Why do the Japanese have less heart disease?

24. April 2011 William Davis (49)
We should look to the Japanese to teach us a few lessons about preventing heart disease. A Japanese male has only 65% of the risk of an American male (despite 40% of Japanese men being smokers), while a Japanese woman has 80% less risk than an American woman. While the U.S. is near the top of the list of nations with highest cardiovascular risk, Japan is the lowest.

What are they doing right?

There is no one explanation, but several. Genetics probably does not play a substantial role, by the way, as demonstrated by observations of Japanese people who emigrate to Western cultures. People of Japanese heritage living in Hawaii, for instance, develop the same cardiovascular risk as non-Japanese living in Hawaii. They also develop obesity and diabetes.

Among the factors that likely contribute to reduced risk in Japanese people:

--A style of eating that does not include a lot of sweet foods. No breakfast cereal or donuts for breakfast, for instance, but miso soup with tofu, fish, green onions, and daikon (as takuan, or pickled radish).
--Seaweed--It's probably a combination of the green phytonutrients and iodine. Typical daily iodine intake is in the neighborhood of 5000 mcg per day from nori, kombu, wakame, and other seaweed forms. (The average American obtains 125 mcg per day of iodine from diet.)
--Seafood--Fish in many forms not seen in the U.S. are popular.
--Green tea--Consumption of green tea has been confidently linked to reduced cardiovascular risk, probably via visceral fat-reducing, anti-oxidative, and anti-inflammatory effects. Although tea in Japan is often the less flavonoid-rich oolong tea, softer benefits from this form are likely.
--Soy--Tofu, miso, and soy sauce are staples. It's not clear to me whether soy is intrinsically beneficial or whether it is beneficial because it serves to replace unhealthy alternatives. (Genetic modification may change this effect.)
--Reduced exposure to cooked animal products (except seafood). This is not a saturated fat issue, but probably an advanced glycation end-product/lipoxidation issue that result from cooking.
--The lack of a "eat more healthy whole grain" mentality, the advice that has plunged the entire U.S. into the depths of a diabetes and obesity crisis (along with high-fructose corn syrup and sugar). Noodles like udon and ramen do have a place in their diet, as do some dessert foods. But the overall wheat exposure is less--no bagels, sandwiches, and breakfast cereals.
--Less overweight and obesity--The above eating style leads to less weight gain.

Japanese foods have a unique taste, consistency, and mouth-feel that go well with saltiness, thus the downside of their diet: salt consumption. On a broad scale, high salt consumption has been associated with hypertension and gastric cancer. But the tradeoff has, on the whole, been a favorable one.


One study trying to find some answers:

Dietary patterns and cardiovascular disease mortality in Japan: a prospective cohort study.

Shimazu T, Kuriyama S, Hozawa A et al.
Division of Epidemiology, Department of Public Health and Forensic Medicine, Tohoku University Graduate School of Medicine, Japan.


We prospectively assessed the association between dietary patterns among the Japanese and CVD mortality. Dietary information was collected from 40 547 Japanese men and women aged 40-79 years without a history of diabetes, stroke, myocardial infarction or cancer at the baseline in 1994.
During 7 years of follow-up, 801 participants died of CVD.

Factor analysis (principal component) based on a validated food frequency questionnaire identified three dietary patterns: (i) a Japanese dietary pattern highly correlated with soybean products, fish, seaweeds, vegetables, fruits and green tea, (ii) an 'animal food' dietary pattern and (iii) a high-dairy, high-fruit-and-vegetable, low-alcohol (DFA) dietary pattern. The Japanese dietary pattern was related to high sodium intake and high prevalence of hypertension. After adjustment for potential confounders, the Japanese dietary pattern score was associated with a lower risk of CVD mortality (hazard ratio of the highest quartile vs the lowest, 0.73; 95% confidence interval: 0.59-0.90; P for trend = 0.003). The 'animal food' dietary pattern was associated with an increased risk of CVD, but the DFA dietary pattern was not.

The Japanese dietary pattern was associated with a decreased risk of CVD mortality, despite its relation to sodium intake and hypertension.
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Comments (49) -

  • Anonymous

    4/24/2011 3:50:12 PM |

    they also drink alcohol daily

  • Anonymous

    4/24/2011 5:36:40 PM |

    I wouldn't entirely dismiss genetic factors to.

    I believe the Japanese apo e profile may be better than caucasian (on average) --

    A racial difference in apolipoprotein E allele frequencies between the Japanese and Caucasian populations

    http://onlinelibrary.wiley.com/doi/10.1111/j.1399-0004.1986.tb01901.x/abstract

    A bad Western diet may trump this genetic profile, hence why those who leave Japan/eat poorly still get heart disease.

    But there could be some genetics in play too.

  • Anonymous

    4/24/2011 6:04:33 PM |

    Bear in mind that the soy they consume is typically fermented, including natto, which is extremely high in vitamin K2 - MK7.

  • Anonymous

    4/24/2011 7:37:04 PM |

    I just returned to the US after having spent the last 10 years there.  Some observations:

    (1) While it is true that consumption of breakfast cereal or donuts for breakfast is exceedingly rare, virtually nobody under the age of 70 eats miso soup with tofu, fish, green onions, etc. for breakfast.  The typically breakfast for younger people nowadays is a fried egg, white toast, and coffee.  And lunch and dinner often includes white rice and/or wheat noodles.

    (2) Contrary to what the first anonymous said, the typical Japanese does NOT drink alcohol everyday.

    (3) Contrary to what the third anonymous said, most soy is consumed in the form of tofu, and only a relatively small percentage of Japanese eat natto on a regular basis.

    (4) The amount of refined wheat products consumed by the average Japanese is large and growing.  For example, you will see a huge number of bread, cake, pastry, etc. shops in virtually every neighborhood in Japan nowadays.  Take a stroll down a supermarket aisle in Japan and you will see large amounts of goods made from refined wheat products (bread, cookies, etc).

    (5) US fast food chains are ubiquitous and always packed with young people.

    Based on the eating habits among young people I've observed there, my guess is that we'll be seeing an increase in heart disease to rival that of the US.

  • majkinetor

    4/24/2011 8:02:53 PM |

    If Japanese consume K2 a lot, this might be big part of the solution to this enigma (since natto is the best source of K2 in the world). Calcification of soft tissues is one of the major CV problems and eliminating it from equation changes the scene.

    I wonder what is the reference for "less sugary foods" claim.

    It was the main issue in Alan Aragon's bashing of "Sugar: The bitter truth" video by Lustig. While I think that Alans review is junk, it has some interesting points, among others, the suspicious claim that Japanese people don't consume suggary food.

  • Might-o'chondri-AL

    4/24/2011 8:39:56 PM |

    Japan Public Health Center 1990 dietary highlights for 40,000 men and women +/- 48 - 50 years old. All were without cardio vascular disease and had BMI of +/- 23.5.

    The women:
    calories/d = 1,227-1,491
    rice gr/d  = 164-182
    fish gr/d  = 31-54
    % miso 3x/d= 18-33% did

    The men:
    calories/d = 1,910-2,344
    rice gr/d  = 294-336
    fish gr/d  = 38-66
    % miso 3x/d= 23-46% did

    Nationwide for Japan in 1990 3% of adults had a BMI of 30 or more (obese); and at that time, 20% of women plus 24% of men had a BMI of 25-29 (overweight).

    Compared to 1960 statistics by 1994 there were 4 times the number of overweight adults; and the increase in overweight adults was higher among the rural population.
    A Japan National Survey (exact year not in my notes) stated the average adult protein intake was +/- 60 grams of protein per day; with 1/2 of that protein coming from rice.

  • Gretchen

    4/24/2011 9:32:43 PM |

    1. Re salt. I read an article recently showing that in people with diabetes, the higher the salt intake, the lower the overall mortality. This is only one study and might be a fluke, but it's interesting.

    2. Re sugar. This is annecdotal. Many moons ago, in early 1960s when I was in college, I lived in a Coop dorm where we did all the cooking. One night a friend and I were trying to make a casserole that ended up bland, so we kept adding things to improve the taste. It got worse and worse, and there was no time to start over again.

    Finally, when the rest of the dorm was nagging us to get the food on the table, we threw in a can of pineapple.

    A student then said to us, "I hope dinner is extra good tonight, because I have a friend from Japan visiting, and I want to impress her." We were very embarrassed.

    Afterward the Japanese woman came up and asked if we'd cooked the meal. We had to say yes. She said, "Oh thank you so much! This is the first food I've had in America that was sweet enough."

    Now, maybe she was unusual. Maybe her family was adopting American tastes. But it's made me question comments about Japanese not eating sugar.

    I suspect the key may be the amount of food consumed in meals. Those beautifully displayed boxes of food don't actually contain a lot. Maybe they like sweet things but don't eat a lot of them.

  • Might-o'chondri-AL

    4/24/2011 9:33:59 PM |

    Natto is said to be more popular in the east of Japan, like Tokyo; and less popular in Osaka & Kobe regions. Here's the average natto consumption for select decades I have:

    1960 =  0.45 kg/yr/person
    1970 =  1.1 kg/yr/person
    1980 =  1.3 kg/yr/person

    Natto generally is sold in +/- 40 gram unit packets; so 365 days in a year x 40 gr. natto = 1.46 kg/yr/person , which would be the contemporary natto eaters intake. One gram of Natto +/- =  0.17 gr. protein + 0.14 gr. carbohydrate + 0.108 gr. total fat (0.016 gr. saturated fat) + 10 mcg. Mk-7 + 0.84 mcg. Mk-8 + 0.0072 gr. nattokinase +  0.55 gr. water.

    By mid 2000s there were Japanese newspaper reports that the natto consumption was trending downward.
    Apparently, the natto industry response was to make hybrid natto food products to attract the younger Japanese market.

  • Kurt

    4/24/2011 10:33:38 PM |

    I agree with Anonymous. Japanese people have begun eating lots of puffy white bread/pastries. It will take some time for this to be reflected in the heart disease stats.

  • Anonymous

    4/24/2011 11:39:33 PM |

    I've lived in Japan for the past three years in southern Osaka. The claim that Japanese people (below, say the age of 60 or so) don't eat many sweet things is patently false.

    There, I think, has been a huge shift in diet trends over the past generation or two, with the older generation still eating mostly as the article suggests, and the younger generations eating progressively more and more like westerners.

    Most people I talk to consider fluffy white sweet bread (lots of sweetener in the dough itself) topped with extra sweet jam or jelly with some orange juice or heavily sweetened coffee breakfast.

    Even some slightly more traditional dishes like sukiyaki are cloyingly sweet as prepared by most people, or if made from packaged mixes (fewer people can / are interested in cooking, especially from scratch, nowadays).

    Another example that comes to mind is Kimchi. That Korean stuff is a tangy, spicy, fermented delight, white most of it found in Japanese supermarkets is filled with sugar -- sometimes even as the second or third ingredient after hakusai!

    It's true, however, that the "heart healthy whole grains" message is largely absent here, and that there is really no fear of fatty meat (yakiniku!).

    Regardless, the article flies in the face of what contemporary Japan actually eats; the article sounds more like a stereotype of what people ate just before or just after WW2.

    Besides, the Okinawans have (or rather had) the longest life expectancy of all, and they practically revered pork fat! Pork, fish, sea vegetables, tubers, and veggies, is what their traditional diet is purported to be.

    (end ramble)

  • Dr. William Davis

    4/25/2011 12:23:38 AM |

    Several commenters make the crucial point that the Japanese diet is changing. I agree: Western influence, from Dunkin Donuts to McDonalds, has infiltrated their culture. I expect that we will see the cardiovascular advantage of the Japanese erode over the coming decades. But the point remains: At least at one time, they followed a diet that likely provided at least part of the reason for their reduced risk for heart disease.

    I am Japanese and, when we were kids, we lived on tofu, taukuan, rice, omeboshi, natto, and all the other foods from Japan that we could get from shops in New York. We did eat rice cakes containing sweet beans, but sweet was simply, at least in that period, not a prominent part of the diet. Salt was, however.

  • Anonymous

    4/25/2011 12:50:15 AM |

    I would be interested to know what this dietary pattern consisted of since it was also associated with an increase in CVD:  "The 'animal food' dietary pattern was associated with an increased risk of CVD"

    Stephanie A.

  • Chooky F.

    4/25/2011 12:55:32 AM |

    I have heard that they have a much higher incidence of stroke.  I'm not sure if this is true or not but I have seen data suggesting it is 5X as likely in Japan as it is in the U.S.  I have also heard that dying from heart disease is considered less honorable than dying from stroke.  There is some speculation that the Japanese diagnose death due to stroke at higher rates.  The two can be difficult to diagnose correctly.  Stroke and heart disease are the same problem.  I think their diet in general is less stroke/heart prone than the US but their arteries may not be as unclogged as the heart disease numbers suggest.

  • Boo

    4/25/2011 1:08:31 AM |

    I'm another long-time Japanese resident. While taking care of my wife in the hospital here, I noticed what seemed like an epidemic of diabetes. So even without massive obesity, and without the same level of heart disease, the modern Japanese diet (toast for breakfast, lots of white rice) is having its effects.

  • Adam Michael

    4/25/2011 1:38:30 AM |

    Once again, I really believe it comes down to eating as many whole foods as possible while reducing the amount of processed products.  This article on the Japanese lifestyle coincides with my conviction.

    We do not necessarily have to adopt the exact regimens they follow, but understand that the closer we align ourselves with whole, natural foods, the closer we will be to improving health.

  • Might-o'chondri-AL

    4/25/2011 1:46:45 AM |

    "It's the small things in life"; seems worth noting, since we in the west overlook what we don't have a frame of reference for. A Japanese meal is traditionally accompanied by things we don't think much of.

    Old style pickles ("Nukazuke") were food items embeded (buried) in a rice bran medium; the "bed" innoculated the pickles with micro-organisms. It could be interpreted to be a pro-biotic dietary practise. (I have an easy rice bran pickle recipe if anyone wants.)

    Miso's many substrates, and some pickles (ex: eggplant; recipe on request) are made by embedding the substrate in Koji. Koji is usually rice innoculated with a fungus strain of Aspergillus oryzae.

    Soybean miso is the most commonly known miso,in one form or another, in the west; people attribute it's benefit to what they know (the soy). Actually the koji is what lowers the per-oxidation of linoleic acid; and it is the koji fraction that provides the beneficial scavenger activity against our cell oxidants.

    Koji in miso is infused with the fungal (A. oryzae's) tri-acyl-glycerol lipase gene and gluco-amylase pro-chymosin gene. It can make some of the miso substrate's medium chain fatty acids into a form we can absorb (ie: esterified); with  attendant anti-oxidant properties.

    Oh, and those lectins in grains and beans people seem to disparage these day? Well fungi, like A. oryzae, have enzymes to break lectins down; so koji fermented foods enhance mineral bio-availability.

    For east coast USA Koji and Natto contact "Katagiri" Japanes Grocery in N.Y.C. (on an east 70+ street, near Bloomingdales). For west coast USA bulk (35 lbs. box or six 1 lb. tubs box) white rice Koji contact producer  "Miyako" Oriental Foods in Baldwin Park (near L.A.). For Japanese cultures to make your own contact "G.E.M." Cultures, now in Wash. state. I have no financial interest in any venture; gotta go check on today's natto batch....

  • Anonymous

    4/25/2011 4:06:51 AM |

    Why is more Iodine helpfull?

  • Might-o'chondri-AL

    4/25/2011 4:27:18 AM |

    edit needed for my last comment above, see the 6th paragraph (next to last)....
    Replace the word "lectin" with "phytates" ; and then the enzyme which fungi have are going to be a "phytase", the type of enzyme with ability to break down "phytates".

  • LifeCoachAndy

    4/25/2011 6:41:00 AM |

    Rice consumption cited in one comment above clearly indicate that rice consumption has inverse association to increasing cvd. It again sugggest that increased consumption of other foods such as more animal foods, more fat, junk, McDOnalds, sugar etc, which probably replaced rice therefore increasing incidence of CVD.

  • rhc

    4/25/2011 12:47:27 PM |

    @ Might-o...where can I get instructions. Do they come with the order? Or are you offering some here? I'd love to make some. Great post...again.

  • Fuel Rest Motion.

    4/25/2011 12:59:35 PM |

    I have been here 10 plus years and even in that time I have seen a  visible increase  in the number of overweight and the recent  "Metabo"  metabolic syndrome craze.

    Go to any supermarket: it's aisle of processed grains, snacks, cookies and cakes for miles.
    Go to any convenience store and see one whole aisles of "Snack pun" - snack bread. This stuff is hideous. 400-600 calories of bleached white bread,  margarine and sugar rich fillings. Its essentially mostly sugar and this  kind of thing is replacing the fish and  miso breakfast. A staggering  large percentage of teens and young adults consider this a decent  breakfast or lunch.
    As a teacher I frequently see  students buying two snack puns at the cafeteria  and that's their lunch.  1000  calories of basically sugar.
    Instant Noodles are hugely popular and not helping either.
    This current generation is going to  seriously dent  the  precedent of statistics their grandparents and great grandparents.

    As for the good stuff, yes still more fish consumed on the whole than  elsewhere but huge amounts of grain fed overproceesed meats.
    Seaweed- yes still about and definitely  beneficial and the ubiquitous onigiri is still popular, though  at the convenience store  the snack breads seem to rule in terms of selection these days.
    An for grains have you seen the standard food pyramid in Japan? or the spinning top as it's called.
    Very grain heavy.

    http://www.mhlw.go.jp/bunya/kenkou/pdf/eiyou-syokuji5.pdf

    More walking - much much more walking in Japan compared to the  USA has more to do with it I suspect!

  • Peter

    4/25/2011 1:19:54 PM |

    The Japanese used to eat a lot less than us. I bet eating 2700 calories a day average of any diet ups your cvd risk.

  • Anonymous

    4/25/2011 1:56:48 PM |

    What about chlorine in the Japanese water supply - do they use as much chlorine as we do in the US?

  • Fuel Rest Motion.

    4/25/2011 2:20:31 PM |

    chlorine? A heavily industrialized nation like Japan? you better believe it! but it  does vary to place to  place.
    Some cities  it's like the water is coming straight out of a swimming pool.
    The tap water is ok to drink after some basic filtration.

  • Might-o'chondri-AL

    4/25/2011 3:56:23 PM |

    Hi rhc,
    I am not selling anything; the sources for specialty items are all places I have bought from. If you can't track them down online then I'll get you contact details; assuming Doctor Davis doesn't object.

    To make your own Natto it is really easy. Koji making involves more steps, but there are a lot of different things you can do with it.

    Rice bran pickles are the simplest of all to crank out daily, once your rice bran "bed" builds up it's microbial flora. The rice bran "bed" needs to be stirred (ideally)daily to keep funky microbes from taking over; but if you put some (say)veggies in the rice bran bed you can hand stir it then and enjoy those "pickles" later the same day. Sacks of rice bran are sold in many Japanese groceries (like Katagiri) and I've used "Bob's Red Mill" brand rice bran (health food store/mail order).

    G.E.M. Cultures is now run by Gorden E. McBride's daughter up in Washington state. They mail order the pure Japanese Natto spores I've used for years and send instructions a novice can follow. (I have some incubating now at +/- 105* Farenheit in a covered dish set up over a scrapped food dehydrator's heat coil base.)

    G.E.M. also provides the culture for making Koji; they actually have several Koji strains, depending on what end product you want to make - instructions always are included. To make white rice  Koji from scratch you want to be able to get "sticky" white rice (ex: "Hakubai" or "Wel-Pac" Sweet Rice, from JFC International) and steam cook it.

    G.E.M. also sells the already innoculated Koji and a little bit doesn't really go very far except for experimenting. Miyako Oriental Foods is a modern Koji "factory"; they sell rice Koji (and Miso) to places like Katagiri in individual tubs under the label "Cold Mountain". Koji has a very long shelf life (dry stored, no direct heat), so refrigeration is not absolutely essential.

  • Anonymous

    4/25/2011 5:54:03 PM |

    For those who have lived in Japan, do the Japanese do any formal exercise? walk a lot?

  • steve

    4/25/2011 6:27:14 PM |

    It would be interesting to hear your thoughts on French diet as they too have a much lower incidence of heart diseas( not as low as Japanese), but their diet is western oriented.  My guess would be lack of sugar, junk food, and minimum Omega 6 intake.  They do eat wheat, but not in quantities similar to those in U.S.

  • rhc

    4/25/2011 6:56:12 PM |

    @ might-o... Thanks so much for the additional info. I've printed it all out and will start investigating the sources and processes.

  • Anonymous

    4/25/2011 10:51:33 PM |

    @ Steve:

    http://wholehealthsource.blogspot.com/2010/11/observations-from-france.html

    http://wholehealthsource.blogspot.com/2010/05/does-red-wine-protect-cardiovascular.html

    http://www.vinopic.com/index.php/roger-corder/roger-corder-intrinsic-quotient#red-wine-quality

    Cheers!

  • Might-o'chondri-AL

    4/26/2011 1:14:02 AM |

    The body's internal ratio of Magnesium (Mg) to Calcium  (Ca) in East Asia and the USA
    typically differ; with African Americans having even lower Mg % than their caucasian countrymen. Specificly the East Asians statisticly have/had more Mg relative to Ca; and conversely Americans had less Mg relative to Ca in their bodies.

    The Japanese living outside of Japan (or those eating more like the west inside) Japan could be having less Mg %; this could explain several things. Low Mg is implicated in inflammation, insulin resistance, metabolic syndrome & Type II diabetes; 2000 data for U.S.A. showed 79% were below MDR Mg.

    In other words the American diet supplying much more Ca in relation to more sparse Mg creates a ratio, that in the body is involved in the dynamic of pathological development. Ca is not "bad" in itself, but in the context of too little Mg the inflammatory underpinning of many diseases wrecks havoc (ex: coronary heart disease, insulin resistance, Type II diabetes, etc.).

    Ca has systemic roles in signalling for various cell cycles. Mg plays a role in (among other things) DNA repair and lowering insulin levels. Special gut ion uptake channels  with the gene TRPM 7 (transient receptor potential melastatin) regulate Mg.++ balance; shear volume of Ca++ can interfere with that ion channel taking up the Mg (Ca & Mg ion charges tend to compete).

    One researcher thinks the really low Mg to strong Ca ratio explains the African American susceptibility to more coronary events. Maybe this Mg:Ca ratio explains some (not all) of the  data showing Japan has/had less heart disease; and also a big factor why Japanese in the west are/were relatively more prone to heart disease.

  • Dr. William Davis

    4/26/2011 1:16:50 AM |

    Might--

    Fascinating detail on the organisms used to ferment!

    I'm also quite impressed that you can actually eat natto. Even though I was exposed to it by my Mom as a kid, I still can't stomach the stuff.

  • Sue Ek

    4/26/2011 3:08:19 AM |

    The Birth Control Pill only recently became legal in Japan. To me it points to the sudden increase in heart disease among Japanese women.
    ~ Sue Ek, BOMA-USA

  • Bob

    4/26/2011 3:36:21 AM |

    Physical activity is more fundamental than diet.

  • Might-o'chondri-AL

    4/26/2011 3:44:07 PM |

    East Asia = 1 Magnesium  per 1.6 Calcium
    U.S.A.    = 1 Mg. per 2.8 Ca
    Of course, those are statistical generalizations of vast regions of people. One researcher speculates the "American Heart Healthy" diet benefit, of eating more whole grains, might be due to their extra Mg.

    Meta-analysis of adult women taking Ca supplements may provide another clue. For every 1,000 women taking Ca supplements over 5 years time there were 6 extra heart problems (strokes and infarctions); while for the same scenario (1,000 over 5 years) the Ca supplementing only prevented 3 fractures.

    That analysis went on to speculate it is not the exact dose of Ca that mattered; since the risk factor went up whether taking less than 500 mg. Ca or 1,000 mg. Ca. daily. The theory proposed was that it was the 5 years of abrupt blood Ca loading that created the risk.

    Data was that (with Ca pill) the risk of myocardial infarction
    rose 25 - 30 % and the stroke risk rose 15 - 20 %; with obese women having less fatal events than their non-obese counterparts (more tissue mass to stash the Ca load ?). If wondering, the addition of vitamin D to the Ca supplement seemed not to be a factor in mitigating or increasing the risk.

    If the Ca supplement implications
    (women only studied) are suggestive and we add to the body equation a poor base line Mg ratio to Ca maybe this explains some of the historical pattern of heart disease. America went in big for non-whole grain food and favored dairy (ie: Ca)in the post-wars 1900s; Japan during that same epoch wasn't big on milk and had (in theory?) better Mg. intake ratio.

  • Renfrew

    4/26/2011 8:11:38 PM |

    Interesting how many readers have lived in Japan. My wife is Japanese, so I have some first hand experience, besides living there for a ferw years.

    Not mentioned so far is the close and cohesive social network that most Japanese enjoy. While in Okinawa I saw lots of old people gathering daily, doing things together, playing games, ball, eating together and generally share the news and gossip. This kind of social web is heart-protecting. We know from studies that loneliness and hostility is detrimental to cardiac health. Possible physiological mechanism: Stress hormone Cortisol would go down, Oxytocin would go up.
    Another factor: "Hara hachibu", this means literally "Stomach 80%".
    It refers to the habit of filling your stomach only 80% and not 100%. Thus eating less and therefore practicing a mild form of caloric restriction, which we know, is clearly life extending.  
    In all, I think it is a mix of everything mentioned here and each part is contributing.
    Renfrew

  • Marc

    4/27/2011 2:27:56 PM |

    Might-

    I couldn't agree with you more about the calcium/magnesium link to heart problems.  I've thought that for years after doing a minor study of magnesium related issues.  In fact the clear implications of magnesium deficiency is astonishing. When you consider the large number of processes that it is responsible for and the lack of it in the American diet it becomes increasing obvious that it has a very important part to play in all of this.

    Marc

  • Anonymous

    4/27/2011 4:37:17 PM |

    My sister lives in Japan, and she sent my kids some Japanese Chocolates for Christmas. The Japanese Chocolate was not nearly as sweet as American Chocolate. I think Americans have a problem with moderation. We want to much of a 'good' thing. The sugar in Japanese chocolate is just a small example, but could be an indicator that there are small differences in everything they do that add up to make a difference. Smile

  • Diana

    4/27/2011 8:49:28 PM |

    Dr. Davis,

    I note that in your post you OMIT the fact that the staple food of the Japanese is rice, and that carbs traditionally comprise 80% of the Japanese diet.

    Stop lying to and misleading people about carbs and weight gain.

    You and I are on the same side about sugar and refined junk carbs.

    OK?

  • Kevan

    4/28/2011 5:55:11 PM |

    Diana, I note that in your post you OMIT any links or proof that the Japanese eat an 80% carb diet. If you are going to make statements and claim them as "fact", you need to prove them. Otherwise, it's just your opinion.

  • Peter

    5/7/2011 6:33:47 PM |

    If I eat much rice my blood sugar goes way up.  Did that happen to Japanese on the traditional diet?

  • sally

    5/14/2011 7:44:20 PM |

    The Japanese eat seaweed.

  • Tom

    5/15/2011 11:15:50 PM |

    It can't even be said with 100% certainty that the high amont of salt they may consume is bad.

  • Laura

    5/17/2011 2:12:57 PM |

    Very interesting point! Yes, he did not mention rice, but the other components are all very good for you. Great posting, Dr.

  • Gabby

    7/10/2011 10:49:40 AM |

    Gosh, I wish I would have had that infrmoation earlier!

  • King

    7/10/2011 11:07:37 AM |

    And I was just wnodeirng about that too!

  • Frenchie

    7/10/2011 10:01:51 PM |

    IJWTS wow! Why can't I think of thgins like that?

  • Fanni

    7/11/2011 1:59:42 PM |

    To think, I was confused a mtinue ago.

  • J Diz

    2/28/2012 3:32:55 PM |

    In visiting France (Cannes and Paris), I noticed that there is a focus on fresh (whole) foods everywhere, and I mean EVERYWHERE.  Only in highly populated urban areas did I see availability of processed snacks and junk food.  Fresh vegetables and free-range meats were what i found.  Most importantly, the portion sizes were small (similar to Japanese).  Though they did eat numerous times through the day, portions were small.  Sweets are big in France, but no one ever over-indulges.  They take the time to savor and enjoy their sweets from a patisserie or cafe.  It''s their food culture from the ground up that has led to their long lives and, quite frankly, very attractive frames.

  • Patricia Arland

    6/16/2012 10:27:37 AM |

    I am a bit confused by the mention of soy sauce......Kikkoman ingredients read, "Water, WHEAT .........."  thought the idea was to stay away from wheat

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All posts by william-davis

Does high cholesterol cause heart disease?

3. October 2008 William Davis (15)
How often does someone develop coronary heart disease from high cholesterol alone?

Believe drug industry propaganda and you'd think that everyone does. Physicians have bought into this concept also, driving the $27 billion annual sales in statin cholesterol drugs.

In my experience, I can count the number of people who develop coronary disease from high cholesterol alone on one hand. It happens--but rarely.

That's not to say that cholesterol is not an issue. That rant populates many of the kook websites and conversations on the internet that argue that high cholesterol is a surrogate for some other health issue, or that it is part of a medical conspiracy.

The problem with conventional measurement of cholesterol is that it ignores the particle size issue: whether particles are large or small. Small LDL are flagrant causes of coronary atherosclerotic plaque. Large LDL is a rather meager cause. Simple cholesterol measurement also ignores the presence of other factors that lead to heart disease, like lipoprotein(a) and vitamin D deficiency.

Conventional total and LDL cholesterol do not distinguish between large and small particles, nor reveal the presence of other hidden patterns. An LDL cholesterol of 150 mg/dl, for instance, may contain 100% large LDL--a relatively good situation that by itself is unlikely to cause heart disease, or it might contain 100% small LDL--a very bad situation that is likely to cause heart disease. Just knowing that LDL is 150 mg/dl tells you almost nothing. In 2008, most people have some mixture of the two, particularly with the proliferation of "healthy whole grains" in the American diet, foods that trigger formation of small LDL.

The imprecision and uncertainty of conventional total and LDL cholesterol has provided ammunition for some to discount the entire cholesterol concept. And they are right to a degree: cholesterol by itself is indeed a lousy predictor of heart disease. But small LDL is a very reliable predictor of potential for heart disease. Dismissing the entire concept because the standard measurement stinks is not right, either.

It is therefore an unfortunate oversimplification to say that high cholesterol causes heart disease or that it doesn't. It can--but not always, depending on size and other factors. In my view, it is therefore irreponsible to treat total or LDL cholesterol without knowledge of particle size. I've seen this play out many times: Someone with an LDL cholesterol of 150 mg/dl but all large still gets prescribed a statin drug by his/her doctor. Or someone with an LDL of 100 mg/dl--generally "favorable" by most standards--is not treated but it is all small and the person is truly at high risk. (Also, knowledge that all LDL particles are small does not mean that statins are the preferred agent. In my view, they are not.)

Are humans meant to be omnivores?

28. September 2008 William Davis (24)
Are humans meant to be omnivores?

Does the ideal human diet include animal products like meat, fish, cheese, eggs, and dairy products?

Or should the ideal diet be devoid of all animal products?a vegetarian diet?

Though the argument is distorted by modern food processing methods (e.g., factory farming, long-term administration of antibiotics), convenience foods, and pseudo-foods crafted by food manufacturers, there are, obviously, proponents of both extremes.

The Atkins’ diet, for instance, advocates unrestricted intake of animal products, regardless of production methods or curing (sausage and bacon). At the opposite extreme are diets like Ornish (Dr. Dean Ornish’s Program for Reversal of Heart Disease) and the experiences of Dr. Colin Campbell, articulated in his studies and book, The China Study, in which he lambasts animal products, including dairy, as triggers for cancer and heart disease.

So which end of the spectrum is correct? Or ideal?

For the sake of argument, let's put aside philosophical questions (like not wanting eat animal products because of aversion to killing any living being) or ethical concerns (inhumane treatment of farm animals, cruel slaughtering practices, etc.). Does the inclusion of animal products provide advantage? Disadvantage?

The traditional argument against animal products has been saturated fat. If we accept that we’ve demoted the saturated fat question to a place far down the list of importance (though this is yet another argument to discuss another time), several questions emerge:

• If humans were meant to be vegetarian, why do omega-3 fatty acids (mostly from wild game and fish) yield such substantial health benefits, including dramatic reduction in sudden death from heart disease?

• Why would vitamin K2 (from meats and milk, as well as fermented foods like natto and cheese), obtainable in only the tiniest amounts on a vegetarian diet, provide such significant benefits on bone and cardiovascular health?

• Why would vitamin B12 (from meats) be necessary to maintain a normal blood count, prevent anemia, keep homocysteine at bay, and lead to profound neurologic dysfunction when deficient?


Omega-3 fatty acids and vitamins K2 and B12 cannot be obtained in satisfactory quantities from a pure vegetarian diet. The consequences of deficiency are not measured in decades, but in a few years. The conclusion is unavoidable: Evolutionarily, humans are meant to consume at least some foods from animal sources.

That's not to say that we should gorge ourselves on animal products. Gout (excessive uric acid) and kidney stones are among the unhealthy consequences of excessive quantities of meats in our diets.

It pains me to say this, since I’ve always favored a vegetarian lifestyle, mostly because of philosophical concerns, as well as worries about the safety of our factory farm-raised livestock and rampant inhumane practices.

But, stepping back and objectively examining what nutritional approach appears to stack the odds in favor of optimal health, I believe that only one conclusion is possible: Humans are meant to be omnivorous, meant to consume some quantity of animal products in addition to vegetables, fruits, nuts, and other non-animal products.

The question is how much?

Are you wheat-free?

24. September 2008 William Davis (25)
According to the recent Heart Scan Blog poll, Are you wheat-free?, the 173 respondents said:

Yes, I am free of wheat products.
87 (50%)

No, I include wheat products in my diet.
73 (42%)

I'm not sure.
1 (0%)

I think you're nuts.
12 (6%)


That's kind of what I expected.

There are people who have eliminated wheat and experienced nothing except a feeling of deprivation. These people are in the minority. Though the poll was not set up to reflect this (i.e., asked who tried it and experienced no perceptible benefit), in my experience, this applies to about 20% of people. Little happens with elimination of wheat beyond modest weight loss. Those are the people who generally think I'm nuts.

Or, these people may have been brainwashed by "official" agencies like the USDA, the American Diabetes Association, and American Heart Association and the constant marketing of (high markup) grain products like Cheerios and Shredded Wheat . Some people are really uncomfortable going against the "grain" of popular public opinion.

Then there are the people who try to eliminate wheat and fail. They can't deal with the overwhelming fatigue, mental fog, and moodiness that comes with withdrawal from wheat, the phenomenon of converting from a sugar-burning metabolism to a fat-burning metabolism. Although wheat withdrawal usually runs its course in 2-5 days, some people find it intolerable. (That would be another fun poll to run: Have you experienced wheat-withdrawal?) Occasionally, the withdrawal is replaced by endless cravings, a phenomenon that applies to only about 10% of people. These are the true "wheat addicts." These are the people who eliminate wheat, lose 40 lbs, then regain it when they have one cracker and the floodgates of impulse control crumble.

Then there are the majority, 50% in the poll, though more like 70% in my face-to-face experience. Why is my experience skewed? Well, the people I deal with every day come because of coronary disease in some form (abnormal heart scan score, for instance) or because of lipid or lipoprotein abnormalities. So my experienced is skewed towards people who are likely to have something abnormal, such as high triglycerides or small LDL particles, both of which are created by including wheat in the diet.

This last group also shows unexpected effects of wheat elimination: substantial weight loss, dramatic reductions in blood sugar and triglycerides, increase in HDL, reductions in small LDL, reduction in c-reactive protein and other inflammatory measures. Appetite shrinks considerably. Not uncommonly, improved well-being, reduction in bowel complaints like cramping or "irritable bowel syndrome" is experienced, some rashes clear, occasionally arthritis will improve. See below for some of the testimonials to this experience.

When I first set out to advise people to eliminate wheat, I did it because I reasoned that it would be a quick and simple way to get people to reduce blood sugars and help correct the ubiquitous metabolic syndrome that afflicts nearly 50 million Americans now. And it did indeed accomplish that simple goal. But I did not expect all the other benefits to develop, the dramatic weight loss, improved well-being, reduction in hunger, etc.

I view wheat elimination as an easy-to-remember, digestible way to obtain enormous health benefits in a coronary plaque-control program, one that works for most--but not all--people. And I relate this experience not to sell you something, but to simply relate what I see as the truth, a way that is contrary to conventional advice yet works enormously well.



Unsolicited testimonials of people who have successfully been wheat-free:

Barbara W said:

It's true! We've done it. My husband and I stopped eating all grains and sugar in February. At this point, we really don't miss them any more. It was a huge change, but it's worth the effort. I've lost over 20 pounds (10 to go)and my husband has lost 45 pounds (20 to go). On top of it, our body shapes have changed drastically. It is really amazing. I've got my waist back (and a whole wardrobe of clothes) - I'm thrilled.

I'm also very happy to be eating foods that I always loved like eggs, avocados, and meats - without feeling guilty that they're not good for me.

With the extremely hot weather this week in our area, we thought we'd "treat" ourselves to small ice cream cones. To our surprise, it wasn't that much of a treat. Didn't even taste as good as we'd anticipated. I know I would have been much more satisfied with a snack of smoked salmon with fresh dill, capers, chopped onion and drizzled with lemon juice.

Aside from weight changes, we both feel so much better in general - feel much more alert and move around with much greater flexibility, sleep well, never have any indigestion. We're really enjoying this. It's like feeling younger.

It's not a diet for us. This will be the way we eat from now on. Actually, we think our food has become more interesting and varied since giving up all the "white stuff". I guess we felt compelled to get a little more creative.

Eating out (or at other peoples' places) has probably been the hardest part of this adjustment. But now we're getting pretty comfortable saying what we won't eat. I'm starting to enjoy the reactions it produces.


Weight loss, increased energy, less abdominal bloating, better sleep--I've seen it many times, as well.


Dotslady said:

I was a victim of the '80s lowfat diet craze - doc told me I was obese, gave me the Standard American Diet and said to watch my fat (I'm not a big meat eater, didn't like mayo ... couldn't figure out where my fat was coming from! maybe the fries - I will admit I liked fries). I looked to the USDA food pyramid and to increase my fiber for the constipation I was experiencing. Bread with 3 grams of fiber wasn't good enough; I turned to Kashi cereals for 11 years. My constipation turned to steattorrhea and a celiac disease diagnosis! *No gut pains!* My PCP sent me to the gastroenterologist for a colonscopy because my ferritin was a 5 (20 is low range). Good thing I googled around and asked him to do an endoscopy or I'd be a zombie by now.

My symptoms were depression & anxiety, eczema, GERD, hypothyroidism, mild dizziness, tripping, Alzheimer's-like memory problems, insomnia, heart palpitations, fibromyalgia, worsening eyesight, mild cardiomyopathy, to name a few.

After six months gluten-free, I asked my gastroenterologist about feeling full early ... he said he didn't know what I was talking about! *shrug*

But *I* knew -- it was the gluten/starches! My satiety level has totally changed, and for the first time in my life I feel NORMAL!


Feeling satisfied with less is a prominent effect in my experience, too. You need to eat less, you're driven to snack less, less likely to give in to those evil little bedtime or middle-of-the-night impulses that make you feel ashamed and guilty.



An anonymous (female) commenter said:

My life changed when I cut not only all wheat, but all grains from my diet.

For the first time in my life, I was no longer hungry -no hunger pangs between meals; no overwhelming desire to snack. Now I eat at mealtimes without even thinking about food in between.

I've dropped 70 pounds, effortlessly, come off high blood pressure meds and control my blood sugar without medication.

I don't know whether it was just the elimination of grain, especially wheat, or whether it was a combination of grain elimnation along with a number of other changes, but I do know that mere reduction of grain consumption still left me hungry. It wasn't until I elimnated it that the overwhelming redution in appetite kicked in.

As a former wheat-addicted vegetarian, who thought she was eating healthily according to all the expert advice out there at the time, I can only shake my head at how mistaken I was.



Stan said:

It's worth it and you won't look back!

Many things will improve, not just weight reduction: you will think clearer, your reflexes will improve, your breathing rate will go down, your blood pressure will normalize. You will never or rarely have a fever or viral infections like cold or flu. You will become more resistant to cold temperature and you will rarely feel tired, ever!


Ortcloud said:

Whenever I go out to breakfast I look around and I am in shock at what people eat for breakfast. Big stack of pancakes, fruit, fruit juice syrup, just like you said. This is not breakfast, this is dessert ! It has the same sugar and nutrition as a birthday cake, would anyone think cake is ok for breakfast ? No, but that is exactly the equivalent of what they are eating. Somehow we have been duped to think this is ok. For me, I typically eat an omelette when I go out, low carb and no sugar. I dont eat wheat but invariably it comes with the meal and I try to tell the waitress no thanks, they are stunned. They try to push some other type of wheat or sugar product on me instead, finally I have to tell them I dont eat wheat and they are doubly stunned. They cant comprehend it. We have a long way to go in terms of re-education.

Yes. Don't be surprised at the incomprehension, the rolled eyes, even the anger that can sometimes result. Imagine that told you that the food you've come to rely on and love is killing you!


Anne said:

I was overweight by only about 15lbs and I was having pitting edema in my legs and shortness of breath. My cardiologist and I were discussing the possible need of an angiogram. I was three years out from heart bypass surgery.

Before we could schedule the procedure, I tested positive for gluten sensitivity through www.enterolab.com. I eliminated not only wheat but also barley and rye and oats(very contaminated with wheat) from my diet. Within a few weeks my edema was gone, my energy was up and I was no longer short of breath. I lost about 10 lbs. The main reason I gave up gluten was to see if I could stop the progression of my peripheral neuropathy. Getting off wheat and other gluten grains has given me back my life. I have been gluten free for 4 years and feel younger than I have in many years.

There are many gluten free processed foods, but I have found I feel my best when I stick with whole foods.


Ann has a different reason (gluten enteropathy, or celiac disease) for wanting to be wheat-free. But I've seen similar improvements that go beyond just relief of the symptoms attributable to the inflammatory intestinal effects of gluten elimination.



Wccaguy said:

I have relatively successfully cut carbs and grains from my diet thus far.

Because I've got some weight to lose, I have tried to keep the carb count low and I've lost 15 pounds since then.

I have also been very surprised at the significant reduction in my appetite. I've read about the experience of others with regard to appetite reduction and couldn't really imagine that it could happen for me too. But it has.

A few weeks ago, I attended a party catered by one of my favorite italian restaurants and got myself offtrack for two days. Then it took me a couple of days to get back on track because my appetite returned.

Check out Jimmy Moore's website for lots of ideas about variations of foods to try. The latest thing I picked up from Jimmy is the good old-fashioned hard boiled egg. Two or three eggs with some spicy hot sauce for breakfast and a handful of almonds mid-morning plus a couple glasses of water and I'm good for the morning no problem.

I find myself thinking about lunch not because I'm really hungry but out of habit.

The cool thing too now is that the more I do this, the more I'm just not tempted much to do anything but this diet.

No more canned foods

21. September 2008 William Davis (12)
If you haven't already caught the news, it's time to eliminate canned foods and exposure to plastics that contain the chemical, bisphenol A (BPA). A worrisome and unexpected association with heart disease and diabetes has been found.

This issue has been debated for some years ever since scientists at the NIH detected BPA in the blood samples of 93-95% of Americans, with consumer protection advocates calling for more research or even the outright banning of BPA , while industry representatives have argued that the data fail to conclusively prove adverse health effects.

Well, the argument has been tilted heavily in favor of increased consumer protection with the publication of a study in the Journal of the American Medical Association by Dr. Iain Lang and associates at the University of Exeter, UK, and the University of Iowa. Their study, released Sept. 17, 2008, Association of urinary bisphenol A concentration with medical disorders and laboratory abnormalities in adults, persuasively demonstrated a 40% increased incidence of coronary heart disease, heart attack, and diabetes with increasing exposure to BPA (as judged by urine levels) among the nearly 1500 adults aged 18-74 years. People with coronary heart disease had double the blood level of BPA compared to those without.

In addition, higher urine levels of BPA were associated with abnormalities of two liver tests, GGT and alkaline phosphatase.

Interestingly, although much of the debate over adverse health effects of BPA have centered around concern over cancer and reproductive risks, an association with cancer did not hold. (No analysis for reproductive issues was conducted in these adults, since most of the concern is for children exposed through polycarbonate baby bottle use. Some BPA critics have raised questions like low birth weight developing from exposure.) No relationship to thyroid disease was identified, also.

The editorial accompanying the study added some sharp commentary:

"Subsequent to an unexpected observation in 1997, numerous laboratory animal studies have identified low-dose drug-like effects of BPA at levels less than the dose used by the US Food and Drug Administration and the Environmental Protection Agency to estimate the current human acceptable daily intake dose (ADI) deemed safe for humans. These studies have shown adverse effects of BPA on the brain, reproductive system, and--most relevant to the findings of Lang et al--metabolic processes, including alterations in insulin homeostasis and liver enzymes. . . For example, when adults rats were fed a 0.2 microgram/kg per day dose of BPA for 1 month (a dose 250 times lower than the current ADI), BPA significantly decreased the activities of antioxidant enzymes and increased lipid peroxidation, thereby increasing oxidative stress. When adult mice were administered a 10 microgram/kg dose of BPA once a day for 2 days ( a dose 5 times lower than the ADI), BPA stimulated pancreatic beta cells to release insulin."

This study, piled on top of the worrisome literature that precede it, are enough for me: No more tin cans (which are lined with BPA), no more hard plastics labeled with recycling code #7 or #3, no more polycarbonate water bottles (the hard ones, often brightly colored). Microwaveable-safe may also mean human-unsafe, as highlighted by this damning assurance from the Tupperware people that BPA is not a health hazard.

The National Toxicology Program also issued these advice in response to the Lang study to reduce BPA exposure (reported by the Washington Post) :

· Don't microwave polycarbonate plastic food containers. Polycarbonate may break down from overuse at high temperatures and release BPA. (Manufacturers are not required to disclose whether an item contains BPA, but polycarbonate containers that do usually have a No. 7 on the bottom.)

· Reduce use of canned foods, especially acidic foods such as tomatoes that can accelerate leaching of BPA from plastic can linings. Opt for soups, vegetables and other items packaged in cardboard "brick" cartons, made of safer layers of aluminum and polyethylene plastic (labeled No. 2).

· Switch to glass, porcelain or stainless-steel containers, particularly for hot food or liquids.

· Use baby bottles that are BPA-free; in the past year, most major manufacturers have developed bottles made without BPA.

Add Boston Globe to the list of heart scan blunders

17. September 2008 William Davis (15)
Yet another piece of mass media misinformation hit the airwaves today. This time it's not from the New York Times or the LA Times, both of which have previously mangled the issues surrounding heart scans. This time it's from the Boston Globe.

In an article titled What is a calcium scan for heart disease, and who should undergo the test?, the report states:

". . . calcium scans may not be a good idea, or prove terribly useful, for most people. For one thing, the scans expose a patient to significant radiation - equivalent to roughly 50 chest X-rays" said Dr. Warren Manning, chief of noninvasive cardiac imaging at Beth Israel Deaconess Medical Center."

As many before him, Dr. Manning is confusing two tests: CT coronary angiography and CT heart scanning. Perhaps we can't blame him: This technology has had its weakest following in the northeast, for reasons not entirely clear to me. (In fact, Track Your Plaque followers have had the greatest struggle obtaining heart scans in that part of the country.) Nonetheless, you'd think he'd have his simple facts straight before talking to the press. Unfortunately, hospital public relations departments will usually just grab whoever they can willing to talk to the press--regardless of their expertise or lack of.


The story goes on to say:

. . ." it's not clear what to do with the results from a calcium scan. If you have diabetes, high cholesterol, high blood pressure, or a family history of heart disease, you already know - or should know - that you are at increased risk of heart problems and should lower these risk factors. So, a calcium scan provides little additional information," Manning said.

"Moreover, even a high score doesn't necessarily mean that the calcified plaque in your arteries is obstructing blood flow, said Dr. Adolph Hutter, a cardiologist at Massachusetts General Hospital."

"The vast majority of people with high calcium tests don't have obstructions and they do fine long-term. So you'd have to test lots and lots of people to prevent one heart attack or sudden death," said Manning.

And if you get a low calcium score, a sign of little or no calcification of plaques, that's not very useful, either, because it could be wrong, or it could be right but lull you into believing you do not have to exercise and watch your diet, cholesterol, and blood pressure levels. "You can still be at risk even if your calcium test is negative," Hutter said.


It is truly shocking how little many (not all, thank goodness) of my colleagues really know about 1) heart scans, 2) coronary disease prevention, and 3) prevention in general. These same "experts" likely advocate high-dose statin drugs and low-fat diets for people at risk. They likely refer patients to the American Heart Association for diet advice and themselves obtain a lot of information from the pharmaceutical industry. The notion of identification, tracking, and purposeful reversal of coronary plaque is entirely foreign to this bunch.

"The vast majority of people with high calcium tests don't have obstructions and they do fine long-term. So you'd have to test lots and lots of people to prevent one heart attack or sudden death." Well, take a look at a graph from a database of 25,000 people undergoing heart scans then observed for several years afterwards:




You can see quite clearly from the curves that heart scan scores very clearly predict your future (if no preventive action is taken). The higher the score, the greater the likelihood of heart attack and death. How much clearer can it get?

The most recent addition to this literature is the PREDICT study which concluded:

Hazard ratios relative to CACS [coronary artery calcium scores] in the range 0-10 Agatston units (AU) were: CACS 11-100 AU, 5.4 (P = 0.02); 101-400 AU 10.5 (P = 0.001); 401-1000 AU, 11.9 (P = 0.001), and >1000 AU, 19.8 (P < 0.001).

In other words, a heart scan score of >1000 is associated with a 20-fold increased risk of cardiovascular events (without preventive efforts). That kind of predictive power and quantitative confidence simply cannot be squeezed out of blood pressure and cholesterol values.

How about the 2008 University of California-Irvine study from the New England Journal of Medicine (do the northeast docs even pay attention to something that is published in their own neighborhood?) that reported:

There were 162 coronary events, of which 89 were major events (myocardial infarction or death from coronary heart disease). In comparison with participants with no coronary calcium, the adjusted risk of a coronary event was increased by a factor of 7.73 among participants with coronary calcium scores between 101 and 300 and by a factor of 9.67 among participants with scores above 300 (P<0.001 for both comparisons). Among the four racial and ethnic groups, a doubling of the calcium score increased the risk of a major coronary event by 15 to 35% and the risk of any coronary event by 18 to 39%.

How about the Prospective Army Coronary Calcium (PACC) project (men average age 43 years):

"In these men, coronary calcium was associated with an 11.8-fold increased risk for incident coronary heart disease (CHD) (p = 0.002) in a Cox model controlling for the Framingham risk score. Among those with coronary artery calcification, the risk of coronary events increased incrementally across tertiles of coronary calcium severity (hazard ratio 4.3 per tertile)."

Calcium score provided additional information even after factoring in the Framingham risk score.

That's just a sample of the studies. There are a number more.

Add to these conversations the fact that, unlike reducing blood pressure or LDL cholesterol, the heart scan score is a quantification of the disease itself. It can also be tracked over time to gauge the success or failure of prevention efforts. To believe that blood pressure reduction or LDL cholesterol reduction is sufficient to eliminate risk is something only a fool would believe.



Contary to the above statements, the data are clear:

--The higher the heart scan score, the greater the risk. This has been demonstrated beyond any shadow of a doubt in at least a dozen published studies. In fact, heart scan scores outshine lipid/cholesterol values several-fold.

--A person with a zero score has a nearly zero risk for cardiovascular events over a 5-year timeline.

--Heart scans are the only quantitative test available of coronary atherosclerotic plaque. This means that they can be repeated to gauge progression or regression. Cholesterol does not do that. Stress tests do not do that.

--Heart scans are not the same as CT coronary angiography.

--The lack of "need" for a procedure does not equate to the absence of disease.

The power of heart scans is that they can uncover evidence for coronary atherosclerotic plaque 10 years before a cardiac disaster strikes. Witness Tim Russert's heart scan score of 210 in 1998 at age 48. 10 years later, you know what happened.

Beware the camipaign of misinformation and ignorance that continues that is hell-bent on maintaining the procedural status quo or locking us into a "drugs for all" mentality.

What's worse than sugar?

16. September 2008 William Davis (11)
There are a number of ways to view the blood sugar-raising or insulin-provoking effect of foods.

One way is glycemic index (GI), simply a measure of how high blood sugar is raised by a standard quantity of a food compared to table sugar. Another is glycemic load (GL), a combination (multiplied) of glycemic index and carbohydrate content per serving.

Table sugar has a GI of 65, a GL of 65.

Obviously, table sugar is not good for you. The content of white table sugar in the American diet has exploded over the last 100 years, totaling over 150 lb per year for the average person. (Humans are not meant to consume any.)

What is the GI of Rice Krispies cereal, organic or not? GI = 82-- higher than table sugar. GL is 72, also higher than table sugar.

How about Corn Flakes? GI 81, GL 70--also both higher than sugar.

How about those rice cakes that many dieters will use to quell hunger? GI 78, GL 64.

How about Shredded Wheat cereal? GI 75, GL 62.

All of the above foods with GI's and GL's that match or exceed that of table sugar are made of wheat and cornstarch. Some, like Shredded Wheat cereal and rice cakes, don't even have any added sugar.

Stay clear of these foods if you have low HDL, high triglycerides, high blood sugar, or small LDL. Or, for that matter, if you are human.

Keep the eloquent words of New York University nutritionist, Marion Nestle, author of the book, Food Politics, in mind:

“Food companies—just like companies that sell cigarettes, pharmaceuticals, or any other commodity—routinely place the needs of stock holders over considerations of public health. Food companies will make and market any product that sells, regardless of its nutritional value or its effect on health. In this regard, food companies hardly differ from cigarette companies. They lobby Congress to eliminate regulations perceived as unfavorable; they press federal regulatory agencies not to enforce such regulations; and when they don’t like regulatory decisions, they file lawsuits. Like cigarette companies, food companies co-opt food and nutrition experts by supporting professional organizations and research, and they expand sales by marketing directly to children, members of minority groups, and people in develop countries—whether or not the products are likely to improve people’s diets.” ??

Are sterols the new trans fat?

13. September 2008 William Davis (16)
By now, I'm sure you're well-acquainted with the hydrogenated, trans fat issue.

Hydrogenation of polyunsaturated oils was a popular practice (and still is) since the 1960s, as food manufacturers sought a substitute for saturated fat. Bubbling high-pressure hydrogen through oils like cottonseed, soybean, and corn generates trans fatty acids. These man-made fatty acids, while safe in initial safety testing, proved to be among the biggest nutritional mistakes of the 20th century.

Trans fatty acids have been associated with increased LDL cholesterol, reduction in HDL, oxidative reactions, abnormal rigidity when incorporated into cell membranes, and cancer. Trans fats still dominate many processed foods like chips, cookies, non-dairy creamers, food mixes, and thousands of others. They're also found prominently in fast foods.

Fast forward to today, and most Americans have become aware of the dangers of trans fats and many try to avoid them.

But I worry there is yet another substance that has worked its way into the American processed food cornucopia that has some potential for repeating the trans fat debacle: sterol esters.


Sterols are naturally-occurring oils found in vegetables, nuts, and numerous other foods in small quantities. Most of us take in 200-400 milligrams per day just by eating plant-sourced foods.

Curiously, the chemical structure of sterols are very similar to human cholesterol (differing at one carbon atom). Sterols, by not fully understood means, block the intestinal absorption of cholesterol. Thus, sterol esters, as well as the similar stanol esters, have been used to reduce blood levels of total and LDL cholesterol.

So far, so good.

The initial commercial products, released in the late 1990s, were Take Control (sterol) and Benecol (stanol), both of which were marketed to reduce cholesterol when 2-3 tbsp are used daily, providing 3400 – 5100 mg of sterol or stanol esters, about 10- to 20-fold more than we normally obtain from foods. Several clinical trials have conclusively confirmed that these products reduce cholesterol levels.

They do indeed perform as advertised. Add either product to your daily diet and LDL cholesterol is reduced by about 10-15%. In fact, in the original Track Your Plaque book, these products were advocated as a supplemental means of reducing LDL when other methods fell short.

In 2008, there are now hundreds of products that have additional quantities of sterol esters in them, such as orange juice, mayonnaise, yogurt, breakfast cereals, even nutritional supplements. Most of these products proudly bear claims like "heart healthy." Stanol esters have not enjoyed the same widespread application. (I believe there may be patent issues or other considerations. However, it's the sterols that are the principal topic here, not stanols.)

Now, here's where it gets a bit tricky. There is a rare (1 per million) disease called sitosterolemia, a genetic disorder that permits the afflicted to absorb more than the usual quantity of sterols from the intestine. While you and I obtain some amount of sterols from plant-based foods, absorption is poor, and we absorb <10% of sterols ingested. However, people with sitosterolemia absorb sterols far more efficiently, resulting in high blood levels of sterols that result in coronary disease and aortic valve disease, with heart attacks occurring as young as late teens or 20s. Treatment to block sterol absorption are used to treat these people.

There are also a larger number, though still uncommon (1/500) of people who have only one of the two genes that young people with sitosterolemia have. These people may have an intermediate capacity for sterol absorption.

Okay, so what does this have to do with you? Well, if you and I now take in 10-20 times greater amounts of sterol esters, do our blood levels of sterols increase?

Several studies now suggest that, yes, sterol blood levels increase with sterol ingestion. One study from Finland, the STRIP Study, showed that children who had double usual sterol intake increased blood levels by around 50%.

Similarly, a Johns Hopkins study in adults with only one of the genes ("heterozygotes") for sitosterolemia increased sterol blood levels by between 54-116% by ingesting 2200 mg of sterols added per day, despite reduction of LDL cholesterol levels.

Even people with neither gene for sitosterol hyperabsorption can increase their blood levels of sterols. But the crucial question: Do the blood levels of sterols that occur in unaffected people or in heterozygotes increase the risk of coronary heart disease? The answer is not known.

Despite the several clinical trials performed with sterol esters, all of them have examined LDL and total cholesterol reduction as endpoints, not cardiovascular events. It is conceivable that, while sterol esters reduce cholesterol, risk for heart disease is increased due to higher blood levels of sterols.

The question is not settled. For now, it is just a suspicion. But that's enough for me to steer clear of processed foods supplemented with these uncertain sterol esters. My previous recommendations for sterol ester products will be removed with the next edition of Track Your Plaque. Until we have solid evidence that there are no adverse cardiovascular effects of sterol esters, in my view they should not be part of anyone's heart-disease prevention program.

(The same argument does not seem to apply to stanol esters, such as that contained in butter-substitute Benecol, since stanol esters are not absorbed at all and remain confined to the intestine.)

The Diabetes Gold Rush

11. September 2008 William Davis (9)
Lou came into the office. Clearly, his program had gone sour.

Lou had initially obtained wonderful control over his heart scan score of 1114, having reversed modestly in his first three years of effort through correction of his multiple causes (including low HDL, severe small LDL, Lp(a), and a diabetic tendency).

But Lou now came into the office red-faced and sporting a big bulging abdomen. Blood sugar? Now in the overtly diabetic range. Lou said that his primary care doctor had suggested that he start on three new medications (glucophage, injectable Byetta, and Actos) to control his blood sugar. His doctor also told him to increase his intake of fibers by eating more "healthy" breakfast cereals like Cheerios.

Lou had apparently done just that (added "healthy" fiber-rich foods) even before his doctor had suggested it. (Lou failed to remember the several conversations we'd had about healthy eating.) Unfortunately, Lou also failed to connect his increased intake of "healthy fiber-rich foods" and his growing abdominal girth (his "wheat belly").

Here's the dirty little secret: Much of the world wants you to be diabetic. It is the health gold rush of this century. "Go West, young man!"




To find out what I mean, you need only ask: Who profits when people become diabetic? That's easy:

The pharmaceutical industry--Diabetes is a booming growth industry, a source of tens of billions of dollars of revenue, poised for enormous growth as the population ages and gets fatter. It is common for a newly-diagnosed diabetic to be given new prescriptions for two or three drugs with a monthly cost of $300. Of course, the chronic nature of the disease make this far more profitable than, say, a two week course of antibiotics. Presently, 70 new drugs are under development.

Diabetes drug maker Novo Nordisk reported a 25% increase in revenues in 2007 from diabetic agents in the North American market, along with near $2 billion increase in profit for the year. Merck's recently-released DPP-4 inhibitor, Januvia, has already sold $668 million in 2007 and is growing rapidly.

The medical device and supply industry. Take a look at the Medtronic quarterly earnings report, detailing the breakdown of their record-setting quarterly revenue of $3.7 billion:

Diabetes revenue of $269 million grew 12 percent driven by sales
of consumables, the accessories required by insulin pump users, and
continuous glucose monitoring products. Revenue from international
sales grew 31 percent over the same quarter last year.

That's what I call a growth industry.

The processed food industry. The food industry is as big or bigger than the drug industry. ADM, Kraft, General Mills all have annual revenues in the $12-50 billion range. There are plenty of others.

When we're told, for instance, that Cheerios reduces cholesterol, we're not told that it skyrockets blood sugar or triggers small LDL. When we're sold whole wheat crackers, Cocoa Puffs (which the American Heart Asscociation says is heart-healthy), or granola bars, hunger is stimulated, impulse to eat more grows, blood sugar escalates, we get fat, we get diabetic. It's a simple formula.

So be aware that there is little incentive among corporate giants in the food, medical device, or drug industries to encourage behaviors that decrease the incidence of diabetes. In fact, there is enormous financial incentive to make sure that diabetes continues to grow at the startling rate it has over the last decade.

To be sure, the drug and medical device industry will also develop better tools to deal with diabetes and its complications. But the very best way to deal with diabetes is to not develop it in the first place.

What else is there?

7. September 2008 William Davis (11)
This question comes up frequently:

Aren't there any alternatives to heart scans performed on a CT or EBT device?

Yes, there are.

First of all, heart scans are performed best on an electron-beam CT device (EBT) or a 64-slice multi-detector CT (MDCT) device. (While they are also obtainable through less-than-64 slice CT devices (e.g., 16 slices and less), I would advise against it because of the excessive radiation exposure and poor accuracy.) CT heart scans are not to be confused with now more popular CT coronary angiograms, which are performed on the same devices but require intravenous x-ray dye and many times more radiation.(See CT scans and radiation exposure and Heart scan frustration.) Heart scans currently form the basis for the Track Your Plaque program, a program of tracking plaque in the hopes of stopping or reversing the otherwise inevitable 30% per year increase.

Let's confine our discussion to people without symptoms, meaning people like you and me sitting at home, not in an emergency room having chest pain or other similar acute symptomatic presentation.

Among the other ways to uncover hidden coronary plaque:

--Heart catheterization--to yield a coronary angiogram. Yes, this does tell us whether coronary plaque is present. However, it is invasive, expensive, and crude. (I've performed 5000 over my career; they are crude, though useful, tools in acute settings like unstable symptoms or heart attack, a different situation.) Coronary angiography is also non-quantitative. While they provide a value like "40% blockage mid-way in right coronary" or "90% blockage in left anterior descending" they do not provide a trackable lengthwise index of total plaque volume. Identifying severe blockages in people with symptoms leads to stents, bypass surgery and the like, but it is not practical nor of long-term usefulness in apparently, healthy people without symptoms.

--Carotid ultrasound--Here's is where a lot of confusion comes from. Standard carotid ultrasound (U/S) performed in virtually every hospital and many clinics will yield crude qualitative results, e.g., "16-49% stenosis (blockage) in right internal carotid artery". The crude value range is because much of carotid U/S is based on flow velocities, not just direct visualization of the plaque itself ("2-D imaging). However, if carotid stenosis of any degree is identified, the likelihood of silent coronary plaque is much greater.

Limitations: The qualitative, non-quantitative nature of carotid U/S make it difficult to follow long-term in a precise way. Also, this is carotid plaque, not coronary plaque. It makes it very difficult to follow carotid plaque as an indirect means of tracking coronary plaque. The two arterial territories, carotid and coronary, do not track together: there are divergences in many people, with carotid plaque absent in some people with advanced coronary plaque, carotid plaque more susceptible to different risk factors than coronary. So carotid U/S is helpful for its own purposes, but not terribly helpful for coronary tracking.

How about carotid intimal-medial thickness (CIMT) obtained also with carotid U/S? CIMT is a useful index of bodywide atherosclerosis. CIMT is simply a measure not of plaque (and is measured in regions of the carotid artery away from plaque), but of the thickness of the lining of the carotid arteries. Everybody has a measurable CIMT, but it thickens as atherosclerosis grows. CIMT is a radiation-free test that takes several minutes.

Limitations: Hardly anybody does it outside of research protocols. I know of no hospital or clinic in my area that performs CIMT, though it is slowly being adopted in some centers. It is also difficult to rely on repeated tests, because there is substantial variation when one technologist or another performs it. CIMT is also a flawed index of coronary plaque. When CIMT is compared to heart scan scores, CT coronary angiography, or conventional coronary angiography, CIMT correlates about 60-70% with the degree of coronary atherosclerosis.

CIMT is therefore a useful test for research, but a distant 2nd choice--if you can obtain it.

--Ankle-brachial index (ABI)--ABI is a crude measure, simply a comparison of the blood pressure (obtained with a blood pressure cuff) in the legs divided by blood pressure in the arms. The ratio is called ABI. Any ABI <1.0, meaning less pressure in the legs compared to the arms, is indirectly indicative of advanced coronary disease. ABI is, in fact, a very powerful predictor of cardiovascular events. If ABI is <1.0, your future risk for heart attack is very high, even in the absence of symptoms.

Limitations: The vast majority of people with heart disease, even those having undergone stents or bypass surgery, have normal ABI's. Virtually all people with high heart scan scores have normal ABI's. In other words, ABI is a measure of very advanced atherosclerosis only.

--Stress tests--I lump all stress tests together in their various forms, e.g., stress thallium, stress Cardiolite, stress Myoview, persantine/adenosine Cardiolite, dobutamine echocardiography, etc. Stress tests are tests of coronary blood flow, not of plaque. Stress tests are useful in people with symptoms, like chest pain or breathlessness, since stress tests are provocative tests that can help determine whether reduced coronary blood flow is the cause behind a symptom, or whether hiatal hernia, esophagitis, gallstones, pleurisy, musculoskeletal causes, or some other process is behind symptoms.

Limitations: Stress test are virtually useless in people without symptoms. This is why people like Tim Russert and Bill Clinton, both without symptoms, underwent several (Russert 3, Clinton 5) nuclear stress tests---all normal. You know what happened to them. Stress tests do not reliably uncover hidden coronary plaque in people without symptoms. Stress tests are, like coronary angiograms, non-quantitative. They are normal or abnormal.


Outside of experimental settings, that's it.

You can probably see why I advocate CT heart scans for tracking plaque. I do not advocate heart scans because I sell them (I don't), because scan centers pay me to say these things (they don't, and in fact my relationship with my usual heart scan centers has become deeply contentious, though I still endorse the technology). I say that heart scans are superior because they are, in 2008, the only way to 1) identify and 2) track coronary plaque that is easy, safe, low-radiation, and reasonably priced (<$200 in Milwaukee at 5 centers).

The need for a technology that allows tracking of plaque, not just initial identification, is also an important distinction. People who've had some measure of atherosclerosis all catch on to this eventually. "Can I reverse it?" is an inevitable question once the disease is identified in some way. So a tool for tracking over time to gauge the success or failure of a program of prevention can be assessed.

Perhaps in 10 years, another technology will emerge as the preferred means to do the same, but better. If that proves true, we will convert to that technology. But today heart scans performed on CT heart scans are the only rational way to both detect, then track, coronary atherosclerotic plaque.

Let's gamble with your health

5. September 2008 William Davis (4)
Let's play a game.

I'm going to list some lipid patterns and you tell me whether or not the person with these values has heart disease.

Patient 1

Total cholesterol 150 mg/dl
LDL cholesterol 75 mg/dl
HDL 50 mg/dl
Triglycerides 125 mg/dl


Patient 2

Total cholesterol 300 mg/dl
LDL cholesterol 200 mg/dl
HDL cholesterol 35 mg/dl
Triglycerides 325


Patient 3

Total cholesterol 300 mg/dl
LDL cholesterol 100 mg/dl
HDL cholesterol 25 mg/dl
Triglycerides 875 mg/dl



Let's say that any one of these profiles is yours. Should you be getting your affairs in order, preparing for your cardiac catastrophe? Should you demand a stress test from your doctor, hoping that it will shed some light on your dilemma? Should you go ahead and go to the all-you-can-eat rib restaurant, content that you will be attending your granddaughger's wedding in 2020 in full health?

If you can tell, you're a lot better at this than I am.

I provide consultation to other physicians and patients on complex hyperlipidemias in my area. In other words, if someone has a difficulty to manage lipid disorder, the doctor sends the patient to me.

Managing these wildly variable values is the easy part. Deciding whether or not heart disease is concealed within the patient . . . well, that's the hard part.

Let's take it a step further: Suppose all three profiles also have 50% of all LDL particles as the abnormal small particles. And they all have a lipoprotein(a) level of 50 mg/dl, an abnormally high level.

How about now: Can you tell whether any or all of these people have hidden heart disease?

What if they are 20 years old? Does that make a difference?

What if they are all females over 65 years--how about now?

If the only tool you have to divine the presence of hidden heart disease is a lipid panel, or even a lipoprotein panel, then the best you can manage is to hazard a guess based on statistical probability. You also assume that this "snapshot" represents the sorts of values someone has had for their entire lives. You cannot factor in the fact that the first person gained 60 lbs in the last three years since completing menopause. You can't factor in that patient 2 smoked two packs of cigarettes a day for 25 years, but quit 10 years ago.

It's also foolhardy to believe that every known cause of heart disease is currently identifiable and revealed by modern-day blood testing.

A heart scan is simply a means to quantify the sum-total of risk factors--causes--that have exerted an effect up until the moment of your scan. It will reveal the quantity of coronary atherosclerotic plaque present, regardless of whether you stopped smoking 20 years ago or lost 30 lbs last year.

For these reasons, nothing can replace the value of quantifying plaque: not cholesterol, not the Framingham risk calculation, not measures of small LDL or lipoprotein(a), not the presence or absence of symptoms. In 2008, the method of choice for measuring plaque remains a CT heart scan. Perhaps in 10 years it will be some other method.

As always, let me remind Heart Scan Blog viewers that I make this point NOT to sell heart scans, which I have no reason whatsoever to do. I say this because we require a tool to track this potentially fatal disease. We require a yardstick for tracking progression or regression. The only tool that suits these purposes in 2008 is a CT heart scan.