No more cookies

Jeanne enjoyed her Christmas holidays. She especially liked sharing the cookies she made for her grandchildren, sneaking 2 or 3 every day over a couple of weeks. On top of this, she enjoyed the Christmas candy, egg nog, leftover stuffing and cranberry sauce, topped off with a night of nutritional debauchery on New Year's Eve.

Lipid panel in October:

Total cholesterol 146 mg/dl
LDL cholesterol 72 mg/dl
HDL cholesterol 64 mg/dl
Triglycerides 49 mg/dl

Lipid panel in early January:

Total cholesterol 229 mg/dl
LDL cholesterol 141 mg/dl
HDL cholesterol 59 mg/dl
Triglycerides 147 mg/dl


I call the holidays The Annual Wheat and Sugar Frenzy. It's the carbohydrates, especially those from products made of wheat and sucrose, that caused the marked shifts in Jeanne's lipid patterns. Let's take each parameter apart:

--Triglycerides go up due to de novo lipogenesis, liver conversion of carbohydrates into triglycerides. Triglycerides enter the bloodstream as VLDL particles which, in turn, interact with LDL and HDL.

--LDL goes up because carbohydrate exposure increases VLDL, followed by conversion to LDL. The triglyceride-rich LDL created is converted to small LDL particles. Had we measured small LDL changes in Jeanne, we likely would have measured something like an increase (by NMR) from 800 nmol/L to 1600 nmol/L, a carbohydrate effect.

--The increased VLDL also makes HDL triglyceride-rich, cause more rapid degradation of HDL particles. (It also makes them smaller, like LDL.) Given sufficient time (a few more months), HDL would drop into the 40's.

--Total cholesterol changes reflect the composite of the above numbers. (Total cholesterol = LDL cholesterol + HDL cholesterol + Trig/5) (Note that, as HDL drops, so will total cholesterol; that's why this value is worthless and should be ignored.)

So don't be surprised by the above distortions after a period of carbohydrate indulgence. Although your unwitting primary care doc will see such changes as opportunity for Lipitor, it is nothing more than the cascade of effects from a carbohydrate-driven distortion of lipoproteins.

Comments (13) -

  • Michaelf

    1/15/2011 2:59:27 PM |

    Why so many lipid panels?

    Doesn't cholesterol naturally ebb and flow?  Or does it only ebb and flow when we feed it?

    For my taste the second panel is better, other than the HDL.  I'd say she did a good job getting her Cholesterol up over the holidays....

    One of the highlighted lines in my Taubes book is the piece about the lower the cholesterol the higher the incidence of cancer.  Correlation I know but wasnt all the science about cholesterol a well choreographed dance around correlation.

    My father was a cancer patient and a heart patient.  He "naturally" had cholesterol in the 150-160 range and was sick his whole life.  

    IMHO that womans cholesterol is doing what it does to save her life.  Rising to wrangle up the garbage she's dumping down her throat.  

    My fathers never rose to combat the garbage he was dumping down his throat.  What are your thoughts on that?

    If this stuff happens as you say, a fairly simple pattern, then why the differences?

  • Brent

    1/15/2011 3:22:09 PM |

    Dr. Davis - This is off topic for this particular post, but I want to suggest the next blog post for you.  

    First, cudos for keeping this blog informational only, without a hint of commercialism in in.  However, I and perhaps others who read it have seriously considered contacting your office for an appointment to become patients, even though we live in other parts of the country.

    Would you consider posting a topic on the blog of how this could work?  My thoughts are to have necessary tests done in advance of a visit, so that things which normally take 2-3 visits could be accomplished in one. Is a list of these things something that could be determined by a phone interview with your office staff when the appointment is being made?  Can your office arrange for heart scans to be done in Milwaukee in the AM for a PM appointment with you?

    Important question: Is a heart scan at a closer facility (Still 3 hours away) & track your plaque membership (not yet done because I've not had a scan yet) just as good as a visit to your office once a year or would I get additional benefits becoming a patient? i.e., can you rely on scan scoring done by others if I wanted your opinion on the results?

  • Lori Miller

    1/15/2011 4:38:56 PM |

    Two other things all those carbs will do to susceptible people is give them bloating and acid reflux. The posts on that subject have been my two most popular over the past month.

    Re: cholesterol, mine is 140. The total didn't change much when I cut way back on the carbs, but the ratio of HDL:LDL improved. If I'm sick or riddled with cancer, I'm afraid it's escaped my notice. My liver must be making all I need.

  • Anna

    1/15/2011 5:16:45 PM |

    I don't miss the cookies, overly sweet eggnog, and Christmas candy at all, since I revised my diet in early 2004.  I don't gain holiday weight anymore; in fact, some years I lose a couple pounds between Thanksgiving and New Years.

    When I celebrate during the holidays with food, I do indulge (if you can call it, that because my indulgences tend to be nutrient-dense and very satisfying, too) with rich paté, lovely artisan cheeses, fish roe (caviar) and deviled eggs, fresh veggie slices, and bacon-wrapped scallops and shrimp, etc.  I make egg nog that isn't nearly so sweet as well as super easy homemade truffles with very dark chocolate, which has just a small amount of sugar.

  • revelo

    1/15/2011 5:21:24 PM |

    I eat a high carb diet (60% typically, lots of oats, beans, potatoes) and just got back my first test result:

    Cholesterol, Total   152
    Triglycerides         39
    HDL Cholesterol       70
    VLDL Cholesterol calc  8
    LDL Cholesterol calc  74

    I'm lean (16% body fat according to my electronic scale, 12% according to a formula I found on the internet) and get plenty of moderate exercise (yoga and walking). So it appears all those carbs are NOT turning to Triglycerides in me.

    Rather, when I eat carbs, the glucose goes into the muscles. After I finish my last meal for for the day, the body gradually burns off this stored glucose so that the muscles are mostly depleted by the next morning, when I break my nightly fast. Isn't this how the body is supposed to work? I have to disagree with this notion that the muscles can only store a couple of hundred grams of glucose. I think that amount of glucose that can be stored increases in lean people who exercise and routinely eat large amounts of carbs.

  • Michaelfgu

    1/15/2011 5:33:52 PM |

    Brent, You have been reading my mind! Yes, Dr Davis please tell us how best this could best be accomplished as per Brent's comment!

  • Might-o'chondri-AL

    1/15/2011 7:05:52 PM |

    Bit over simplified; unless holiday indulgences (prior to patient's Jan. lab test) were made rich tasting without using any fat &/or cholesterol content
    (and wasn't over eating, nor lazing around).

    Clinic patients are presumably often already suffering with metabolic syndrome. An absolute admonishment is going to become rote patient visit after patient visit.

    Is a prevention strategy for everyone, or just the sedentary and geneticly pre-disposed? One's adult health may be doing well with a contrary diet. By middle age Doc's restrictions might be a pre-emptive strategy for countering metabolic changes to come.

  • shutchings

    1/15/2011 8:26:23 PM |

    So if Jeanne returns to restricting sugar and flour from her diet in January, her profile improves.  Did she leave lasting damage?  Is the risk only that disease will develop during her holiday relapse?

  • Dr. William Davis

    1/15/2011 10:26:20 PM |

    Anna--

    I love the gourmet-bent you've taken with your diet. That's a great direction to go.


    Brent and Michael--

    You can call my office at 414-456-1123 to arrange an out-of-town visit. Alternatively, call the same number to arrange a video teleconference to review lipoproteins or your coronary prevention program. (Video teleconference is not covered by insurance, however.)

  • Anonymous

    1/15/2011 10:54:00 PM |

    I treat so much cholesterol in my patients with bio-identical hormone therapy in addition to nutritional biochemistry / blood test to help rebuild the adrenals and help the body convert the excess cholesterol into the LDL and then into the next hormone called pregnenolone. Most people who have high cholesterol have silent adrenal dysfunctions/ burn out / PTSD whereby the cholesterol does'nt convert into the next hormone.
    Most MD's won't look to check the adrenal and sex hormones in conjunction with and cholesterol test.
    What an oversight eh !

  • Marc

    1/16/2011 7:57:03 PM |

    I used to have very lows trigs (35-45 range), I start eating high fat low carb & 6 month later my trig went up to 79.

    Carbs = elevated trigs??
    Not for me.

      My lowest trigs were in my vegetarian days eating whole wheat, oats, beans etc...when I started upping the fats & meat my trigs went up (even when cutting down wheat, which I dont eat it anymore)

    Could you provide an answer to this mr Davis?

  • Sophie

    1/24/2011 10:49:24 AM |

    I agree that holidays is a season to increase weight gain. Uncontrollable eating can risk our health. There is no any guarantee how long can our body take the cholesterol we're feeding. So proper self-discipline is needed. Low carbohydrate diet is the best diet for those who want to lose weight especially for diabetic people.

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Where do you find fructose?

Where do you find fructose?

Apple, 1 medium: Fructose 10.74 g




Honey: Fructose 17.19 grams per 2 tablespoons



Barbecue Sauce: HFCS number 1 ingredient
Ingredients: High Fructose Corn Syrup, Vinegar, Concentrated Tomato Juice (Water, Tomato Paste), Water, Modified Food Starch, Salt, Honey, Contains Less Than 2% of Molasses, Natural Flavor, Paprika, Spice, Mustard Flour, Guar Gum, Red 40.



A1 Steak Sauce: HFCS number 2 ingredient
Ingredients: Tomato puree (water, tomato paste), high fructose corn syrup, vinegar, salt, water dried onions, contains less than 2% of black pepper, modified food starch, citric acid, dried parsley, dried garlic, xanthan gum, caramel color, potassium sorbate and calcium disodium EDTA as preservatives, molasses, corn syrup, sugar, spices, tamarind, natural flavor

Comments (25) -

  • Gretchen

    7/15/2009 1:04:39 PM |

    You forgot agave syrup, which a lot of people are using as an "all natural" low-glycemic replacement for HFCS. In fact, it contains more fructose than HFCS.

    One manufacturer's products include “low glycemic monosacharide.” Gosh, I wonder what that is.

  • PERKDOUG

    7/15/2009 3:10:43 PM |

    It would be a service, if you (or someone) posted a "fructose" content list which includes all the common fruits and berries. I eat a lot of berries and have wondered if that is such a good idea. A list would help us define "good calories" regarding these possible fructose bombs.

  • Anonymous

    7/15/2009 4:23:16 PM |

    Thanks for the visuals and labels on fructose...I am very aware of fructose contents and fruit -- especially since I have experience with fruit and gout attacks that may or may not be supported in literature.  I will only add that every time you purchase a product DO NOT ASSUME CONTENTS ARE THE SAME as when you last purchased.  For example, Classico pasta sauces which I used as base for soups and stews (all LC) has started adding sugar.  CostCo Kirkland brand marinated artichoke hearts (again LC) started out using olive oil, now uses cannola oil. My experience as label-reading shopper is food producers are now adding sugars including fructose to just about everything because the buying public perceives sugar to be tastier...even the rotisserie chickens most grocery delis have now...be careful if you very LC to whether the spice rub has sugar in it.

  • Anonymous

    7/15/2009 4:38:34 PM |

    What don't you find it in?

  • Anonymous

    7/15/2009 5:11:25 PM |

    Finding it hard to believe that an apple wouldn't have some other redeeming value that counteracts or balances the fructose content: soluble fiber, fiber, vitamins, minerals, etc.  Hopefully this is not an indictment of all fresh fruits?

  • GK

    7/15/2009 5:30:00 PM |

    It's all very well to measure fructose content, but it is meaningless unless we know what intake levels have to be before they become problematic.

    In my own case, when I went "paleo" a couple of years ago, I swore off sugar, grain, and processed foods.  I lost 15 lbs over six months without trying.  Now this was before I heard about the fructose issue, and I was eating fruit like I never had before in my life, 3 to 4 pieces a day, and the sweet ones, too:  apples, bananas, grapes, dates, etc.  Surely I was ingesting more fructose than I had been before with a blob of ketchup here, steak sauce there...

  • Anonymous

    7/15/2009 9:49:50 PM |

    Not to put too fine a point on it, but what you show as A.1. Steak Sauce is actually their marinade. Real A.1. Steak Sauce (at least my bottle) contains no HFCS, but does have 2g sugar per serving. Thank you for spending the time you do on this blog; you, along with some others, have given me the intellectual and scientific basis I needed to change my diet. The improvements, physical and mental, have been astounding.

  • Nameless

    7/16/2009 12:01:15 AM |

    The fructose info is interesting, but I agree with GK. We really need to know what is considered a safe level before condemning all fructose sources.

    Fruits do have certain health benefits, some more than others, especially berries. There is also the possibility that by becoming super fructose-phobic and avoiding all fruits/berries,  that one could decrease their chances of heart disease, just to succumb to cancer instead.

  • Laura in Arizona

    7/16/2009 2:19:25 AM |

    Perkdoug, I have found that the web site "nutrition data" has a breakdown of sugars for things. Go to nutritiondata.com and type in the food you are interested in. Choose the right food and quantity and then go down to the section on carbohydrate and click the see more details. When I did that for dates, 1 medjool has about 7.6 grams of fructose (eek!). Like many folks I am cutting down on my fructose consumption so use this table a lot.

  • Anonymous

    7/16/2009 3:01:42 PM |

    How about the king of HFCS--Soft drinks and candy.

  • pmpctek

    7/17/2009 3:22:57 AM |

    As someone else asked, "what don't you find it in?"

    Fructose can be found in many vegetables too.  One sweet onion has 6.69 grams, a half head of cabbage has 6.58 grams, a head of lettuce has 5 grams, a cup of chopped red peppers has 3.37 grams, a medium sized cucumber has 2.62 grams.  In fact nutritiondata.com lists 138 vegetables which have some amount of fructose in them (albeit many having very small amounts.)

    So, if one's goal is to avoid all sources of fructose and still maintain any semblance of good health, well good luck.

  • Anonymous

    7/17/2009 5:00:37 PM |

    @Nameless: Well put!

  • country mouse

    7/17/2009 6:56:16 PM |

    I think tossing fruit is a bit of the baby out with the bathwater.Fruit has the most wonderful spectrum of bright tastes and flavors of any food we have on the planet. "Healthy" vegetables encompassed the bitter, the flat, and the algae like part of the flavor spectrum. Me, is meet and nice in small to medium quantities but when eaten in low-carb volumes, it just becomes something you shovel in to make hunger go way.

    Fruit is a wonderful gift. Adding a little sugar and heating some berries produces this wonderful sauce you can pour over pancakes or creps (if my diabetes let me have crepes). Some fat, flour, and salt makes a wonderful crust that you wrap around sliced and spiced fruit. Cold cherries crunch between your teeth dribble juice around your tongue while you roll the stone around your mouth cleaning off the last of the fruit meat. Peaches with ginger, peach blackberry, blueberry pie. Sliced and cored apples cooked in red-hot cinnamon sauce on the stove and then chilled before serving on Christmas Eve. On a hot August day, wandering through an orchard and dodging Yellowjackets when picking a beautifully ripe peach off the tree.  Pulling a crisp apple out of winter store in November and tasting what will become cider.

    On a more practical level, I also need to make the decision on how much fruit versus how much bulk  laxative? If I eat one piece every days, I'm looking 8+ tablespoons of Metamucil.  bleck.  I'd rather starve myself in  other areas to make room for the delightful sweetness of fruit.

  • Dr. William Davis

    7/18/2009 2:50:28 AM |

    Who said throw fruit out?

    I believe you are reading things that aren't there.

  • country mouse

    7/18/2009 4:51:08 AM |

    I disagree.  without giving a threshold of "bad", your presentation implies that all fructose at any level is bad.  I read some comments as expressing fear or doubt that they were eating too much fruit.  others like me what to know the threshold of bad.

    just between you and me, I'd give up living before I gave up fruit.  no joke.  the flavours of fruit are that important to me.  I've already lost enough food ground with diabetes, I'm not giving up any more.

  • Anne

    7/18/2009 12:51:34 PM |

    According to Dr. Richard Bernstein, fruit does not have to be a part of a healthy diet. Here is what he says in his book, Diabetes Solution:

    "Although eliminating fruit and fruit juices from the diet can initially be a big sacrifice for many of my patients, they usually get use to this rapidly, and they appreciate the effect upon blood sugar control. I haven't eaten fruit in almost forty years and I haven't suffered in any respect. Some people fear that they will lose important nutrients by eliminating fruit, but that shouldn't be a worry. Nutrients found in fruits are also present in the vegetables you can safely eat."

    Dr. Bernstein has had T1DM for about 50 years and advocates a very low carb diet to help normalize blood sugars. http://www.diabetes-book.com/

    Because of blood sugar problems I have eliminated all sources of HFCS and have greatly limited my fruits. I find I can eat a few berries or a bite or two of other fruits without raising my blood glucose, but I mostly stick with colorful low carb veges.

  • Nameless

    7/18/2009 6:28:10 PM |

    Dr: Davis -- "Who said throw fruit out? I believe you are reading things that aren't there."

    Yet you start this post with a photo of an apple. Although perhaps it wasn't  your intention, it certainly implies that fruit is bad.

  • TedHutchinson

    7/19/2009 8:44:44 AM |

    National estimates of dietary fructose intake increased from 1977 to 2004 in the United States.
    high-fructose corn syrup percentage of sweeteners increased from 16% in 1978 to 42% in 1998
    Since 1978, mean daily intakes of added and total fructose increased in all gender and age groups, whereas naturally occurring fructose intake decreased or remained constant.
    If you can't get the full text at least read the abstract. The full text has some interesting charts presenting the data more clearly.
    It isn't eating naturally sourced fructose from whole fruit driving increased obesity. Increases in fruit consumption are dwarfed by greater increases in total daily energy and carbohydrate intakes.

  • Anonymous

    7/20/2009 9:20:21 PM |

    RE: Comment by Nameless (“Yet you start this post with a photo of an apple. Although perhaps it wasn't your intention, it certainly implies that fruit is bad”)
    -------------------------------------------------------------------------------------------

    The good doctor is merely demonstrating in effective graphic terms that
    too much of a good thing is not good. The numbers (ie gms of fructose)
    are important guidelines. There’s no point in getting your nuts in wringer over it!

  • Anonymous

    8/4/2009 11:19:11 PM |

    Bernstein developed Diabetes at age 12. He was born in 1934, so at age 75, he has been diabetic for 63 years. No diabetic complications. Normal blood sugar for all!!

  • David Gillespie

    8/23/2009 10:35:41 PM |

    I think its more helpful to express sugar content (and fructose if known) as a percentage rather than an amount per (varying) serve.  It makes it easier to compare apples to apples (scuse pun).  I've prepared a few listings of various food groups (several hundred items in each) on this basis at www.howmuchsugar.com if you are interested.

  • Anonymous

    8/30/2009 8:58:49 PM |

    Some people suffer from fructose malabsorption. One source states that it is found in approximately 30-40% of the population of Central Europe. If one has that condition, then it would be prudent to avoid all fructose, even the fructose found in fruit. I love the taste of fruit, but it is destroying my health due to malabsorption issues. Fortunately, we know that some cultures lived very healthy lives without eating fruit (e.g. Eskimos).

  • John

    12/1/2009 7:17:24 PM |

    I don't get it. What am I not seeing?

    How much high fructose corn syrup is in a serving of the BBQ sauce? How much in a serving of the steak marinade?

    You state such figures for a serving of apple (1 medium), and for a serving of honey (2 Tablespoons).

  • Anonymous

    10/19/2010 10:53:28 PM |

    I had to give up fruit to prevent further beta cell damage (above 140 apparently for pre-diabetics, and maybe everyone, I don't know). Fruit and many veggies are toxic to people with glucose intolerance. I had to give up veggies for now, until I can find one that I can tolerate. Cabbage was too hard on my blood sugar. I am slowly trying to figure out what I can eat and how to minimize the glycemic impact. Unfortunately, I might have to damage my beta cells to find out what works. The system told me I was fine, even though I told them I had sugar problems. I gave up on doctors 10 years ago, since they were useless. I finally bought a meter and started testing, and the truth is painful.

  • buy jeans

    11/3/2010 6:47:15 PM |

    In addition, since I have been involved with cardiac CT for now nearly 24 years, the PLC also affords me an opportunity to develop a CT coronary angiography training program for cardiologists and radiologists (www.cardiaccta.us). Together, these new efforts are merely an extension of my interests in prevention, patient care, and teaching.

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Planned obsolence

Planned obsolence

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



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

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

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

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

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

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

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

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

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

Comments (1) -

  • Anonymous

    5/12/2008 9:04:00 PM |

    My father was working in Detroit in 1980 and 81, arguably the center of America's anti Japanese car hatred at the time.  I can remember when he came home he would tell stories of the destruction of Japanese cars that auto workers did.  If you drove a Japanese car in Detroit at that time, I got the impression  that there was an excellent chance the auto would be crashed into on purpose while sitting at a stop light or someone at night possibly might take a sledge hammer to the hood or windshield.

    Many people have a hard time handling change. What happened with Americas auto employee's rage over competition from Japanese car isn't much different than you see in the stock market, I believe.  People have a tendency to believe something will last forever.  They don't want to believe that events tend to occur in cycles.  Even when all evidence seems to point toward an event happening, they  find reasons to ignore it, and later act in disbelief when it occurs.        

    Times have been good for many health care professionals.  But the writing seems to be on the wall that change is coming.  Hopefully, I am guessing it will, inexpensive heart disease prevention will play a larger role in the future.  The results prevention bring are too good to ignore.

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Let Dr. Friedewald rest in peace

Let Dr. Friedewald rest in peace

In the 1960s, doctors struggled with the concept of cholesterol and its relationship to heart disease. It was becoming clear that higher levels of cholesterol were predictive of heart disease. It was also becoming clear that the low-density fraction of cholesterol, or LDL, was somewhat better than total cholesterol in predicting heart attack.

Cholesterol was easily measurable in the 1960s. LDL was not. So, Dr. Friedewald, a noted lipid researcher at the National Institutes of Health, proposed an easy method to calculate LDL cholesterol from total choleseterol, HDL, and triglycerides:

LDL cholesterol = Total cholesterol – HDL cholesterol – triglycerides/5

This simple manipulation would put LDL cholesterols into the hands of the practicing physician and the American public. Dr. Friedewald recognized that this calculation only represented an approximation of LDL cholesterol and that it was thrown off, sometimes substantially, by any abnormal rise in triglycerides or reduction in HDL. But it served its purpose at an age when most doctors hadn’t even heard of cholesterol and the public was still sold on whole milk and “farm-fresh” butter, and Chesterfields were the cigarette choice of most doctors.



The world has since changed. Most doctors have heard about cholesterol and, along with the public, have been drowned in drug company marketing for cholesterol-reducing drugs. Most people with some level of common sense and health awareness no longer use butter or whole milk, and no longer believe that the brand of cigarette you choose can be healthy. But we’re still using Dr. Friedewald’s original calculation for LDL cholesterol. When you get an LDL cholesterol from your clinic, doctor, or hospital, >99% of the time it is obtained using Dr. Friedewald’s calculation.

Is it because there’s nothing better available? No, it’s not. There’s two reasons why your neighborhood primary care physician or cardiologist is still using this dinosaur of testing called LDL:

1) The lag in science to practice is 20 years. Accept that most primary care doctors are 20 years behind the times on many issues, LDL cholesterol included.

2) Insurance companies vigorously discourage testing beyond conventional lipids. The array of objections we get from insurance companies is mind-boggling. It would be funny if human life and finances weren’t at stake. These “new” tests are “experimental”, “unproven”, not endorsed by standard guidelines, not approved by some internal committee, or simply “We don’t know what this test is” ?we’ve heard them all.

What are the tests that are superior to Dr. Friendewald’s calculated LDL? There are several, listed here in order of best to worst:

1) LDL particle number--the value generated by NMR lipoprotein testing. This is the gold standard, most reliable test available, and the one I recommend.

2) Apoprotein B--More widely available even from conventional laboratories in hospitals. Not as accurate as NMR LDL particle number, but a pretty good choice. Apo B is the principal protein in LDL, VLDL, and IDL particles, and so it’s a better reflector of risk from all of these lipoprotein fractions, not just LDL.

3) “Direct” LDL--This is LDL that is actually measured. Unfortunately, it ignores the issues of LDL size and has some other pitfalls, but it’s still better than calculated LDL

4) Non-HDL cholesterol--So-called because it incorporates all undesirable cholesterol-containing lipids except good HDL, thus “non-HDL”. This is another calculation, though better than LDL (because it sums up the risk from other apoprotein B-containing lipoproteins). Non-HDL is calculated from Total cholesterol – HDL. It’s therefore available from any standard lipid panel. It’s little used in everyday practice, however, because most people and their physicians find it confusing.

5) Friedewald calculated LDL--You can see that calculated LDL is last on a list of choices. Yet this is the measure that doctors use day in, day out. It’s the measure that drug companies base billions of dollars of revenue and profits on.

It’s an everyday occurrence in my office that calculated LDL is 89 mg/dl, but the real value is somewhere between 160 and 200 mg/dl. That’s a big difference. Imagine your realtor tells you your house’s estimated value is $200,000 and that’s what you sell it for to an eager buyer. After closing, you find out your house was really worth $300,000. You’d be upset. But that’s what you’re often getting with LDL cholesterol?a bum deal.

It’s part of the reason people will say, “My doctor said my cholesterol was fine and that no cause for my heart disease can be found. He said it was genetic.” In reality, they could have sky-high LDL cholesterol revealed by LDL particle number or apoprotein B.

Use LDL cholesterol in a pinch when you’ve got nothing else. It’s also helpful to gauge any treatment effect of diet, functional foods, drugs, etc. But it is a seriously flawed tool to diagnose your initial level of risk.

Comments (1) -

  • buy jeans

    11/3/2010 9:04:52 PM |

    It’s part of the reason people will say, “My doctor said my cholesterol was fine and that no cause for my heart disease can be found. He said it was genetic.” In reality, they could have sky-high LDL cholesterol revealed by LDL particle number or apoprotein B.

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How far wrong can cholesterol be?

How far wrong can cholesterol be?

Conventional thinking is that high LDL cholesterol causes heart disease. In this line of thinking, reducing cholesterol by cutting fat and taking statin drugs thereby reduces or eliminates risk for heart disease.

Here's an (extreme) example of just how far wrong this simpleminded way of thinking can take you. At age 63, Michael had been told for the last 20 years that he was in great health, including "perfect" cholesterol values of LDL 73 mg/dl, HDL 61 mg/dl, triglycerides 102 mg/dl, total cholesterol 144 mg/dl. "Your [total] cholesterol is way below 200. You're in great shape!" his doctor told him.

Being skeptical because of the heart disease in his family, had a CT heart scan. His coronary calcium score: 4390. Needless to say, this is high . . . extremely high.

Extremely high coronary calcium scores like this carry high likelihood of death and heart attack, as high as 15-20% per year. So Michael was on borrowed time. It was damn lucky he hadn't yet experienced any cardiovascular events.

That's when Michael found our Track Your Plaque program that showed him how to 1) identify the causes of the extensive coronary atherosclerosis signified by his high calcium score, then 2) correct the causes.

The solutions, Michael learned, are relatively simple:

--Omega-3 fatty acid supplementation at a dose sufficient to yield substantial reductions in heart attack.
--"Normalization" of vitamin D blood levels (We aim for a 25-hydroxy vitamin D level of 60-70 ng/ml)
--Iodine supplementation and thyroid normalization
--A diet in which all wheat products are eliminated--whole wheat, white, it makes no difference--followed by carbohydrate restriction.
--Identification and correction of all hidden causes of coronary plaque such as small LDL particles and lipoprotein(a)

Yes, indeed: The information and online tools for health can handily exceed the limited "wisdom" dispensed by John Q. Primary Care doctor.

Comments (32) -

  • Jan

    8/17/2011 6:36:25 PM |

    Time to stop bashing primary care docs, doc. Online sites are full of B.S.
    Show me the evidence that testing with CAC improves outcomes (Sure it predicts risks, not the same as actually preventing disease, especially in those at lower risk of CAD.)

  • Might-o'chondri-AL

    8/17/2011 8:11:19 PM |

    Hi Jan,
    Since you accept plaque showing up as being a cardio-vascular risk factor then if Doc reports he has treated some patients whose measurement of plaque has diminished using his protocol would you also accept the proposition that those patients have reduced one of their cardio-vascular risk factors?
    If Doc has patient records showing diminished plaque and therefore one less risk might that not be considered preventative due to his patient following his protocol ?
    As for those individuals with hypothetically lower risk of CAD (ex: the 63 year old low cholesterol example Doc gave) are they not going to undergo changes as they age ?  
    A primary care physician is valuable and yet older westerners are increasingly engaging specialists for good reasons.  Doc has a self-professed specialty tracking plaque  that he wants to impart; sure, his blogging tone may not always be mellow.

  • Jan

    8/18/2011 2:52:13 AM |

    Dear Might,
    Your comment is akin to those who report the association of statin use with lowered risk of MI. A correlation does not prove causation until valid  scientific research confirms.
    How do we know treating CAC lowers risk of MI until a study proves this? Docs have been wild to accept the association of statin use lowering cholesterol components as the mechanism of effectiveness for prevention of MI, ignoring studies in which dietary measures that did the same were ineffective. Just pointing out the need for caution in going so far as to treat a test without evidence that the intervention is working on the test findings (rather than something else).
    Perhaps there are studies that are underway or perhaps the evidence, er association, is just considered too strong, (Bradford-Hill criteria) to ethically justify a trial. My concern is for individuals who score in the lower range of abnormal. At what cost do we label and treat those?

  • joel oosterlinck M.D.

    8/18/2011 9:21:42 AM |

    just remembret the lyon heart study, by  Renaud & de Lorgeril demonstrating the efficacy  of mediterranean diet in lowering the risk of recurrent MI in French patients. although cholesterol levels were higher with diet than with statins. Dietary measures seem there to demonstrate  efficacy

  • Dr. William Davis

    8/18/2011 12:15:43 PM |

    Not only is it NOT time to stop bashing primary care docs, but it's time to begin accepting that their role is outdated. In fact, an average nurse practitioner or physician's assistant can do an equal, if not better, job than most primary care physicians. How health care is dispensed is going to undergo dramatic transformation, just as the business of travel agents and real estate have been transformed by rapid information exchange.

    In our program, we see virtually NO heart attacks. Not a randomized clinical trial, but watching heart attacks drop from a weekly event to almost never is good enough for me to not accept the status quo and continue to work along a path that, from every indication, works exceptionally well.

  • JC

    8/18/2011 12:49:19 PM |

    If high crab diets are considered unhealthy then why do some cultures like the rural Chinese live long healthy lives on nearly 100% crabs,mostly rice and vegetables?

  • majkinetor

    8/18/2011 2:16:50 PM |

    Isn't the best thing for calcium on wrong places vitamin K2 ?
    In my country doctors even prescribe it for calcification issues.
    Dose is around 100mcg/day for 6-12 mo.

  • Marlene

    8/18/2011 4:06:07 PM |

    Read Gary Taubes' "Good Calories, Bad Calories" to find several instances of other cultures eating the typicial high carb food yet seemingly stay within the healthy range.

  • Jan

    8/18/2011 4:22:12 PM |

    Trust my care (or a family members care) to a NP or PA who does not have the capability of complex medical decision making - no thanks. NP's actually are complimentary to physicians with different skill sets. So glad to know your level of knowledge about them. PA's are nothing but junior medical students with enormous salaries. Working 9 to 5 - oh, yeah!

    I'm certain your referral network of primary care docs would be interested in your belief system.

  • Joe

    8/18/2011 4:49:51 PM |

    Dr. Davis:
    I don't know if you've seen this new video yet, but I think you'll want to.
    http://www.youtube.com/watch?v=3vr-c8GeT34&feature=player_embedded
    If you do watch it, I have a question. This doctor thinks sugar (by itself) plays a huge role in causing plaque to rupture and cause heart attacks, etc. If after watching the video you agree with him, would you please tell me how (biologically) it does this?
    Thanks!

    Joe

  • Might-o'chondri-AL

    8/18/2011 8:51:08 PM |

    Hi Jan,
    True correlation does not necessarily equate to causation. As for statins, it seems that statins act to lessen inflammatory processes; and it is this dynamic, rather than numerically lowering cholesterol, that is a crucial way that statins correlate with reduced risk. Which, to me,  seems to further support Doc's contention here in this posting that  low cholesterol levels doesn't  tell one if they have abnormal plaque (ex: patient above with "exceedingly high" score) .

    I will accept Doc's data, as given ,that very high plaque is a 15-20% risk factor since many other published sources cite even carotid plaque as a risk factor . As far as who to test for what, and when, I am not qualified to make recommendations. I do know that time can remodel some cellular dynamics and the aging cardio-vascular system is vulnerable to alterations.  Doc's got my attention because no one at all in my paternal male ancestral line lived past their late 50's due to heart problems and I am 60; while my 61 year old brother already was hospitalized from transient ischemic attack  .

  • Might-o'chondri-AL

    8/18/2011 9:33:17 PM |

    Mediterranean diet's efficacy for heart health is probably due to the % of poly-amines per calorie consumed and of course isn't in keeping with Doc Davis' detestation of modern wheat (among other protocols). As we age our poly-amine levels decrease and Mediterranean diet supplies lots of poly-amines.

    Poly-amines ( molecules inelegantly named spermine, spermadine and putrescine) are all anti-inflammatory, especially spermine; in our body we synthesize poly-amines from arginine. Mediterranean diet's high poly-amine levels spares the amount of arginine our body uses in synthesizing poly-amines; and thus we can more readily produce the vaso-dilator signalling molecule NO (nitric oxide) from body's arginine. NO is valuable to keep oxygenated blood reaching the heart muscle cells; NO keeps vessels from constricting dangerously.

    Poly-amines lower inflammation and in the context of age associated problems the less low grade inflammation the better.  Inflammation leads to defectively functioning cells and molecular processes; with time the  over stimulation of immunological responses (both innate and adaptive immunity) leaves the body burdened with unknown clones of T cells (both memory and effector types). Eventually the build up of  T cell clones limits new variants and what occurs is more macrophages circulating; once an over abundant macrophage stage reins the body is essentially always in low grade inflammation , and prone to various age associated pathology (including cardio-vascular).

  • Dr. Johns

    8/19/2011 12:25:40 AM |

    @jan....
    A vast majority of primary care doctors are extremely limited in their abilities to treat/advise patients for CVD risks. They don't understand nutrition, effects of supplements upon serum biomarkers, nor effective diagnostic testing for heart disease.
    CAC is a much better biomarker for who is at greater risk of CVD than serum markers:
    http://www.eurekalert.org/pub_releases/2011-08/jhmi-sfc081611.php

    I seriously doubt even 1:100 primary care docs see studies like the aforementioned one.
    And I seriously doubt the one doc would understand it....
    Dr. John

  • Gene K

    8/19/2011 1:48:19 AM |

    An interpretation of the same study for a broader audience just appeared at http://www.webmd.com/heart-disease/news/20110818/is-calcium-test-the-best-way-to-check-for-heart-risk.

  • Thomas White

    8/19/2011 2:09:49 AM |

    I'd accept a bashing of physicians in general.   But to single out primary care physicians - overwhelmed with paperwork and patients with multiple problems, and vastly underpaid and underappreciated, and continually put down by "Partialists" - Really ? Cardiologists are superior? Really ?

    Forget my support and admiration henceforth.

  • Might-o'chondri-AL

    8/19/2011 5:43:43 AM |

    CRP (C-reactive protein), an inflammation marker surrogate, does not directly correlate with whether there is coronary artery calcium (CAC), or the degree of CAC severity. CRP is also subject to variables of race and age, so it loses some potential as a predictive marker. Yet looking at CAC along with CRP is considered useful for complex insight into a patients pathology.

    Analysis of the Multi-Ethnic Study  of Atherosclerosis (MESA) involving 6,800 men & women seems to indicate that inflammatory markers (ex: CRP) relate to the physiology of pathological processes other than CAC laid down; possibly because plaque undergoes morphological changes over time. The CRP level is proposed, by some, to relate more to the stability of plaque from rupturing and the incidence of blood clotting in a thrombosis.

    The inflammatory marker of Interleukin-6 (IL-6) anti-bodies seems to be better than CRP and fibrinogen for correlating an individual's trend toward CAC. Thus the cytokine IL-6 is a better indicator of sub-clinical atherosclerosis; Doc likes to cut to the chase, eyeball the plaque and track it with current technology ( that is not available worldwide).

  • David

    8/19/2011 6:16:33 AM |

    Is it typical for someone with such low ldl and high hdl to have such a high CAC score? Had he previously had a higher LDL and then been placed on a statin?

  • TT

    8/19/2011 12:36:37 PM |

    The energy expenditure of the rural Chinese is very high.  They don't drive, they walk, or ride bicycles.  They don't sit in office from 9am to 5pm, they work hard in the rice field from 5am to 9pm.  They can eat anything without gaining weight.
    For the urban Chinese, it is a different story.  They have the same life sytle as ours, and they are getting heavier every year.  More and more people become diabetic, even young kids.

  • Dr. William Davis

    8/19/2011 1:51:32 PM |

    K2 is indeed a fascinating nutrient. There are extensive discussions about it on the Track Your Plaque website.

  • Dr. William Davis

    8/19/2011 1:53:33 PM |

    Thanks, Joe. I watched the entire thing and was impressed with Dr. Diamond's grasp of the issues.

    I'm going to post this on the main page because I think his overview was extremely effective.

  • Dr. William Davis

    8/19/2011 1:55:24 PM |

    Sorry you see it that way. This was a comment directed at the system of primary care in general.

    I reread the post and I didn't see the name "Dr. Thomas White" mentioned anywhere. If you choose to feel slighted in some way, that's your choice.

  • Kent

    8/19/2011 3:20:32 PM |

    Jan, I would certainly trust my care (or a family members care) to a NP or PA who looks outside just the pharma driven medical journals which primarily support a diagnose & drug philosophy.  And I'll take an NP or PA who actually uses some common sence rather than being a puppet given to the pushy drug rep.

    I live in a family of MD's, and they have made it clear as to their terribly limited training and knowledge they gain from med school on the level of building and supporting the body from within.  Example, I have an Aunt that is currently suffering from stage 4 cancer. Due to the chemo treatment that she's instructed to not spend time in the Sun. Her Dr. has not even checked her for vitamin D levels. This is not the exception, but the norm when it comes to common sence treatment, pathetic.

  • Joe

    8/19/2011 6:56:14 PM |

    Okay, Dr. Davis.  I'll be looking for it. When you do, please take a moment and explain how you think that sugar might be responsible for plaque rupture.
    Thanks again!

    Joe

  • steve

    8/19/2011 7:06:59 PM |

    Sugar is just one part of the equation.  As Dr. Davis has covered on this website, small LDL is also a villian and needs to be minimized as much as possible.

  • Might-o'chondri-AL

    8/19/2011 8:05:24 PM |

    Hi Joe,
    Thanx for the video ... maybe the following answers you.

    Regarding sugar: see 59:33 into presentation, where diagram shows "sugar" blurb  - lecturer is using compact word sugar to represent how glucose's glycation end products alter the artery and make the artery vulnerable. It is not a molecule of sugar acting all by itself; lecturer explains slide when talks of how glycation is a problem (another of  Doc Davis'  peeves).

    Follow up at 1:01 into presentation: see diagram's top left  where the various adverse influences on artery  are specified as "modified lipoprotein", "hemodynamic insult" (includes, but is not limited to blood sugar's  glycation end products affect on artery), "reactive oxygen species" (ROS) and "infectious agents".

  • Thomas White

    8/20/2011 12:22:15 PM |

    Thank you for all your hard work and dedication to your web site and education.

    I apologize for cluttering up the discussion with a personal statement.

    TRW

  • Joe

    8/20/2011 4:13:56 PM |

    Thank you, Might. I guess I'm going to have to do some research on glycation before I can fully understand what you're saying above.

    I didn't even notice the PowerPoint Presentation that was included with Dr. Diamond's video presentation.  Sigh.

    Thanks again!

    Joe

  • Jim

    8/20/2011 7:55:03 PM |

    AMEN! Right on target.

  • Louis

    8/23/2011 2:05:01 PM |

    I don't know if you're aware of the differences between calculated test that most doctors use and NMR that Dr. Davis uses. When your diet consists of mostly carbohydrates leading to chronic high blood sugar level, it tends to raise your SMALL DENSE LDL level but calculated cannot measure it accurately. It often greatly underestimate it.  Dr. Davis has covered it many times. Dig through his website for it.

  • Louis

    8/23/2011 2:16:27 PM |

    Optimal vitamin D level helps lower IL-6. It can be a big problem with black people as they tend to have the lowest vitamin D level of any races. Dr. Cannell mentioned that in his new book called Athlete's Edge Faster Quicker Stronger with vitamin D with the hope that the word about vitamin D would spread out faster if more and more professional athletes started using it to gain some advantage over opponents much like what East Germany and formerly USSR used to do in 1960 and 1970s at the Olympic games and other world events.

  • live-healthcare

    8/27/2011 4:31:48 AM |

    Yes Joe i have seen the video you linked. That's right i also think the same.

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Statin mono-failure

Statin mono-failure

Evan's first heart scan score in November, 2006 yielded a high score for a 56-year old male: 542.

So he put up little fuss when his doctor prescribed simvastatin at a high dose.

Evan's LDL cholesterol before simvastatin: 158 mg/dl

Evan's LDL cholesterol on simvastatin: 72 mg/dl.

By conventional standards, Evan has had an excellent response. The rest of his lipid (cholesterol) panel was unrevealing: HDL 62 mg/dl, triglycerides 78 mg/dl. Evan doesn't smoke, has a normal blood pressure, and he is not diabetic. That should do it, right?

So his doctor thought. So Evan asked if another heart scan was in order. In December, 2007, after one year of simvastatin, his second heart scan score: 705--a 30% increase over one year.

Recall that, with no effort at prevention whatsoever, the natural progression of heart scan scores is a 30% per year increase. Did simvastatin do nothing?

This is quite typical of people who do nothing more than take a statin drug. While some people do slow plaque growth (we say "decelerate") modestly on a statin drug, Evan's experience is not unusual: plaque continues to grow despite high-dose statin drug and an apparently favorable cholesterol panel.

In fact, I can count the number of people who reduced their heart scan scores taking a statin drug alone on one finger.

Statins do not represent a cure for heart disease. They cannot be used as sole therapy to reduce risk for heart attack. In fact, given sufficient time, the majority of people who do nothing more than follow this standard line of treatment (along with the equally lame low-fat diet, etc.) will have done nothing more than postpone their heart attack. Elimination of risk? Nope.

This is among the reasons we developed the Track Your Plaque approach. While not foolproof, I know of no better approach to seize control over plaque growth.

Additional conversations on clinical studies which, as with Evan's experience, demonstrated how statin drugs fail to slow plaque growth can be found in previous Heart Scan Blog posts:

Don't be satisfied with "deceleration"

Study review: Yet another Lipitor study



Copyright 2008 William Davis, MD

Comments (6) -

  • BarbaraW

    2/1/2008 4:01:00 PM |

    Dr. Davis,
    Have you seen the recent statin drug articles?  

    There's the NY Times response section to Tara Parker-Pope's January 29th article "Great Drug, but Does It Prolong Life?"?  The comments (blog) area is called "Will Cholesterol Pills Save Your Life?" and the cross-section of responses is fascinating.  Here's the link:
    Will Cholesterol Pills Save Your Life?

    And the January 17th Business Week cover story "Do Cholesterol Drugs Do Any Good?"

    It's disturbing to read comments from the people who have had such dreadful problems with statin drugs, but it's good on many levels to see the topic of statin use getting aired in major publications.

  • Dr. Davis

    2/1/2008 4:05:00 PM |

    Hi, Barbara--

    Waht bothers me is that, with the re-examination of LDL and statin drugs, I believe the media has also gotten it wrong.

    The basic problem--beyond bald profiteering by drug companies--is that LDL is a calculated, you might say "fabricated", number that often bears little resemblance to reality. Yet the $27 billion (annual revenues) statin industry is built on treatment of this number.

  • Anonymous

    2/1/2008 7:05:00 PM |

    I think I remember reading in Malcolm Kendrick's work that post mortem studies showed that people on statins  had as much if not more plaque than non-statin users, and that the plaques were smaller in number, but bigger in size. Statins causing plaque stabilisation (less likely to rupture) but not a reduction in plaque quantity??

    Neil

  • Anonymous

    2/1/2008 10:34:00 PM |

    Very interesting, as you know Dr. Agaston believes there is no such thing as reversal and says in his South Beach Heart book that if you get your plaque down to a less than 10% INCREASE per year you have done everything you can to stop your risk of heart attack. he considers that the goal !!!!

  • Dr. Davis

    2/2/2008 6:31:00 AM |

    Dr. Agatston has made a major contribution to the national discussion on diet. But I'm afraid that he is flat wrong on the issue of whether heart scan scores can be stopped or reduced. I've seen substantial drops of heart scan scores in many people.

  • Lily

    2/5/2009 7:57:00 PM |

    So, if your doctor says you need to take a statin and you don't have insurance, what do you do?  I found a very good prescription discount card at www.rxdrugcard.com.  I pay only $9 for my Simvastatin.  That's a great discount.  They have discounts on brands too, but their generic prices are great!

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Damage control

Damage control

Medical device manufacturer, Cordis, is launching a new marketing program to promote its Cypher drug-coated stent. You can view the details at www.CypherUSA.com , including the slick TV commercial that HeartHawk posted a blog about.

The campaign opens with:

When you open up your heart, you open up your life.

Lives hampered by angina. By shortness of breath. By restricted blood flow. These lives are changing. Because of a state-of-the-art advancement. One that can have a huge impact on arteries around your heart. The CYPHER® Stent. It can open up your arteries. Increase flow of blood and oxygen. And change your restricted life. To an active life worth living. Your new life is...

Life Wide Open


Direct-to-consumer drug advertising has been around for a few years. While it has increased awareness of drugs and the "conditions" they are supposed to treat, it has also highlighted the aggressive profit-motive of the drug industry. This is not health care for the needy and sick, but health care for profit.

So now we're beginning to see the emergence of direct-to-consumer (DTC) advertising for medical devices. There was also a brief, though unsuccessful, foray into DTC advertising for implantable defibrillators, of all things, by Medtronic a couple of years ago, also.

What is the purpose of Cordis' marketing effort? Is it to educate and inform the public who might unknowingly receive non-drug coated stents and be deprived of the restenosis-inhibiting advantage of a drug-coated device? Is it meant to right a systematic wrong, a failure of cardiologists to insert the technologically, biologically, and ethically superior coated stents?

I find that doubtful. A more likely motive is damage control. With some of the (both deserved and undeserved) negative press the drug-coated stents have received lately, Cordis, eager to protect their $20 billion (annual revenues, 2006) medical device franchise, came up with this DTC strategy. After viewing the smiling faces of people , elated because of their "wide open" arteries and lives, Cordis hopes to see people going to their doctors insisting on the stent that is "opening millions of lives," since, "when your arteries narrow, so does your life."

Cool, trendy, liberating. That's the message they wish to deliver. Cool music, beautiful people, flashy high-tech images. Who wouldn't want a Cypher stent?

Beyond damage control, it's a familiar marketing theme: You're slender, glamorous, and sexy if you drink Coke, you're a caring mother if you feed your children Jif peanut butter, you're health conscious and smart if you eat Total cereal . . . you're cool and know what you want from life if you insist on a Cypher stent.

I don't object to advertising. It's part of the capitalistic economic system. It drives awareness and grows businesses. I do get concerned when advertising is so slick and effective that the people who are not properly armed with information can be duped into thinking that they need something that they don't really need.

Or, for which there are powerful, viable alternatives. Even hear about "prevent the disease in the first place?"

Comments (5) -

  • Sue

    12/16/2007 1:59:00 AM |

    "Prevent the disease" - it will affect the profits - lets make sure the disease takes hold and progresses!!  For just $999 (first instalment) you too can have your very own stent - limited lifetime guarantee!!

  • jpatti

    12/16/2007 2:20:00 PM |

    Do people really do this?  I can see going for a checkup and asking for a particular medication, but is someone in a cath lab being prepped for surgery really gonna ask for a particular brand of stent?

  • Dr. Davis

    12/16/2007 2:29:00 PM |

    Yes. I've actually been asked that question a number of times.

  • Anonymous

    12/16/2007 10:15:00 PM |

    I agree with your comments. Three months ago I had an overly aggressive cardiologist put 5 Cypher stents in me. My current, new cardiologist says that I only needed one and wants to do another angiogram in 3 months (6 months after the procedure) to check for scar tissue. Is that unusual?  I am getting wary of medical procedures.

  • Dr. Davis

    12/17/2007 2:16:00 AM |

    Without knowing full details of your case, it's not possible to say with absolute confidence what is going on. However, it is highly unusual to perform a "routine" repeat catheterization to check for scar. That is not a standard reason for heart catheterization. The same information can nearly always be obtained by less invasive means, such as a stress test or echocardiogram.

    I wonder if it's time for a 3rd opinion.

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More catheterizations would make me happy!

More catheterizations would make me happy!

I received this fax today from a cardiologist seeking a position:

"I would prefer to perform as many interventions [stents, angioplasties, etc.] as possible..."

That about sums it up, doesn't it? The goal of this young man, trained in major universities including Columbia University, Harvard, and Emory, is not to pursue an avenue of investigation or healthcare that yields real answers. His goal is to perform as many procedures as possible.

This attitude is deeply ingrained in cardiologists. It's also shared by all procedural medical specialties: the drive to do more and more procedures. It's not because it does more good for the public, but it fulfills a primitive impulse to spread your influence, enlarge your territory, and--of course--make more money.

Personally, I find this impulse repulsive. The fact that this young cardiologist looking for a position is willing to make this statement out in the open demonstrates how widely accepted this attitude is. Imagine your cancer surgeon, looking for a new job, said, "I'm looking to remove as many tumors as I can."

My colleagues have lost sight of the fact that we're trying to reduce or eliminate disease, not enrich our pockets or service some primitive impulse to beat others at our game.
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Are there any alternatives to niacin?

Are there any alternatives to niacin?

In the Track Your Plaque program, we tend to rely a great deal on niacin. When used properly, 90-95% of people will do just fine and achieve their lipid and lipoprotein goals with the help of niacin, along with their other efforts.

Unfortunately, around 5% of people simply can't take niacin without intolerable "hot flush" effects, or occasionally excessive skin sensitivity--itching, burning, etc.

Why does this happen? These 5% tend to be "rapid metabolizers" of niacin, i.e. they convert niacin (nicotinic acid, or vitamin B3) into a metabolite called nicotinuric acid. Nicotinuric acid is the compound responsible for the skin flush. Most people can slow or reduce the effects of nicotinuric acid by:

--Taking niacin with dinner, so that food slow tablet dissolution.

--Taking with plenty of water. Two 8-12 oz glasses usually eliminates the flush entirely in most people.

--Taking with an uncoated 325 mg tablet of aspirin in the first few weeks or months. Eventually, you will need to revert back to a better stomach tolerated dose of 81 mg, preferably enteric coated. But a full 325 mg uncoated can really help in the beginning, or when you have any niacin dose increases, e.g., 500 mg to 1000 mg.

But even with these very effective strategies, some people still struggle. That's when the question arises: Are there any alternatives to niacin?

Well, it depends on why niacin is being used. If you and your doctor are using niacin for:

Raising HDL--Then weight loss to your ideal weight; reduction of processed carbohydrates, especially wheat products; avoidance of hydrogenated ("trans") fats; a glass or two of red wine per day; dark chocolates (make sure first ingredient is chocolate or cocoa, not sugar), 40 gm per day; fish oil; exercise; other prescription agents (fibrates like Tricor; TZD agents for diabetes; cilostazol (Pletal)). Niacin is by far the most effective agent of all, but, if you're intolerant, raising HDL is still possible through a multi-faceted effort.

Reduction of small LDL--The list of effective strategies is the same as for raising HDL, but add raw almonds (1/4-1/2 cup per day), oat bran and other beta-glucan rich foods like oatmeal. Reduction of processed carbohydrates is especially important to reduce small LDL.

Reduction of Lipoprotein(a)--This is a tricky one. For men, testosterone and DHEA are effective alternatives; for women, estrogen and perhaps DHEA. Hormonal preparations of testosterone and estrogen are stricly prescription; DHEA is OTC. I have not seen the outsized benefits on lipoprotein(a) claimed by Rath et al by using high-dose vitamin C, lysine, and profile, unfortunately. We are clearly in need of better alternatives to treat this difficult and high-risk disorder.

Reduction of triglycerides/VLDL/IDL--I lump these three together since they all respond together. If you're niacin intolerant, maximixing your fish oil can be crucial for reduction of these patterns using doses above the usual starting 4000 mg per day (providing 1200 mg EPA+DHA). Reduction of processed carbohydrates, eimination of processed foods that contain high-fructose corn syrup, and weight loss to ideal weight are also very effective. "Soft" strategies with modest effects include green tea (>6 cups per day) or theaflavin 600-900 mg/day; raw nuts like almonds, walnuts, and pecans; exercise; soy protein.

Reduction of LDL--Lots of alternatives here including oat bran (3 tbsp per day), ground flaxseed (3 tbsp per day), soy protein (25 grams per day), Benecol butter substitute (for stanol esters), soluble fibers like pectin, psyllium, glucomannan; raw nuts like almonds, walnuts, and pecans.

In future, should torcetrapib become available (by prescription), this will add to our available tools for these areas when niacin can't be used. Until now, the alternatives to niacin depend on what you and your doctor are trying to achieve. In the vast majority of cases, HDL, small LDL, triglyceride, etc. goals for heart scan score control can be achieved, even when niacin is not well tolerated.
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