia's LDL particles are large, with little or no small. This situation throws off the crude assumptions built into the LDL calculation, making it appear that she has very high LDL cholesterol.

Do you think that Big Pharma advertises this phenomenon?

I've now seen several people who have either caused themselves to be diabetic or to have other phenomena associated with excessive consumption of carbohydrates, all by innocently indulging in a carbohydrate-packed smoothie every morning.

Kay, for instance, has a smoothie of a half-pint blueberries, a banana, a scoop of whey, low-fat yogurt, a cup of milk every morning. The rest of her diet was fairly healthy: salads with oil-based dressing for lunch, salmon and asparagus for dinner, only an occasional carbohydrate indulgence outside of her morning smoothie ritual. Yet she had a HbA1c (a reflection of prior 60 to 90 days average blood sugar) at the near-diabetic range of 5.9%.

The mistake most people make when making smoothies is relying too heavily on carbohydrates like fruit. A smoothie like the one made by Kay can easily top 50, 60, or 70 grams carbohydrates per serving, more than sufficient to send blood sugars up to 150 mg/dl or more.

So what can you put in your smoothie and not send you over the edge to diabetes, small LDL, and all the other undesirable phenomena of excessive carbohydrates? Here's a list:

--coconut milk, unsweetened almond milk. Less desirable: milk, full-fat soymilk
--ground flaxseed
--oils: flaxseed oil, coconut oil (melted), extra-light olive oil, walnut oil
--dried coconut
--extracts: vanilla, almond, coconut, cherry, hazelnut
--spices: cinnamon, nutmeg, ginger
--herbs: mint leaves, cilantro
--cocoa powder (unsweetened)
--nut or seed butters (peanut butter, almond butter, sunflower seed butter)
--tofu
--exotic ingredients (ingredients you wouldn't expect in a smoothie): spinach, kale, cucumber

How do you sweeten a smoothie? This is what trips up most people. If you resort to fruit like bananas, pineapple, or apple, you will readily send your blood sugar skyward. Honey, agave syrup, and sugar, of course, all increase blood sugar and/or have the adverse effects of fructose. Be careful of yogurt, also, for similar reasons.

Therefore, to sweeten your smoothie, consider:

--Small servings of berries, e.g., 8-10 blueberries, 2 strawberries, a few wedges of apple, half a kiwi
--Non-nutritive sweeteners like stevia, Truvia, sucralose, xylitol, erythritol. Also, sugar-free (sucralose-based) syrups like those from DaVinci and Torani are useful. (Just be aware that non-nutritive sweeteners can increase appetite--use sparingly.)

Also, note that, if you have divorced yourself from wheat, cornstarch, and sugars, your desire for sweet should be much reduced. Foods other people find just right will taste sickeningly sweet to you. You might therefore find that foods like peanut butter or coconut milk have a mild natural sweetness; added sweetness is only minimally necessary.

Coming next: I'll share a smoothie recipe or two of mine. Anyone want to share a recipe?

Dairy products have the peculiar property of triggering pancreatic release of insulin. The research group at Lund University in Sweden have contributed the most to documenting this phenomenon:

Mean (±SEM) incremental changes (?) in serum insulin in response to equal amounts of carbohydrate from a white-wheat-bread reference meal (x) and test meals of whey (?), milk (?), cheese (?), cod (?), gluten-low (?), and gluten-high (?) meals. From Nilsson 2004.

Note that it is the area under the curve (AUC), not the peak value, that assumes greatest importance.

Dairy products, especially milk, whey, and yogurt, are insulin secretagogues: they stimulate pancreatic release of insulin. The effect is likely due to amino acids and/or polypeptides in dairy products. (The effect is less prominent with cheese. Also see this study.)

By conventional wisdom, this may be a good thing, since the excess insulin will blunt the glucose rise after consumption. However, in my book, this is not such a good thing, since most of us have tired, beaten, overworked pancreatic beta cells from our decades of carbohydrate overconsumption. I fear that the effect of dairy products just take us a bit closer to beta cell failure: diabetes.

Good news: The effect is least with cheese.

While I've discussed this before, it is such a confusing issue that I'd like to discuss it again.

I advocate wheat elimination because consumption of products made from modern dwarf Triticum aestivum:

--Triggers formation of extravagant quantities of small LDL and LDL particle number (or apoprotein B)
--Triggers inflammatory phenomena like c-reactive protein, increases leptin resistance, and reduction of the protective adipocytokine, adiponectin.
--Encourages accumulation of deep visceral fat ("wheat belly") that is inflammatory and causes resistance to insulin
--Increases blood sugar more than nearly all other foods--higher than a Milky Way bar, higher than a Snickers bar, higher than table sugar.
--Is being linked to a growing number of immune-mediated diseases, including celiac disease (quadrupled over past 50 years), type 1 diabetes in children, and cerebellar ataxia and peripheral neuropathies.

This last group of wheat-related phenomena are primarily due to gluten, the collection of 50+ proteins found in each wheat plant. For this reason, people diagnosed with celiac disease are advised to eliminate gluten from wheat and other sources (barley, rye, triticale, bulgur) and to eat gluten-free foods.

Gluten-free has therefore come to be viewed as wheat-free and problem-free. It ain't so.

Among the few foods that increase blood glucose higher than wheat: cornstarch, rice starch, potato starch, and tapioca starch--Yup: the ingredients commonly used to replace wheat in gluten-free foods. They are also flagrant triggers of the small LDL pattern, along with increased triglycerides, reduced HDL, increased visceral fat, increased blood pressure. In short, gluten-free foods lack the immune and brain effects of wheat gluten, but still make you fat, hypertensive, and diabetic.

I tell patients to view gluten-free foods like jelly beans: Gluten-free pancakes, muffins, breads, etc. are indulgences, not healthy replacements for wheat. It's okay to have a few jelly beans now and then. But they should not be part of a frequent or daily routine. Same with gluten-free foods.

Diabetes is where the action is.

While, for virtually all of history, type 2 diabetes was an uncommon condition of adults, the disease has spread so much to all levels of American society that even kids are now developing the adult form. Researchers from the Center for Disease Control and Prevention predict that, by 2050, one in three adults will be diabetic.

The diabetes market is booming, handily surpassing growth of the oil industry, the housing market, even technology. It makes Bernie Madoff’s billions look like small potatoes. In health, few markets are growing as fast as diabetes—-not osteoporosis, not heart disease, not cancer.

Americans are getting fat from carbohydrate consumption, becoming diabetic along with it. While kids hanging around the convenience store gulp down 26 teaspoons of sugar in 32-ounce sodas and 56-grams-of-sugar in 16-ounce frozen ices, health-minded adults are more likely eating two slices of 6-teaspoons sugar-equivalent “healthy whole grain” bread, wondering why last year’s jeans are too tight.

The U.S. is not the only nation affected. Globally, 2.8% of the world’s population are diabetic, a number expected to double over the next 20 years.

Pharmaceutical companies boast double-digit growth for diabetes drugs, growth rates that keep profit-hungry investors happy. Merck’s Januvia, for instance, introduced in 2006, recently catalogued 30% growth in sales, with annual sales approaching $1 billion. Recently FDA-approved Victoza, requiring once-a-day injection, is expected to reap $4 billion in sales per year for manufacturer Novo Nordisk. Such numbers can only warm a drug company CEO’s heart.

Most diabetics don’t just take one medication, but several. A typical regimen for an adult diabetic after a couple of years of treatment and following the dietary advice of the American Diabetes Association includes metformin, Januvia, and Actos, a triple-drug treatment that costs around $420 per month. Two forms of insulin (slow- and fast-acting), along with two or three oral medications, is not at all uncommon.

“Collateral” revenues from the other health conditions that develop from a diet rich in “healthy whole grains,” such as drugs for hypertension, drugs to slow the progression of kidney disease in diabetes, drugs for “high cholesterol,” and drugs for high triglycerides, and you have a pharmaceutical drug bonanza. You, too, would throw all-expenses-paid, fly-the-entire-sales-force-to-the-Caribbean sales meetings.

The global diabetes market has already topped $25 billion and is growing at double-digit rates. Forget the Internet, gold stocks, or solar energy—-diabetes is where the money is. This fact has not been lost on the very market-savvy pharmaceutical industry. As with any successful business, they have devoted substantial resources to develop and grow this booming business.

Alex is a big guy: 6 ft 4 inches, 273 lbs.

On 10,000 units per day of vitamin D in gelcap form, his 25-hydroxy vitamin D level was 38.4 ng/ml. One year earlier, his 25-hydroxy vitamin D level, prior to any vitamin D supplementation was 9.8 ng/ml.

According to the latest assessment offered by the Institute of Medicine (IOM):

Vitamin D need for a 13-month old infant: 600 units per day

Vitamin D need for a 6 ft 4 in, 273 lb male: 600 units per day

I paint this picture to highlight some of the absurdity built into the smug assumptions of the IOM's report. It would be like trying to fit a large, full-grown man into the diapers of a 13-month old. Few nutrients or hormones (in fact, I can't think of a single one) are required in similar quantity by an infant or toddler and a full grown adult. However, according to the IOM's logic, their vitamin D needs are identical, regardless of age, body size, skin color, genetics, etc. One size fits all.

Just as the original RDA assessment by the Institute of Medicine kept thinking about vitamin D somewhere in the Stone Age, so does this most recent assessment.

Chris has 90% small LDL particles.

On his (NMR) lipoprotein panel, of the total 2432 nmol/L LDL particles ("LDL particle number"), 2157 nmol/L are small, approximately 90% (2157/2432).

Bad news: Having this severe excess of small LDL particles virtually guarantees heart attack and stroke in Chris' future.

Good news: It means that Chris potentially has spectacular control over his lipoprotein and lipid values, achieving statin-like values without statin drugs.

Typically, extravagant quantities of small LDL particles are accompanied by low HDL, high triglycerides, and pre-diabetes or diabetes. Chris' HDL is 26 mg/dl, triglycerides 204 mg/dl; HbA1c 5.9% (a reflection of prior 60-90 days average blood glucose; desirable 4.8% or less), fitting neatly into the expected pattern.

Chris' pattern tells me several things:

1) He overconsumes carbohydrates, since carbohydrates trigger this pattern.
2) He likely has a genetic susceptibility to this effect (e.g., a variant of the gene for cholesteryl ester transfer protein, perhaps hepatic lipase). Only the most gluttonous and overweight carbohydrate consumers can generate this high a percentage small LDL without an underlying genetic susceptibility.
3) Provided he follows the diet advised, i.e., elimination of all wheat, cornstarch, oats, and sugars, he is likely to have an extavagant drop in LDL particle number. Should he achieve the goal I set of small LDL of 300 nmol/L or less, his LDL particle number will likely be around 500 nmol/L. This translates to an LDL cholesterol of 50 mg/dl . . . 50 mg/dl.

In many people, this notion of taking statin drugs for "high cholesterol" is an absurd oversimplification. But it is a situation that, for many, is wonderfully controllable with the right diet.

The results of the latest Heart Scan Blog poll are in. The poll was prompted by yet another observation that the American Heart Association diet is a destructive diet that, in this case, made a monkey fat.

Because I am skeptical of "official" organizations that purport to provide health advice, particularly nutritional advice, I thought this poll might provide some interesting feedback.

I asked:

The American Heart Association is an organization that:

The responses:
Tries to maintain the procedural and medication status quo to benefit the medical system and pharmaceutical industry for money
240 (64%)

Doesn't know its ass from a hole in the ground
121 (32%)

Is generally helpful but is misguided in some of its advice
79 (21%)

Accomplishes tremendous good and you people are nuts
6 (1%)

Worrisome. Now, perhaps the people reading this blog are a skeptical bunch. Or perhaps they are better informed.

Nonetheless, one thing is clear: The American Heart Association (and possibly other organizations like the American Diabetes Association and USDA) have a serious PR problem. They are facing an increasingly critical and skeptical public.

Just telling people to "cut the fat and cholesterol" is beginning to fall on deaf ears. After all, the advice to cut fat, cut saturated fat, cut cholesterol and increase consumption of "healthy whole grains" in 1985 began the upward ascent of body weight and diabetes in the American public.

Believe it or not, my vote would be for something between choices 1 and 3. I believe that the American Heart Association achieves a lot of good. But I also believe that there are forces within organizations that are there to serve their own agendas. In this case, I believe there is a substantial push to maintain the procedural and medication status quo, the "treatments" that generate the most generous revenues.

I believe that I will forward these poll results to the marketing people at the American Heart Association. That'll be interesting!

I've discussed this question before:

Can aortic valve stenosis be stopped or reversed using a regimen of nutritional supplements?

I had a striking experience this past week. Don has coronary plaque and began the Track Your Plaque program. However, discovery of a murmur led to an echocardiogram that measured his effective aortic valve area at 1.5 cm2. (Normal is between 2.5-3.0 cm2.)

Because of his aortic valve issue, I suggested that, in addition to the 10,000 units of vitamin D required to increase his 25-hydroxy vitamin D level to 70 ng/ml, he also add vitamin K2, 1000 mcg per day, along with elimination of all calcium supplements. (I asked Don to use a K2 supplement that contained both forms, short-acting MK-4 and long-acting MK-7.)

One year later, another echocardiogram: aortic valve area 2.6 cm2--an incredible increase.

This is not supposed to happen. By conventional thinking, aortic valve stenosis can only get worse, never get better. But I've now witnessed this in approximately 10% of the people with aortic valve stenosis. The majority just stop getting worse, an occasional person gets worse, while a few, like Don, get better.

Aortic valve stenosis is to the aortic valve as degenerative arthritis is to your knees: A form of wear-and-tear that leads to progressive dysfunction. When the aortic valve becomes stiff enough (i.e., "stenotic"), then it leads to chest pains, lightheadedness or losing consciousness, heart failure, and, eventually, death. Bad problem.

Aortic stenosis typically starts in your 50s with calcification of the valve, getting worse and worse until the calcium makes the valve "leaflets" unable to move. The treatment: a new valve, a major undertaking involving an open heart procedure.

What if taking vitamins D and K2 and avoiding calcium do not just reverse or stop aortic valve stenosis once established, but prevents it in the first place? Tantalizing possibility.

Pressures on my time being what they are, I've not had the freedom to put together a prospective study to further examine this fascinating question. But it is definitely worth pursuing.

What happens when blood glucose hits 160 mg/dl?

A blood glucose at this level is typical after, say, a bowl of slow-cooked oatmeal with no added sugar, a small serving of Cheerios, or even an apple in the ultra carb-sensitive. Normal blood sugar with an empty stomach, i.e., fasting; high blood sugars after eating.

Conventional wisdom is that a blood sugar of 160 mg/dl is okay, since your friendly primary care doctor says that any postprandial glucose of 200 mg/dl or less is fine because you don't "need" medication.

But what sort of phenomena occur when blood sugars are in this range? Here's a list:

--Glycation (i.e., glucose modification of proteins) of various tissues, including the lens of your eyes (cataracts), kidney tissue leading to kidney disease, skin leading to wrinkles, cartilage leading to stiffness, degeneration, and arthritis.
--Glycation of LDL particles. Glycated LDL particles are more prone to oxidation.
--VLDL and triglyceride production by the liver, i.e., de novo lipogenesis.
--Small LDL particle formation--The increased VLDL/triglyceride production leads to the CETP-mediated reaction that creates small LDL particles which are, in turn, more glycation- and oxidation-prone.
--Glucotoxicity--i.e., a direct toxic effect of high blood glucose. This is especially an issue for the vulnerable beta cells of the pancreas that produce insulin. Repeated glucotoxic poundings by high glucose levels lead to fewer functional beta cells.

A blood glucose of 160 mg/dl is definitely not okay. While it is not an immediate threat to your health, repeated exposures will lead you down the same path that diabetics tread with all of its health problems.

Although drug manufacturers claim that muscle side effects from statin drugs occurs in only around 2% or people or less, my experience is very different.

I see muscle weakness and achiness develop in the majority of people taking Lipitor, Crestor, Zocor, Vytorin, etc. I'd estimate that nearly 90% of people get these feelings sooner or later.

Thankfully, the majority of the time these feelings are annoyances and do not lead to any impairment. Full-blown muscle destruction is truly rare--I've seen it once in over 10 years and thousands of patients.

The higher the dose of statin drug and the longer you take it, the more likely you're going to have muscle aches.

I experienced a strange phemomenon myself today. I worked outdoors for about 4 hours, pulling weeds, digging in the dirt, spreading topsoil. (I have an area of overgrowth in the front yard.) Admittedly, I worked pretty hard and it was a warm, humid day.

I was sore, as you'd expect at age 49. But, much more than that, I was exhausted--my muscles ached and I had barely enough strength to get up the stairs.

Hoping for some relief, I took an extra dose of coenzyme Q10. I usually take 50-100 mg per day. Today, when I felt this overwhelming muscle fatigue, I took an additional 200 mg. Within 10 minutes, I felt a surge of energy. It was, in fact, a perceptible, quite dramatic feeling.

I am thoroughly convinced, through my own experiences on Lipitor (I have a high LDL particle number despite a healthy lifestyle, among other abnormalities), and the experiences of many other people, that coenzyme Q10 can be an extremely useful tool to minimize the muscle aches and weakness of the statin drugs.

If you do indeed need to take one of these agents, coenzyme Q10 is worth knowing about. Supplementing coenzyme Q10 has, for me, been a real lifesaver. For many people, LDL reduction is a crucial part of their heart scan score control program. In my experience, many of them would not be able to take the drug without eozyme Q10.

Nearly all of us can use an extra boost in reducing LDL cholesterol. We have a large number of people, in fact, who have reduced LDL into the Track Your Plaque range of 60 mg/dl or less without the use of statin cholesterol-reducing drugs.

Oat bran is among my favorite ways to reduce LDL. Three tablespoons per day is a really effective method to drop your LDL around 20 points. There's twice the beta glucan (soluble, or "viscous", fiber)in oat bran, as compared to the more popular oatmeal. Add oat bran to anything you can think of: yogurt, cottage cheese, vegetarian chili, oatmeal, top desserts with it, etc. Some people struggle to find oat bran in the grocery store. Most health food stores that sell bulk products will have oat bran, usually less than a $1 per pound. Many grocery stores will also have an oat bran hot cereal along with the Cream of Wheat and oatmeal. That's okay, provided the only ingredient is oat bran--no added sugars, etc.

Another dynamite method to reduce LDL 10-20 points is adding raw almonds to your daily food choices. One or two handfuls per day works great. We find it at Sam's Club for around $12.99 for a 3 lb. bag. The plentiful fibers and monounsaturates in almonds keep you full and satisified, take the edge off your sweet tooth, and even blunt the blood sugar rise caused by other foods.

Both these foods are also great ways to combat the metabolic syndrome. Since both fiber-rich oat bran and almonds slow the release of sugars into the blood, blood insulin level is also reduced. This results in a happy cascade of less small LDL, increased HDL, and a reduction in inflammation.

All these wonderful effects contribute to inching you closer to success: dropping your heart scan score.

We pay special attention to pre-diabetes, in all its varied manifestations, in the Track Your Plaque program. This is because these factors are potent instigators of coronary plaque growth.

Early in the Track Your Plaque program we ignored these measures. After all, this is a program for heart disease risk reduction, not for mangement of diabetes. But we saw explosive rates of plaque growth when pre-diabetic factors were not controlled--even when cholesterol and related factors were under excellent control.

It became increasingly clear that factors associated with pre-diabetes needed to be managed, as well. This includes small LDL, increased blood sugar, high blood pressure, increased inflammation (as CRP).

Many people, however, have normal blood sugars (100 mg/dl or less) with a high blood insulin level (>10 microunits/ml). (This blood test is available in most laboratories.) This means that they have early resistance to insulin. The pancreas, the source of insulin, responds to the body's unresponsiveness to insulin by increasing insulin production.

Increased blood insulin with normal blood sugar will drive production of higher triglycerides, a drop in HDL, creation of small LDL, and inflammation--and coronary plaque growth, as evidenced by increasing CT heart scan score.

Blood insulin levels can be very effectively dropped by weight loss; exercise; reduction of processed carbohydrates like breads, pretzels, and breakfast cereals; and increased raw nuts and oat products; and vitamin D replacement to normal levels. Drug manufacturers are desperately trying to make this a mandate for drug treatment (Actos, Avandia), but are encountering resistance, since most people without overt diabetes don't want to take diabetic medication (rightly so!).

You and your doctor should consider insulin as a factor to track, especially if you have small LDL, low HSL, or high triglycerides, or any of the other manifestations listed above.

Janet is a 58-year old schoolteacher. At 5 ft 3 inches and 104 lbs, she had barely an ounce of fat on her size-2 body. For years, Janet's primary care physician complimented her on her cholesterol numbers: LDL cholesterol values ranging from 100 to 130 mg/dl; HDL cholesterol of 50-53 mg/dl.

Yet she had coronary disease. Her heart scan score: 195.

Lipoprotein analysis uncovered a single cause: small LDL. 95% of all of Janet's LDL particles were in the small category. What was surprising was that this pattern occurred despite her slender build. Weight is a powerful influence on the small LDL pattern and the majority of people with it are overweight to some degree. But not Janet.

How did she get small LDL if she was already at or below her ideal weight? Genetics. Among the genetic patterns that can account for this pattern is a defect of an enzyme called cholesteryl-ester transfer protein, or CETP. This is the exact step, by the way, that is blocked by torcetrapib, the new agent slated for release sometime in future (The manufacturer, Pfizer, is apparently going to sell this agent only packaged in the same tablet as Lipitor. This has triggered an enormous amount of criticism against the company and they are, as a result discussing marketing torcetrapib separately.)

Also note that Janet had a severe excess of small LDL despite an HDL in the "favorable" range. (See my earlier conversation on this issue, The Myth of Small LDL at http://drprevention.blogspot.com/2006/06/myth-of-small-ldl.html.)

With Janet, weight loss to reduce small LDL was not an option. So we advised her to take fish oil, 4000 mg per day; niacin, 1000 mg per day; vitamin D, 2000 units per day; use abundant oat bran and raw almonds, both of which suppress small LDL. This regimen has--surprisingly--only partially suppressed her small LDL pattern by a repeat lipoprotein analysis we just performed. We're hoping this may do it, i.e., stop progression or reduce her heart scan score.

The lesson: Small LDL is a very potent pattern that can be responsible for heart disease, even if it occurs in isolation. And, contrary to conventional thinking, small LDL can occur as an independent abnormality, even when HDL is at favorable levels.

Today's discussions at the Society for Cardiovascular Computed Tomography (SCCT) focused on atherosclerotic "plaque characterization".

As CT scanners get better and better at imaging the various components of plaque, some fascinating issues emerge:

--CT heart scans provide insights into what exactly is contained in an individual's atherosclerotic plaque that are not often provided even during heart catheterization. In other words, CT heart scanning is, in many instances, superior to heart catheterization, since it provides images of the artery wall, not just the internal contents.

--Progression (i.e., increase) in heart scan score is a powerful predicter of heart attack risk. Dr. Matthew Budoff of UCLA argued persuasively that the annual rate of increase in score is probably the most accurate measure of risk available, superior to cholesterol and calculated measures like the Framingham risk score.

--Coronary calcium scoring remains the best method to gauge total plaque throughout the entire coronary tree. In a person free of symptoms, the risk of a cardiac "event" (heart attack, death, procedures) is low and additional imaging (like CT angiography) is generally unnecessary.

Dr. Budoff, among the true thought leaders in CT heart scanning, also recounted his perspective on the history of heart scans. He noted that the questions asked through the years have evolved:

1995-2000 Should we do coronary calcium scans?

2000-2002 Do high or low risk patients benefit from coronary calcium scoring?

2003-2004 What is the better scanner, EBT or MDCT?

2006 How often should we perform coronary calcium imaging?

I believe that Dr. Budoff summarizes wonderfully where the Track Your Plaque programs fits into the overall scheme of things: Serial (repeated)CT heart scans to gauge progression or reversal is the wave of the future. We shouldn't just be interested in identifying persons at risk for heart attack. We should also be interested in showing the person at risk exactly how to reduce or eliminate that risk.

I'm presently attending the Society for Cardiovascular Computed Tomography meetings in Washington, DC, along with 500 of my colleagues. It's exciting to see how interest in CT scanning for heart disease has balloonned in the past couple of years.

Several trends are noticeable today, based on the content and tone of the discussions:

--CT scanning of the heart, and imaging in general, is just getting started. In other words, the capabilities for CT scanners and other devices to detect heart disease (coronary and otherwise) are where the gasoline engine was in the 19th century. Scanning is getting faster, easier, safer, and more precise. Just as few people in 1905 could have predicted that automobiles would be computer-enhanced, high-speed, ubiquitous devices with several per household, the potential for CT imaging for heart disease is truly in its infancy.

--CT coronary angiography (so-called "64-slice CT scans") are not screening tests for hidden coronary disease in people without symptoms. I was grateful that this point has been made and reiterated by several speakers, as this is consistent with our views. Simple CT heart scans for coronary calcium scoring, in contrast, are screening tests. When the radiation exposure of CT angiograms are reduced to tolerable levels, then they may be used as screening tests. We are probably 3-4 years away from this point.

--Both stress testing and heart catheterizations will be partially replaced by CT scanning. In particular, over the next decade, you will see a dramatic drop in unnecessary catheterizations, i.e,, far less people saying "I had a heart cath but they told me that it was normal."

There has been heavy focus on applications of CT scanning for acute settings, particularly the emergency room and hospitals.

What has surprised me is that there is virtually no conversation whatsoever about the preventive uses of CT heart scanning. So far, only Dr. Daniel Berman of UCLA has shown that he has "seen the light": CT scans are a crucial tool for identification of early coronary plaque, and this tells us whether prevention is necessary and with what intensity.

There has been, however, no discussion at all about quantification of plaque in a program of reversal. Perhaps that should come as no surprise, given the imaging-technology focus of this convention. For most of my colleagues, prevention is also not terribly interesting. Identification and treatment of acute disease like impending heart attack is.

Of course, applying the information from your CT heart scan to empower you in a program and reversal is what the Track Your Plaque program is all about. I hope you see the light. I admit that it's not always easy to follow what we are advocating here. Perhaps not too different than telling someone in his horse-drawn buggy that one day he'll be driving a sleek car with onboard computerized mapping, air-conditioning, and micro-chips to modulate engine performance. He's probably tell us we're nuts.

I'll continue to update if any news relevant to our interests crops up in these meetings.

I’d love to tell you that the Track Your Plaque program track record is of 100% success. It’s not.

It is very successful. But we’ve had some people who have failed and failed BIG. These are the people who've undergone bypass surgery, received one or more stents, or had heart attacks. Lesser failures are the people who’ve had large, undesirable increases in heart scan scores of >30% in one year. (The expected rate of increase in your heart scan score without preventive efforts is 30% per year, on average.)

What can we learn from those failures? There were several characteristics that stand out among this small group:

· Non-compliance--meaning they just didn’t stick with it. They started out right but then rapidly lost interest in maintaining all the pieces of the program and neglected their fish oil, niacin, gain weight, etc. Matthew did this and ended up with three stents to his left anterior descending. His slow start was due to skepticism that the program worked and just plain forgetfulness.

· Extreme stress--One of our earliest failures was a 38-year old man whose heart scan score doubled in one year, despite doing everything right. But three family members, all close to him, died within the space of six months, including his mother and a brother. I regard this as one of those instances in which we were powerless, unfortunately, though it is a graphic example of the power of unresolved stress and grief.

· Having a “better way”--These are the couple of people who were convinced that they had a better way to control their heart scan score. David firmly believed that his two dozen supplements and exercise program would drop his score. Instead, they permitted a 42% increase. Lee relied exclusively on chelation, along with several supplements of his own design. Lee had three-vessel bypass surgery.

· Starting too late--Gerome started with a score of 1179, but also was having chest pressure with emotional stress. His stress test was abnormal, with the entire upper half of his heart not receiving blood with exercise on a stress nuclear study (“anterior ischemia”). Gerome received four bypass grafts. Unfortunately, Gerome never really had a chance to engage in the Track Your Plaque program, since his health and safety were in jeopardy as soon as he started.

Have we had any big failures of people who did everything right, were compliant, were not subject to extreme stress (more than just job stress, or financial worries), didn’t neglect the basic requirements of the Track Your Plaque program, and had sufficient time (at least 6 months to 1 year)? No, thankfully, we have not.

No one who has stuck to the program has had a big failure.

“Do you need a stent?”

Sad to say, but that sentence condenses the wisdom of over 90% of practicing cardiologists.

Prevention of heart disease means take Lipitor or some other statin and cutting the saturated fat in your diet. That’s it. Maybe throw in exercise.

Regression of coronary plaque? That phrase has only entered the conversation since the AstraZeneca-supported trial of Crestor succeeded in achieving 8% regression of plaque (Track Your Plaque Members: See News) as demonstrated by intracoronary ultrasound.

In other words, in the minds of my colleagues, it can’t be true until a drug company tells them it’s true. It’s beyond me why this brainwashing of otherwise intelligent people has occurred, but it is blatantly evident in practice.

Fish oil is another example. The spectacular benefits of fish oil have been known for 20 years. But only recently has it become a “mainstream” practice to recommend fish oil, largely because a drug manufacturer has put a preparation through the rigors of FDA approval (Omacor) and is now marketing directly to physicians. All of a sudden, fish oil is a good thing? No, it’s just achieved legitimacy in the eyes of practitioners because it graces marketing literature.

If you’re reading this, you’re likely interested in coronary plaque regression using the only tool available for you to measure, track, and regress coronary plaque: CT heart scans. Intracoronary ultrasound will achieve the same goal, but it is an invasive procedure performed at heart catheterization, involves threading a wire and imaging probe all the way down the artery, involves real risk of tearing the inner lining of the artery, and is costly (around $14,000-$20,000 for the entire package). Do it every year? That’d be nuts.

If you’re thinking about coronary plaque regression, using fish oil, concerned about patterns like low HDL and small LDL, aware of the vitamin D deficiency issue as a coronary risk factor, etc., you are far more aware than the vast majority of practicing cardiologists. They are interested in what new brand of anti-coagulant to use during their heart catheterization (because the product representative gushes about the new agent—only $1200 a dose!). Or, they are interested in gaining the procedural skills to put in a new device like a biventricular pacemaker. Regress/reverse coronary plaque? What for?

You already know that a conversation about coronary plaque reversal will not be obtained in your cardiologist’s office. Your family practice doctor or internist? Fat chance! Knee arthritis, pap smears, pneumovax inoculations, sore throats, gout, back pain—they’re spread far too thin to know anything more than the most superficial amount about coronary plaque control. Most know nothing.

That’s where we come in. That’s our mission: Educate people about the extraordinary tools that you have available to you, all in the cause of control or reversal of coronary plaque.

Frank came to the office for an opinion, sent by his (proactive) family physician.

"I really don't know why I'm here, to be honest."

Two years earlier, Frank had a heart attack, survived and received two stents to his circumflex coronary artery. He now took Zocor and his LDL cholesterol was a reasonably favorable 89 mg, total cholesterol 183 mg.

"I walk with my wife every other day. I've been avoiding fish fries. You'll never see me eat fast food."

Frank was correct: If we were going to engage in the conventional approach to coronary disease, Frank was on the right track. We would have postponed his next heart attack or procedure by a couple of years. Stroke, aneurysm, and other atherosclerotic manifestations would be set back, likewise, a few years.

Would Frank have profound control over his disease? Absolutely not. In fact, his disease had probably advanced a huge amount just in the two years since his stents were placed and he was on his "prevention" program. Without his current effort, his coronary plaque would be expected to grow 30% per year. On Zocor and his modest lifestyle efforts, plaque growth was probably in the 14-28% per year range.

So I explained the unique Track Your Plaque approach to Frank. First, we start with a CT heart scan to establish where he was starting. Although he had two stents in his circumflex artery, we still had two other arteries (LAD, right coronary) to score and track.

We then attempt to identify all hidden causes of his heart disease and then correct them.

Of course, Frank had multiple hidden causes:

--HDL too low at 38 mg/dl
--Small LDL-severe, in fact, with 95% of all LDL particles in the small category
--Triglycerides too high
--Excesses of several triglyceride-containing particles (VLDL, IDL)
--Pre-diabetes--Frank had both a borderline high blood sugar and a high insulin level. This is a sure-fire stimulus to coronary plaque growth.
--A severe deficiency of vitamin D (<20 ng/ml)
--An excessivelyhigh blood pressure during exercise--With a blood pressure of 190/102 on the treadmill.

There were others(!), but that was the bulk of the causes behind Frank's coronary disease.

Once Frank recognized that there was indeed a huge panel of hidden causes for heart disease, not just too much fat in his diet and LDL cholesterol, he jumped into the program head first.

The message: The conventional approach is absurdly oversimplified, a certain path to failure for the majority of people. Even if you don't have known coronary disease like Frank, but just have a heart scan score >zero, the same principles apply to you.

Gary is an avid jogger. On an average day, he runs 5-6 miles at a good clip. On two occasions recently, however, Gary experienced an ache in his left shoulder at mile 4. It was a toothache-like feeling, but he kept on going without difficulty.

Gary also had a heart scan score of 370.

Upon hearing of Gary’s score and his shoulder sensation, the cardiologist who saw him advised a heart catheterization “to define coronary anatomy”. (This is a real incident.)

What exactly does that mean? Why would Gary’s cardiologist need to define it?

In my view, this is an absurd notion. No one needs to “define coronary anatomy”. This catch-all phrase is commonly used to justify heart procedures. I believe what the cardiologist is saying is that it’s the easiest (for the cardiologist) and perhaps most generously reimbursed method to determine whether Gary’s symptoms are warning of an impending heart attack or not.

The problem is that the question can also be answered quite well by doing a stress test. Though not perfect diagnostic tests, stress tests are useful when symptoms are present that are doubtful in nature. Gary’s left shoulder ache could have been related to his heart, but the likelihood was that it was not. A stress test would have answered the diagnostic question quite adequately.

Instead, this man was subjected to an invasive test that was likely unnecessary. This happens dozens, if not hundreds, of times per day just around here. Nationwide, it is an epidemic of malpractice.

There are, indeed, times when a person should proceed directly to a heart catheterization. This is commonly and appropriately performed when a person develops unstable heart symptoms, such as chest discomfort or breathlessness at rest while not doing anything physical, or if the frequency is increasing, or if a stress test shows an important abnormality. There is no question that heart procedures can be lifesaving at times.

The problem is that thousands of people every year are scared into these procedures inappropriately. Beware!

"How are your food choices?" I asked.

"What does it matter, doc? I take Lipitor. Doesn't that take care of it? I eat what I want!"

So declared Matthew. What he "wanted" was pretty much the diet of a teenager: pizza, cheeseburgers, soft drinks, snacks. His "beer belly" (visceral fat) gave it away. So did his blood work that showed flagrant lipoprotein abnormalities--small LDL, an HDL of 37 mg, and a severe after-eating flood of fat represented by increased "intermediate-density lipoprotein" (IDL).

Like many people, Matthew had been persuaded (or chose to believe) that LDL cholesterol was the sole cause for heart disease. Lipitor was therefore was all he needed. It must be great--how else could they afford all those slick TV commercials?

Well, it is definitely not true. In fact, with the persistence of Matthew's abnormal lipoprotein patterns, we should expect his heart scan score to continue to grow by 30%--the very same rate of increase as if he were taking nothing.

Specifically, Lipitor and drugs like it do not:

--Raise HDL.

--Correct or reduce the proportion of small LDL.

--Block after-eating flood of fat, nor do they accelerate clearance of unhealthy fats persisting in the bloodstream after eating.

Yes, what you eat does have real consequences, even if you take a statin drugs. In fact, the foods you ingest have a remarkably rapid and dramatic effect on what your blood contains. Any diabetic who checks his/her blood sugar knows this. They eat a slice of whole wheat toast and watch their blood sugar skyrocket.

Mind what you eat. Make it enjoyable, of course. But drugs do not provide impunity.

Sam is a 69-year retired physician. He was thoroughly enjoying retirement: golf, travelling, going out to dinner two or three times a week, spending weekends with his grandchildren. His lifestyle tended towards overindulgence, but he managed to stay fit and trim. At 6 ft 1 inch, he weighed 194 lbs and could still run 3 miles without too much difficulty. Not as good as his marathon-running days, but still not too bad for 69.

Sam's heart scan score in 2003 was a concerning 1983--extensive plaque. His doctor wasn't much help in interpreting the scan and so Sam simply chose to ignore it.

A chance conversation with a physician friend 18 months later made Sam think that perhaps this shouldn't be ignored. That's when he came to my office.

I find that sometimes the best way to motivate someone to take action is to demonstrate just how fast plaque grows if action isn't taken. So I advised Sam to get another scan first, since 18 months had passed. His score: 2441, or a 23% increase.

Sam was now starting to catch on. We made several changes in his prevention program (starting from virtually nothing). He did undergo a stress nuclear (thallium type) of test, which he passed without difficulty--normal blood flow in all heart territories despite the extensive plaque.

But, for some reason, Sam simply allowed himself to drift back to old habits: poor choices in food, overindulging in hard liquor, missing his fish oil and other supplements, and his medication, sometimes up to several days a week.

Sam started having unusual feelings in his chest. He described a sort of nervousness along with skipped heart beats. So we repeated a stress test. This time, a large area of reduced blood flow in the front of his heart ("anterior left ventricle") was detected. Sam ended up receiving three stents in a difficult procedure.

The moral: If you're starting out with a lower heart scan score of, say, 100 or 200, maybe you'll get by without trying too hard--maybe. But if your score is higher, say, several hundred or in the thousands, you got to try harder.

You're starting later in the process. Your disease will allow you very little slack. Let your guard down and it will get you. Control over your plaque is, indeed, very possible--we do it all the time. Score reduction is also possible. But your effort must be more serious and consistent.

Fallen Enron CEO, Kenneth Lay, was pronounced dead early this a.m. after suffering a heart attack.

Mr. Lay apparently had no history of heart disease and there's been no indication that symptoms provided any warning. His death was therefore classified as "sudden cardiac death".

Yet here's a man previously worth hundreds of millions of dollars with access to any test or medical system he desired--many times over. Even more recently, with his wealth reduced following his legal troubles, he and his wife managed to put away $4 million dollars to ensure an income from the interest through annuities, untouchable by the courts.

Detecting Mr. Lay's heart disease would have cost him around a few hundred dollars or whatever it costs for a CT heart scan in his city. This would have alerted his (hopefully knowledgeable) doctor that he was a time-bomb. Pile on all the stress he'd been suffering, whether deserved or no, and the diagnosis would have required little thought.

Instead, Mr. Lay has joined the thousands of Americans who will die this year because of failing to get a simple, 30-second test that costs one-tenth the cost of a stress test. Mr. Lay wasn't as lucky as former President Bill Clinton, whose doctors likewise blundered their way through and missed obvious levels of heart disease.

All Mr. Lay needed was better information: get a heart scan, then follow a program of prevention like the Track Your Plaque program. You may not have hundreds of millions of dollars, but you have the information on how to not follow in Ken Lay's footsteps. Track Your Plaque--and stay alive.

Sometimes it's hard to know what is really important in your plaque-control or plaque-reducing efforts.

There are, indeed, crucial make-it-or-break-it factors that are necessary to gain control over plaque. If you hope to stack the odds of reducing your heart scan score as much as possible in your favor, then fish oil, vitamin D, 60-60-60 in the way of standard lipids, elimination of small LDL, etc. -- all the elements of the Track Your Plaque program--are necessary.

But there's lots of things that sidetrack people. I spend much of my day fielding questions from patients about all the things that either provide very little benefit for plaque control, or provide none at all.

Among the things that we have found to be too weak or useless for plaque control, or are "non-issues", include:

--Caffeine--Go ahead and enjoy a couple cups a day (though not a pot). The effect is too trivial to make much difference.

--Hawthorne--Yes, it may dilate coronary arteries modestly, but not enough to make any difference.

--Garlic--with the possible exception of a specific preparation called Aged Garlic Extract (an acqueous, non-oil-based, extract from Kyolic), garlic's effects are too tiny to help, e.g., drop in blood pressure 1-2 points. Use it, but don't expect much. Aged Garlic Extract may be an exception, in that a single study from UCLA suggested specific effects on slowing coronary plaque growth. We await more info on this.

--Anti-oxidants--There is no shortage of extravagant claims about the benefits of anti-oxidants. Unfortunately, there's very little human exerience with pine bark extract, pycnogenol, grapeseed extract, and so on. Is the purported benefit from anti-oxidation or through some other means, e.g., enhancement of nitric oxide synthase? No data.

--Policosanol--If you've followed the Track Your Plaque Special Reports, you already know what a disappointment this agent has been, despite the too-good-to-be-true clinical data. It doesn't work.

--"No-flush niacin"--Unfortunately, no flush, no effect. This high-priced supplement is still sold widely in the U.S. despite its complete lack of efficacy. It does not work in humans. (It works great in rats!)

Track Your Plaque continues to try to be the arbiter of truth in what works, what doesn't in truly stopping or reversing your coronary plaque. The proof positive? Stopping or dropping your heart scan score.

If you've been following the Track Your Plaque program, you know that we are advocates of "bio-identical hormones", i.e., hormone replacement using forms that are identical to the naturally-occuring human form.

In other words, we find it criminal that pharmaceutical manufacturers continue to promote use of non-identical hormones despite a probable increased side-effect and complication profile (a la Premarin). This unhappy situation persists because bio-identical hormones cannot be patent protected, meaning profits cannot be protected. Synthetic hormones can be patented and profits protected, thus their popularity among drug companies.

If that's not bad enough, Wyeth Pharmaceuticals--maker of synthetic hormone preparations, Premarin and Prempro--has filed an FDA petition to disallow the use of bio-identical hormones as prepared and dispensed by "compounding pharmacies". These are specialty pharmacies that mix and dispense hormones like estrogens (human estradiol, estriol, and estrione) and testosterone. They do so only with a doctor's prescription. Most are members of the Professional Compounding Centers of America (www.pccarx.com), a professional organization devoted to promoting quality-control over compounding practices.

Compounding pharmacies are occasionally guilty of compounding some suspect preparations. Witness the Fentanyl lollipops of 2002 in which the pain medication, Fentanyl, was put into lollipops for patients with chronic pain. This posed obvious dangers to any children who unsuspectingly ate the lollipops.

But the majority of compounding pharmacies are not guilty of such exotic practices. Most are simply pharmacies who might, for instance, mix a specific dermatologic preparation according to the orders of a dermatologist. Likewise with bio-identical hormones.

We have extensive experience with such a pharmacy in Madison, Wisconsin, the Women's International Pharmacy. They have filled hundreds of hormone prescription for us. They are responsible in their dispensing practices, in our experience. In fact, they have been at least as good, if not better, than other pharmacies we've dealt with.

We believe in protecting our rights to prescribe and you to use the choice of hormone preparations you and your doctor desire. This should include bio-identical hormones. The transparent profit motive from Wyeth should raise the hairs on your neck.

If you would like to post your comment to the FDA, there's a little time left. The folks at Womens' International Pharmacy have made it easy by posting links on their website. Go to http://www.womensinternational.com and just follow the instructions.

Here's a sample of some of the objections citizens have raised to Wyeth's petition:

I have been taking bioidentical hormones for two years. Bioidentical Hormones have been a great relief to me without the risk. I consult with my Physician who prescribes bio-identical hormones specifically for me, and my pharmacist prepares them. Without this medication and I would not be able to sleep; I would not be able to work due to the constant hot flashes. Without this medication, I find that I have less tolerance and I am considerably disagreeable. I also have problem with my memory without them. I want the bioidentcial hormones for the health benefits they provide. I urge you to not be swayed by Wyeth's petition. The product Premarin made by Wyeth, is made from pregnant horses not natural sources. Wyeth's hormones have been shown to cause cancer. I would not expect my government and its officials to submit to the highly funded petitioning of a pharmaceutical company who product is threatened by bioidentcial hormones. I do not expect my government to approved Wyeth's petition and leave me no choice of bioidentcial hormones and only the choice of Wyeth's cancer causing drugs Preamrin and Prempro. I ask that the FDA reject Wyeth's petition Docket #2005P-0411.

Another petitioner writes:

As a woman I take exception to Wyeth accusing the Compounding Pharmacy industry of unsafe practices. As a citizen of the United States I expect the FDA to stand up for my rights and the rights of all women who have found or in the future may seek consistent, safe and effective treatment with bioidentical hormones. Eliminating options by bowing to a large pharmaceutical company like Wyeth is not in the public interest and would deprive hundreds of thousands of American women from access to bioidentical hormones. Synthetic hormone replacement has been proven unequivocally unsafe in a government sponsored study and should not be forced as the sole treatment option for women. I hereby request the FDA rule against Wyeth's request. The FDA should not close down the bioidentical option of healthcare. I welcome studies of bioidentical hormones even though they are already FDA-approved and have been working effectively for decades. We already have the proof - hundreds of thousands of women, who over the past two decades have chosen bioidentical hormones based on their physicians' assessments. They are living proof that bioidentical hormones are safer and more effective and reliable than synthetic hormone drugs.

A physician and user of bio-identical hormones writes:

Wyeth, the filer of this complaint, is trying to prevent women from being able to choose less expensive compounded options for hormone replacement. There is medical evidence that in modifying the structure of their drugs (such as Premarin and Prempro) so that they could be patented, they may have introduced factors that cause the health risks identified in the Women's Health Initiative. This complaint appears to be filed for commercial purposes because of the market share that has shifted from Wyeth's products to bio-identical products from compounding pharmacies. If the complaint were upheld, patients and their doctors would not have a choice in hormone treatments. Wythe's commercial strategy of trying to eliminate the 'competition' from compounding pharmacies is against the public interest and in the interest of its own corporate profits. Women and their doctors should be able to choose between patented formulations such as those offered by Wyeth, bioidentical formulas available from compounding pharmacies, and no hormone treatment. I have been taking bio-identical hormones for several years and have had excellent results in improving my symptoms. I have been unable to take other synthetic hormones in the past, and am very concerned that my best treatment option will be taken away.

With new 64-slice CT scanners popping up everywhere nowadays, be sure to get your heart scan with it.

The new scanners do indeed provide wonderful images of the coronary arteries. But, say you have a 20% blockage in one artery by a coronary angiogram generated on one of these devices. What will you do in 1, 2, or 3 years when you want to know if you have progressed? Should you have the CT angiogram repeated?

Well, if you did you'll be exposed to a large dose of radiation--appropriate for a diagnostic test, but not for a screening test. The radiation exposure is not that different from undergoing a full conventional cardiac catheterization, or up to 100 chest x-rays.

"20% blockage" is also, contrary to popular opinion, not a quantitative measure. It is just an estimate of the diameter reduction at one spot. That number says nothing about the lengthwise extent of plaque. It also says nothing about the potential for "remodeling", the phenomenon of artery enlargement that occurs as plaque grows. In other words, if you had another CT coronary angiogram a year later and was told that your blockag was still 20%, in reality you could have had substantial plaque growth but it would not be reflected in that value.

People will come to me after having a CT angiogram for an opinion. Unfortunately, I send them back to their scan center to get a simple coronary calcium score. That measure is easy, quantitative, precise, and can be repeated yearly if necessary to track progression. (Track Your Plaque--I hope most of you get this by now.) Some physicians poke fun at the heart scan, or calcium, score--it's old, boring, only a measure of hard plaque. None of that's true. The coronary calcium score is a measure of total plaque (hard and soft). And when you are empowered to learn how to control and reduce your score, then it's the most exciting number in your entire health program!

Don't fall for the hype. If you go to a scan center and they insist on a 64-slice CT scanner, or if your doctor orders one, you should insist on getting a calcium score out of the test. Just ask. If they refuse, go somewhere else. Centers that refuse to generate a score have one thing on their mind: identifying people with severe blockages sufficient to obtain the downstream financial bonanza--angioplasty, stents, and bypass surgery.

Clair has coronary disease.

Clair first came to attention at age 57 when she suffered a large heart attack involving the front of her heart (the "anterior wall") two years ago. Her cardiologist implanted a drug-coated stent. Her doctors advised her to "cut the fat" in her diet, exercise, and take Lipitor.

One year later, she required a stent to another artery (circumflex). At this point, Clair was thoroughly demoralized and terrified for her future. Her first heart attack left her heart muscle with only 50% of normal strength.

She came to my office for another opinion. Of course, one of the first things we did was to identify all causes of her heart disease. No surprise, Clair had 7 new causes not previously identified, including low HDL (37 mg/dl), a severe small LDL particle pattern (75% of all particles were small), and Lp(a).

Her blood pressure was also 190/88, despite her relatively slender build and 3 medications that reduced blood pressure. That's a Lp(a) effect: Exagerrated coronary risk along with unexpected hypertension that often seems inappropriate.

In fact, I saw several patients just this week with lipoprotein(a), Lp(a), and exagerrated high blood pressure (hypertension). It's not that uncommon.

Though it has not been described in the medical literature, our experience is that hypertension is a prominent part of the entire Lp(a) "syndrome".

Lp(a) is responsible for much-increased potential for coronary disease (coronary plaque). It increases in importance as estrogen recedes in a woman (pre-menopause and menopause) and testosterone in a man, since both hormones powerful suppress Lp(a) expression (though why and how nobody knows).

I believe that Lp(a) is also responsible for hypertension that most commonly develops in a persons mid-50s and onwards, often with a vengeance. 3 or 4 anti-hypertensive medications and still not controlled.

Role of l-arginine

L-arginine may be more helpful in this situation than others. L-arginine, recall, is the supply for your body's nitric oxide, a powerful dilator of the body's arteries and thereby reduces blood pressure. We use 6000 mg twice a day, a large dose that requires use of powder preparations rather than capsules.

More reading about l-arginine and nitric oxide is available through Nobel laureate, Dr. Louis Ignarro's book, NO More Heart Disease : How Nitric Oxide Can Prevent--Even Reverse--Heart Disease and Stroke, available at Amazon.com ( http://www.amazon.com/gp/product/0312335814/104-1247258-6443909?v=glance&n=283155).

Will l-arginine truly reverse heart disease on its own? No, I don't believe so. Contrary to Dr. Ignarro's extravagant claims, I find l-arginine a facilitator of plaque regression, i.e, it helps other strategies achieve regression, but it does not achieve regression or reversal by itself. (Note that Dr. Ignarro is a lab researcher who studies rats and has never treated a human being.)

But l-arginine may have special application in the person with lp(a), particularly if hypertension is part of the syndrome.

Note: As always, please note that I talk frankly about l-arginine and other supplements and medications but have no hidden agenda: I am not selling anything, nor am I affiliated with any source/website/store etc. that sells these products. If I advocate something, I do so because I truly believe it, not because I'm trying to sell something. I make this point because so much nonsense is propagated in the media because of profit-motive. That's not true here.

In the era up until the 1980s, most Americans indulged in excessive quantities of saturated fats: fried chickem, spare ribs, French fries, gravy, bacon, Crisco, butter, etc.

Along came people like Nathan Pritikin and Dr. Dean Ornish, both of whom were vocal advocates of a low-fat nutritional approach. In their programs, fat composed no more than 10% of calories. This represented a dramatic improvement--at the time.

In 2006, a low-fat diet is a perversion of health. It means over-reliance on breads, breakfast cereals, pasta, crackers, cookies, pretzels, etc., the foods that pack supermarket shelves and that now constitute 70-80% of most Americans' diet.

Dr. Ornish still carries great name recognition. As a result, his outdated concepts still gain media attention. The June, 2006 issue of Reader's Digest, in their RDHealth column, carried an interview with Dr. Ornish in which he reiterates his fat-phobia.

However, on this occasion he takes a different tack. This time he rails against the "dangers" of fish oil and omega-3 fatty acids. "I've recently learned that omega-3s are a double-edged sword...In some cases, omega-3s could be fatal."

He goes on to say that, while he believes that fish oil may prevent heart attacks, it has fatal effect if you already have heart disease.

Does this make sense to you?

He's basing his views on a single, obscure study published in 2003 conducted in rural England that showed an increase in death and heart attack on fish oil. Most authorities have not taken these findings seriously, since they are wildly contrary to all other observations and because the study had some design flaws.

Despite the fact that this isolated study runs counter to all other, better-conducted studies seems not to matter to Dr. Ornish.

Clinging to the low-fat concept is like hoping 8-track tapes will make a comeback. It's not going to happen. We enjoyed the benefits while they lasted, appropriate for the era. But now, they're woefully outdated.

The overwhelming evidence is that fish oil provides tremendous benefits with little or no downside. In the Track Your Plaque program, fish oil remains a crucial supplement to gain control over your coronary plaque and stop or reduce your heart scan score. Ignore the doomsday preachings of Dr. Ornish.

(Watch for an article I wrote updating the benefits of fish oil for Life Extension magazine.)

Evan spotted the kiosk set up in the middle of the local mall. "Free cholesterol screenings. Know your heart health!" the sign declared.

It was a free cholesterol screening being offered by a local hospital.

The friendly nurse behind the kiosk had Evan fill out a form, then pricked his finger. Five minutes later, she reported to him with a smile, "Sir, your cholesterol is 177--your heart's fine! We get concerned when cholesterol is over 200. So you're in a safe range."

What the nurse failed to recognize is that Evan's HDL was 30 mg, a low value that actually places him at high risk for heart disease. Low HDL also signifies high likelihood of the small LDL particle pattern, a marked predisposition towards pre-diabetes and diabetes, a probable over-reliance on processed carbohydrates in his diet, a dramatically increased probability of hidden inflammation (e.g., elevated C-reactive protein), increased tendency for high blood pressure. . .

In other words, Evan's "favorable" total cholesterol is, in truth, nonsense. It's misleading, falsely reassuring, and provided none of the insight that a real effort might have yielded. Like hippies, tie-dye, other relics of the 1960s, total cholesterol needs to be put to rest. It has served many people poorly and been responsible for countless deaths.

When you see a kiosk or other service like this, even if it's free, run the other way.

So announced a Boston newspaper recently, featuring a story about new heart program at a local hospital.

They were announcing how a hospital had entered the cardiovasculare procedure game and how it would boost their bottom line. The article discussed how the hospital administration was anticipating "a surge in patients from the baby boom generation."

To justify this new program, the article quoted an administrator from another hospital: "Cardiovascular issues is [sic] the number one cause people sought treatment at our hospital."

The hospital featured in the story had spent $13.5 million dollars to develop their program.

Do you think they'll make it back?

You bet they will--many times over. Hospitals are businesses, complete with a bottom line, an expectation of profit and an eye towards growth.

The hospitals in the city where I live (Milwaukee, Wisconsin) are, as in Boston and elsewhere, very aggressive--expanding into new territories, hiring new "salesmen" (physicians), all to capture more marketshare and produce more "product" (your coronary angioplasty, stent, bypass surgery, defibrillator, etc.).

The equation for hospital profits is tried and true. Ignore your heart disese risk and you can help your local hospital grow its business. Neglect to get your heart scan and you can help your hospital pay down its debt. Get a heart scan, then do nothing about it, and you may even justify a pay raise for the hospital administrators for record revenue growth and profit.

Hospitals are a growth business because of the failure of most people and their doctors to 1) identify hidden coronary disease (CT heart scan to obtain your heart scan score), then 2) seize control over it (the Track Your Plaque program or, at least, your doctor's guidance along with your efforts at prevention).

Unless you do so, you are highly likely to help your hospital boost its annual goal for procedures.

Take a look at the list of foods on the American Heart Association's (AHA) Check Mark endorsement program (below). After I saw the list, I was convinced either that the people who designed the program are either startlingly ignorant, or the AHA simply does this for money.

Many of these foods have nothing to do with health, heart or otherwise. In fact, many of these foods are prominent culprits that contribute to the American epidemic of obesity. There are cured meats with sodium nitrite (a potent cause of colon cancer). Some of these companies have been accused of unhealthy food manufacturing practices. Tyson Foods, for instance, has been in court many times defending their brutal factory farm practices and were the focus of a federal investigation for paying bribe money to USDA Secretary, Mike Espy. (Espy was acquitted but two Tyson executives were convicted, only to be later pardoned by then President Bill Clinton.)

This is a smarmy list to be included on. Though there are some rare healthy exceptions on the list, from the Track Your Plaque viewpoint, this is a list of shame, foods that have no place in a genuinely heart healthy nutrition program.

8th Continent, LLC
8th Continent Fat Free Premium Original Soymilk
8th Continent Fat Free Premium Vanilla Soymilk
8th Continent Light Chocolate Soymilk
8th Continent Light Original Soymilk
8th Continent Light Vanilla Soymilk
8th Continent Premium Chocolate Soymilk
8th Continent Premium Original Soymilk
8th Continent Premium Vanilla Soymilk

American Italian Pasta Company
Golden Grain Mission Whole Grain Penne Rigate
Golden Grain Mission Whole Grain Rotini
Golden Grain Mission Whole Grain Spaghetti
Heartland Whole Grain Penne
Heartland Whole Grain Rotini
Heartland Whole Grain Spaghetti
Heartland Whole Wheat Angel Hair
Heartland Whole Wheat Elbow Macaroni
Heartland Whole Wheat Penne
Heartland Whole Wheat Rotini
Heartland Whole Wheat Spaghetti
Mueller's Whole Grain Penne
Mueller's Whole Grain Rotini
Mueller's Whole Grain Spaghetti

Atalanta Corporation
Celebrity 99% Fat Free Premium Imported Healthy Ham

Beefmaster Cattlemen, L.P.
Nolan Ryan's All Natural Ground Beef Round 96/4, 4% Fat

Bimbo Bakeries USA
Bimbo's 100% Integral/Bimbo 100% Whole Wheat Bread
Mrs. Baird's 100% Whole Wheat Bread
Oroweat 100% Whole Wheat Bread
Oroweat Country 100% Whole Wheat Bread
Oroweat Double Fiber Bread
Oroweat Original Health Nut Bread
Boar's Head Provisions Company, Inc.
Boar's Head Aroastica Seasoned Boneless Skinless Chicken Breast
Boar's Head Blazing Buffalo Style Boneless Skinless Roasted Chicken Breast
Boar's Head Branded Deluxe 42% Lower Sodium Ham
Boar's Head Cracked Pepper Mill Smoked Turkey Breast
Boar's Head Golden Classic Oven Roasted Boneless Skinless Chicken Breast
Boar's Head Hickory Smoked Black Forest Turkey Breast - 43% Lower Sodium
Boar's Head Hickory Smoked Boneless Skinless Chicken Breast
Boar's Head Italian Style Oven Roasted Seasoned Beef with Classic Braciole Seasoning
Boar's Head Lemon Pepper Boneless Skinless Roasted Chicken Breast
Boar's Head Londonport Top Round Seasoned Roast Beef
Boar's Head Maple Glazed Honey Coat Cured Turkey Breast
Boar's Head Mesquite Wood Smoked Skinless Roasted Breast of Turkey
Boar's Head Our Deluxe Low Sodium Low Fat Oven Roasted Choice Beef Cap Off Top Round
Boar's Head Our Premium Oven Roasted 47% Lower Sodium Turkey Breast - Skinless
Boar's Head Our Premium Oven Roasted 50% Lower Sodium Turkey Breast
Boar's Head Ovengold Roast Breast of Turkey
Boar's Head Ovengold Roast Breast of Turkey - Skinless
Boar's Head Pastrami Seasoned Turkey Breast
Boar's Head Salsalito Roasted Breast of Turkey
Bryan Foods, Inc.
Bryan 97% Fat Free Butcher Fresh Pork Tenderloin

Bumble Bee Foods LLC
Kirkland Signature Solid White Albacore Tuna in Water
Member's Mark Solid White Albacore Tuna in Water

California Giant
California Giant Strawberries
California Strawberry Commission
California Fresh Strawberries
California Frozen Strawberries

Campbell Soup Company
Calcium Enriched V8 100% Vegetable Juice
Campbell's Chunky Healthy Request Chicken Noodle
Campbell's Chunky Healthy Request Classic Chicken Noodle Microwaveable Bowl
Campbell's Chunky Healthy Request Grilled Chicken and Sausage Gumbo
Campbell's Chunky Healthy Request Grilled Chicken and Sausage Gumbo Microwaveable Bowl
Campbell's Chunky Healthy Request Hearty Beef Barley
Campbell's Chunky Healthy Request New Englad Clam Chowder
Campbell's Chunky Healthy Request Old Fashioned Vegetable Beef
Campbell's Chunky Healthy Request Vegetable
Campbell's Healthy Request Condensed Chicken Noodle Soup
Campbell's Healthy Request Condensed Chicken Noodle Soup (Food Service)
Campbell's Healthy Request Condensed Chicken Rice Soup
Campbell's Healthy Request Condensed Cream of Celery Soup
Campbell's Healthy Request Condensed Cream of Chicken Soup
Campbell's Healthy Request Condensed Cream of Mushroom Soup
Campbell's Healthy Request Condensed Homestyle Chicken Noodle
Campbell's Healthy Request Condensed Minestrone Soup
Campbell's Healthy Request Condensed Tomato Soup
Campbell's Healthy Request Condensed Vegetable Beef Soup
Campbell's Healthy Request Condensed Vegetable Soup
Campbell's Healthy Request Tomato Juice
Campbell's Low Sodium Tomato Juice
Campbell's Select Healthy Request Chicken and Egg Noodles
Campbell's Select Healthy Request Italian Style Wedding Microwaveable Bowl
Campbell's Select Healthy Request Italian-Style Wedding
Campbell's Select Healthy Request Mexican Style Chicken Tortilla
Campbell's Select Healthy Request Mexican Style Chicken Tortilla Microwaveable Bowl
Campbell's Select Healthy Request Savory Chicken and Long Grain Rice
Campbell's V8 Fusion Strawberry Banana
Campbell's V8 Fusion Tropical Orange
Campbell's V8 Regular Vegetable Juice
Campbell's V8 V.Fusion Light Peach Mango
Campbell's V8 V.Fusion Light Strawberry Banana
Campbell's V8 V.Fusion Pomegranate Blueberry
Essential Antioxidants V8 100% Vegetable Juice
Low Sodium V8 100% Vegetable Juice
Prego Heart Smart Mushroom Italian Sauce
Prego Heart Smart Traditional Italian Sauce

Cargill Meat Solutions
96/4 All Natural Extra Lean Ground Beef
Excel's Tender Choice 97% Fat Free Pork Tenderloins
Excel's Tender Choice Extra Lean Boneless Pork Loin
Our Certified 100% Pure All Natural Ground Beef 96/4
Sterling Silver Extra Lean Pork Tenderloins - 12% Marination
Sterling Silver Lean Boneless Pork Loin - 12% Marination

Chiquita Brands Company, N.A.
Chiquita Bananas

Clearwater Seafoods Limited Partnership
Clearwater Frozen Arctic Surf Clams

Cliffstar Corporation
Deerfield Farms No Sugar Added 100% Grape Juice (Purple)
Safeway 100% Grape Juice (Purple)
Sam's Choice 100% Grape Juice (Purple)
Walgreens 100% Grape Juice (Purple)

Clougherty Packing Company
Farmer John® California Natural® 4% Fat Extra Lean Ground Pork
Farmer John® California Natural® Premium Extra Lean Boneless Pork Tenderloins

Minute Maid Premium Blends - Orange Passion Calcium Juice-Frozen
Minute Maid Premium Blends - Orange Tangerine Calcium Juice - Frozen
Minute Maid Premium Country Style Orange Juice
Minute Maid Premium Country Style Orange Juice - Frozen
Minute Maid Premium Extra Vitamins C and E Plus Zinc Orange Juice - Frozen
Minute Maid Premium Home Squeezed Style Calcium + Vitamin D Orange Juice
Minute Maid Premium Low Acid Orange Juice
Minute Maid Premium Low Acid Orange Juice - Frozen
Minute Maid Premium Original Calcium + Vitamin D Orange Juice
Minute Maid Premium Original Calcium Orange Juice - Frozen
Minute Maid Premium Original Orange Juice
Minute Maid Premium Original Orange Juice - Frozen
Minute Maid Premium Pulp Free Calcium + Vitamin D Orange Juice
Minute Maid Premium Pulp Free Orange Juice
Minute Maid Premium Pulp Free Orange Juice - Frozen
Simply Orange Calcium Pulp Free 100% Orange Juice
Simply Orange Country Stand Calcium Medium Pulp 100% Orange Juice
Simply Orange Grove Made High Pulp 100% Orange Juice
Simply Orange Original Pulp Free 100% Orange Juice

Colleen Strawberries, Inc. / EKT Farms
Colleen Strawberries

ConAgra Dairy Foods
Egg Beaters 99% Real Eggs-Frozen
Egg Beaters 99% Real Eggs-Refrigerated
Egg Beaters Cheese & Chive
Egg Beaters Egg Whites
Egg Beaters Garden Vegetable
Egg Beaters Ham & Cheese
Egg Beaters Southwestern

ConAgra Food Service
Lamb Weston Sweet Things Mashed Sweet Potatoes, Frozen

ConAgra Frozen Foods
Healthy Choice Café Selections Apple Glazed Pork Medallions
Healthy Choice Café Selections Beef Merlot
Healthy Choice Café Selections Cajun Style Chicken & Shrimp
Healthy Choice Café Selections Chicken Fried Rice
Healthy Choice Café Selections Chicken Margherita
Healthy Choice Café Selections Chicken Tuscany
Healthy Choice Café Selections Creamy Dill Salmon
Healthy Choice Café Selections Four Cheese Pizza
Healthy Choice Café Selections General Tso's Spicy Chicken
Healthy Choice Café Selections Gourmet Supreme Pizza
Healthy Choice Café Selections Grilled Basil Chicken
Healthy Choice Café Selections Grilled Chicken & Roasted Red Pepper Alfredo
Healthy Choice Café Selections Grilled Chicken Baja
Healthy Choice Café Selections Grilled Chicken Caesar
Healthy Choice Café Selections Grilled Chicken Marinara
Healthy Choice Café Selections Grilled Whiskey Steak
Healthy Choice Café Selections Italian Style Pepperoni Pizza
Healthy Choice Café Selections Roasted Chicken Chardonnay
Healthy Choice Café Selections Roasted Chicken Marsala
Healthy Choice Complete Selections Asiago Chicken Portabello
Healthy Choice Complete Selections Beef Pot Roast
Healthy Choice Complete Selections Beef Stroganoff
Healthy Choice Complete Selections Beef Tips Portabello
Healthy Choice Complete Selections Beef with Classic BBQ Sauce
Healthy Choice Complete Selections Blackened Chicken
Healthy Choice Complete Selections Chicken Broccoli Alfredo
Healthy Choice Complete Selections Chicken Parmigiana
Healthy Choice Complete Selections Chicken Teriyaki
Healthy Choice Complete Selections Classic Grilled Chicken BBQ
Healthy Choice Complete Selections Country Breaded Chicken
Healthy Choice Complete Selections Country Herb Chicken
Healthy Choice Complete Selections Creamy Garlic Shrimp
Healthy Choice Complete Selections Fiesta Chicken
Healthy Choice Complete Selections Four Cheese Manicotti
Healthy Choice Complete Selections Glazed Chicken
Healthy Choice Complete Selections Grilled Chicken Monterey
Healthy Choice Complete Selections Grilled Turkey Breast
Healthy Choice Complete Selections Grilled White Meat Chicken with Smokehouse BBQ Sauce
Healthy Choice Complete Selections Honey Balsamic Chicken
Healthy Choice Complete Selections Lemon Pepper Fish
Healthy Choice Complete Selections Meatloaf
Healthy Choice Complete Selections Mushroom Roasted Beef
Healthy Choice Complete Selections Roasted Chicken
Healthy Choice Complete Selections Salisbury Steak
Healthy Choice Complete Selections Sweet Bourbon Steak
Healthy Choice Complete Selections Sweet and Sour Chicken
Healthy Choice Complete Selections Traditional Turkey Breast
Healthy Choice Low Fat Premium Sorbet & Cream Bars-Orange or Strawberry
Healthy Choice Premium Caramel Swirl Sandwich
Healthy Choice Premium Fudge Sandwich
Healthy Choice Premium Fudge Swirl Sandwich
Healthy Choice Premium Low Fat Ice Cream Bar
Healthy Choice Premium Vanilla Sandwich
Healthy Choice Simple Selections Breaded Chicken Breast Strips with Gravy
Healthy Choice Simple Selections Cheese French Bread Pizza
Healthy Choice Simple Selections Cheesy Chicken and Rice
Healthy Choice Simple Selections Chicken Enchilada
Healthy Choice Simple Selections Chicken Fettuccini Alfredo
Healthy Choice Simple Selections Chicken Rigatoni
Healthy Choice Simple Selections Four Cheese Manicotti
Healthy Choice Simple Selections Glazed Chicken
Healthy Choice Simple Selections Grilled Chicken White Meat Chicken & Pasta
Healthy Choice Simple Selections Grilled White Meat Chicken & Gravy
Healthy Choice Simple Selections Lasagna Bake
Healthy Choice Simple Selections Macaroni & Cheese
Healthy Choice Simple Selections Mandarin Chicken
Healthy Choice Simple Selections Pepperoni French Bread Pizza
Healthy Choice Simple Selections Roast Turkey Breastin Savory Sauce with Mushrooms
Healthy Choice Simple Selections Salisbury Steak
Healthy Choice Simple Selections Sesame Chicken
Healthy Choice Simple Selections Slow Roasted Turkey Breast with Gravy
Healthy Choice Simple Selections Spaghetti
Healthy Choice Simple Selections Supreme French Bread Pizza

ConAgra Grocery Foods
ACT II 94% Fat Free Butter Microwave Popcorn
ACT II 94% Fat Free Butter Mini Bags Microwave Popcorn
ACT II 94% Fat Free Kettle Corn Microwave Popcorn
Healthy Choice Bean & Ham Soup
Healthy Choice Beef Pot Roast Microwavable Bowl Soup
Healthy Choice Chicken & Dumplings Soup
Healthy Choice Chicken Tortilla Soup
Healthy Choice Chicken with Rice Microwavable Bowl Soup
Healthy Choice Chicken with Rice Soup
Healthy Choice Country Vegetable Microwavable Bowl Soup
Healthy Choice Country Vegetable Soup
Healthy Choice Fiesta Chicken Soup
Healthy Choice Garden Vegetable Soup
Healthy Choice Garlic & Herb Pasta Sauce
Healthy Choice Hearty Chicken Soup
Healthy Choice New England Clam Chowder Soup
Healthy Choice Old Fashioned Chicken Noodle Microwavable Bowl Soup
Healthy Choice Old Fashioned Chicken Noodle Soup
Healthy Choice Split Pea & Ham Soup
Healthy Choice Traditional Pasta Sauce
Healthy Choice Vegetable Beef Soup
Healthy Choice Zesty Gumbo with Chicken & Sausage Soup
Hunt's Family Favorites Seasoned Tomato Sauce for Lasagna
Hunt's Organic Crushed Tomatoes
Hunt's Organic Diced Tomatoes
Hunt's Organic Pasta Sauce Roasted Garlic
Hunt's Organic Whole Tomatoes
Hunt's Tomatoes Crushed in Thick Tomato Puree
Hunt's Tomatoes Diced
Hunt's Tomatoes Diced in Sauce
Hunt's Tomatoes Diced with Mild Green Chilies
Hunt's Tomatoes Diced-Green Pepper, Celery & Onions
Hunt's Tomatoes Petite Diced
Hunt's Tomatoes Stewed-No Salt Added
Hunt's Tomatoes Whole
Hunt's Tomatoes Whole-No Salt Added
Orville Redenbacher's Mini Bags Smart Pop Butter Microwave Popcorn
Orville Redenbacher's Mini Bags Smart Pop Butter/Kettle Corn Microwave Popcorn Variety Pack
Orville Redenbacher's Mini Bags Smart Pop Kettle Corn Microwave Popcorn
Orville Redenbacher's Organic Kernal Jar
Orville Redenbacher's Organic Smart Pop Butter Microwave Popcorn
Orville Redenbacher's Original Kernal Jar
Orville Redenbacher's Original Kernal Jug
Orville Redenbacher's Smart Pop Butter Microwave Popcorn
Orville Redenbacher's Smart Pop Kettle Corn Microwave Popcorn
Orville Redenbacher's Smart Pop Movie Theater Butter Microwave Popcorn
Orville Redenbacher's White Kernal Jar
Rosarita Diced Green Chilies
Rosarita Green Chilies Strips
Rosarita Whole Green Chilies

ConAgra Refrigerated Foods
Healthy Choice Deli Thin Baked Cooked Ham
Healthy Choice Deli Thin Honey Ham
Healthy Choice Deli Thin Honey Ham & Honey Roasted & Smoked Turkey Breast Variety Pack
Healthy Choice Deli Thin Honey Roasted & Smoked Turkey Breast
Healthy Choice Deli Thin Mesquite Turkey Breast
Healthy Choice Deli Thin Oven Roasted Chicken Breast
Healthy Choice Deli Thin Oven Roasted Turkey Breast
Healthy Choice Deli Thin Pastrami
Healthy Choice Deli Thin Smoked Ham
Healthy Choice Deli Thin Smoked Turkey Breast
Healthy Choice Deli-97% Fat Free Honey Ham
Healthy Choice Deli-97% Fat Free Honey Maple Ham
Healthy Choice Deli-97% Fat Free Medium Cooked Roast Beef-20% Marination
Healthy Choice Deli-97% Fat Free Mesquite Smoked Honey Ham
Healthy Choice Deli-97% Fat Free Roast Beef-20% Marination
Healthy Choice Deli-97% Fat Free Smoked Ham
Healthy Choice Deli-97% Fat Free Virginia Brand Ham
Healthy Choice Deli-98% Fat Free Browned Chicken Breast
Healthy Choice Deli-98% Fat Free Chicken Breast
Healthy Choice Deli-98% Fat Free Golden Oven Roasted Turkey Breast
Healthy Choice Deli-98% Fat Free Honey Roasted & Smoked Turkey Breast with Broth
Healthy Choice Deli-98% Fat Free Mesquite Smoked Chicken Breast
Healthy Choice Deli-98% Fat Free Mesquite Smoked Turkey Breast
Healthy Choice Deli-98% Fat Free Smoked Turkey Breast
Healthy Choice Deli-98% Fat Free Southwest Grill Turkey Breast
Healthy Choice Deli-Honey Cured Ham
Healthy Choice Deli-Honey Roasted & Smoked Turkey Breast
Healthy Choice Deli-Oven Roasted Chicken Breast
Healthy Choice Deli-Oven Roasted Turkey Breast
Healthy Choice Deli-Roast Beef-20% Marination
Healthy Choice Deli-Virginia Brand Cooked Ham
Healthy Choice Deluxe Thin-Sliced Baked Cooked Ham
Healthy Choice Deluxe Thin-Sliced Honey Ham
Healthy Choice Deluxe Thin-Sliced Honey Ham/Oven Roasted Turkey Breast Variety Pack
Healthy Choice Deluxe Thin-Sliced Oven Roasted Turkey Breast
Healthy Choice Honey Ham
Healthy Choice Low Fat Smoked Sausage
Healthy Choice Pre-Sliced Sandwich Solutions Roast Beef
Healthy Choice Pre-Sliced Sandwich Solutions Skinless Oven Roasted Turkey Breast
Healthy Choice Pre-Sliced Sandwich Solutions Skinless Smoked Turkey Breast
Healthy Choice Pre-Sliced Sandwich Solutions Virginia Brand Ham
Healthy Choice Virginia Brand Ham
Healthy Choice Zip Pack Cooked Ham
Healthy Choice Zip Pack Honey Ham
Healthy Choice Zip Pack Oven Roasted Chicken Breast
Healthy Choice Zip Pack Oven Roasted Turkey Breast
Hebrew National 97% Fat Free Beef Franks

ConAgra Retail Foods
Healthy Choice Hearty 100% Whole Grain Bread
Healthy Choice Hearty 7-Grain Bread

Coolham Holdings, Inc. DBA SunMilk Dairy Co.
SunMilk-Fat Free Milk with Sunflower Oil (The Taste of 1%)
SunMilk-Fat Free Milk with Sunflower Oil (The Taste of 2%)

Cooper Farms
Cooper Farms All Natural Turkey Breast Fillet

Crider, Inc.
Kirkland Signature Premium 99% Fat Free Chunk Chicken Breast

Dare Foods Incorporated
Breton Reduced Fat & Sodium Wheat Crackers

El Aguila Food Products, Inc.
El Aguila Stoneground Corn Tortillas

Eurofresh Inc.
Eurofresh Campari Tomatoes

FPL Foods, LLC
96/4 All Natural Extra Lean Ground Beef

Farmland Foods
Farmland 97% Fat Free Fresh Ground Pork
Farmland Nutrition Wise 97% Fat Free Boneless Center Cut Pork Loin Filet
Farmland Nutrition Wise Boneless Butterfly Cut Pork Loin Chops
Farmland Nutrition Wise Boneless Center Cut Pork Loin
Farmland Nutrition Wise Boneless Center Cut Pork Loin Chops
Farmland Nutrition Wise Boneless Center Cut Pork Loin Roast
Farmland Nutrition Wise Boneless Pork Chops - America's Cut
Farmland Nutrition Wise Boneless Pork Tenderloin
Farmland Nutrition Wise Boneless Pork Top Round Roast
Farmland Nutrition Wise Boneless Pork Top Round Steak
Farmland Nutrition Wise Boneless Sirloin Tip Pork Roast
Farmland Nutrition Wise Pork Cube Steak
Farmland Nutrition Wise Pork Cubes
Farmland Nutrition Wise Pork Scallopini
Farmland Nutrition Wise Pork Strips

Fieldale Farms Corporation
Jewel All Natural 99% Fat Free Boneless Skinless Chicken Breasts with Rib Meat
Jewel All Natural 99% Fat Free Chicken Breast Tenders
Our Premium 98% Fat Free Boneless Skinless Breast with Rib Meat - 15% Marination
Springer Mountain Farms All Natural 98% Fat Free Boneless Skinless Breasts

Florida's Natural Growers
Florida's Natural Calcium & Vitamin D No Pulp Orange Juice
Florida's Natural Growers Style Most Pulp Orange Juice
Florida's Natural Home Squeezed Calcium & Vitamin D with Pulp Orange Juice
Florida's Natural Home Squeezed with Pulp Orange Juice
Florida's Natural Original No Pulp Orange Juice

FoodTech International
Veggie Patch California Veggie Burgers

Foster Poultry Farms
Foster Farms 98% Fat Free Honey Roasted & Smoked Breast of Turkey
Foster Farms 98% Fat Free Oven Roasted Breast of Turkey
Foster Farms 98% Fat Free Oven Roasted Chicken Breast
Foster Farms 99% Fat Free 100% Natural Boneless & Skinless Breast Fillets
Foster Farms 99% Fat Free 100% Natural Boneless & Skinless Breast Steaks
Foster Farms 99% Fat Free 100% Natural Boneless & Skinless Breast Tenders
Foster Farms 99% Fat Free Honey Roasted & Smoked Turkey Breast
Foster Farms 99% Fat Free Oven Roasted Turkey Breast
Foster Farms All Natural 99% Fat Free Boneless & Skinless Chicken Breast Tenders (8% Marination)
Foster Farms Fresh & Easy 99% Fat Free 100% Natural Boneless & Skinless Breast Fillets
Kirkland Signature/Foster Farms 99% Fat Free 100% Natural Boneless & Skinless Breasts
Kirkland Signature/Foster Farms All Natural 99% Fat Free Boneless & Skinless Chicken Breasts (8% Marination)

Fresh Express Incorporated
Chiquita Apple Bites
Fresh Express American Salad
Fresh Express Hearts of Romaine Salad
Fresh Express Italian Salad
Fresh Express Triple Hearts Salad

GFA Brands, Inc.
Smart Balance Smart 'N Healthy Deluxe Microwave Popcorn
Smart Beat Healthy Fat Free Non-Dairy Slices - American Flavor
Smart Beat Healthy Fat Free Non-Dairy Slices - Lactose Free
Smart Beat Smart Squeeze Nonfat Margarine Spread

General Mills, Inc.
Apple Cinnamon Cheerios
Berry Berry Kix
Berry Burst Cheerios-Strawberry Banana
Berry Burst Cheerios-Triple Berry
Berry Lucky Charms
Cheerios
Cheerios Crunch
Chocolate Lucky Charms
Cocoa Puffs
Cookie Crisp
Count Chocula
Dora The Explorer
Frosted Cheerios
Fruity Cheerios
Heart Smart Bisquick
Honey Nut Cheerios
Kix
Lucky Charms
Multi-Grain Cheerios
Oatmeal Crisp Crunchy Almond
Oatmeal Crisp Hearty Raisin
Oatmeal Crisp Maple Brown Sugar
Pillsbury Oven-Baked Whole Wheat Dinner Rolls
Progresso Healthy Favorites Chicken & Wild Rice Soup
Progresso Healthy Favorites Chicken Gumbo Soup
Progresso Healthy Favorites Chicken Noodle Soup
Progresso Healthy Favorites Garden Vegetable Soup
Progresso Healthy Favorites Italian-Style Wedding Soup
Progresso Healthy Favorites Minestrone Soup
Total Cranberry Crunch
Total Honey Clusters
Total Raisin Bran
Total with Strawberries
Trix
Whole Grain Total
Yogurt Burst Cheerios Strawberry
Yogurt Burst Cheerios Vanilla

Hain Celestial Group, Inc., The
DeBoles Organic Ancient Grain Penne
Health Valley Empower Cereal
Hodgson Mill, Inc.
Hodgson Mill Oat Bran All Natural Hot Cereal
Hodgson Mill Whole Wheat Angel Hair
Hodgson Mill Whole Wheat Fettuccine
Hodgson Mill Whole Wheat Lasagna
Hodgson Mill Whole Wheat Penne
Hodgson Mill Whole Wheat Spinach Spaghetti
Hodgson Mill Whole Wheat Whole Grain Elbows
Hodgson Mill Whole Wheat Whole Grain Spaghetti

Indiana Packers Corp.
Indiana Kitchen All Natural Boneless Pork Sirloin Roast
Indiana Kitchen All Natural Pork Tenderloin

Interstate Brands Corporation
Home Pride Whole Grains 100% Honey Whole Wheat Bread
Home Pride Whole Grains 100% Whole Wheat Bread
Merita Country Whole Grains 100% Whole Wheat Bread

KFP International, Ltd.
Kedem 100% Pure Concord Grape Juice-No Sugar Added

Kansas City Steak Company
Kansas City Seasoned Beef Chuck Tender Steak
Kansas City Seasoned Beef Medallions

Kashi Company
Kashi Heart to Heart Honey Oat Waffles
Kashi Heart to Heart Honey Toasted Cereal
Kashi Heart to Heart Instant Oatmeal - Apple Cinnamon
Kashi Heart to Heart Instant Oatmeal - Golden Brown Maple
Kashi Heart to Heart Instant Oatmeal - Raisin Spice
Kashi Heart to Heart Oat Flakes & Wild Blueberry Clusters

Kellogg USA, Inc.
Kellogg's All-Bran Bran Buds
Kellogg's All-Bran Extra Fiber
Kellogg's All-Bran Original
Kellogg's Frosted Mini-Wheats - Strawberry Delight
Kellogg's Frosted Mini-Wheats - Vanilla Creme
Kellogg's Frosted Mini-Wheats Big Bite
Kellogg's Frosted Mini-Wheats Bite Size
Kellogg's Frosted Mini-Wheats Maple & Brown Sugar
Kellogg's Smart Start Antioxidants - Original
Kellogg's Smart Start Healthy Heart - Maple & Brown Sugar
Kellogg's Smart Start Healthy Heart - Original
Kellogg's Smart Start Healthy Heart Cinnamon Raisin

King Soopers
Ground Beef 96/4 Extra Lean

Kroger Company, The
Kroger Moist & Tender Silver Platter Pork Tenderloin

Laura's Lean Beef Company
Laura's Lean Beef - Beef Pot Roast Au Jus
Laura's Lean Beef - Shredded Beef with Barbecue Sauce
Laura's Lean Beef 4% Fat Ground Round
Laura's Lean Beef 4% Ground Sirloin
Laura's Lean Beef Sirloin Steak

LiDestri Foods, Inc.
Francesco Rinaldi No Salt Added Traditional Pasta Sauce

Lido Veal & Lamb Inc.
Veal USA Boneless Veal Shoulder Roast from Lido Veal
Veal USA Low Fat Ground Veal from Lido Veal
Veal USA Veal Leg Cutlets from Lido Veal
Veal USA Veal Stew from Lido Veal

M & I Seafood Manufacturing Inc.
Chesapeake Bay Gourmet Crab Cakes

MW Polar Foods
Polar All Natural Chunk Light Tuna in Water
Polar All Natural Solid White Albacore in Water
Polar Chunk Light Tuna in Water
Polar Solid White Albacore Tuna in Water

Malt-O-Meal Company
Malt-O-Meal Balance
Malt-O-Meal Crispy Rice
Malt-O-Meal Frosted Mini Spooners
Malt-O-Meal Honey & Oat Blenders
Malt-O-Meal Honey Nut Scooters
Malt-O-Meal Hot Wheat Cereal - Chocolate
Malt-O-Meal Hot Wheat Cereal - Maple & Brown Sugar
Malt-O-Meal Hot Wheat Cereal - Original
Malt-O-Meal Maple & Brown Sugar Mini Spooners
Malt-O-Meal Mom's Best 100% Natural Quick Oats
Malt-O-Meal Mom's Best Instant Oatmeal - Apples & Cinnamon
Malt-O-Meal Mom's Best Instant Oatmeal - Maple & Brown Sugar
Malt-O-Meal Mom's Best Instant Oatmeal Variety Pack - Maple & Brown Sugar/Apples & Cinnamon/Cinnamon & Spice
Malt-O-Meal Raisin Bran
Malt-O-Meal Scooters

Maple Leaf Consumer Foods
Maple Leaf Sodium Reduced 98% Fat Free Cooked Ham with Natural Juices

Maverick Ranch Association
Maverick Ranch 96/4 Extra Lean Grass Fed Organic Ground Beef
Maverick Ranch 96/4 Extra Lean Natural Ground Buffalo
Maverick Ranch 96/4 Extra Lean Natural Ground Pork Sirloin
Maverick Ranch Free-Range Chicken-All Natural Air Chilled Boneless Skinless Chicken Breast
Maverick Ranch NaturaLite 96/4 Extra Lean Ground Beef Round
Maverick Ranch NaturaLite Beef - 96/4 Extra Lean Ground Beef Chuck
Maverick Ranch NaturaLite Beef - 96/4 Extra Lean Ground Beef Sirloin
Maverick Ranch Natural Beef Cubed Steak
Maverick Ranch Natural Beef Top Sirloin Steak
Maverick Ranch Natural Buffalo Top Sirloin Steak
Maverick Ranch Natural Center Cut Pork Loin Chops
Maverick Ranch Natural Lite 96/4 Extra Lean Natural Ground Beef
Maverick Ranch Natural Pork 4% Fat Extra Lean Pork Tenderloin
Maverick Ranch Natural Skinless Chicken Drumsticks
Maverick Ranch Natural Skinless Chicken Thighs
Maverick Ranch Organic Air-Chilled Boneless Skinless Chicken Breasts

Mayoli Inc.
Mayoli All Natural Reduced Fat Mayonnaise Dressing with Pure Olive Oil

McNeil Nutritionals, LLC
LACTAID® Calcium-Fortified Fat Free Milk
LACTAID® Fat Free Milk

Meijer Distribution, Inc.
Meijer Purple Grape Juice

Michael Foods, Inc.
All Whites Egg Whites - White Cheddar
Better 'n Eggs Ham & Cheese
Better 'n Eggs Plus
Better 'n Eggs Three Cheese
Kirkland Signature Egg Starts
Kroger Break-Free 100% Liquid Egg Whites
Kroger Break-Free Real Egg Product
Papetti Foods All Whites - 100% Liquid Egg Whites
Papetti Foods Better 'n Eggs

Mills Family Farms
Mills Family Farms Green Cascade Mix-Baby Romaine & Baby Green Leaf
Mills Family Farms Wholeaves Sandwich & Salad Lettuce - Green Leaf
Mills Family Farms Wholeaves Sandwich & Salad Lettuce - Red Leaf
Mills Family Farms Wholeaves Sandwich & Salad Lettuce - Romaine
Milton's Baking Company
Milton's Baking Classics Cinnamon Raisin Wheat Bread
Milton's Baking Classics Corn Bread
Milton's Baking Classics Oat Bran Bread
Milton's Baking Classics Wheat Bread
Milton's Healthy Multi-Grain Plus Bread
Milton's Healthy Whole Grain Plus Bread
Milton's Original Healthy Multi-Grain Bread
Milton's Whole Grains 100% Whole Wheat Bread

Motts LLP
Yoo-hoo Lite Chocolate Drink

Murray's Free Roaming Chicken, Inc.
Murray's Extra Lean 99% Fat Free Boneless & Skinless Chicken

New World Pasta Company
Ronzoni Healthy Harvest Multi-Grain Pasta-Fusilli
Ronzoni Healthy Harvest Multigrain Pasta - Spaghetti Style
Ronzoni Healthy Harvest Whole Wheat Blend Extra Wide Noodle - Style
Ronzoni Healthy Harvest Whole Wheat Blend Pasta - Linguine
Ronzoni Healthy Harvest Whole Wheat Blend Pasta - Penne Rigate
Ronzoni Healthy Harvest Whole Wheat Blend Pasta - Rotini
Ronzoni Healthy Harvest Whole Wheat Blend Pasta - Spaghetti Style
Ronzoni Healthy Harvest Whole Wheat Blend Pasta - Thin Spaghetti
Ronzoni Healthy Harvest Whole Wheat Blend Pasta-Lasagna
Ronzoni Healthy Harvest Whole Wheat Blend Wide Noodle - Style

Nonna's Kitchen, Inc.
Columbus Reduced Sodium Turkey Breast

North American Beverage Company
Chocolate Moose - All Natural Premium Milk Chocolate Drink
Chocolate Moose - Cookies & Cream Premium Milk Chocolate Drink
Mega Moose Energy Drink-Strawberry Blast

Nulaid Foods Inc.
Nulaid ReddiEgg Real Egg Product

Oberto Sausage Company
Kirkland Signature Premium Brisket Roast Beef

Old Orchard Brands LLC
Old Orchard 100% Grape Juice
Old Orchard 100% Grape Juice - Frozen Concentrate

POM Wonderful, LLC
POM Wonderful Fresh Pomegranate Arils
POM Wonderful Frozen Pomegranate Arils
POM Wonderful Pomegranates

Packerland Processing Co., Inc.
Meijer Extra Lean Ground Beef 96/4

Peco Foods, Inc.
Member's Mark All Natural Boneless Skinless Chicken Breasts with Rib Meat
Member's Mark All Natural Boneless Skinless Chicken Tenderloins

Pepperidge Farm, Inc.
Pepperidge Farm 100% Natural 100% Whole Wheat Bread
Pepperidge Farm 100% Natural 9 Grain Bread
Pepperidge Farm 100% Natural German Dark Wheat Bread
Pepperidge Farm 100% Natural Honey Flax Bread
Pepperidge Farm 100% Whole Wheat Bagels
Pepperidge Farm 100% Whole Wheat English Muffins
Pepperidge Farm 100% Whole Wheat Hearty Texture Whole Grain Bread
Pepperidge Farm 100% Whole Wheat Mini Bagels
Pepperidge Farm 15 Grain Hearty Texture Whole Grain Bread
Pepperidge Farm Farmhouse Soft 100% Whole Wheat Bread
Pepperidge Farm Golden Harvest Grains Hearty Texture Whole Grain Bread
Pepperidge Farm Light Style 7 Grain Bread
Pepperidge Farm Light Style Soft Wheat Bread
Pepperidge Farm Oatmeal Hearty Texture Whole Grain Bread
Pepperidge Farm Soft Honey Oat Smooth Texture Whole Grain Bread
Pepperidge Farm Soft Honey Whole Wheat Smooth Texture Whole Grain Bread
Pepperidge Farm Very Thin Soft 100% Whole Wheat Bread
Pepperidge Farm Whole Grain Multi-Grain Bagels
Pepperidge Farm Whole Grain Swirl Bread - Cinnamon
Pepperidge Farm Whole Grain Swirl Bread - Cinnamon with Raisins

Perdue Farms, Inc.
Perdue Individually Frozen All Natural 99% Fat Free Chicken Tenderloins
Perdue Tender & Tasty 99% Fat Free Individually Frozen Boneless Skinless Chicken Breasts
Perdue Tender & Tasty 99% Fat Free Individually Wrapped Boneless Skinless Chicken Breasts
Perdue/Kirkland Signature Individually Frozen All Natural 99% Fat Free Boneless Skinless Chicken Breasts

Pilgrim's Pride Corporation
Eat Well Stay Healthy Chicken Breast Salad
Eat Well Stay Healthy Fresh Boneless Skinless Chicken Breasts with Rib Meat (15% Chicken Broth)
Eat Well Stay Healthy Fresh Boneless Skinless Chicken Thin Sliced Breasts with Rib Meat (15% Chicken Broth)
Eat Well Stay Healthy Fresh Chicken Breast Tenderloins (15% Chicken Broth)
Eat Well Stay Healthy Fully Cooked Rotisserie Skinless Chicken Split Breasts - Garden Herb
Gold Kist Farms 100% Natural 99% Fat Free Boneless Skinless Chicken Breast
Gold Kist Farms All Natural 99% Fat Free Boneless Skinless Breasts
Gold Kist Farms/Kirkland Signature All Natural 99% Fat Free Boneless Skinless Breasts
HyVee/Country Pride 97% Fat Free Boneless Skinless Chicken Breast Fillets with Rib Meat (15% Chicken Broth)
HyVee/Country Pride 97% Fat Free Skinless Split Chicken Breasts with Ribs (12% Chicken Broth)
HyVee/Country Pride 99% Fat Free Boneless Skinless Chicken Breast Tenderloins (15% Chicken Broth)
Meijer Fresh Boneless Skinless Chicken Breast Tenderloins (15% Marination)
Meijer Fresh Boneless Skinless Chicken Breasts with Rib Meat (15% Marination)
Pilgrim's Pride Eat Well Stay Healthy Grilled Chicken Breast Fillets
Pilgrim's Pride Eat Well Stay Healthy Grilled Chicken Breast Strips
Pilgrim's Pride Eat Well Stay Healthy Italian Style Grilled Chicken Breast Fillets
Pilgrim's Pride Eat Well Stay Healthy Key Lime Flavor Chicken Breast Fillets
Pilgrim's Pride Eat Well Stay Healthy Kids Fully Cooked Breaded Chicken Nuggets
Pilgrim's Pride Eat Well Stay Healthy Kids Fully Cooked Breaded Popcorn Chicken
Pilgrim's Pride Eat Well Stay Healthy Lemon Herb Chicken Breast Fillets
Pilgrim's Pride Eat Well Stay Healthy Savory Chicken Breast Fillets
Pilgrim's Pride Eat Well Stay Healthy Szechwan Chicken Breast Tenderloins
Pilgrim's Pride Fresh Boneless Skinless Chicken Breasts with Rib Meat Individually Wrapped (15% Chicken Broth)
Pilgrim's Pride Fresh Chicken 100% Natural Boneless Skinless Breasts with Rib Meat
Pilgrim's Pride Fresh Chicken 100% Natural Boneless Skinless Breasts with Rib Meat (15% Chicken Broth)
Pilgrim's Pride Fresh Chicken 100% Natural Breast Tenderloins
Pilgrim's Pride Fresh Chicken 100% Natural Breast Tenderloins (15% Chicken Broth)
Pilgrim's Pride Fresh Chicken 100% Natural Skinless Split Breasts with Ribs
Pilgrim's Pride Fresh Chicken 100% Natural Skinless Split Breasts with Ribs (12% Chicken Broth)
Pilgrim's Pride Fresh Chicken Breast Tenderloins Individually Wrapped (15% Chicken Broth)
Pilgrim's Pride Individually Frozen Fully Trimmed 99% Fat Free All Natural Boneless Skinless Chicken Breasts (15% Chicken Broth)
Schnucks 99% Fat Free Chicken Breast Tenderloins
Schnucks 99% Fat Free Skinless Chicken Breast Fillets
Schnucks 99% Fat Free Thin Sliced Skinless Chicken Breast Fillets

Quaker Oats Company/Tropicana Products, Inc., The
Crystal Wedding Oats
Old-Fashioned Quaker Oats
Quaker Cinnamon Life
Quaker Essentials Oat Bran
Quaker Essentials Oatmeal Squares - Brown Sugar
Quaker Essentials Oatmeal Squares - Cinnamon
Quaker Essentials Toasted Oatmeal - Brown Sugar
Quaker Essentials Toasted Oatmeal - Honey Nut
Quaker Honey Graham Life
Quaker Instant Oatmeal - Apple Crisp
Quaker Instant Oatmeal - Apples & Cinnamon
Quaker Instant Oatmeal - Cinnamon & Spice
Quaker Instant Oatmeal - Cinnamon Roll
Quaker Instant Oatmeal - Flavor Variety
Quaker Instant Oatmeal - Maple & Brown Sugar
Quaker Instant Oatmeal - Raisins & Spice
Quaker Instant Oatmeal - Regular Flavor
Quaker Instant Oatmeal Bakery Favorites Variety Pack (Apple Crisp/Cinnamon Roll/Banana Bread)
Quaker Instant Oatmeal Crunch - Apples & Cinnamon
Quaker Instant Oatmeal Crunch - Magicolor Cinnamon
Quaker Instant Oatmeal Crunch - Maple & Brown Sugar
Quaker Instant Oatmeal Crunch - Mixed Berry
Quaker Instant Oatmeal Lower Sugar - Apples & Cinnamon
Quaker Life
Quaker Life Chocolate Oat Crunch
Quaker MultiGrain Hot Cereal
Quaker Oat Bran Hot Cereal
Quaker Take Heart Instant Oatmeal - Blueberry
Quaker Take Heart Instant Oatmeal - Golden Maple
Quick 1 Minute Quaker Oats
Tropicana Pure Premium Calcium + Vitamin D No Pulp Orange Juice
Tropicana Pure Premium Fiber Some Pulp Orange Juice
Tropicana Pure Premium Golden No Pulp Grapefruit Juice
Tropicana Pure Premium Grovestand Calcium + Vitamin D Lots of Pulp Orange Juice
Tropicana Pure Premium Grovestand Lots of Pulp Orange Juice
Tropicana Pure Premium Healthy Heart No Pulp Orange Juice with Omega 3
Tropicana Pure Premium Homestyle Some Pulp Orange Juice
Tropicana Pure Premium Light 'n Healthy Calcium No Pulp Orange Juice
Tropicana Pure Premium Light 'n Healthy Calcium No Pulp Orange Juice
Tropicana Pure Premium Low Acid No Pulp Orange Juice
Tropicana Pure Premium Original No Pulp Orange Juice
Tropicana Pure Premium Ruby Red Some Pulp Grapefruit Juice

R.A.B. Food Group LLC
Manischewitz Premium 100% Grape Juice

Rader Farms, Inc.
Rader Farms Nature's Three Berries

Red Gold, LLC
Sacramento Tomato Juice from Concentrate with Enhanced Tomato Flavor

Ruprecht Company
Sommers 100% Organic Extra Lean Beef Burgers

Sal & Judy's Products, LLC
Sal & Judy's Heart Smart Italian Sauce

Sealord North America, Inc.
Sealord Deep Sea Dory Fillets
Sealord Orange Roughy Fillets

Setton International Foods, Inc.
Setton Farms Heart Healthy Mix

Simmons Foods, Inc.
Member's Mark All Natural 99% Fat Free Boneless Skinless Chicken Breast

Smithfield Lean Generation Cuts
SLG: All Natural Pork Tenderloin
SLG: Marinated Hickory Sweet Center Cut Boneless Pork Loin
SLG: Marinated Hickory Sweet Pork Chops
SLG: Marinated Hickory Sweet Pork Loin Filet
SLG: Marinated Hickory Sweet Pork Tenderloin
SLG: Marinated Peppercorn & Garlic Pork Tenderloin
SLG: Marinated Pork Loin Fillet - Peppercorn & Garlic
SLG: Self-Basting Boneless Pork Loin Center Cut Chops
SLG: Self-Basting Boneless Whole Pork Loin
SLG: Self-Basting Pork Tenderloin

Smithfield Lean Generation Deli
SLG Deli: 98% Fat Free Canadian Brand Maple Ham
SLG Deli: 98% Fat Free Cooked Ham
SLG Deli: 98% Fat Free Honey Cured Ham
SLG Deli: 98% Fat Free Tavern Ham
SLG Deli: 98% Fat Free Virginia Brand Ham

Smithfield Premium Cuts
Smithfield: Self-Basting Pork Tenderloin

Solis Brands, Inc.
ZOIC Belgian Chocolate Nutrition Drink
ZOIC French Vanilla Nutrition Drink

Springerhill Ranch Meat Products
Springerhill Ranch Brand All Natural 98% Fat Free Beef Tenderloin Steaks
Springerhill Ranch Brand All Natural Ground Beef-98% Lean 2% Fat

StarKist Seafood Company
StarKist Chunk Light Tuna in Water
StarKist Chunk White Albacore Tuna in Water
StarKist Gourmet Choice Albacore Tuna Fillet in Water
StarKist Gourmet Choice Chunk Light Tuna in Water
StarKist Gourmet Choice Solid Light Tuna Fillet in Water
StarKist Low Sodium Chunk Light Tuna in Water
StarKist Solid White Albacore Tuna in Water
StarKist Very Low Sodium Chunk White Albacore Tuna in Water

Sunrise Growers, Inc.
Sunrise Growers California Strawberries

Swift Foods dba Swift & Company
Extra Lean Ground Pork
Swift Boneless Pork Sirloin Cutlets
Swift Natural Fresh Pork-Boneless Pork Center Cut Loin Chops
Swift Natural Fresh Pork-Boneless Pork Leg for London Broil
Swift Natural Fresh Pork-Boneless Pork Top Loin Roast
Swift Natural Fresh Pork-Pork Strips for Barbecue
Swift Pork Center Cut Loin
Swift Pork Sirloin Tip Roast
Swift Pork Tenderloin
Swift Premium Guaranteed Tender Pork-Boneless Bottom Round
Swift Premium Guaranteed Tender Pork-Boneless Center Cut Loin Chops
Swift Premium Guaranteed Tender Pork-Boneless Pork Loin Filet
Swift Premium Guaranteed Tender Pork-Boneless Pork Tenderloin
Swift Premium Guaranteed Tender Pork-Boneless Sirloin Cutlets
Swift Premium Guaranteed Tender Pork-Boneless Strips for Barbecue
Swift Premium Guaranteed Tender Pork-Pork Top Round
Swift/Kirkland Signature Pork Sirloin Tip Roast
Trader Joe's Butcher Shop - Pork Sirloin Tri Tip
Trader Joe's Butcher Shop Boneless Center Cut Pork Loin Cutlets
Trader Joe's Butcher Shop Natural Pork-Boneless Pork Loin Chops
Trader Joe's Butcher Shop Natural Pork-Pork Shoulder Boneless Strips
Trader Joe's Butcher Shop-Pork Tenderloin

T. J. Kraft, Ltd.
Hawaiian Pacific Ahi Tuna Steaks

Taylor Packing Co., Inc.
Century Farm 96/4 Extra Lean Ground Beef

The Baker
The Baker 7-Grain Sourdough Whole Wheat Bread

Thumann's Inc
Thumann's All Natural Black Forest Brand Ham
Thumann's All Natural Capless Roast Beef
Thumann's All Natural Oven Roasted Gourmet Chicken Breast
Thumann's All Natural Oven Roasted Gourmet Turkey Breast
Thumann's Buffalo Style Oven Roasted Chicken Breast
Thumann's Capless Roast Beef
Thumann's Golden Roasted Filet of Turkey - Rotisserie Flavor
Thumann's Golden Roasted Gourmet Turkey
Thumann's Our Short Cut Deluxe Cooked Ham - Lower Sodium
Thumann's Oven Roasted Premium Chicken Breast

Tony Downs Foods Company
Member's Mark 98% Fat Free Premium Chunk Chicken Breast in Water

Topco Associates, LLC
Food Club Individually Frozen Boneless Skinless Chicken Breasts-15% Seasoned Chicken Broth
Food Club Individually Frozen Chicken Tenderloins-15% Seasoned Chicken Broth

Tumaro's Inc.
Tumaro's Chipotle Chili & Peppers Healthy Flour Tortillas
Tumaro's Garden Spinach & Vegetables Healthy Flour Tortillas
Tumaro's Honey Wheat Healthy Flour Tortillas
Tumaro's Jalapeno & Cilantro Healthy Flour Tortillas
Tumaro's Pesto & Garlic Healthy Flour Tortillas
Tumaro's Premium White Healthy Flour Tortillas
Tumaro's Sun-Dried Tomato & Basil Healthy Flour Tortillas

Tyson Foods, Inc.
Tastybird Individually Frozen Chicken-Boneless, Skinless Breast Portions with Rib Meat
Tastybird Individually Quick Frozen Chicken-Boneless, Skinless Tenderloins
Tyson 100% All Natural Thin 'N Fancy Boneless Skinless Chicken Breasts with Rib Meat (<3% Water)
Tyson 100% All Natural Boneless Skinless Chicken Breasts with Rib Meat (<1%/,2% Water)
Tyson 100% All Natural Boneless Skinless Chicken Thighs (15% Natural Chicken Broth)
Tyson 100% All Natural Chicken Breast Tenderloins (15% Natural Chicken Broth)
Tyson 100% All Natural Chicken Breast Tenderloins (<1% Water)
Tyson 100% All Natural Premium Boneless Skinless Chicken Breasts with Rib Meat (15% Natural Chicken Broth)
Tyson 100% All Natural Skinless Split Chicken Breasts with Ribs (12% Natural Chicken Broth)
Tyson 100% All Natural Skinless Split Chicken Breasts with Ribs (>3% Water)
Tyson 100% All Natural Thin 'N Fancy Boneless Skinless Chicken Breasts with Rib Meat (15% Natural Chicken Broth)
Tyson Ice Glazed Chicken Individually Frozen 99% Fat Free Boneless, Skinless Breast Tenderloins (8% Seasoned Chicken Broth)
Tyson Individually Fresh Frozen All Natural 99% Fat Free Boneless Skinless Chicken Tenderloins (8% Water & Kosher Salt)
Tyson Individually Fresh Frozen Boneless Skinless Chicken Breasts with Rib Meat (15% Chicken Broth)
Tyson Individually Fresh Frozen Chicken Tenderloins (15% Chicken Broth)
Tyson Individually Frozen 100% All Natural Individually Wrapped Boneless Skinless Chicken Breasts (15% Natural Chicken Broth)
Tyson Individually Frozen All Natural 99% Fat Free Boneless Skinless Chicken Breast Tenderloins (8% Chicken Broth)
Tyson Individually Frozen All Natural Boneless Skinless Chicken Breasts with Rib Meat (8% Broth Glaze & 15% Seasoned Chicken Broth)
Tyson Individually Frozen All Natural Extra Lean Boneless Skinless Chicken Breast with Rib Meat (8% Chicken Broth)
Tyson Individually Frozen Boneless Skinless Chicken Breasts with Rib Meat (15% Chicken Broth)
Tyson/Kirkland Signature All Natural 99% Fat Free Boneless Skinless Chicken Breast (8% Water & Kosher Salt)
Tyson/Tastybird Individually Frozen Boneless Skinless Breasts with Rib Meat (10% Seasoned Chicken Broth)
Tyson/Tastybird Individually Frozen Chicken-Boneless Skinless Breasts with Rib Meat (10% Natural Chicken Broth)

Tyson Fresh Meats, Inc.
100% Pure Extra Lean Ground Beef 96/4
96/4 All Natural Extra Lean Ground Beef

United Food Group, LLC
Miller's 100% Pure Ground Beef - 4% Fat
Moran's All Natural 4% Fat 100% Ground Beef Hamburger Patties
Moran's All Natural 4% Fat Ground Beef
Trader Joe's Butcher Shop 4% Fat Ground Beef

Welch Foods, Inc.
Welch's 100% Grape Juice (Purple)
Welch's 100% Grape Juice (Purple) - Frozen Concentrate
Welch's 100% Grape Juice (Purple) - Pourable Concentrate
Welch's 100% Grape Juice Calcium (Purple)
Welch's 100% Grape Juice with Fiber
Welch's Organic 100% Concord Grape Juice
Welch's Organic 100% Concord Grape Juice - Frozen Concentrate

West Liberty Foods, LLC
Honey Roasted & Smoked Breast of Turkey - 98% Fat Free
Kirkland Signature All Natural Fully Cooked Sliced Turkey Breast
Oven Roasted Breast of Turkey Browned in Soybean Oil - 98% Fat Free

I'm very troubled by the American Heart Association's (AHA) willingness to lend its logo and stamp of approval to a multitude of garbage foods like Cocoa Puffs and Berry Kix cereals.

So I contacted the AHA and spoke to the manager of the Food Certification Program, Ms. Linda Rupp. Ms. Rupp proved very helpful in helping me to understand.

I originally called her to find out just how many products were turned down. In view of 768 products on the approved list, I wondered how many had been rejected to generate this "select" group.

Unfortunately, she said that the number of products rejected was not tracked, though she did intimate that it was not a lot. Sometimes, she added, a rejected product will undergo a few "improvements" to help it achieve the criteria necessary for AHA approval.

What exactly is considered in an application for the Food Certification Program?

A food must have 1)total fat 3.0 grams or less, 2) saturated fat 1.0 gram or less, 3) 20 grams or less cholesterol, 4) 480 mg or less sodium, all per serving.

She also pointed out that, given the fact that a food as useless and lacking in health qualitites as jelly beans could meet this criteria, the AHA employs a special "Jelly Bean Rule" that stipulates that 10% of the Daily Value of 6 nutrients (e.g., fiber, vitamins A and C, etc.) must also be contained in a serving.

So those are the startlingly lax requirements to gain the privilege of affixing the AHA Heart Check Mark on your product and informing the public that your box of Cocoa Puffs, Cookie Crisp cereal, or Berry Kix is "heart healthy."

There is an epidemic of obesity in the U.S. I don't believe that the AHA endorsement helps. In fact, I believe that it has been a contributor to obesity.

Pardon me while I eat this bag of M&M's for my heart.

Stan did everything right.

He followed the Track Your Plaque "Rule of 60". He was slender, had run a marathon a few months earlier, in fact. He included fish oil at therapeutic doses. He replenished vitamin D to a blood level of 57 ng/ml 25-OH-vitamin D3. Though ambitious and hard-working, he was a generally happy, optimistic person.

Yet his CT heart scan score increased 28% in one year, from a starting score of 379 to 485.

What did he do wrong?

Well, Stan did nothing wrong. But I suggested to him that one "hole" in his program could be exercise-induced high blood pressure. I've witnessed this effect many times. Blood pressure normal or "borderline" high while seated and relaxed, sky-high with exercise.

So we put Stan on a treadmill. Starting blood pressure: 123/76. Blood pressure with exericse (13 mets): 220/78--sky high. That's why Stan's heart scan score went up. A good pressure with this level of exercise: 150/70, but certainly no higher than 170/80.

If blood pressure is high with exercise, it's probably high with emotional upset, anxiety, being in a hurry, etc., also, all the irritations and pressures of life.

We'll see in future how much of a role reducing Stan's blood pressure will play in gaining better control over his heart scan score. A practical difficulty will be in assessing the adequacy of blood pressure control in Stan, since its full potential only becomes evident with exerise. It means that future blood pressure assessments are more likely to be on a treadmill.

It would also explain why Stan's thoracic aorta was mildly enlarged and his aortic valve was mildly leaky when I met him, both potential consequences of intermittent high blood pressure.

If you've been following the Track Your Plaque conversation, you know that, contrary to prevailing opinion among many cardiologists, there is an emerging notion that coronary calcification is an active process, a true part of the disease.

Vitamin D3 is an important aspect of this question. So is vitamin K2. Not to be confused with K1 that plays a role in blood coagulation, K2 has an important role in calcium metabolism. Thus, vitmain K2 deficiency is related to osteoporosis and to coronary calcification.

Getting K2, like getting D, is difficult from food sources. The choices for K2 sources includes:

--Natto--generally, an impalatable choice. I've had it and it was intolerably gooey and weird-tasting. It is, nonetheless, the most concentrated food source of K2.

--Pate--Though liver products have the potential for containing many other unhealthy things, like pesticide residues, since the liver acts as a filter for the blood.

--Fermented cheeses--Since K2 is a product of fermentation of cheese, as it is in Natto.

For years, we've advised people to avoid or minimize cheese because of saturated fat or cholesterol content. I think that there's reason to re-think this advice based on the emerging data.

How can you tell the difference between fermented and non-fermented cheese? First, look for the holes in the cheese. The holes are the remnants of gas pockets created during fermentation. Second, look for the word "cultures" on the label, meaning organisms for fermentation were added. If "processed cheese" is anywhere on the label, this is a dairy product that has been chemically coagulated and is not fermented.

Fermented cheeses are generally "gourmet" cheeses, not eaten a pound at a time on a pizza, but meant to be eaten in small portions.

How much fermented cheese is necessary for its presumed inhibitory benefits on coronary calcification and osteoporsis? Are some fermented cheeses better than others? These issues remain unsettled. Stay tuned.

Anyone following the Track Your Plaque conversation know that we are rabid fans of normalizing blood vitamin D blood levels (25-OH-vitamin D3).

A wonderful report on vitamin D was aired this morning on the NBC Today show. The interviewed guests did a good job of describing the health effects of vitamin D, thought the focus was on some new data on the use of vitamin D for breast and prostate cancer.

I learned that shiitake mushrooms have some vitamin D--I didn't know that! (They contain 260 units per 4 mushrooms.)

Unfortunately, the closing comments from the guests, among whom was nutritionist and author, Joy Bauer,MS, was that you should get vitamin D from your multivitamin or your calcium with vit D.

That is absolutely wrong. When you check blood levels of vitamin D, as we do in everybody we see, you quickly learn what works and what doesn't.

Vitamin D in multivitamins is very poorly absorbed, if at all. Likewise, about 90% of the D in most calcium preparations is not absorbed. The vast majority of tablet or powder preparations, such as those in calcium tablets, are not absorbed to any significant extent. Take all you want and you remain vit D-deficient with osteoporosis, growing coronary plaque, low HDL, and exposed to risk for prostate and colon cancer.

If you take vitamin D in supplement form, it must--MUST--be in an oil-based capsule. The tablets are simply much too poorly and erratically absorbed to be reliable. There's nothing more frustrating to take, for instance, 4000 units of vitamin D in tablet form, only to have a blood level of 12 ng/ml--severe deficiency. Take the same 4000 unit dose in capsule form and blood level skyrockets to 58 ng/ml. And it's no more expensive.

One other thing: If you want to waste time and money, take the prescription vitamin D prescribed by many doctors. This is vitamin D2, also known as "ergocalciferol". Why use the synthetic vitamin D2 when D3 is the form your body needs? Because the D2 is patent-protectable and profitable to the drug manufacturer, similar to using Premarin (horse estrogens) when human preparations would suffice--or be superior. I saw a woman today taking 50,000 of prescription D2 once per week. Her blood level of 25-OH-vitamin D3? 17 ng/ml--severe deficiency. Don't waste your time with this garbage.

I am continually amazed at the amount of time and energy we all expend in the search for truth.

Rely on your hospital and you will be steered towards strategies that, at worst, aim to increase your use of hospital procedures. At best, they steer you towards physicians who are often under their employ.

How about your doctor? This is a source of immense frustration. Doctors remain interested in treating the catastrophic illness. They remain lukewarm towards prevention and self-empowerment. Thus, supplements are dangerous, everything requires a doctor's endorsement.

Drug companies? That's like relying on a used car salesman for truth. Exagerration, slick talk, and plain deception might be better descriptions of what you can count on from the drug manufacturers.

The internet? Perhaps, if you're selective. WebMD? An obvious voice-box for the drug industry. Just look at the proliferation of drugs ads that accompany each report. In fact, the majority (80%) of WebMD's revenues come from drug manufacturers.

The profit motive has created a mountain of good information. It has also created a sea of mis-information, all created to provide personal financial enrichment.

But I continue to be optimistic that the internet will also become a forum for truth, particularly through its capacity for networked interaction among participants. As our collective wisdom permits us to more effectively separate the wheat from the chaff in looking for the truth, I believe that we will zigzag towards a system of healthcare that is self-empowering, self-directed, and resorts to hospitals and procedures only in the most dire circumstances, saving billions of dollars every year.

The American Heart Association (AHA) has a program called the Heart-Check Mark, an "approval" process that permits a food manufacturer to affix the AHA logo and stamp of approval on various food products.

A company simply makes application to the AHA. The application and product details are reviewed and then approved or turned down.

To date, 106 companies have obtained the AHA stamp of approval on 768 products. What kinds of products are on the approved list? Here's a sample:

--Honey Bunches of Oats

--Kellogg's Frosted Mini-Wheats

--Cocoa Puffs cereal

--Cookie Crisp cereal ("The great taste of chocolate chips in every bite!")

There are 764 others. If you doubt this, just go to the store and take a look at the product containers.

What the heck is going on here? Most of us with any judgment know that these products are pure sugar. They may contain "no more" than 15-40 grams sugar per sugar, but the principal products--corn, wheat, fructose--mean that these products are, in effect, nearly pure sugar. Yet they carry the AHA stamp of approval.

What do products like this cause? It's a long list but the major effects include:

--Obesity

--Diabetes

--Drop in HDL

--Rise in triglycerides

--Small LDL particles

--Heightened inflammation (i.e., C-reactive protein)

--Mental cloudiness

Need I go on? Why are products like these and many others deserving of the AHA heart-check approval? Because they lack high fat and saturated fat (3.0 grams, 1.0 grams respectively, by AHA criteria). In other words, just lacking these ingredients means that, to the AHA, they qualify as "heart healthy."

By that same line of reasoning, many candy bars are "heart healthy", as are many cookies and cupcakes.

What's the reason behind this extraordinary absurdity? Is the AHA stupid?

There may be many reasons, but one very suspicious fact becomes immediately obvious when you realize these endorsements product a substantial revenue source for the AHA, since companies must pay for the right to use the heart-check approval mark. Also, just look at the major contributors (millions of dollars) to the AHA: ConAgra, General Mills, Kraft, etc.) You get the picture.

Does this make the AHA evil? Not necessarily. But it seriously erodes credibility. it also should make you very leery of any advice that comes from such an agency that is reluctant to bite the food manufacturer hands that feed it.

In my view, we simply cannot rely on the AHA for genuine, unbiased heart health advice.

Charles was visibly confused.

He'd gotten his CT heart scan after hearing one of the local scan center's ads on the radio. His score 2773, obviously in the 99th percentile for any age.

"Do you think the score means anything? My primary doctor said that it was meaningless because it was all in the deep wall of the artery. He said that it has nothing to do with risk for heart attack. As long as I feel good, he says don't do anything."

What exactly did his doctor mean, in the "deep wall of the artery"?

What the doctor is referring to is the fact that some people with a long history (many years) of diabetes or kidney failure (also for many years) tend to develop calcium deposits in the media, or muscular layer of arteries. The media is the tissue thin layer just below the intima, the most inner layer of arteries that we usually associate with atherosclerotic plaque and the layer that is most prone to calcium accumulation that we score on heart scans.

Aging, generally into your late 70s, 80s, and onwards, also increases the likelihood of medial calcification. Lastly, longstanding deficiency of vitamin D encourages medial calcification.

Is there any way to distinguish intimal vs medial calcification on a heart scan? No, there is not. Having read many thousands of CT heart scans, I can tell you that there is no practical way in 2007 to tell the difference.

Then how did this doctor "know" that Charles' calcium was "deep walled" or medial? Simple: He didn't. This was yet another example of ignorance based on old thinking. Unfortunately, he did Charles a serious disservice by dismissing his heart scan score that predicted a 25% per year risk for heart attack.

Interestingly, whether calcium is intimal as in atherosclerotic plaque, or medial, both are strongly associated with risk for heart attack. In other words, if calcium is confined to the intima, heart disease risk is present. If calcium is limited to the media, risk is still present.

In all practicality, the only difference we make of the intima vs. media argument (that is, when the distinction has been made by some other means like intracoronary ultrasound, the test that is truly necessary to distinguish the two patterns) is that medial calcification may be more powerfully related to vitamin D deficiency. Thus, someone with heavy medial calcification may require closer attention to maintaining a perfect year-round blood level of 25-OH-vitamin D3. But that's the only practical difference.

"My primary care doctor said to stop the vitamin D because it's toxic. So I stopped it and I just take a multivitamin. He said that a multivitamin and two glasses of milk a day was all I needed."

So proclaimed Eleanor to me. This happens around once every week by doctors frightened of the vitamin D.

So I reminded Eleanor that, before starting vitamin D supplementation, her blood level of 25-OH-vitamin D3 had been 17 ng/ml--severe deficiency.

On 4000 units per day (oil-based gelcap), her blood level had been 37 ng/ml--still deficient, below the desirable range of 50-60 ng/ml. That's the dose Eleanor's doctor had declared "toxic."

When exactly does deficiency develop? There's not full agreement on this, but Dr. Michael Holick of Boston University, among the most experienced and insightful authorities on vitamin D, states that toxicity is more likely when blood levels exceed 150 ng/ml (Nutr Clin Pract. 2007 Jun;22(3):297-304).

In other words, Eleanor and her doctor should not be concerned with toxicity, but with the persistent levels of deficiency she is suffering.

Some authorities call the behavior of vitamin D "bi-phasic": Deficiency is toxic, excessive levels are toxic. We're really just trying to achieve a middle ground in vitamin D levels that are above deficiency but below toxicity.

In reality, deficiency is exceptionally common. In fact, it's the rule around here (northern U.S.), with >95% of everybody we check severely deficient in winter, mildly-moderately deficient in summer. Very few people approach normal levels year round without supplementation.

Toxicity, on the other hand, is exceedingly rare. I have seen it once in a woman who was taking a toxic dose of 50,000 units a day on the instructions of her (mis-guided) doctor. Thankfully, no ill-effects developed from this little "experiment."

So, it's not toxicity that is the overwhelmingly common worry, but deficiency, severe and sustained.

Take a look at your local hospital and you're likely to notice several curious things:

1) It is likely non-profit, meaning it enjoys a non-profit status with the Internal Revenue Service and enjoys the tax benefits of not paying taxes on profits. This provides an advantage to tax-protected hospitals. 70% or more of hospitals in the U.S. are "non-profit."

2) Non-profit or no, many hospitals operate under the guise of a religious affiliation, e.g., St. Mary's Hospital, Trinity Hospital, All Saints', Jewish Hospital, etc.

3) Executives in non-profit hospitals can make capitalistic salaries. One CEO of a Milwaukee hospital took home $3.7 million dollars in salary last year. That's not including the very substantial perks and business interests in the spin-off businesses the hospital owns, including pharmacies, drug and medical device disitributors, even a venture capital division. "Non-profit" does not have to mean that executives within the operation can't benefit handsomely.

That same hospital system spends over $10 million dollars in a year in local marketing for TV ads, print advertising, etc. Ads are slick and professionally produced.

Make no bones about it: These are "non-profit" for tax purposes only . They are for-profit in every other sense of the phrase, including rich rewards for the insiders.

Guess how those fat executive salaries and large marketing budgets are paid for? That's right: the 12-inch incision in your chest; the four stents, defibrillator, and repeated nuclear stress tests; the revolving door of hospitalization after hospitalization that typifies the "heart patient" experience.

See the hospital for what it is: In the 21st century, it is no longer a charitable operation worthy of your volunteer time and donations. It is a business no different than Home Depot, IBM, or--Enron. Yes, they do perform needed services, as well. But the perverse equation that often determines who needs hospitalization and who doesn't, who needs a heart procedure and who doesn't, is not always based on necessity but on financial return. Just ask the CEO.

I spend a lot of my day bashing statin drugs and helping people get rid of them.

But are there instances in which statin drugs do indeed provide real advantage? If someone follows the diet I've articulated in these posts and in the Track Your Plaque program, supplements omega-3 fatty acids and vitamin D, normalizes thyroid measures, and identifies and corrects hidden genetic sources of cardiovascular risk (e.g., Lp(a)), then are there any people who obtain incremental benefit from use of a statin drug?

I believe there are some groups of people who do indeed do better with statin drugs. These include:

Apoprotein E4 homozygotes

Apoprotein E2 homozygotes

Familial combined hyperlipidemia (apoprotein B overproduction and/or defective degradation)

Cholesteryl ester transfer protein homozygotes (though occasionally manageable strictly with diet)

Familial heterozygous hypercholesterolemia, familial homozygous hypercholesterolemia

Other rare variants, e.g., apo B and C variants

The vast majority of people now taking statin drugs do NOT have the above genetic diagnoses. The majority either have increased LDL from the absurd "cut your fat, eat more healthy whole grains" diet that introduces grotesque distortions into metabolism (like skyrocketing apo B/VLDL and small LDL particles) or have misleading calculated LDL cholesterol values (since conventional LDL is calculated, not measured).

As time passes, we are witnessing more and more people slow, stop, or reverse coronary plaque using no statin drugs.

Like antibiotics and other drugs, there may be an appropriate time and situation in which they are helpful, but not for every sneeze, runny nose, or chill. Same with statin drugs: There may be an occasional person who, for genetically-determined reasons, is unable to, for example, clear postprandial (after-eating) lipoproteins from the bloodstream and thereby develops coronary atherosclerotic plaque and heart attack at age 40. But these people are the exception.

Nutrition in the modern world has become an increasingly problematic topic. From genetic modification to commercialized methods of mass production, we are having to navigate all manner of complex issues in food choices, particularly if ideal health, including maximal control over coronary plaque, is among our goals.

We will therefore be releasing a series of discussions on the Track Your Plaque website in the coming months, a series I call "Track Your Plaque Advanced Topics in Nutrition." These will be, as the series title suggests, discussions for anyone interested in more than the "eat a balanced diet" nonsense that issues from "official" sources. Among the topics to be covered:

1)Advanced Glycation End-products--both endogenous and exogenous, including peripheral issues like lipoxidation and acrylamides.

2)Dietary influences on LDL oxidation--including the concept of "glycoxidation." Protection from oxidative phenomena is not just about taking antioxidants.

3) Foods you MUST eat--We've talked a lot about foods that you shouldn't eat. How about foods you should eat?

The New Track Your Plaque Guide is now available!

The Track Your Plaque program has evolved over its 8 year history. While the original Track Your Plaque book reflected the program details that got the program started back in 2003-2004, plenty has changed.

This new version of the book, what I call the program Guide, represents version 2.0 of Track Your Plaque and includes:

--Updated lipoprotein treatment strategies--including new and expanded treatment choices for small LDL and lipoprotein(a).

--An entire chapter on vitamin D and its crucial role in cardiovascular health and plaque control.

--A new and expanded diet--All the reasons why the New Track Your Plaque Diet can achieve spectacular improvement in lipids/lipoproteins, reversal of insulin resistance/pre-diabetes/diabetes, weight loss, reduction in blood pressure, etc. are discussed in considerable detail. The diet is crafted to achieve maximum control over both metabolic responses and coronary plaque.

--An entire chapter on the role of omega-3 fatty acids is included.

--A detailed discussion on the role of iodine and thyroid health--One of the newest additions to the Track Your Plaque menu of strategies is to achieve and maintain ideal thyroid health. This tips the scales in your favor for improved control over lipids/lipoproteins, weight, blood sugar, and coronary plaque.

The new guide, as well as our new Member kits that include the new Track Your Plaque Recipe Book, At-Home Lab Test kits, and nutritional supplements, are all available in the Track Your Plaque Marketplace.

While there is more to wheat's adverse effects on human health than celiac disease, studying celiac disease provides important insights into why and how wheat--the gluten component of wheat, in this case--is so destructive to human health.

Modern wheat, in particular, is capable of causing "celiac disease" without intestinal symptoms---no cramping or diarrhea--but instead shows itself as brain injury (ataxia, dementia), peripheral nervous system damage (peripheral neuropathy), joint and muscle inflammation (rheumatoid arthritis, polymyalgia rheumatica and others), and gastrointestinal cancers.

One neurological manifestation of wheat's effect on the human brain is a condition called cerebellar ataxia. This is a condition that can affect adults (average age 48 years) and children and consists of incoordination, falls, and incontinence.

Because brain tissue has limited capacity for healing and regeneration, symptoms of cerebellar ataxia usually improve slowly and modestly with meticulous elimination of wheat and other gluten sources.

Such observations are relevant even to people without celiac disease. Celiac disease sufferers are more susceptible to such extra-intestinal phenomena, but it can also happen in people without positive celiac antibodies.

Some references:

Neurological symptoms in patients with biopsy proven celiac disease

A total of 72 patients with biopsy proven celiac disease (CD) (mean age 51 +/- 15 years, mean disease duration 8 +/- 11 years) were recruited through advertisements. All participants adhered to a gluten-free diet. Patients were interviewed following a standard questionnaire and examined clinically for neurological symptoms. Medical history revealed neurological disorders such as migraine (28%), carpal tunnel syndrome (20%), vestibular dysfunction (8%), seizures (6%), and myelitis (3%). Interestingly, 35% of patients with CD reported of a history of psychiatric disease including depression, personality changes, or even psychosis. Physical examination yielded stance and gait problems in about one third of patients that could be attributed to afferent ataxia in 26%, vestibular dysfunction in 6%, and cerebellar ataxia in 6%. Other motor features such as basal ganglia symptoms, pyramidal tract signs, tics, and myoclonus were infrequent. 35% of patients with CD showed deep sensory loss and reduced ankle reflexes in 14%. Gait disturbances in CD do not only result from cerebellar ataxia but also from proprioceptive or vestibular impairment.

Gluten ataxia in perspective: epidemiology, genetic susceptibility and clinical characteristics

Two hundred and twenty-four patients with various causes of ataxia from North Trent (59 familial and/or positive testing for spinocerebellar ataxias 1, 2, 3, 6 and 7, and Friedreich's ataxia, 132 sporadic idiopathic and 33 clinically probable cerebellar variant of multiple system atrophy MSA-C) and 44 patients with sporadic idiopathic ataxia from The Institute of Neurology, London, were screened for the presence of antigliadin antibodies. A total of 1200 volunteers were screened as normal controls. The prevalence of antigliadin antibodies in the familial group was eight out of 59 (14%), 54 out of 132 (41%) in the sporadic idiopathic group, five out of 33 (15%) in the MSA-C group and 149 out of 1200 (12%) in the normal controls. The prevalence in the sporadic idiopathic group from London was 14 out of 44 (32%). The difference in prevalence between the idiopathic sporadic groups and the other groups was highly significant (P < 0.0001 and P < 0.003, respectively). The clinical characteristics of 68 patients with gluten ataxia were as follows: the mean age at onset of the ataxia was 48 years (range 14-81 years) with a mean duration of the ataxia of 9.7 years (range 1-40 years). Ocular signs were observed in 84% and dysarthria in 66%. Upper limb ataxia was evident in 75%, lower limb ataxia in 90% and gait ataxia in 100% of patients. Gastrointestinal symptoms were present in only 13%. MRI revealed atrophy of the cerebellum in 79% and white matter hyperintensities in 19%. Forty-five percent of patients had neurophysiological evidence of a sensorimotor axonal neuropathy. Gluten-sensitive enteropathy was found in 24%. HLA DQ2 was present in 72% of patients. Gluten ataxia is therefore the single most common cause of sporadic idiopathic ataxia.

Among the most common effects of wheat are those on the brain.

Consume wheat and susceptible individuals will experience a subtle euphoria. Others experience mental cloudiness or sleepiness. (This is what I personally get.)

It gets worse. Children with ADHD and autism have difficulty concentrating on a task and have behavioral outbursts after a cookie. Schizophrenics experience paranoid delusions, auditory hallucinations, and worsening of social detachment. People with bipolar disorder can have the manic phase triggered by a breadcrumb. All these effects are blocked by administering drugs that block the brain's opiate receptors. (This is why, by the way, a drug company is planning to release an oral agent, naltrexone, formerly administered to heroin addicts to help control addiction, for weight loss: block the euphoric effect, take away the temptation, lose weight.)

Here is Heart Scan Blog reader, Nicole's, mental fog story:

I have been grain-free (no gluten free grains either) for quite a long time (about a year and a half). Earlier this week, I decided to try white bread and pasta. The experiment only lasted two days. I had horrible terminal insomnia both nights, causing me on the second night to wake up at 2:30 am unable to get back to sleep at all. I felt drugged and in a mind-fog all the next day and even dozed off a few times! Luckily I had the day off work.

I had very bad forgetfulness also. I forgot that I left my bag and groceries at work, so I had to go back for them. Then I had to use my husband's keys to get in because I thought my keys were in my bag, but it turns out they were in my pocket. Then I got my bag, set the alarm, locked the door and then realized I forgot my groceries. So I had to re-open the door, unset the alarm, and go back for the groceries. Then I locked the door, forgetting to set the alarm, so I had to unlock it, open up and set the alarm. It was just ridiculous, I am NEVER like that!

In addition to the insomnia and forgetfulness, I also had horrible anxiety and paranoia, almost to the point of panic. Which I NEVER have, I am usually very easy-going, even-tempered, and worry-free. But this was horrible, I really was quite paranoid and anxious about everything. Weird!

And the worst, was that in just two days of eating wheat, I gained 4 lbs and 2% bodyfat!! It's two days wheat-free now, and it's finally going back down, but wow. Just two days of wheat-eating caused that much weight and fat gain!

Anyway, I've learned my lesson and will continue to avoid grains (including gluten free grains) entirely.

Eat more "healthy whole grains"? Modern dwarf Triticum aestivum, perverted even further by agricultural geneticists and modern agribusiness, subsidized by the U.S. government to permit $5 pizza, is better than any terrorist plot to discombobulate the health and performance of the American people.

Dr. Eric Westman has been a vocal proponent of carbohydrate restriction to gain control over diabetes, as have Drs. Richard Bernstein, Mary Vernon, Richard Feinman, and Jeff Volek.

Several studies over the years have demonstrated that reductions in carbohydrate content of the diet yield reductions in weight and HbA1c (glycated hemoglobin, a reflection of average blood glucose over the preceding 60-90 days).

Among the more important recent clinical studies is a small experience from Duke University's Dr. Eric Westman. In this study, obese type 2 diabetics reduced carbohydrate intake to 20 grams per day or less: no wheat, oats, cornstarch, or sugars. Participants ate nuts, cheese, meats, eggs, and non-starchy vegetables.

After 6 months, average weight loss was 24.4 lbs, BMI was reduced from 37.8 to 34.4. At the end of the study, 95% of participants on this severe carbohydrate restriction reduced or eliminated their diabetes medications.

That was only after 6 months. Note that the ending BMI was still quite well into the obese range. Imagine what another 6-12 months would do, or achieving BMI somewhere closer to ideal.

Curiously, this idea of severe low-carbohydrate restriction to cure or minimize diabetes is not new. Sir William Osler, one of the founders of Johns Hopkins Hospital and author of the longstanding authoritative text, Principles and Practice of Medicine, advocated an diet identical to Dr. Westman's diet. So did Dr. Frederick Banting, discoverer of the pancreatic extract, insulin, to treat childhood diabetics. Before insulin, Banting and his colleagues at the University of Toronto used carbohydrate elimination (less than 10 g per day) to prolong the lives of children with diabetes.

This lesson was also learned many times during war time, when staples like bread were unavailable. The Siege of Paris in 1870 yielded cures for diabetes in many (or at least they stopped passing urine that tasted--yes, tasted--sweet and attracted flies), only to have it recur after the siege was over.

These are lessons we will have to relearn. As long as the American Diabetes Association and most physicians continue to advocate a diet of reduced fat, increased carbohydrate that includes plenty of "healthy whole grains," diabetics will continue to be diabetics, taking their insulin and multiple medications while developing neuropathy (nervous system degeneration), nephropathy (kidney disease and failure), atherosclerosis and heart attack, cataracts, and die 8 to 10 years earlier than non-diabetics.

All the while, we've had the combined wisdom from antiquity onwards: Carbohydrates cause diabetes; elimination of carbohydrates cures diabetes.

(This applies, of course, only to adult overweight type 2 diabetics, not type 1 or some of the other variants.)

There are a number of ways to gauge your dietary carbohydrate exposure and its physiologic consequences.

One of my favorite ways is to do fingerstick blood sugars for a one-hour postprandial glucose. I like this because it provides real-time feedback on the glucose consequences of your last meal. This can pinpoint problem areas in your diet.

Another way is to measure small LDL particles. Because small LDL particles are created through a cascade that begins with carbohydrate consumption, measuring them provides an index of both carbohydrate exposure and sensitivity. Drawback: Getting access to the test.

For many people, the most practical and widely available gauge of carbohydrate intake and sensitivity is your hemoglobin A1c, or HbA1c.

HbA1c reflects the previous 60 to 90 days blood sugar fluctuations, since hemoglobin is irreversibly glycated by blood glucose. (Glycation is also the phenomenon responsible for formation of cataracts from glycation of lens proteins, kidney disease, arthritis from glycation of cartilage proteins, atherosclerosis from LDL glycation and components of the arterial wall, and many other conditions.)

HbA1c of a primitive hunter-gatherer foraging for leaves, roots, berries, and hunting for elk, ibex, wild boar, reptiles, and fish: 4.5% or less.

HbA1c of an average American: 5.2% (In the population I see, however, it is typically 5.6%, with many 6.0% and higher.)

HbA1c of diabetics: 6.5% or greater.

Don't be falsely reassured by not having a HbA1c that meets "official" criteria for diabetes. A HbA1c of 5.8%, for example, means that many of the complications suffered by diabetics--kidney disease, heightened risk for atherosclerosis, osteoarthritis, cataracts--are experienced at nearly the same rate as diabetics.

With our wheat-free, cornstarch-free, sugar-free diet, we have been aiming to reduce HbA1c to 4.8% or less, much as if you spent your days tracking wild boar.

Ever notice the warnings on your car's battery? "Danger: Sulfuric acid. Protective eyewear advised. Serious injury possible."

Sulfuric acid is among the most powerful and potentially harmful acids known. Get even a dilute quantity in your eyes and you will suffer serious burns and possibly loss of eyesight. Ingest it and you can sustain fatal injury to the mouth and esophagus. Sulfuric acid's potent tendency to react with other compounds is one of the reasons that it is used in industrial processes like petroleum refining. Sulfuric acid is also a component of the harsh atmosphere of Venus.

Know what food is the most potent source of sulfuric acid in the body? Oats.

Yes: Oatmeal, oat bran, and foods made from oats (you know what breakfast cereal I'm talking about) are the most potent sources of sulfuric acid in the human diet.

Why is this important? In the transition made by humans from net-alkaline hunter-gatherer diet to net-acid modern overloaded-with-grains diet, oats tip the scales heavily towards a drop in pH, i.e., more acidic.

The more acidic your diet, the more likely it is you develop osteoporosis and other bone diseases, oxalate kidney stones, and possibly other diseases.

Here's one reference for this effect.

We frequently discuss the advisability of consuming fats, carbohydrates, and various types within each category.

But what's the worst of all? Combining fats with carbohydrates.

Putting aside the wheat-is-worst form of carbohydrate issue and treating bread as a prototypical carbohydrate, let's play out a typical scenario, a make-believe feeding study in which a theoretical person is fed specific foods.

John is our test person, a 40-year old, 5 ft 10 inch, 210 lb, BMI 27.7 (roughly the mean for the U.S.) He starts with an average American diet of approximately 55% carbohydrates and 30% fat. Starting lipoproteins (NMR):

LDL particle number 1800 nmol/L
Small LDL 923 nmol/L

(The LDL particle number of 1800 nmol/L translates to measured LDL cholesterol of 180 mg/dl, i.e., drop last digit or divide by 10.)

Also, calculated LDL cholesterol is 167 mg/dl (yes, underestimating "true" measured LDL), HDL 42 mg/dl, triglycerides 170 mg/dl.

We feed him a diet increased in carbohydrates and reduced in fat, especially saturated fat, with more breakfast cereals, breads and other wheat products, pasta, fruit juices and fruit, and potatoes. After four weeks:

LDL particle number 2200 nmol/L
Small LDL 1378 nmol/L

Note that LDL particle number has increased by 400 nmol/L due entirely to the increase in small LDL particles triggered by carbohydrate consumption. Lipids show calculated LDL cholesterol 159 mg/dl--yes, a decrease, HDL 40 mg/dl, triglycerides 189 mg/dl. (At this point, if John's primary care doctor saw these numbers, he would congratulate John on reducing his LDL cholesterol and/or suggest a fibrate drug to reduce triglycerides.)

John takes a rest for four weeks during which his lipoproteins revert back to their starting values. We then repeat the process, this time replacing most carbohydrate calories with fats, weighed heavily in favor of saturated fats like fatty red meats, butter and other full-fat dairy products. After four weeks:

LDL particle number 2400 nmol/L

Let's

Here's a simple recipe for chocolate peanut butter cup smoothie.

The coconut milk, nut butter, and flaxseed make this smoothie exceptionally filling. If you are a fan of cocoa flavonoids for reducing blood pressure, then this provides a wallop. Approximately 10% of cocoa by weight consists of the various cocoa flavonoids, like procyanidins (polymers of catechin and epicatechin) and quercetin, the components like responsible for many of the health benefits of cocoa.

Ingredients:
1/2 cup coconut milk
1 cup unsweetened almond milk
2 tablespoons cocoa powder (without alkali)
2 tablespoons shredded coconut (unsweetened)
1 tablespoon ground flaxseed
1 teaspoon almond extract
1 1/2 tablespoons natural peanut, almond, or sunflower seed butter
Non-nutritive sweetener to taste (stevia, Truvia, sucralose, xylitol, erythritol)
4 ice cubes

Combine ingredients in blender. Blend and serve.

If you plan to set any of the smoothie aside, then leave out the flaxseed, as it absorbs water and will expand and solidify if left to stand.

For an easy variation, try adding vanilla extract or 1/4 cup of sugar-free (sucralose) vanilla or coconut syrup from Torani or DaVinci and leave out the added sweetener.

The compromise I draw here is the use of non-nutritive sweeteners. Beware that they can increase appetite, since they likely trigger insulin release. However, this smoothie is so filling that I don't believe you will experience this effect with this recipe.