Man walks after removing wheat

9. May 2010 William Davis (27)
No, this isn't some National Enquirer headline like "Woman delivers alien baby."

Tom is a 26-year old man with a complex medical condition, a malformation he was born with and has had reconstructed. Aside from this, he leads a normal life: works, is married, and is, in fact, quite intelligent.

He came to me for an opinion regarding his overall health. Tom was worried that his congenital condition would impair his long-term health and longevity prospects, so he wanted to optimize all other aspects of his health.

But, when I examined Tom, he could barely get himself up on the exam table without wincing in pain. When I asked him to walk, he hobbled a few steps, again clearly in pain. When I asked him what hurt, he said "everything." He said that all his joints hurt just to move.

He told me that his several doctors over the years didn't know why he was in such pain: It wasn't rheumatoid arthritis, gout, pseudogout, or any of the other inflammatory joint diseases that might account for virtually incapacitating this 26-year old man. Even the rheumatologists were stumped. It was also unrelated to his repaired congenital condition. So Tom went on with his life, barely able to even go for a walk with his wife without pain, slowing him down to the pace of an 80-year old.

So I suggested that he eliminate all wheat products. "I don't know for a fact whether it will work, Tom. But the only way to find out is to give it a try. Why not try a 4-week period of meticulously avoiding wheat? Nothing bad will come of it."

He and his wife look perplexed, but were so desperate for a solution that they agreed to give it a try.

Tom returned 6 weeks later. He walked into the room briskly, then bounded up on the exam table. He told me that, within days, all his joint pains had completely disappeared. He could walk, stretch, do all the normal physical things with none of the pain he had suffered previously.

Tom told me, "I didn't think it could be true. I thought it was just a coincidence. So I had a sandwich about 2 weeks into it. In about 5 minutes, I got about half my pains back."

Tom now remains wheat-free and pain-free, thankfully with no discernible joint impairment.

So, yes, Tom walked freely and without pain simply by eliminating wheat from his life.

Is it an immune phenomenon? Does wheat gluten trigger some inflammatory reaction in some people? There is surely something like this underlying experiences like Tom.

Wheat contains far more than gluten. Modern wheat is a collection of hundreds of different proteins, though gluten is the most plentiful, the one that confers the "viscoelasticity" of dough. But there's plenty more to wheat than gluten or celiac disease.

AGEing gracefully

5. May 2010 William Davis (32)
Advanced Glycation End-products, or AGEs, have the potential to change our entire conversation about diet.

AGEs come from two principal sources:

1) Endogenous--Glucose-protein interactions that arise from high blood glucose levels

2) Exogenous--From diet

The first is sensitive to glucose levels: the higher the glucose level, the greater the AGE formation. The second depends on the quantity of AGE in the food consumed.

A compelling body of evidence points towards AGEs as an agent of aging, as well as kidney dysfunction, dementia, and atherosclerosis. Some of the observations made include:

--If AGEs are infused into an experimental animal, it develops atherosclerosis, kidney disease, and other "diseases of senescence" within weeks to months.

--In endothelial cells (cells lining arteries), AGE induces expression of adhesion molecules and inflammatory signals. In fibroblasts, AGE provokes collagen production. In smooth muscle cells, AGE triggers migration and proliferation. In monocytes and macrophages, AGEs induce chemotaxis and release of inflammation mediators. In short, AGEs have been implicated in just about every step leading to atherosclerosis.

--In humans, greater quantities of AGEs are present in diabetics, pre-diabetics and people with insulin resistance. We all know that these people develop atherosclerosis, kidney disease, cataracts, and other conditions at an accelerated rate.

--Foods containing greater quantities of AGEs cause endothelial dysfunction, i.e., artery constriction via blockade of nitric oxide and other mechanisms.

Short of taking agents that block AGE activity, how can you minimize the absorption or production of AGEs? There are two general strategies:

1) Keep blood glucose low--The Whitehall study demonstrated increased cardiovascular mortality with a postprandial (actually 2-hour post- 50-gram glucose challenge) blood sugar of 83 mg/dl. Lower blood glucose, less glycation. Less carbohydrates in the diet, the lower the blood sugar, the less the glycation. Studies like Whitehall demonstrate that glycation begins with glucose values within the normal range. Thus, aging occurs even with normal glucose levels. It occurs faster with higher glucose levels.

2) Choose and prepare foods with lower AGE content. Food content of AGEs is a major determinant of blood AGE levels. Fats and meats are the primary dietary source of AGEs, particularly if cooked at high temperature (broiling, frying). While this does not mean that meats and fats need to be avoided, it can mean that limiting serving size of meats and fats, while being selective in how they are prepared, are important. This can mean cutting your meats in thinner slices or smaller pieces to permit faster cooking, eating rare when possible (not poultry, of course), avoiding cooking with sauces that contain sugar (which enhances AGE formation). Is this an argument in favor of sashimi?

Minimizing exposure to AGEs, endogenous or exogenous, has the potential to slow the aging process, or at least to lessen the likelihood of many of the phenomena of aging.

More on this to come.

Small LDL: Simple vs. complex carbohydrates

4. May 2010 William Davis (17)
Joseph is a whip-smart corporate attorney, but one who accepts advice at his own pace. He likes to explore and consider each step of the advice I give him.

Starting (NMR) lipoprotein panel on no treatment or diet change:

LDL particle number 2620 nmol/L (which I would equate to 262 mg/dl LDL cholesterol)
Small LDL 2331 nmol/L--representing 89% of LDL particle number, a severe dominance of small LDL

I advised him to eliminate wheat, cornstarch, and sugars, while limiting other carbohydrate sources, as well. Joseph didn't like this idea very much, concerned that it would be impractical, given his busy schedule. He also did a lot of reading of the sort that suggested that replacing white flour with whole grains provided health advantages. So that's what he did: Replaced all sugar and refined flour products with whole grains, but did not restrict his intake of grains.

Next lipoprotein panel with whole grains replacing white refined flour:

LDL particle number 2451 nmol/L
Small LDL 1998 nmol/L--representing 81.5% of LDL particle number.

In other words, replacing white flour products with whole grain products reduced small LDL by 14%--a modest improvement, but hardly great.

I explained to Joseph that any grain, complex, refined, or simple--will, just like other sugars and carbohydrates, still provoke small LDL. Given the severity of his patterns, I suggested trying again, this time with full elimination of grains.

Next lipoprotein panel with elimination of whole grains:

LDL particle number 1320 nmol/L
Small LDL 646 nmol/L--48.9% of total LDL particle number, but a much lower absolute number, a reduction of 67.6%.

This is typical of the LDL responses I see with elimination of wheat products on the background of an overall carbohydrate restriction: Big drops in precisely measured LDL as LDL particle number (i.e., an actual count of LDL particles, not LDL cholesterol) and big drops in the number of small LDL particles.

You might say that wheat elimination and limitation of carbohydrate intake can yield statin-like values . . . without the statin.

Is Cocoa Puffs no longer heart healthy?

29. April 2010 William Davis (17)
Until recently, Cocoa Puffs enjoyed the endorsement of the American Heart Association (AHA) as a heart-healthy food.

For a price, the AHA will allow food manufacturers to affix a heart "check mark" signifying endorsement by the AHA as conforming to some basic "heart healthy" requirements.

Odd thing: The list of breakfast cereals on the check mark program has shrunk dramatically. When I last posted about this, there were around 50-some breakfast cereals, from Cocoa Puffs to Frosted Mini Wheats. Now, the list has been trimmed down to 17:

Berry Burst Cheerios-Triple Berry
Cheerios
Cheerios Crunch
Honey Nut Cheerios
Kashi Heart to Heart Honey Toasted Oat Cereal
Kashi Heart to Heart Oat Flakes & Wild Blueberry Clusters
Kashi Heart to Heart Warm Cinnamon Oat Cereal
Multi Grain Cheerios
Oatmeal Crisp Crunchy Almond
Oatmeal Crisp Hearty Raisin
Quaker Cinnamon Life
Quaker Heart Health
Quaker Life
Quaker Life Maple & Brown Sugar
Quaker Oat Bran
Quaker Oatmeal Squares - Brown Sugar
Quaker Oatmeal Squares - Cinnamon


According to sales material targeted to food manufacturers, the American Heart Association boasts that "The American Heart Association’s heart-check mark is the most recognized and trusted food icon today . . . Eighty-three percent of consumers are aware of the heart-check mark. Sixty-six percent of primary grocery shoppers say the heart-check mark has a strong/moderate influence on their choices when shopping."

So, is Cocoa Puffs no longer heart healthy?

I suspect that agencies like the AHA, the USDA, the American Diabetes Association as starting to understand that they have blundered big time by pushing low-fat, having contributed to the nationwide epidemic of obesity and diabetes, and that it is time to quietly start backpedaling.

While it's a step in the right direction, judging from the above list of breakfast cereal "survivors" of the check mark program, the criteria may have been tightened . . . but not that much.

Fractures and vitamin D

27. April 2010 William Davis (25)
This is a bit off topic, but it's such an interesting observation that I'd like to pass it on.

Over the past several years, there have been inevitable bone fractures: People slip on ice, for instance, and fracture a wrist or elbow. Or miss a step and fracture a foot, fall off a ladder and fracture a leg.

People will come to my office and tell me that their orthopedist commented that they healed faster than usual, often faster than anyone else they've seen before. My son was told this after he shattered his hand getting slammed against the boards in hockey; his orthopedist took the screws and cast off much sooner than usual since he judged that healing had occured early. (My son was taking 8000 units vitamin D in gelcap form; I also had him take 20,000 units for several days early after his injury to be absolutely sure he had sufficient levels.)

My suspicion is that people taking vitamin D sufficient to enjoy desirable blood levels (I aim for a 25-hydroxy vitamin D level of 60-70 ng/ml) heal fractures much faster, abbreviating healing time (crudely estimated) by at least 30%.

For any interested orthopedist, it would be an easy clinical study: Enroll people with traumatic fractures, randomize to vitamin D at, say, 10,000 units per day vs. placebo, watch who heals faster gauged by, for instance, x-ray. My prediction: Vitamin D will win hands down with faster healing and perhaps more assured fusion of the fracture site.

T3 for accelerating weight loss

25. April 2010 William Davis (57)
Supplementation of the thyroid hormone, T3, is an underappreciated means to lose weight.

Thyroid health, in general, is extremely important for weight control, since even subtle low thyroid hormone levels can result in weight gain. The first step in achieving thyroid health is to be sure you are obtaining sufficient iodine. (See Iodine deficiency is real and Healthy people are the most iodine deficient) But, after iodine replacement has been undertaken, the next step is to consider your T3 status.

I've seen T3 ignite weight loss or boost someone out of a weight loss "plateau" many times.

Endocrinologists cringe at this notion of using T3. They claim that you will develop atrial fibrillation (an abnormal heart rhythm) and osteoporosis by doing this. I have yet to see this happen.

Adding T3 revs up metabolic rate at low doses. The idea is to push free T3 hormone levels to the upper limit of normal, but not to the hyperthyroid range. While an occasional person feels a little "hyper" like they've had a pot of coffee, most people just feel energized, clear-headed, and happier. And weight trends down much more readily.

Taking T3 by itself with no effort at weight loss generally yields only a modest weight reduction. However, T3 added to other weight reducing efforts, such as wheat elimination and exercise, accelerates the weight loss effect considerably. 5 lbs lost will likely be more like 8 to 10 lbs lost; 10 lbs lost will likely be more like 15 to 20 lbs, etc.

It's also my suspicion that more and more people are developing a selective impairment of T3, making it all the more important. I believe that you and I are being exposed to something (perchlorates, bisphenol A, perflurooctanoic acid, and others?) that may be impairing the 5'-deiodinase enzyme that converts the T4 thyroid hormone to the active T3. Relative lack of T3 leads to slowed metabolism, weight gain, and depressed mood. While avoiding or removing the toxin impairing 5'-deiodinase would be ideal, until we find out how to do this, taking T3 is a second best.

The tough part: Finding a prescriber for your T3.

The world according to the Wheat Foods Council and the Whole Grains Council

23. April 2010 William Davis (26)

You might get a kick out of what the Wheat Foods Council and the Whole Grains Council recommend for a sample meal plan:

Breakfast: Whole grain raisin toast
Lunch: Sandwich on whole grain
Snack: Rye bread crackers
Dinner: Whole grain pasta with your favorite sauce

Breakfast: Whole grain waffles 
Lunch: Hamburger on whole grain bun
Snack: Graham crackers
Dinner: Whole grain homemade pizza on whole grain pita crust

Remember Morgon Spurlock's documentary movie, Super Size Me? (If you haven't already seen it, Super Size Me is viewable for free on Hulu.) Spurlock conducts a self-inflicted 30-day experiment of eating at McDonald's fast food restaurants every day. In short, the results on Spurlock's weight and health are disastrous. 

How about Wheat Belly: The Movie? We would chronicle our star through a 30-day course of meals served up by the Wheat Foods and Whole Grains Councils, all featuring wonderful wheat products in every meal. We could measure blood sugar, triglycerides, LDL, small LDL, weight, etc.


Any predictions?

Why bananas increase cholesterol

21. April 2010 William Davis (0)
Anything that increases postprandial (after-eating) blood sugar will increase the number of LDL particles in the blood.

An increase in LDL particles is an important factor in causing heart disease: The greater the number of LDL particles, the more opportunity they have to interact with the walls of arteries, contributing to atherosclerosis.

Carbohydrates increase small LDL, especially if postprandial sugar is increased. Here's another way carbohydrates increase LDL particles: The duration of time LDL particles hang around in the blood stream is doubled.

When blood sugar increases, such as after the 30 grams carbohydrates in a medium-sized banana, glycation of LDL particles occurs. This means that a gglucose (sugar) molecule reacts with a lysine residue in the apoprotein B of the LDL particle. This induces a change in conformation that makes it less readily recognized by the LDL receptor. Thus, the glycated LDL particle persists for a longer period of time in the blood stream.

LDL particles are therefore cleared less efficiently, numbers of LDL particles increase.

Plant-based or animal-based?

19. April 2010 William Davis (78)
The ideal diet for heart and overall health restricts carbohydrate intake. I say this because carbohydrates:

Make you fat--Carbohydrates increase visceral fat, in particular.
Increase triglycerides
Reduce HDL
Increase small LDL particles
Increase glycation of LDL
Increase blood pressure
Increase c-reactive protein

Reducing carbohydrates reverses all the above.

But here's a common mistake many people make when following a low-carbohydrate diet: Converting to a low-carb, high-animal product diet.

It accounts for a breakfast of a 3-egg omelette with cheese and butter, 4 strips of bacon, 2 sausages, cream in coffee. Low-carb? It certainly is. But it is a purely high-animal product, no-plant-based meal.

I believe a strong argument can be made that a low-carbohydrate but plant-based diet with animal products as the side dish is a better way to go.

Consider that:

1) Animal products have little to no fiber, while plant-based products like spinach, avocado, and walnuts and other raw nuts have substantial quantities.

2) Plant products are a source of polyphenols and flavonoids--This encompasses a large universe of nutrients, from epigallocatechins in tea, polymeric procyanidins from cocoa, to hydroxytyrosol from olives, and anthocyanins from red wine and eggplant. The inflow of these beneficial compounds needs to be frequent and generous, not piddly amounts taken infrequently.

3) Vitamin C--While it's easy to obtain, the fact that you and I need to obtain vitamin C from frequent ingestion of plant sources suggests that humans were meant to eat lots of plants. While it may require a few months of deficiency before your teeth fall out, imagine what low-grade deficiency can do over a long period.

4) Vitamin K1--Rich in green vegetables, vitamin K1 is virtually absent in animal products.

5) Tocotrienols--I've been watching the data on this fascinating family of powerful oil-soluble antioxidants unfold for 20 years. Tocotrienols come only from plants. (I recently had an extended conversation with the brilliant biochemist, Dr. Barrie Tan, who is incredibly knowledgeable about tocotrienols, having developed several methods of extraction from plants, including his discovery of the highly concentrated source, annatto. Be sure to watch for future conversations about tocotrienols.)

6) Meats and dairy yield a net acid load--While plant foods are net basic. At the very least, this yields risk for osteoporosis, since acids are ultimately buffered by basic calcium salts from the bones. Tissue and blood pH is a tightly regulated system; veering off just a teensy-weensy bit from the normal pH of 7.4 to an acidic pH of, say, 7.2, leads to . . . death. In short, pH control is very important. A net acid challenge from animal products is a lot like drinking carbonated soda, a huge acid challenge that leads to osteoporosis and other health issues.

Conversely, a pure plant-based diet has its own set of problems. Eating a pure plant-based diet can lead to deficiencies of vitamin B12, omega-3 fatty acids (no, linolenic acid from flaxseed will NOT cut it), vitamin K2, carnitine, and coenzyme Q10.

So, rather than a breakfast of 3-egg omelet with bacon, sausage, cream, and cheese, how about a handful of pecans, some blueberries, and a 2-egg omelet made with basil-olive oil pesto? Or a spinach salad with walnuts, feta cheese, and lots of olive oil?

Fat is not the demon

16. April 2010 William Davis (36)
So my patient, Dane, generously volunteered to be on the Dr. Oz show, as I discussed previously.

What we didn't know, nor did the producer who contacted us mention, that Dane would be counseled by low-fat guru Dr. Dean Ornish on a strict low-fat diet. The teaser introduction essentially tells the entire story.

Ironically, that is the exact opposite of the dietary program that I advocate. I rejected the 10% fat diet long ago after I became a type II diabetic, gained 30 lbs, and suffered miserable deterioration of my cholesterol values on this diet. I also witnessed similar results in many hundreds of people, all following a strict low-fat diet. In fact, elimination of wheat--whole, white, or otherwise--along with limitation or elimination of all other grains has been among the most powerful health strategies I have ever witnessed.

I now regret having subjected my patient to this theatrical misinformation. Dane is a smart cookie--That's probably why he was not allowed more than a "yes" or "no" during Dr. Oz's monologue, else Dane might have pitched in about some ideas that would have tripped Oz and Ornish up.

In their defense, if we took 100 Americans all following a typical 21st century diet of fast food, white bread buns, Coca Cola and other soft drinks, chips, barbecue sauce, and French fries, converting to a plant-based, high-carbohydrate, grain-rich diet is indeed an improvement. People will, at first, lose weight and enjoy an initial response. (The occasional person with the Apo E4 genetic pattern, heterozygote or homozygote, may even enjoy long-term benefits, a topic for another day.)

But the majority of people, in my experience, after an initial positive response to an Ornish-like low-fat, high-carbohydrate diet will either plateau (stay overweight, have low HDL, high triglycerides, plenty of small LDL, and high blood sugars) or deteriorate, much as I did.

Thankfully, Dane has been a good sport about this, understanding that this is essentially show business. I believe he understands that the information was all well-intended and, after all, we are all working towards the same goal: reduction of heart disease risk.

By the way, regardless of which diet you follow, it is, in my view, absurd to believe that diet alone will do it. What about vitamin D normalization, thyroid normalization (thyroid disease is incredibly common), omega-3 fatty acids from fish oil, identification of hidden sources of risk (something that is unlikely in Ornish, since small LDL particles skyrocket on a low-fat diet), postprandial glucoses, etc., all the pieces we focus on to gain control over coronary plaque? Eating green peppers and barley soup alone is not going to do it.
"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.
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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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