I've been using the NatureMade fish oil because it's frequently 2-for-1 at Rite Aid. My VAP cholesterol test was excellent while on the product, but I suppose that doesn't ensure that the product is doing anything. Thanks for the info.

Fresh fish does not smell like fish. Only when the fish tissue starts to decompose does it start to smell like "fish".

First of all, Doc, thanks for taking the time to do this blog. It's great to have such an expert "in the trenches" practitioner helping ordinary people like me make much better decisions on keeping my heart going!
Specifically on this post, when you write these companies, I'd suggest writing a letter and sending it by post right to the CEO.
I've found that usually gets a better, more personalized response to my concerns.

What is a person with very low Vitamin D levels, but prone to kidney stones, to do?

I wonder if that letter was generated by a worker at an overseas customer service center who, as you suggested, just opened a file and inserted text.  How many hits does your blog get?

I've wondered if the USP seal on vitamins actually means anything -- apparently, it doesn't count for much.

I have had a company actually admit to a problem with their supplements once (Jarrow), where their Ubiquinol gelcaps were leaking (found goo at the bottom of my bottle). They admitted the capsules were faulty and they planned to change the manufacturer of their gels, and even sent me a replacement bottle. So... some companies will actually admit to problems and take care of them, but that is still probably the minority.

Hi Dr. Davis,

Have your patients had any experience with CostCo's 2000 IU vitamin D3 gelcaps?

In Italy, Vit D3 drugs are available over the counter at pharmacy. They are ultra cheap. I go for an injection every 2 months as 5 vial cost less than five €.
What prevent US consumers from going to a pharmacy and buy registered drugs instead of supplements?
Quality control for drug companies is surely a bit harsher than for supplement companies.
Then, regulation can be different.

good to know, I used to buy Nature Made all the time... now I am wondering if the "gummy bear" vitamins and vitamin D I give my kids actually are vitamins.  What if they are just candy.  How can you tell for sure?

Impudent--

Great idea.

Perhaps I will send future emails and say that there are thousands of people reading this blog who will await their response!

Gary--

Because we have only one Costco (i.e., only one store), we have had too few people buying this product to say with any confidence.

It never hurts to have your blood level checked.

You might consider me 'weird' but  I actually like to chew my fish oil capsules - I like the taste of the oil and the capsule itself. This has an added important benefit: I can taste if it's fresh BEFORE I swallow. I must say I've never had a rancid one yet. Presently am using Spring Valley from Walmart. I often do the same with my liquid vit D3 caps as well.

Dr. Davis, thank you so much for all the info you put out for us.

I am a fan of your blog, but honestly this is a very low standard of "proof" that you are using. If you feel strongly about it why not get a certificate of analysis done yourself?

I'm a psych NP. My patient took 7000iu Naturemade tabs with no effect on blood level after 2 months. Have heard tabs don't absorb, so have stearing people away from them. Thanks for the info on their softgels.

If I had to get a "certifcate of analysis" performed for every supplement I questioned, we'd go bankrupt just on the testing.

I'll be interested to see what organizations like Consumer Lab, who test a broad range of supplements, come up with.

I subscribe to Consumerlabs.

When they tested vitamin D3  (1/18/10) they only tested up to 1000iu/d capsules/tablet/liquid and also some combination products.

I'm sure readers here are all aware  1000iu/daily can, at best, only raise 25(OH)D 10ng/ml = 25nmol/l.
Most readers require significantly more than that to reach >50ng/ml+ ensuring their body has an emergency stored reserve supply of Vitamin D3.

People who are overweight or suffer diabetes, Celiac or any other inflammatory condition will generally require even more than 1000iu/daily/D3 per 25lbs weight.

The LEF report Startling Findings About Vitamin D Levels in Life Extension® Members By William Faloon shows IN PRACTICE 5000iu/daily/D3 averages only just above 42ng/ml so if we are trying to achieve a level that does more that just meet our daily requirements but also enables the body to store Vitamin D for emergencies, then we require MORE THAN just 5000iu daily/vitamin D3.

At latitude 52 with a BMI just under 25 I take 5000iu/daily + regular short full body prone uvb/winter/sun/summer exposure
My 25(OH)D stays @ 64ng/ml.

I am not convinced Consumerlabs testing of tablet formulations of 400iu or even up to 1000iu has any relevance to correcting vitamin D insufficiency.

Dr. Davis

My name is Douglas Jones, I am with in Corporate Communications at Pharmavite the makers of Nature Made Vitamins.  We take your comments very seriously and need the information that Marissa asked for in her e mail.

All of our products are tested fully before they are shipped to our customers.

Please feel free to contact me directly at djones@pharmavite.net

Thank you

Thank you, Mr. Jones.

Because I identify these cases one by one over months, I don't have my patients bring in their bottles.

I have to say that I am also impressed that I got beyond the girl in the cubicle on this one.

In future, I will ask patients to bring the bottles in. If I know this leads somewhere, then it's worth the extra effort.

However, I remain confident that there is a problem.

Do you recommend multivitamins and/ or Vitamin D brands?

I am 34 years old and at an ideal body weight but had moderately low HDL when blood work was done...Just following your blog and trying to figure out ways to raise my HDL and to help prevent heart disease (My mother is in her 50s and has been on statins for bad cholesterol, a path I don't want to follow).

heatherlbrandt(at) verizon (dot) net

I had been using NatureMade fish oils for years and no belchback. I got a batch that both my wife and I had bad belching with fish taste. Called the company and they said I had been using the enteric coated. I bought some of the enteric and they don't belch back, they also are not what we had been taking. Looks like I will be switching to a different company too.

My friends have been using NatureMade fish oil for over a year now. She told me that it is very effective. I think I am guess I will giving it a try.

Hi, nice post. I have been thinking about this topic,so thanks for sharing. I will likely be coming back to your blog. Keep up the good work
termpapers99@gmail.com

In Nature Made's defense, I've been using 2,000 Vitamin D from Nature Made for the past 6 months, and my Vitamin D levels have risen about 20 points.  I've been very happy with the result, so I just started using their fish oil. I'm sitting here with a brand new bottle of their fish oil enteric coating 1200 mg pills, and smell no odor at all.  This doesn't mean other people haven't had different experiences, but it might be very dependent on your individual body chemistry, and I would suggest doing blood tests every 6 months to determine if the Vit. D you are taking is working for you.  And no, I do not work for Nature Made, and have no connections to them

I just have to say that letter show what they think of customers and how they have made made their mind to deal with any complaints. They did not even bother to get a competent person who could write a letter. Forget that. They did not even bother to prepare a template response.

There is interesting research on omega 3 bioavailability.

After mixed results with various fish oil capsules resulting in low-tide burps or flatus, i moved to Coromega.  Wonderful product.

Re Costco 2,000 iu oil capsules, i've raised my serum levels to 88 ng/ml with them.

However, given the wide range of factors that affect D uptake/utilization, titrating to standard is the only useful methodology. Blind dosing, especially at very low serum levels, might not raise serum levels at all.

Omega-3 structure may affect bioavailability: Study

By Nathan Gray, 14-Jan-2011

Related topics: Research

The type of omega-3 we take may have a distinct affect on how much is actually absorbed, according to new research.


The study, published in the European Journal of Lipid Science and Technology, suggests that omega-3 concentrates – such as triacylglycerides – have much better bioavailability than purified fish oild

The team of Spanish researchers said that the study contributes to knowledge on the intestinal lipolysis of omega-3 sources, which can be found in many commercial forms, from purified fish oil to concentrates of free fatty acids and ethyl esters.

They said that despite differences regarding their intestinal metabolism, there is lack of information about the specific composition of the absorbable fraction from omega-3-TAG or omega-3-EE concentrates.

“This comparative study showed that the in vitro bioaccesibility of omega-3-polyunsaturated fatty acid (PUFA) seems to be better as omega-3-TAG concentrates than purified fish oils,” said the researchers, led by Dr. Diana Martin from the Universidad Autónoma de Madrid, Spain.

Fish oil

Consumption of fatty acids from the omega-3 family – particularly eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) – have been advised due to their beneficial role as anti-thrombotic, anti-inflamatory, and hypolipidemic fatty acids.

The authors noted, however, that in many populations consumption of fish is quite low and does not achieve levels adequate for reaching the minimal intake level of EPA and DHA. They added that because of this, an easy way of increasing omega-3-polyunsaturated fatty acids (PUFA) intake is by the fish oils supplements oils.

They said that recent studies have produced contradictory evidence for the in vitro metabolism of fish oils and omega-3-concentrates,

The new study compared the in vitro bioaccesibility of omega-3-oils from different sources. The researchers tested salmon oil, tuna oil, enriched-omega-3 oil as triacylglycerols (omega-3-TAG), and enriched-omega-3 oil as ethyl ester (omega-3-EE).

Study details

Dr Martin and colleagues reported the rate of hydrolysis of omega-3-TAG concentrates was continuous throughout the time of reaction, whereas the digestion of salmon oil and tuna oil was initially faster but stopped after 10 min.

They added that poor hydrolysis took place for the enriched-omega-3 oil as omega-3-EE.

The breakdown of omega-3-TAG oil, salmon oil, and tuna oil mainly consisted of free fatty acids (FFAs) and monoacylglycerides, whereas the breakdown from digested omega-3-EE oil consisted of free fatty acids and undigested ethyl esters.

“This comparative study showed that the in vitro intestinal digestion of omega-3 (EPA and DHA) sources as fish oil, triacylglycerides, or ethyl ester concentrates was different,” said Martin and colleagues.

“The highest degree of hydrolysis and inclusion of lipid products … was found for the omega-3-TAG oil, but compared to fish oils long times of digestion were required,” they added.

Source: European Journal of Lipid Science and Technology
Volume 112, Issue 12, pages 1315–1322, doi: 10.1002/ejlt.201000329
“Intestinal digestion of fish oils and ω-3 concentrates under in vitro conditions”
Authors: D. Martin, J.A. Nieto-Fuentes, F.J. Señoráns, G. Reglero, C. Soler-Rivas

http://www.adajournal.org/article/S0002-8223(09)00293-4/abstract

Re vitamin D uptake & utilization, diet (taking D with a meal doubles uptake), existing D levels (see Holick re substrate starvation), D form (D2 v D3), exposure, lifestyle, age (over 50 produce less in skin), obesity (excess bf sequesters D), co-factors (affect utilization), genes, bathing (bathing strips oils off skin), etc. affect D serum levels.

http://www.scribd.com/doc/38595990/D2-D3

http://www.scribd.com/doc/37319962/Vieth-Vit-D

http://www.scribd.com/doc/36940698/D-Test-and-Treat

http://www.scribd.com/doc/45004628/D-review

http://www.scribd.com/doc/49369766/Garland-021811

"Vitamin D has co-factors that the body needs in order to utilize vitamin D properly. They are:
magnesium
zinc
vitamin K2
boron
a tiny amount of vitamin A
Magnesium is the most important of these co-factors. In fact, it is common for rising vitamin D levels to exacerbate an underlying magnesium deficiency. If one is having problems supplementing with vitamin D, a magnesium deficiency could be the reason why."

Dr. I came across your site while looking for someone who was having the same problem w/ their Vitamin D levels and not finding a solution.  In fact, the brand you mentioned has done nothing for me in any of the vitamin area!  However I did come across a vitamin that has taken care of my Vit D problem and other problems.  Honestly I think the brand I am taking is the ONLY brand that is actually helping people.  Everyone I know who gets on them has had great results!  Rob Dillon - rdillon4@cox.net

Incidentally, I like the way you have structured your site, it is super and very easy to follow. I have bookmarked you and will be back regularly. Thank you

i too have suffered from kidney stones. i did a 24 hour urine test and my calcium urine level was 3 times normal. shock horror all round.
i began to take 5000iu of vitamin d3 daily and in a few weeks my calcium urine level was normal, my urologist was amazed that this had happened but i did not tell him why because english doctors do not believe in supplements and he would have had a hissy fit!!.
since then, no more stones!

My problem with Volek's study is that it's analogous to putting someone on a LC diet and then doing a GTT.

They kept people on a low-fat high-carb diet and put others on a high-fat, low-carb diet and then did a lipid tolerance test.

In both cases, your response to the nutrient (carbs in GTT and fat in lipid test) will be impaired because you stop producing enzymes you don't need.

The people on the low-fat diet didn't tolerate fat as well as people who had been on a high-fat diet when suddenly challenged with a tremendous amount of fat.

What I'd want to know would be the lipid responses *during* the 6 weeks on the two diets.

What his results show me is that eating a high-fat diet makes your body adapt to burning fats. This is what I would expect.

While these results are interesting, I wonder how relevant they are in a real life setting. The fat load that generated these results was 123 grams, which would be like eating 1.3 sticks of butter in a single meal, or like sitting down and drinking nearly 3 cups of heavy whipping cream all at once. Who does that?

Dr. Davis, I know you are encouraging 3 hour postprandial TG checks in the TYP program via CardioChek. Are you seeing these types of postprandial results (viz. results similar to Volek's) following meals with less exaggerated (i.e. normal) fat intake?

Here is prospective study done in Sweden with a follow up period of 12 years that shows a higher consumption of dairy fat like butter and cream is associated with a 45% reduction in risk for heart disease. "Nothing in biology must make sense except in the light of evolution"
http://www.mdpi.com/1660-4601/6/10/2626/pdf

After eating low-carb for over a year, my post-prandial triglycerides never go above 100.

I do agree with Gretchen on the adaptation process.  I shudder to think what an OGTT test would show.  Maybe some day, I'll drop $70 to find out if I can get someone to take me.  I'll be in no shape to drive after consuming that much sugar.

I agree Gretchen. There can be a long adaptation period. Dr. Davis's patients are blessed to have him as their doctor, but I suspect he can't quite kick the lipid hypothesis!

At least for me, I think Dr Ron Rosedale's diet is best.  Low carb, protein at 50 to 70 gms. No grain, mostly no dairy.  He says if you want to lose weight you need to avoid saturated fat because saturated fat keeps you insulin and leptin resistant.   Unless you drink olive oil, the diet winds up being low calorie.
Hmmmm.  Maybe that is the answer.

I have to wonder what the mechanism is for high triglycerides causing heart disease? High triglycerides in a high carb diet usually means high insulin, high glucose vs fat metabolism,and low hdl. Aren't high triglycerides in a low carb diet a slightly different picture?

Right or wrong, I admire your willingness to go against the tide (any tide) for what you see as right.

Absolutely!  What amazes me is, in spite of their adaptation to a high fat low carb metabolism, the patients still saw their OGTT triglyceride results improve over time!  This is my experience too.

There is no doubts, on a high animal fat diet or on a high fat diet of any kind, our tolerance to glucose is indeed reduced.  50g in one does is OK for me (I weigh ~65kg) but 100g in one go as sugar would still be too much and would make me feel sick (but the same amount of carbs in vegetables spread over a day would be ok).

It took a good few years to improve my tolerance.  Right after (2 weeks after) I went on a high animal fat LC nutrition (in 1999) I could not tolerate even a 50g of sugar in one shot! Even one bottle of beer (~20g of carbs) would make me feel stomach sick + give me a headache.   It took me more than 2 years to reach this tolerance to carbs, and I even noticed some steady improvement from year 2 to year 7 into this.

It is indeed totally illogical, although unsurprising given the present standards of medical science, to use big glucose shots to assert patients response under  predominantly ketogenic metabolism.

It is a curious lack of curiosity on behalf of the mainstream medicine that no nutrition research group seem interested in studying the exact effects (all beneficial for me), vitamin and nutrient requirements (very different!) and adaptation issues on the high fat low carb diets.

Stan

The last few posts have generated quite a few comments!!!


Anonymous said...
"The last sentence made me cry."


Alfred E. said...
"This is becoming more confusing by the minute. First, no carbs, only fats and protein. Now, no butter, no dairy, no, carbs, just a few drops of fat and protein. I am going to cry, like the previous poster."


Dana Law said...
"I've learned a lot but need some direct guidance. I find that making daily decisions on what to eat difficult. I want to eat healthy and have some variety. Here's the question. What do you eat? What did you have for breakfast this morning? What did you eat last night? What do you keep in the fridge and on the counter to make following your dictates easier. I don't want to over-think it but all this information is overwhelming."


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


The bottom line is that Jimmy Moore, William Davis, Matt Stone, Kurt Harris, Stephan Guyenet, Don Matesz, Art Ayers, Billy E., B.G., T., Mark Sisson, Richard Nikoley, Michael Eades, Matt Metzger, Peter, Arthur De Vany, Chris, Ryan Koch, Chris Masterjohn, Jenny Ruhl, Richard Bernstein, Fred Hahn, Jonny Bowden, Larry McCleary, Mary Vernon, Dave Dixon, Mike O'Donnell, Scott Kustes, Gary Taubes, Rob Wolf, Seth Roberts, Loren Cordain, Sally Fallon, Mary Egin, Keith Thomas, Tom Naughton, PaleoDoc, Nora Gedgaudes, Barry Groves, John Briffa, Laura Dobson, Dana Carpender, Keith Norris, Rusty Moore, Doug McGuff, Martin Berkhan, Bryce Lane, Erwen Le Corre, Dan, Drew Baye, Uffe Ravnskov, Eric Westman, Lierre Keith, Brian Peskin, Steve Parker, Jeff Volek, Stephen Phinney, Diana Schwarzbien, Barry Sears, Nina Planck, Lyle McDonald, T.S. Wiley, James Carlson, Steven Gundry, Keith Berkowitz, Richard Feinmann, Jan Kwasniewski, Konstantin Monastyrsky, etc., etc., etc. cannot come to a cohesive way of eating that is workable for everyone. My guess is there are not two of these people whose diet is identical!!

Is it any wonder we are confused? Many folks are looking to emulate the diets of others - a method that will never provide personal optimal health.

Take the time to watch/listen to the following lecture by Dr. Bruce German from UC Davis. It will help to explain why we have this conundrum.

http://www.researchchannel.org/prog/displayevent.aspx?rID=29854&fID=567

Then read the writings of a Venetian gentleman who lived to be almost 100 yars of age (Born 1467 - Died 1566).

http://www.soilandhealth.org/02/0201hyglibcat/020105cornaro.html


Both of these together put nutrition and health in perspective for me.

Tom

Dr. Davis, please comment on the study released today by the Harvard medical School.  How does one avoid saturated fats and still get proteins if he is a low carber??   http://news.bbc.co.uk/2/hi/health/8580899.stm  Thanks!

Hi, David--

Studies are meant to make observations. That is the reason for the unnatural intake of fats.

People on the Track Your Plaque Diet approach rarely show such high levels because they've reduced or eliminated the foods that form the basis for high postprandial responses (wheat, cornstarch, and sugars) and do not indulge in high fat intakes that cause near-term surges of postprandial particles.

Hi, Gretchen--

I agree, but I believe that the observations are still relevant. It shows us that postprandial responses are sensitive to carbohydrate intake over time. It also shows us that average people have substantial surges postprandially with fat challenges on an average American diet.

While I advocate carbodrate restriction and weighing diet more heavily in fats and oils, you can see that the emerging conversation is that unlimited quantities of oils, low-carb or no, have the potential to generate extravagant postprandial responses.

I tested my postprandial triglycerides after having been on a LC diet for about 11 years and wheat-free even longer (because I discovered that it was wheat that was giving me acid reflux). With about 50 g of fat, the TGs went very high, over 400.

Someone else said his rarely went over 100 after only a year on a LC diet.

The author of "Life Without Bread" presented a graph showing that younger people reduced cholesterol on a LC diet but older people didn't.

We may all react slightly differently to different diets (as well as interpreting them differently, as someone else has pointed out; you can be on a LC diet that includes mostly LC junk food or a LC diet that includes a lot of greens and lean meat).

I have type 2 diabetes, and some people think that metabolic syndrome/type 2 diabetes is basically a disease of disturbed lipid metabolism.

So what worries me is that people with insulin resistance, who may not respond the same way as people without IR, are taking LC advice to eat a lot of fat that is based on the experiences of people without IR.

Here's an article that addresses this issue:

http://www.lipidworld.com/content/4/1/21

This is why some time ago I felt the "GO Diet" by Jack Goldberg and Karen O'Mara, which is LC but emphasizes monounsaturated fat, yogurt, and fiber, was the best solution and helped them rewrite it as "The Four Corners Diet."

Apparently very few people agreed with me, and the book bombed.

I still think LC with restrained fat intake, meaning restrained calorie intake, and real foods along with reasonable exercise is the best solution on the basis of today's evidence.

@Tom (anonymous)

Although there are many voices and styles of presentation, I can state, through frequent communication with them, that my approach at PaNu is a tent that fully covers the diets of Eades, Dr. Stephan, Peter at Hyperlipid, Sisson, Nikoley, and although I do not correspond with them, Bernstein and Groves. There is also significant overlap with the Weston A Price Foundation and even Matt Stone.

If you look for a common element in all of our approaches, and indeed the crux move in choosing a healthy alternative to the SAD, it is actually nothing to do with paleo so much as the simple and total rejection of Ancel Keys and the multiple versions of the lipid hypothesis he spawned 50 years ago.

This then allows the realization that humans are evolved to eat substantial calories from animal products, including animal fats, and further including (on purpose, and without limitation or fear) SATURATED FAT.

All versions of the lpid hypothesis have in common the belief that somehow, somewhere, there is a molecule that is fat, tastes like fat, is  kind of like fat, is associated with fat, or reminds us of fat, and that molecule is perversely designed to give us atherosclerosis and coronary heart disease.

Start to view all these dietary approaches through the filter of whether they reject the lipid hypothesis instead of "low carb" or "paleo" and the dividing line will start to look much much brighter.

So for someone that works out a lot and is suppost to gte something in the 3000-4000 calories per day... what would be the addecuate kind of food to use as high calories source?
I was taking unlimited almonds, but this post makes that look like way too much fats.

@ Dr. Harris,

You obviously did not read/listen to the two links that I provided in my comment.  I happen to believe every word you wrote in your response.   My contention is that personal optimal health and longevity is beyond the simplicity of following 12 simple steps (though I do think they are a huge step in the right direction).  Health is determined at the molecular level based upon an individuals genetics as affected by many factors, particularly, stress. Please Google nutrigenomics, epigenetics and metabolomics.

My apologies to Dr. Davis.

(I may have inadvertantly sent a another version of this comment previously.)

Tom

Isn't this just normal for a well adjusted human? I mean TGs are how fuel (free fatty acids) is transported through the blood from its sources (liver and fat cells) to the places where it is needed i.e. everywhere else.

@ Pythonic Avocado

Yup, eating fat raises TG levels temporarily.  I consume a high-fat diet with lots of nuts, and, based on results from a TG meter, do not see extraordinarily high TG levels (starting from a fasting level near 70).  I also spread meals out during the day, thereby reducing both BG and TG spikes.

The only time I saw a high TG spike was after consuming 2 raw egg yolks!  This influenced how I approach eggs (always cooked, one at a time, mixed with other foods).

btw, if you consume too much fat in one meal, a lot of the fat will end up in your stools, since there is a limit to the lipase that your pancreas can generate on short notice.  Another complication when trying to compare diets.

In other words, low-carb improves postprandial responses substantially--but postprandial phenomena still occur. Postprandial triglycerides of 88 mg/dl or greater are associated with greater heart attack risk because they signify the presence of greater quantities of atherogenic (plaque-causing) postprandial lipoproteins.

Great post, and painfully true for me; my father had to undergo his 2nd coronary bypass operation this past April 2007, and despite the strangely 'status-quo' or 'business as usual' attitude of both the surgeons and assisting doctors and nurses involved in my dad's procedure (yes, the whole thing seemed like such a regular day at the beach to them because Holy Cross in Fort Lauderdale performs so many of these operations on a daily basis, with success, of course) did nothing really to quell my family's fears of the severity of this operation; this is still a monstrous operation that not only takes a heavy toll on the patient, but on the family sitting in that waiting room as well.
I still cry at the memory of having to tell my dad, "hey Pop, you need another CABG" after an invasive angiogram revealed disaster after disaster in his arteries.
And this is why your message is so important, and why it needs to get out every day, and loudly.

I'm rooting for you. And I'm thankful you're here.

A few thoughts about this post:
The first is a question. What do you think about ultrasound screenings for carotid artery plaque, abdominal aortic aneurysm, and peripheral arterial disease? A company called Life Line offers these, saying that they show evidence of plaque build-up in the arteries. Are they useful in conjunction with a heart scan, or can they indicate risk similar to a heart scan? It sounds like they are intended to be early detectors of stroke risk. Are they worth the investment?

The second comment is an observation. Those of us not in the medical field tend to assume that anyone who is knows what he or she is talking about on the subject of the human body and illness. However it is apparent that those with M.D.'s can come to very different conclusions about what causes us to get sick and what we should do to prevent illness. Dr. Dean Ornish is an M.D. You are an M.D. Dr. Atkins was an M.D. Yet the dietary advice differs noticeably, so how do we know who is right and who to listen to? I've learned not to believe something just because a doctor says so, because when I followed the low-fat high-carb advice I got fat and felt horrible, but now that I am following a low-carb plan with plenty of protein and fat, I've lost 25 lbs. and feel great. My bloodwork also supports your claims: low triglycerides, high HDL, and low fasting blood sugar. It's kind of sad in a way that I actually get better medical advice from doctors whose blogs I read on the internet (I'm also a Dr. Eades fan) than from my personal physician. And finally, a thank-you: since reading your advice about Vitamin D, my flower garden is in the best shape it's been in in years, since I have a new knowledge about why it's so important spend some time in the sun and a new motivation, therefore, to be outside pulling the weeds.

And concerning your recent post  about breakfast cereals,congratulations are in order: I've broken my husband's cereal for breakfast habit. (I broke my own years ago.)

I have had good results with the Lifeline service, but only when used in conjunction with a heart scan. It cannot replace a heart scan. This is because, while atherosclerosis is a body-wide process, this disease does not perfectly track in parallel in all arteries of the body. You can, for instance, have lots of plaque in the carotid arteries while having only a modest amount of plaque in the coronary arteries, and vice versa.

I agree with your second comment. In fact, I have posted on this Blog about this.

We are all swimming in a sea of information and mis-information, and blind alleys along the way to the truth. We can only educate ourselves as best as possible and then come to our own judgements about the value of this or that argument.

I have a comment too: I think one reason there is so much confusion is because dietery connection with heart disease hasn't been sufficiently studied. We only saw some partial studies by Drs Ornish, Agatston, Atkins, Hayes but not much independent verification, AFAIK. For example there are some studies done by now on the effects of a high fat low carb nutrition in diabetes and epilepsy but virtually nothing that I know of for cardiac patients.  The only one such study I heard of was halted half way through (after showing very promising results) when the funding was cancelled, 27 years ago.
Stan (Heretic)

A somewhat updated comparison of old care versus new care: I was on American Airlines this week, and looked through their magazine. There was a full page ad from the Cooper Clinic in Texas; a 46 year old woman pictured said "I had no idea I had heart disease, but had a family history...an EBT scan and four stents later, with some lifestyle changes, I'm a new woman".

I understand you can't generalize from one case, and while this seems to represent cutting edge treatment, it also gives me the creeps thinking about the obvious drive for revenue here. Couldn't they have tried your approach for awhile before invading? Thanks.

I think that they tell the stories that have a "WOW!" factor. The Cooper Clinic does indeed engage in a low-level grade of preventive care (AKA Lipitor, etc.)

But I really hate those stories, too.

Saw a lady at shul today, she is convinced of Dr. Esselstein's more carbs- is- better method. Ornish, Esselstein.....hard to refute the drumbeat of eat carbs, cut meat and fat.

Hi Dr. Davis.
I’m actually both pleased and troubled with the link to Dr. Diamond’s presentation that you’ve provided.

On the “pleased” side, Dr. Diamond’s analysis is:
•  An excellent/very well done presentation
•  Fact based (e.g. cites numerous studies, documented references, named experts, etc.)
•  Spans the test of time (e.g. references from the 1800’s thru the present day)
•  Ferrets out the major drivers of our present-day obesity epidemic & debunks other commonly held beliefs
•  Synchs with some of the Track Your Plaque (TYP) tenants (e.g. TYP guidance on triglycerides, diet, sugars, etc.)
•  â€œFlags” potential issues like conflict of interest which might have a tendency to creep into the science on occasion (e.g. the Keys report, the errant conclusions resulting from the NCEP report and supporting studies, etc.)

On the “troubled” side, Dr. Diamond’s analysis seems to:
•  Fly in the face of some of the foundational tenants of TYP
•  His analysis/conclusions, and that of other experts he cites, is that cholesterol of any kind is NOT correlated with Coronary Heart Disease (CHD) – at least as a root cause of heart disease (see Myth #2 and Dr. Diamond’s related analysis)
•  That LDL cholesterol – and although not stated by Dr. Diamond I’m inferring – the “sticky kind”, i.e. the small particles that actually adhere to artery walls (not the fluffy LDL particles that bounce away), are actually good!! On his “Final Issues 2” slide, and later in his related pictorial slides (entitled “What Causes Coronary Heart Disease?”), he makes reference to [LDL] cholesterol as a “Misunderstood Hero”?
•  That small, sticky LDL particles actually help the body recover from the damage created by the real culprits… sugars that work in concert with certain bacterias to create micro-tears in our artery walls
•  That small, sticky LDL actually results in the belt-and-suspenders, Rube-Goldberg “spackle” [which again I infer from Dr. Diamond’s presentation ultimately becomes plaque], that fixes (admittedly in a suboptimal and too-late manner) the damage already done by the artery-tearing, sugar/bacteria combo.  Plaque caused by LDL is actually the ‘finger in the dike’, last ditch effort, to fix the artery tears!  Kind of the last line of defense. [see slides on page 53 and Dr. Diamond’s related YouTube discussion.]

As a result, just curious about your thoughts on Dr. Diamond’s hypotheses.  
1.  Am I getting Dr. Diamond’s message(s) right?
2.  If yes, do you concur with – or tend toward – the theory(-ies) supported by Dr. Diamond and other cited experts about the role of cholesterol in CHD?  I gather from your blog post that you sympathize with his glycation theory(-ies), but how about the rest?
3.  If yes again, does that change some of the TYP direction?  For example, a significant part of the TYP approach is to reduce, as much as possible, small LDL particles. If LDL – and thus the resulting plaque – is indeed a suboptimal last line of defense, does reduction of LDL particles lead to a sub-optimization of the body’s last-ditch defense/“back-up plan” to deal with arterial microtears?
4.  Also, knowing that plaque/“spackle” is admittedly a suboptimal last ditch effort, what consequence does reversing plaque ultimately have given that the real damage – the tears in the artery walls (the seemingly real CHD culprits) – has already occurred. Are we pulling the finger out of the dike… without addressing the real root cause of the problem?  â€¦and if yes, what’s the back-up plan to the body’s back-up plan? If we reduce LDL and plaque, and the arterial damage is already done due to years and years of sugar abuse, what plugs the dike then?  I’m not talking about the preventive approaches of avoiding glycation in the first place… obviously that seems to be the real, preventive answer. I’m referring to those of us – for whom preventative measures are too late because the microtears are already there – who might be already living with the consequences of years of potentially errant diet/health guidance (by Keys, NCEP, etc.) and thus “spackle” in our arteries?  If the "spackle" is removed, does the dike start leaking again?

Although I thought I was “on the path to CHD righteousness”, I’m now confused again as a result of Dr. Diamond’s insights. Thanks for any clarifications Dr. Davis!

Dr. Davis,
I'm also anxious to hear what you think of the "hero" role of LDL in plaque.  I'm hoping he didn't go too far off the reservation on this point because the entire hour long presentation was so well done (comprehensive, well-explained, and credentialed) that it will be a powerful aid in spreading the word on both carbohydrates and how messed up the typical GP is with cholesterol treatment (not their fault - but the ATP-III as you say).  It was the tipping point for me.  I'm going off Lipitor now, which I"ve been on for years and will look into your TYP program to ensure I'm doing the right thing.

HI, Joe--

This "hero" thing, to my knowledge, is extrapolation and supposition. It is an interesting notion. I, too, was impressed with his presentation, but I think that the "hero" thing paints LDL as an entirely innocent player and I don't believe it is. We have only to look at people with heterozygous familial hypercholesterolemia who can have heart attacks in their 30s with pure large LDL to know that there is more to LDL's behavior than a protective function.

Hi, G--

By providing the link to Dr. Diamond's wonderful talk, I didn't mean to suggest that everything he says should be taken as gospel.

Virtually everything he said up until the "spackle" I do agree with. The spackle argument is pure supposition. It makes sense, but only to a degree and ignores the quantitative (e.g., heterozygous familial hypercholesterolemia) and qualitative (small, oxidation- and glycation-prone LDL particles with unique conformations that differ from larger LDL) differences in LDL particles.

Nonetheless, Dr. Diamond's recounting of how this mess was created was enlightening and well-presented and I still enjoyed it.

Dr. Davis,

I watched Dr. Diamond's presentation in its entirety.  I agree that he's done some great investigative medicine, especially looking into long-established research on carbohydrate intake, and, more recently, digging into questions of research funding and conflicts of interest.

His presentation leaves me with a major question about the role of cholesterol.  Diamond claims that high cholesterol levels are not harmful, so long as they are below 300 mg/dL, and that cholesterol has a helpful role.  It is used by arteries to repair themselves after the arterial lining is torn, infected by bacteria, or otherwise damaged.  This is why, he says, we find cholesterol in atherosclerotic plaques, together with white blood cells and dead bacteria.  Yet, we know from your reports and others that an elevated LDL particle number *is* correlated with coronary events.

What's going on here?  Is cholesterol itself harmful, or is high particle number just another symptom of high carbohydrate intake, which causes glycation and loss of elasticity in the arterial walls, leading to damage?

I just read the other comments, so the above question has been answered.  Thanks for all the info!

Hi Brian--
While I truly enjoyed Dr. Diamond's presentation, I think this particular path leads us down a dead end.

I don't think cholesterol per se is harmful; I believe that the particles that contain, among many other things, cholesterol can be harmful, especially small, oxidation-prone, glycation-prone LDL particles. I believe it would be an incredible stretch to say that small LDL particles are somehow protective.

I have inherited cholesterol and just learned from my health store guy that all the grains I have been eating are likely responsible for the high numbers of my small LDL(527) particles.  I thought oatmeal and other whole grains would squeege-mop the bad guys out of my system.  This news is also likely why I haven't  lost any weight (I eat lots of veggies and apples, fibrous fruits and protein.)  I do not use processed foods at all.  I walk a mile to work each day and I am still 10-20 # overweight (and yes it is right in my middle.)  My health guy is the one who directed me to this blog.  Any other information is most welcome.  I am trying to figure out what to fix everyday (supper/dinner) is the hardest.
Joan phillips

Hi Dr. Davis.

Indeed, strange advice there. It seems that in terms of effects on arterial stiffness, compared with postprandial glucose levels lipids are not even on the radar screen:

http://healthcorrelator.blogspot.com/2010/05/postprandial-glucose-levels-hba1c-and.html

That is, as you have been pointing out all along, if one "eats to the meter", lipids tend to fall into place. For most people all it takes is to remove refined carbs and sugars from the diet. For others it means to remove some whole foods as well, such as potatoes and bananas.

Dr. Davis- If the person in your post here has genetic small LDL, what are his options? Isn't he kind of stuck? If he lowers his already fairly low LDL too much more, won't he be oversuppressed? Can niacin lower (or convert, or whatever) the small LDL in "genetic" smLDL type, or should such a person just try to get their smLDL particles as low as possible? (even though they might always stay small?)

Dr. Davis,

What do you look at more, small LDL particles or average LDL size?  Over the period of a year, my small LDL particles have gone down to < 90 nmol/L from around 120 last year, but my average LDL size has decreased (though still pattern A) to 21.1 nanometers (from about 22.3 last year).  

Thanks.

Since it doesn't account for muscle or fat (i.e. athletic or sedentary), I wouldn't think BMI is a very good indicator of anything...

Perhaps if the original poster had said his BODY FAT % is 25.1% then that can be evaluated as "favorable" or not.

QUOTE:
"eliminate wheat, oats, cornstarch, and sugars"

Doctor Davis, based on your many previous posts,  I assume that this is good advice for everybody, not just the individual who asked the question?

The person's trigs/HDL ratio is 0.8 which ought to indicate large pattern LDL.

Is the discrepancy with the VAP test because of this person's genetics, or might some other factor be at play?

Can we generally rely on the trigs/HDL ratio in people who are generally healthy with no signs of the metabolic syndrome?

Christian Wernstedt, I thought that was odd too.  But then again, he is on a boatload of drugs that are designed to manipulate lipid numbers.  You can see that the drugs did indeed give him very low LDL, but seem to have done so by shrinking the particle size, thus the VAP pattern B.  

So in the case of "great" lipid values here, it would seem they are not so great when achieved artificially by means of drugs.  He may have been better off with "high" cholesterol if it used to be large, fluffy LDL, especially if he had the high HDL and low triglycerides back then too.

Christian Wernstedt,

The comment Anonymous left is consistent with my experience. My father's LDL was in the 40s under "control" with statins. He died of a heart attack less than a week after passing a stress test. Reviewing his Berkeley lipid tests, he was solid LDL pattern B, though his trigs and HDL were enviable.

i have a question as a neurosurgeon who completely thinks that Cholesterol is immaterial.  Do you Dr Davis as a cardiologist value the VAP or the HS CRP in your practice for true cardiac risk.  All my reading points to HS CRP......I am not sure that the VAP does anything unless you have a genetic predisposition.  Is this correct thinking or not?  Dr. K

Judging from the comments, a lot more conversation on small LDL is in order.

It's actually quite simple, but the world floods us with misinformation hell bent on leading us towards statins and the small LDL CREATING low-fat diet.

I will address these issues in forthcoming posts.

If I want to find out my small particle number what test should I request.

I am the original poster with the July 2007 blood test results. My April 2010 test results are as follows:
Total = 129
HDL = 79
TRG = <45
LDL = N/A
non HDL = 50
TC/HDL = 1.6

Same meds 185 lbs.

Am I killing myself with these numbers?

Do you still have the small LDL pattern?

Anonymous said...
Do you still have the small LDL pattern?
-------------------------------

No, I have not had that tested since 2007- a university medical center performed that test and was not worried with the LDL pattern B results. No VAP tests since, only the standard lipid tests.

@Peter-

To find out your small LDL particle number, have your doctor order an NMR LipoProfile. You can also order these yourself without a doctor (very inexpensively) from places like privatemdlabs.com. You just order the test online, go to a local blood drawing station at your convenience, and look for the results to be emailed to you in a couple days. That's what I do. Super easy.

David

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Great thread in this blog. Bob, you have good advice here. I am also a big Niacin enthusiast and often use it in combination with a natural lipid lowering group of supplements: Triplichol + Niacin.
Regarding your comment last month "Am I killing myself..." . You have to know that you are doing the best you can, and holding a positive mental attitude is extremely important as well. In my mind/body medicine fellowship we taught people stress management as well as doing the exercise and nutrition side. Weaving this into internal medicine has been rewarding.

Ted wrote "I am a 64yr old male living in the UK. My skin is fairly tanned as I try to get as much full body sun exposure as is available here however I have also been taking 5000iu/daily for a couple of years now. When I was last tested my score was 147.5nmol/l 59ng/ml. I wonder if Anne's numbers are the result of a faulty test."

I said to my endocrinologist that I thought the high test result I had, 384 nmol/L (153 ng/ml), was a lab error, but he was pretty sure it was correct. Maybe it's because I'm slim and can't store the D3 easily so I'll gain serum levels of it easily and lose it equally easily ? I contacted Dr Reinhold Vieth who has done a lot of research into D and he suggested I could have a hypersensitivity to D - if so, this will become apparent when I have my next test.

Anne

Great post

If you have been taking 4000iu D3 daily for several months and then suddenly stop taking any, after a week would depression and lethargy be a side effect?

Thanks

The most important thing to realize about Vitamin D is that your body has many ways to deal with excess quantities, and almost no way to deal with a deficiency.

Once 25(OH)D gets above ~80ng/ml (which takes a LOT of vitamin D over a long period of time), your body begins to store Vitamin D in your fat cells.  The amount that can be safely stored in your fat is almost an order of magnitude larger than what is carried in your blood serum (equivalent of 500-600 ng/ml).  It takes a truly ridiculous amount of Vitamin D3 taken for a long time to saturate your fatty tissue.

If you have sarcoidosis, which often causes problems with conversion of Vitamin D active forms in your body, supplemented Vitamin D will probably make your condition worse.  For everyone else, it is extraordinarily hard to overdose on oral Vitamin D supplementation.

40,000 IU's/day for a month might cause problems for a normal person, but almost nobody will recommend more than 10,000 IU's/day (the same amount a young person's skin can make in 30 minutes of low-latitude, noonday sun).  Another number to be aware of is 4000 IU/day, which is the amount of Vitamin D that an average human body with normal levels of 25(OH)D will use up in a day.

The RDA (at 400 IU's/day) is based on old science.  Completely ignore that number as worthless and dangerously out of date.  That amount will stop rickets and little else.  That's little help for bones, for cancer prevention, for steering calcium away from arterial walls, for all of the other things that Vitamin D will do in your body.

I'm familiar with a couple chemists that tried to make a Vit.D home testing kit.  They looked up older TLC methods for making a Dkit that was similar to the home cholesterol kits.  They spent time on it, and  felt they had a result on one of the tests, but in the end decided it was going to take too much time to do right.  More time than they could offer, so the project was shelved.

Because I'm not ill I'm only really allowed vit D tests yearly (I would probably be seen as an NHS pest if I pursued it), but I'm taking 5000IU for the last year to see what this does to my unsupplemented level of 10nmol/L. I was prescribed 400IU and that only raised me by 11nmol/L to 21nmol/L, so in understanding the relative safeness of D, and how other family members respond to it (almost always needing higher), I don't feel like I'm playing Russian Roulette. I'm allowed a blood test late September though.

This could be grist for another post (along the lines of how disastrously low the US RDA is for Vit. D):

http://www.nytimes.com/2008/08/26/health/research/26rick.html?ref=health

Dr Davis,

Have you watched this video on vitamin D?

http://www.youtube.com/watch?v=78CB21mKlXc

Do you have the same destructive problem making bread from other grains instead of wheat, i.e. rice, barley, spelt? These are all useful for those with wheat intolerance, but I haven't heard you say about using other grains in making your own homemade bread.  I have also read that sourdough leavening is also less destructive.

Quote:

"So what is it in wheat that, for instance, worsens auditory hallucinations in paranoid schizophrenics? Is it the gluten?"

If wheat is associated with auditory hallucinations, is it also associated with olfactory hallucinations?  I've had them at least 20 years.  For me they go away if I take zinc regularly.  

kevin

I'd also be interested to know if there is any type of bread (gluten free) which you feel is safe to eat within moderation.

Rice bread tends to be high-ish in carbs, but at least it avoids the gluten.

Just wondering if rice bread and other gluten-free alternatives cause small LDL like wheat does.

What I've never understood is how the Italians have eaten pasta for so many years without, it appears, great problems.

Hi, Linda--

If you subtract the gluten, you have (mostly) carbohydrates.

It then boils down to how carb-sensitive you are gauged by, for instance, postprandial blood glucose or HbA1c.

Another puzzling bit of information is the northern Indians who eat lots of wheat have a fraction of the heart disease of the rice eating southern Indians.

Regarding pasta and Italians -- it was in North America, not Italy, where pasta graduated to main-course portions, probably because it's cheap.

"But there's an easy cure for the uncertainty: Don't eat it."

That makes sense to me.

But if I have to give up Wheat Chex cereal, can I still eat Corn Chex and Rice Chex?

We've recently gone gluten-free after suspecting gluten intolerance in me and my 3 yr old son. Wow what a difference. After one week off gluten, I gave him one piece of sourdough bread since we were low on groceries and I wasn't able to go out that day. I noticed immediate behavioral changes and changes on his skin (small bumps... my Naturopath says it's a sign he is deficient in certain vitamins, they were going away while he was off gluten). Our lifesavers are quinoa porridge (quinoa, water, milk, egg yolks) and buckwheat pancakes, the kids love them. Makes going grain-free a little easier for my carb-addicted preschooler (we've taken it one step further then gluten-free and eliminated all grains.) Buckwheat pancakes can be used to make sandwiches, as a substitute for bread.  - Valley Mom

What plant or animal source of food has not been severely manipulated over the last 9,000 years? What if I'm sure I don't have Celiacs Disease or Schizophrenia and I control my daily blood glucose and HbA1C? Isn't wheat just another source of carbs/fiber/protein?

Just to expand on your last sentence: if there's no upside to eating wheat, and even the remotest possibility of a downside, then the decision is easy.

Of course there clearly is an upside, or else wheat wouldn't get eaten in the first place. The question is whether or not this upside represents an actual positive impact on health, or a misinterpretation by the brain of signals which normally indicate positive health outcomes. See my blog and ensuing discussion here:

http://sparkofreason.blogspot.com/2010/05/why-do-you-eat-grains.html

For People that make excuses or try to talk their way out of avoiding wheat or any other food item, that is the #1 sign of an allergy addiction.

Take a look at the relationship between low Testosterone and metabolic syndrome and belly fat.

It's not just a sugar thing, more  related to steroids and stress, IMHO

I do not see a single person around my family who doesn’t have some sort of health issue and they all have northern Indian background. Most of them are diabetics, have heart disease, wheat belly, puffy cheeks, unable to run a mile after the age of 30, hypothyroid, over weight. Just for this topic, if I think about all of the hundreds of people that I know who have northern Indian background, most of them have health issues and they all have high carbohydrate, high wheat based diet. Now there are people within the family who are changing their diet ever since they have seen me improving, about every one of them has made improvements after the change.
Everyone is entitled to their opinion but,
I for one believe that the wheat is the one of the biggest culprit in our diet.
Carbohydrates might be the second in line along with iodine shortages and the list goes on.
The high glycoside symptoms are very close to the hypothyroid symptoms.
Every person should own a blood-sugar meter and should have the knowledge to their sugar/carbohydrate reaction profile.
  But I think that finally the time has come where free-will education is being shared in a positive manner which will eventually push the “wanna be Mr Right side” organizations to jump the band wagon sooner or later.
By the way Dr. Davis, after giving up wheat, taking care of thyroid and weight management which helped me loose 40 some pounds, I am happy to report that after reading your blogs religiously and following that low carb diet, I have lost the last 10 pounds. I have never felt this way in my entire life.
Keeping my blood sugar level between 4 and 5.5 almost all of skin problems go away which includes but not limited to 10 years old broken hand palm skin, bloody gums, skin inflammation on back of my head, red patch on the facial skin, less bloody shave etc.  Interestingly, if the after meal blood sugar level stays over 6 and around 8 for few days, then most these issues slowly begin to come back. This might explain why I had bloody stomach few years back. Introduction of more fat in my diet may have also helped in all of above.
All of above is my personal experience so it may not be backed by any study.
Please keep it up, you are The Doctor.

Lindaharper - barley and spelt have gluten similar to wheat and need to be eliminated on a gluten free diet. A gluten free diet eliminates wheat, barley and rye and related grains.

I have gluten intolerance and type 2 diabetes. I can keep my blood sugar in control by limiting carbs. I have not found any grain that will not raise my blood glucose to unacceptable levels. I guess I could eat tiny amount of grain, but why bother. I would rather get my few carbs from highly nutritious low carb veggies.

Eliminating gluten gave me back my life. Eliminating grains in general further improved my health.

A great site to read more about gluten is The Gluten File

@Jim Purdy: Most breakfast cereals contain barley malt even if they don't have wheat. Barley also contains gluten.

My family went through a couple months of substituting gluten-free grains before we decided it wasn't worth it and gave up all grains. Gluten-free substitute foods can help you break the addiction, but in the long run I don't think they're very healthy. In fact, in terms of pure nutrition (ignoring the anti-nutrition) no grain can beat wheat. Everything else is worse.

General Mills brand Rice Chex and Corn Chex have been reformulated to remove the barley malt, so they are now gluten-free.  Some (but not all) Erewhon rice crispy cereals are also gluten-free.

Very interesting information.
I wonder if there is a compounded problem with fructose consumption.

I personally believe that we haven't had the time to evolve
and adjust to the high-carb diets characteristic of agricultural societies.

Some people are more susceptible to problems of increased carbs, refined-carbs, sugars, and fructose. This susceptibility
can take a long time to manifest itself. Its not just insulin-resistance, but growth hormone levels, HTA-axis, and other
hormonal controls but also there
is a growing realization of the effect of refined carbs and sugars on the inflammation process which suggests connections to atherosclerosis, neuronal damage, and even autoimmune diseases.

Last note:
I find it very striking that cancer cells have such a "craving" for sugars that they represent the only cells - other than hepatocytes - that will readily uptake fructose from the plasma.

Just my thoughts.

Aleck H Alexopoulos

Hi Doc, You say a lot about what ISN'T that great for us but where's the stuff that DOES pass the tests? What are the best cereals out there?

Exactly.  It seems my choices are so limited, as I stroll down the isle at the grocery store and every single packaged food is bad for me.  I eat plenty of fruit, but my body needs bread and I need something convinient when I am not able to cook and need food fast.