Fat Head: Tom Naughton's manifesto for low-carb eating

12. March 2010 William Davis (16)
I just got back from Jimmy Moore's low-carb cruise to the Bahamas.

Among the many interesting people I met on the cruise was the creator of the documentary film, Fat Head, Tom Naughton.

Tom brings both creative insights into low-carbohydrate eating as well as humor. Low-carb eating can be a pretty contentious issue, but Tom made it fun. He will make you laugh about many of the odd notions we have about diet.

Among the best parts of Fat Head is Tom's portrayal of the effects of carbohydrates on insulin and fat metabolism:






Fat Head joins the ranks of films like Food, Inc, that make nutrition information entertaining. For anyone interested in a unvarnished look at diet, weight loss, along with a few laughs along the way, Tom Naughton's Fat Head is worth viewing.

Oatmeal: Good or bad?

11. March 2010 William Davis (67)

You've heard it before: oatmeal reduces cholesterol. Oatmeal producers have obtained permission from the FDA to use a cholesterol-reducing claim. The American Heart Association provides a (paid) endorsement of Quaker Oats.

I've lost count of the times I've asked someone whether they ate a healthy breakfast and the answer was "Sure. I had oatmeal."

Is this true? Is oatmeal heart healthy because it reduces LDL cholesterol?

I don't think so. Try this: Have a serving of slow-cooked (e.g., steel-cut, Irish, etc.) oatmeal. Most people will consume oatmeal with skim or 1% milk and some dried or fresh fruit. Wait an hour, then check your blood sugar.

If you are not diabetic and have a fasting blood sugar in the "normal" range (<100 mg/dl), you will typically have a 1-hour blood glucose of 150-180 mg/dl--very high. If you have mildly increased fasting blood sugars between 100 and 126 mg/dl, postprandial (after-eating) blood sugars will easily exceed 180 mg/dl. If you have diabetes, hold onto your hat because, even if you take medications, blood sugar one hour after oatmeal will usually be between 200 and 300 mg/dl.

This is because oatmeal is converted rapidly to sugar, and a lot of it. Even if you were to repeat the experiment with no dried or fresh fruit, you will still witness high blood sugars in these ranges. Do like some people and pile on the raisins, dried cranberries, or brown sugar, and you will see blood sugars go even higher.

Blood sugars this high, experienced repetitively, will damage the delicate insulin-producing beta cells of your pancreas (glucose toxicity). It also glycates proteins of the eyes and vascular walls. The blood glucose effects of oatmeal really don't differ much from a large Snickers bar or bowl of jelly beans.

If you are like most people, you too will show high blood sugars after oatmeal. It's easy to find out . . . check your postprandial blood sugar.

In past, I recommended oat products, specifically oat bran, to reduce LDL, especially small LDL. I've changed my mind: I now no longer recommend any oat product due to its blood sugar-increasing effects.

Better choices: eggs, ground flaxseed as a hot cereal, cheese (the one dairy product that does not excessively trigger insulin), raw nuts, salads, leftovers from last evening's dinner.

Mustard: Super health food?

6. March 2010 William Davis (32)
Could mustard--yes, the yellow condiment you smear on hot dogs--be a super heart healthy food in disguise?

Consider that mustard contains:

Vinegar

Turmeric

No appreciable sugar


The vinegar slows gastric emptying, resulting in slower absorption of any carbohydrates and a reduced glucose area-under-the-curve. Of the little fats contained (about 3 grams per 1/4 cup), most are desirable monounsaturates. Mustards are relatively rich in selenium, with 20 mcg per 1/4 cup, helpful for protection against cancer and thyroid disease, and magnesium, 31 mg per 1/4 cup.

Turmeric is added to most mustards. One of the constituents of turmeric, curcumin, the substance that confers the bright yellow color, has been a focus of interest for its anti-inflammatory effects. Curcumin has been documented to reduce activity of the inflammatory enzymes cyclooxygenase-2 (COX-2), lipoxygenase, and reduce activity of inflammatory signal molecules, tumor necrosis factor-alpha (TNF-a), interleukin (IL)-1,2,6,8, and 12, and monocyte chemoattractant protein (MCP). Curcumin also has been shown to reduce LDL oxidation, a potentially important step in atherosclerotic plaque formation. Turmeric is used as a tea by Okinawans. (Hmmmm . . . )

Turmeric content of mustard can vary, of course. Likewise, sugar content. Look for mustards that are not sweetened, so avoid honey mustard in particular. Look for hot, brown, horseradish, Dijon, etc. If there is a downside to mustard, it's sodium content, though the 709 mg per 1/4 cup should only be a problem for those who are sodium-sensitive (African Americans, in particular).

So perhaps mustard isn't exactly a super health food. But it may have some bona fide health effects and should be used generously especially if you are concerned about blood sugar and inflammatory phenomena.

Exercise and blood sugar

5. March 2010 William Davis (30)
There is no doubt that exercise yields benefits across a spectrum of health: reduced blood pressure,  reduced inflammation, reduced blood coagulation, better weight control, stronger bones, less depression, reduced risk for heart attack.

Exercise also influences blood sugar. Diabetics understand this best: Exercise reduces blood sugar 20, 30, 50 or more milligrams. A starting blood sugar, for instance, of 160 mg/dl can be reduced to 80 mg/dl by jogging or riding a bicycle. (I recently had brunch at an Indian restaurant with my family. Blood sugar one-hour postprandial: 134 mg/dl. I was sleepy and foggy. I got on my stationary bike and pedalled at a moderate clip for 60 minutes. Blood sugar: 90 mg/dl.)

Could the reduction of blood sugar with exercise be THE reason that exercise and physical activity provide such substantial benefits?

Think about it. Reduced blood sugar:

1) Reduces risk for future cardiovascular events.
2) Reduces glycation of proteins, i.e., reduced glucose binding to proteins like the ones in artery walls and the lenses of your eyes.
3) Reduces blood coagulation
4) Reduces endothelial dysfunction (abnormal artery constriction that leads to atherosclerosis)

This might explain why it doesn't require high levels of aerobic activity to derive benefit from exercise, since even modest efforts (e.g., a 15-minute walk after eating) reduce blood sugar substantially.

The incredible 33-year, 18,000-participant Whitehall study tells us that a postprandial (after-eating) blood sugar of an impossibly-difficult 83 mg/dl is required to erase the excess cardiovascular risk of blood sugar. Could this simply be telling us that physical activity or exercise is required to suppress blood sugars to these low levels?

It makes me wonder if an index of the adequacy of exercise is your post-exercise blood glucose.

The most important weight loss tool

4. March 2010 William Davis (15)

Question: What is the most effective tool available to help you lose weight? 


A pedometer (walk 10,000 steps, etc.)?

A treadmill? 




A bicycle?






No. None of the above. 

The most important tool you can use to achieve weight loss is your glucose monitor:



Timing of blood sugars

3. March 2010 William Davis (5)
Because different foods generate different blood sugar (glucose) responses, the timing of your blood sugar is an important factor to consider.

This question has come up a number of times. Commenters have asked whether the one-hour postprandial glucose is timed with the start of the meal or the conclusion of the meal.

In my view, if we simply ignored all aspects of meal composition, then blood glucose should be obtained one hour after the conclusion of a meal. This is because most mixed meals (i.e., mixed in composition among proteins, fats, and carbohydrates) yield peak blood glucose levels at 60-90 minutes after consumption. Timing blood glucose to 60 minutes after the conclusion of a meal puts the sample right about at the peak.

But this is an oversimplification. For instance, here is the blood glucose behavior after so-called "complex" carbohydrates wheat bread, rye bread, rye made with beta glucan, and whole wheat pasta (50 grams carbohydrates each) in slender, healthy volunteers, mean age 29 years:


From Juntunen et al 2002

Note that blood glucose peaks at 35 minutes postprandial. (To convert glucose in mmol/L to mg/dl, multiple by 18. Thus, whole wheat bread increased blood glucose from 94 mg/dl to 122 mg/dl. Also note the lower peak glucose for pasta, but sustained higher glucose levels hours later.)

In another study, older (mean age 64 years), overweight (BMI 27.9) females with diabetes were given 50 grams carbohydrate, 50 grams carbohydrate with olive oil, or 50 grams carbohydrate with butter:


From Thomsen et al 2003. Control meal of soup plus 50 g carbohydrates ({blacktriangledown}), the control meal plus 80 g olive oil ({circ}), and the control meal plus 100 g butter (•).

In this experience, note that postprandial glucose peaks 60-120 minutes after the meals (consumed within 10 minutes), delayed more when either oil is included. Blood glucose started at 144 mg/dl and peaked as high as 230 mg/dl with carbohydrates only; peaks were reduced (along with AUC) when oil was included. (Note the differential effect, olive oil vs. butter.)

These two sets of observations give you a range of blood glucose behavior. One side lesson: Carbohydrates should never consumed by themselves, else you will pay with a high blood sugar (not to mention the hypoglycemic response later for many).

Psssst . . . There's sugar in there

1. March 2010 William Davis (13)
You non-diabetics who check your postprandial blood sugars already know: There are hidden sources of sugar in so many foods.

By now, everybody should know that foods like breakfast cereals, breads, bagels, pretzels, and crackers cause blood sugar to skyrocket after you eat them. But sometimes you eat something you thought was safe only to find you're showing blood sugars of 120, 130, 150+ mg/dl.

Where can you find such "stealth" sources of sugars that can screw up your postprandial blood sugars, small LDL, inflammation, blood pressure, and cause you to grow visceral fat? Here's a few:

Balsamic vinaigrette
Many commercially-prepared balsamic vinaigrettes, especially the "light" varieties, have 3 or more grams carbohydrates per tablespoon. Generous use of a sugar-added vinaigrette can therefore provide 12+ grams carbs. (Some, like Emeril's and Wish Bone, also contain high-fructose corn syrup.)

Hamburgers
I learned this lesson the hard way by taking my blood sugar after having a hamburger, turkey burger, or vegetarian burger (without bun): blood sugar would go way up. The effect is due to bread crumbs added to the meat or soy.

Tomato soup
If it were just tomatoes, it would still be somewhat high in sugars. But commercially-prepared tomato soup often contains added high-fructose corn syrup, sucrose, and wheat flour, bringing sugar totals to 12 to 20+ grams per half-cup. A typical 2-cup bowl of tomato soup can have upwards of 80 grams of sugar.

Granola
Sure, granola contains a lot of fiber. But most granolas come packed with sugars in various forms. One cup of Kellogg's Low-fat Granola with Raisins contains an incredible 72 grams (net) carbohydrates, of which 25 grams are sugar.


Given modern appetites and serving sizes, you can see that it is very easy to get carried away and, before you know it, get exposed to extraordinary amounts of sugar and carbohydrates eating foods you thought were healthy.

And don't be fooled by claims of "natural" sugar. Sugar is sugar--Just check your blood sugar and you'll see. So raw cane sugar, beet sugar, and brown sugar have the same impact as white table sugar. Honey, maple syrup, and agave? They're worse (due to fructose).

How low should blood sugar be?

28. February 2010 William Davis (0)
What should your blood sugar (glucose) be after eating?

Take a look at the data from the Whitehall study reported in 2006. The Whitehall Study stands apart from other studies in that it was very large (over 18,000 participants) who were observed for an unusually long time (33 years). All participants were administered a 50 gram glucose "challenge" at the start with glucose levels checked after the glucose challenge.

Here's what they found:




From Brunner et al 2006.
"Heart scans are experimental"

"Heart scans are experimental"

18. December 2007 William Davis (25)
Let me warn you: This is a rant.

It is prompted by a 44-year old woman. She has a very serious lipoprotein disorder. Her family experiences heart attacks in their 40s and 50s. I asked for a heart scan. Her insurance companied denied it.

This is nothing new: heart scans, like mammograms, have not enjoyed reimbursement from most insurers despite the wealth of data and growing acceptance of this "mammogram" of the heart.

However, 10 minutes on the phone, and the "physician" (what well-meaning physician can do this kind of work for an insurance company is beyond me) advised me that, while CT heart scans for coronary calcium scoring are not covered, CT coronary angiograms are.

Now, I've been witnessing this trend ever since the big players in CT got involved in the game, namely Philips, Siemens, Toshiba, and GE. These are enormous companies with hundreds of billions of dollars in combined annual revenues. They, along with the lobbying power of cardiology organizations like the American College of Cardiology, have gotten behind CT coronary angiograms. This is most likely the explanation of why CT coronary angiograms have rather handily obtaining insurance reimbursement. Interestingly, the insurance company I was speaking to is known (notorious?) for very poor reimbursement practices.

A CT heart scan, when properly used, generates little revenue, a few hundred dollars to a scan center, barely enough to pay for a device that costs up to $2 million. However, CT coronary angiograms, in contrast, yield around $2000 per test. More importantly, they yield downstream revenues, since CT angiograms are performed as preludes to conventional heart catheterizations, angioplasty, stents, bypass surgery, etc. Now we're talking tens or hundreds of thousands of dollars revenue per test.

What puzzles me is that much of that increased cost comes out of the insurance company. Why would they support such tests if it exposes them to more costs? I'm not certain. It could be the greater pressures exerted by the big CT companies and powerful physician organizations. I seriously doubt that the insurance companies truly believe that heart scans for coronary calcium scoring are "experimental" while CT coronary angiograms are "proven." If all we did was compare the number of clinical studies that validate both tests, we'd find that the number of studies validating heart scans eclipses that of coronary angiograms several fold. Experimental? Hardly.

The smell of money by physicians eager to jump on the bandwagon of a new revenue-producing procedure is probably enough to have them lobby insurers successfully. In contrast, plain old heart scans just never garnered the kind of vigorous and vocal support, since nobody gets rich off of them.

If CT coronary angiograms are sufficiently revenue producing that my colleagues and the CT scanner manufacturers have managed to successfully lobby the health insurers, even one as financially "tight" as the one I spoke to today, well then I take that as testimony that money drives testing, as it does the behavior of hospitals, many of my colleagues, and can even force the hand of insurers.
Tags :

Comments (25) -

  • Cindy Moore

    12/19/2007 12:51:00 AM |

    It seems like everything medical is profit driven!!  One of my biggest irritants with insurance companies is the unwillingness to act pro-actively and approve preventative procedures, treatments, etc.

    They spend a fortune each year on statins, but won't cover heart scans. They spend millions on coronary bypass, PTCA, etc but they won't pay for inpatient smoking cessation programs, and many still have no coverage for lifestyle change programs!!

  • Peter

    12/19/2007 6:14:00 AM |

    Nice post this one. Just keep telling yourself; there is no conspiracy. The depth of complexity generated by billions of often quite small acts of personal greed, when combined together, does behave like a coherent plan. Eventually there may be studies looking at this as a phenomenon in its own right. The further out of the mainstream that you live, the more interesting it becomes to consider the hows and whys. No conspiracy, just human greed. Some small quanta of greed, some enormous. You even get personal greed combined with the will to do general good. Very complex.

    Peter

  • Anonymous

    12/19/2007 9:35:00 AM |

    Years ago, my baby was in NICU with a condition that seriously affected his immune system; the drs wanted him on breast milk to help boost the immune system, and since I wasn't always at the hospital anymore (I had returned to work by then), the drs wrote an order for a breast pump.

    Since I worked in that field, I asked the lactation specialist for a catalog of pumps from the same company the insurance company used, and found out the pump I *wanted* cost $300, but the pump the insurance comp wanted me to have cost $1000. I asked the lacto nurse about the pumps, and the cheaper one (shaped like a large purse with a shoulder strap) worked just as good as the more expensive pump (a boxy machine attached to a wheeled pole, like a short IV pole) was better if there were going to be many women pumping.

    Since it was just going to be me pumping, and the cheaper pump was so much easier to transport to work, I asked the insurance company if I could have the $300 version. They denied it, and I had to contest it with my lacto-specialist coworker's written letter that the cheaper one would work just as well.

    The insurance company's nurse told me she was glad I contested it with a letter from a lacto-specialist, because now the company would save money on pumps.

    WOW! It took somebody that had experience in that field with access to a specialist just to get an insurance company to change to a much cheaper, but just-as-effective, medical device. So your story doesn't surprise me at all. Insurance companies are either getting kickbacks, have too many layers of bureaucracy to approve anything different, or might just be dumb sometimes.

    S

  • Anonymous

    12/19/2007 12:43:00 PM |

    How did we get to this point that revenue generation overrides the care of patients?  Can we blame Hollywood for creating a myth of the health care provider that knows it all and worries endlessly over the health of patients, government and insurance companies not giving enough oversight over hospital practices, and/or patients not questioning enough the motives of health care providers?  What ever the answer, I imagine future generations will read about these times and cringe over the health care practices of today.

  • keith

    12/19/2007 1:21:00 PM |

    I asked my cardiologist to order a scan for me in a big boston hospital. My insurance wouldn't cover it until enough "risk factors" were documented on the claim form. The test was $270, money very well spent.

    What is sad is that most people believe patients' health is the medical community's primary concern. Also, interestingly, those with marginal insurance are forced to advocate for themselves and as such can, perversely, end up with better care.

    keith

  • Dr. Davis

    12/19/2007 1:24:00 PM |

    I truly get the sense that there are factors present that we are not privy to: behind-the-scenes maneuvering, closed-door politics, etc. It's surely not always in a health insurer's best interests to follow the policies often in place. So we can only conclude that something fishy is going on.

  • Dr. Davis

    12/19/2007 1:25:00 PM |

    You could be right.

    An inadvertent, collective evil?

  • Dr. Davis

    12/19/2007 1:37:00 PM |

    Yes, Keith. You make a crucial point.

    Caveat emptor, whether it's in the doctor's office, hospital, or used car lot. Watch your wallet and recognize that they all share one thing: they are profit-seeking operations with your welfare second.

  • Thomas

    12/19/2007 3:05:00 PM |

    This is NOT a defense of insurance cos, just an attempt to explain their possible thinking. One reason for an objection to CT heart scans is because there could be potentially very many ordered, relative to CT/angiograms. It is like a pyramid, with a much greater number of lower cost procedures resulting in a higher amount of claims submitted, and higher overall cost experience. So, they say no.

    I don't think insurance cos. engage in collusion with equipment makers or doctors. They just use a logic that isn't necessarily in my or your best interests.

  • Mike

    12/19/2007 3:36:00 PM |

    That is one reason that I am against mandatory medical insurance. The patient and doctor should decide what medical care is appropriate, not an insurance company.

  • Dr. Davis

    12/19/2007 4:55:00 PM |

    It may indeed be as simple as that. And, in fact, that is what I told many people who were frustrated by their insurer's failure to reimburse heart scans. However, more recently, I have begun to wonder if there is more to this question. I've just witnessed this phenomenon too often: When big money is involved, things happen. Heart scans do not make big money for anybody. CT angiograms provide potential for lots of big money.

  • Michael

    12/19/2007 7:54:00 PM |

    Out of curiosity, do insurance companies ever pay for heart scans, if they are considered high risk? That is, have had a heart attack, extremely high lipids, or some other heart disorder?

    The only rationale I can imagine for declining calcium scans, while paying for full CT scans, is what Thomas suggested -- it's a numbers game. Since generally speaking, only high risk people get CT scans, the numbers are relatively low. If everyone got calcium tests (although in the long run it'd pay off for them), insurance companies would have to pay a lot out of pocket now.

    But... if insurance companies paid for calcium scans for high risk people, it'd make sense both in the short and long term for them, I'd think. Then again, in my own experience, I find the behavior of my health insurance company bizarre. They'll gladly pay for physician visits/testing even when I tell them the doctor never actually did those things... yet decline certain tests I need just because less reliable (and cheaper) alternatives exist.

  • Thomas

    12/19/2007 11:52:00 PM |

    The evolution of the marketing and ins. coverage will be interesting to watch. For example, a hospital in the Chicago suburbs markets a 64 slice CT scan direct to the public for $99. No doctor referral needed. You can bet they figure stress tests and angios will follow. Nonetheless, you can get the scan about as cheap as possible.

    In my town far away, cardiologists won a turf war with radiologists to be the exclusive readers of these tests, and they aren't being marketed. And, the tests aren't on sale either. Local politics, and the ability to control patient flow, is probably the most important driver, but if you live in a large metro area, you may find what you're looking for at a decent cost.

  • Dr. Davis

    12/20/2007 4:54:00 AM |

    Some insurers do try and distinguish who is "high risk" or not, depending on conventional risk factors.

    Of course, the difficulty is that conventional risk factors fail to identify many people truly at high risk for heart disease and heart attack. In effect, health insurers have legislated who can or cannot obtain reimbursement for a heart scan.

  • MAC

    12/20/2007 8:11:00 AM |

    I have heard it expressed that insurance companies have no interest in preventative medicine. The benefits are too long term for them to see the results. People change jobs, change insurance carriers, etc.

  • Dr. Davis

    12/20/2007 12:37:00 PM |

    Yes, I believe that is true. From their perspective, better to pay lots for the occasional catastrophe rather than pay for the many more who would use preventive services. Insurance is not in our best interests, but of the collective financial good.

  • Anonymous

    12/20/2007 5:36:00 PM |

    Three years ago I had a stress test done due to chest pains and triglycerides as a risk factor.  I ended having an area of concern and my doctor wanted to do a CTA.  The insurance company approved it and I was all set up to go when I mentioned the test to my allergist.  She was concerned that I may have a reaction to the contrast dye, so the CTA was canceled and they sent me for a calcium score test.  The insurance company wouldn't pay the $195 for the test even though they were ready to pay a few thousand for the CTA!  Anyhow I came back with a big fat 0 for the test so the money was worth the piece of mind.

  • Dr. Davis

    12/21/2007 2:40:00 AM |

    What a great example of how useful cheap, simple heart scans can be. You also spared yourself over 90 chest x-rays of radiation.

  • g

    12/21/2007 4:26:00 AM |

    The latest Oprah mag Jan 2008 has this article about the first sign of heart disease/obstruction is 'fatigue' and reports that the MD may order a heart 'CT scan'... (this health writer is on TOP OF HER GAME -- unlike DR. Oz!!)

    Don't read the proposed 'treatment' -- the writer is not apparently informed on TYP yet!

    http://www.oprah.com/health/omag/health_omag_200801_fatigue_102.jhtml
    Most Often Overlooked Causes of Fatigue (2 or 4)

    Heart Trouble

    Fatigue is a distinct characteristic of cardiovascular disease in women, according to recent research. In one study of 515 female heart attack survivors, 70 percent reported unusual fatigue in the weeks before; just 57 percent had acute chest pain. In another study, fatigue was a symptom for women with dangerously clogged arteries that escaped notice on heart scans.

    Why it's overlooked: Only one in ten women realizes that heart disease is her biggest health threat. And emergency room doctors are six times more likely to give women with serious heart problems (as opposed to men) a clean bill of health.

    Other Symptoms: Shortness of breath. Indigestion. Pain in your shoulder, arm, or jaw. But for many women, nothing at all.

    Tests: Your doctor will order an exercise stress test or angiogram if she suspects clogged arteries in your heart. Because that test isn't always accurate in women, she may order a CT scan or echocardiogram as well. She'll also test your cholesterol, blood pressure, and blood sugar—diabetes can quadruple a woman's heart risk.

    Treatment: You may get a cholesterol-lowering statin and medicines to treat blood pressure, such as diuretics. You'll also be advised to follow a heart-healthy diet and get regular exercise.

    From Why Am I So Tired? in the January 2008 issue of O, The Oprah Magazine.

    THANK YOU! g

  • g

    12/22/2007 4:30:00 PM |

    FYI... Recent pubs -- 12/1/2007 and 12/15/2007 respectively

    Merry Xmas Dr. Davis! You have many buddies in more progressive countries! Regards, g

    (1) Non-invasive screening for coronary artery disease: calcium scoring
    Raimund Erbel1, Stefan Möhlenkamp1, Gert Kerkhoff2, Thomas Budde2, Axel Schmermund3
    http://heart.bmj.com/cgi/content/
    extract/93/12/1620

    Despite the decrease in overall mortality from coronary artery disease, the number of out-of-hospital deaths from myocardial infarction is in the range of 60% of all infarct related case fatalities.1 In patients with known risk of sudden cardiac death (SCD), such as survived resuscitation, left ventricular aneurysm or low left ventricular ejection fraction, the incidence of SCD is in the region of 30% per year. In the general population, it is only 0.5% per year.2 However, the absolute number in this group is 10 times higher than in the patient population with known SCD risk, reaching more than 300 000 case fatalities per year in the USA.2 Even renowned cardiologists such as Ronald W Campbellw1 and Jeffry M Isnerw2, who were experts on the topic of arrhythmias and myocardial infarction, suffered SCD. The MONICA (Monitoring trends and determinants in Cardiovascular disease) study reported that of all coronary . . . [Full text of this article]

    (2) Cardiac computed tomography: indications, applications, limitations, and training requirements

    Report of a Writing Group deployed by the Working Group Nuclear Cardiology and Cardiac CT of the European Society of Cardiology and the European Council of Nuclear Cardiology
    http://eurheartj.oxfordjournals.org
    /cgi/content/abstract/ehm544v1

    As a consequence of improved technology, there is growing clinical interest in the use of multi-detector row computed tomography (MDCT) for non-invasive coronary angiography. Indeed, the accuracy of MDCT to detect or exclude coronary artery stenoses has been high in many published studies. This report of a Writing Group deployed by the Working Group Nuclear Cardiology and Cardiac CT (WG 5) of the European Society of Cardiology and the European Council of Nuclear Cardiology summarizes the present state of cardiac CT technology, as well as the currently available data concerning its accuracy and applicability in certain clinical situations. Besides coronary CT angiography, the use of CT for the assessment of cardiac morphology and function, evaluation of perfusion and viability, and analysis of heart valves is discussed. In addition, recommendations for clinical applications of cardiac CT imaging are given and limitations of the technique are described.

  • g

    12/22/2007 4:42:00 PM |

    Another FYI...  HOLY MOLY This is why the lame Framingham misses the entire picture --- failure to take into acct that 70-80% of the population are on the Metabolic spectrum is like trying to see thru gauze blindfolds. very holey... (I guess it's good I can't access TYP right now... I'm spending my time otherwise well spent *ha*).  I LOVE the first line...'Coronary artery calcification is pathognomonic of coronary atherosclerosis.'  Hope you and your familia have a great holiday season -- full of wishes fulfilled and hope re-ignited!  Thanks for letting me loose *ha ha* Take care, g

    http://content.onlinejacc.org/cgi/
    content/abstract/50/23/2218

    J Am Coll Cardiol, 2007; 50:2218-2225(Published online 14 November 2007).

    CLINICAL RESEARCH: CORONARY ARTERY DISEASE
    Determinants of Progression of Coronary Artery Calcification in Type 2 Diabetes
    Role of Glycemic Control and Inflammatory/Vascular Calcification Markers
    Dhakshinamurthy Vijay Anand, MBBS, MRCP*,,*, Eric Lim, MBChB, MA, MRCP*, Daniel Darko, MD, MRCP, Paul Bassett, MSc, David Hopkins, BSc, MBChB, FRCP||, David Lipkin, BSc, MD, FRCP*,¶, Roger Corder, PhD, MRPharmS and Avijit Lahiri, MBBS, MSc, MRCP, FACC, FESC*
    * Cardiac Imaging and Research Centre, Wellington Hospital, London, United Kingdom

    Objectives: This study prospectively evaluated the relationship between cardiovascular risk factors, selected biomarkers (high-sensitivity C-reactive protein [hs-CRP], interleukin [IL]-6, and osteoprotegerin [OPG]), and the progression of coronary artery calcification (CAC) in type 2 diabetic subjects.

    Background: Coronary artery calcification is pathognomonic of coronary atherosclerosis. Osteoprotegerin is a signaling molecule involved in bone remodeling that has been implicated in the regulation of vascular calcification and atherogenesis.

    Methods: Three hundred ninety-eight type 2 diabetic subjects without prior coronary disease or symptoms (age 52 ± 8 years, 61% male, glycated hemoglobin [HbA1c] 8 ± 1.5) were evaluated serially by CAC imaging (mean follow-up 2.5 ± 0.4 years). Progression/regression of CAC was defined as a change 2.5 between the square root transformed values of baseline and follow-up volumetric CAC scores. Demographic data, risk factors, glycemic control, medication use, serum hs-CRP, IL-6, and plasma OPG levels were measured at baseline and follow-up.

    Results: Two hundred eleven patients (53%) had CAC at baseline. One hundred eighteen patients (29.6%) had CAC progression, whereas 3 patients (0.8%) had regression. Age, male gender, hypertension, baseline CAC, HbA1c >7, waist-hip ratio, IL-6, OPG, use of beta-blockers, calcium channel antagonists, angiotensin-converting enzyme (ACE) inhibitors, statins, and Framingham/UKPDS (United Kingdom Prospective Diabetes Study) risk scores were univariable predictors of CAC progression. In the multivariate model, baseline CAC (odds ratio [OR] for CAC >400 = 6.38, 95% confidence interval [CI] 2.63 to 15.5, p < 0.001), HbA1c >7 (OR 1.95, CI 1.08 to 3.52, p = 0.03), and statin use (OR 2.27, CI 1.38 to 3.73, p = 0.001) were independent predictors of CAC progression.

    Conclusions: Baseline CAC severity and suboptimal glycemic control are strong risk factors for CAC progression in type 2 diabetic subjects.

    Why did they NOT look at 25(OH)D when they were looking at the osteo- whatever thingy. *uurrgghh*

  • g

    12/22/2007 5:03:00 PM |

    I like this guy... he proposes heart CTs for all T2DM to screen for silent MIs. just like colon CA screening... and breast CA screening... wow ya think?

    CAD in most people esp T2DM is diffuse and systemic (maybe someday we can CAC someone's wrist like we do for Bone Mineral Density testing for osteopenia/porosis screening at the local drugstore?)... and very accelerated when glucose and insulin are elevated (without a good mod/high healthy MUFA PUFA diet and systemic TYP strategies).
    http://content.onlinejacc.org/cgi/
    content/abstract/49/19/1918

    Noninvasive Screening for Coronary Atherosclerosis and Silent Ischemia in Asymptomatic Type 2 Diabetic Patients
    Is it Appropriate and Cost-Effective?
    George A. Beller, MD, MACC*
    Cardiovascular Division, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia.

    Coronary artery disease (CAD) accounts for 65% to 80% of deaths in diabetic patients. The merits of screening asymptomatic type 2 diabetic patients for either Innocent the presence of coronary atherosclerosis by imaging of coronary calcification using cardiac computed tomography or (B) silent ischemia by stress myocardial perfusion imaging (MPI) remain controversial. Some observers have advocated for such noninvasive screening in at least the subset of the diabetic population who have significant clinical CAD risk factors, so that the highest risk patients for future cardiac events can be identified and offered more aggressive intensive medical therapy or coronary revascularization and optimum medical therapy. Computed tomography coronary calcium scanning could be the first noninvasive screening test in these clinically high-risk diabetic patients, followed by stress MPI to detect silent ischemia in those who exhibit high coronary calcium scores.

  • Dr. Davis

    12/23/2007 12:36:00 AM |

    Hi, G-

    As you see, some people in the medical community are waking up to the great usefulness of heart scans to detect hidden coronary plaque.

    However, it's going to be another five or more years before they also wake up to the idea of using it to TRACK the disease.

  • g

    12/23/2007 4:56:00 AM |

    Not unless you win global recognition for your achievements and TYP ...  Smile

    Can u imagine a world where the failure to offer TYP would be malpractice...for someone with diabetes? pre-diabetic? with Lp(a) or Homocysteinemia?  I do... and  who knows sooner than u might think.

    I think behind every genius-man, there stands a genius-woman. Once when I couldn't log on, couldn't access 'chat' and couldn't find reports when they were right in front of my *darn* NOSE... a wise woman told me 'you can't know everything.'  *ha ha* give her a hug for me Smile
    g

  • Anonymous

    1/2/2008 1:55:00 AM |

    Just a note to g regarding screening for osteoporosis at the wrist.  These are very ineffectual tests.  It is best to use the spine +/or hip as osteoporosis starts at the center of the body.  By the time it is detected in the distal extremities, you would already have significant bone loss. At least this is my understanding as a technologist. Could this also apply to artery disease?

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