Can I see your linea alba?

2. November 2010 William Davis (19)
As more and more people are eliminating wheat from their diet and losing their "wheat bellies," i.e., the muffin top around their waists along with the visceral fat beneath, I am frequently seeing something I haven't seen in years: the linea alba.

Linea alba, or "white line," refers to the band of connective tissue running vertically from sternum to pubic area. It underlies the depression that separates the horizontal abdominal rectus muscles of the "six pack" abdomen.

It's like digging in your closet and finding something you thought you'd lost years earlier. Surprise! It's been there all along. Buried deep beneath the abdominal fat from dozens of deep-crust pizzas, whole wheat pasta, and whole grain sandwiches is this pleasing anatomical feature long lost from most peoples' anteriors.


Can you see your linea alba?

Dwarf mutant wheat

31. October 2010 William Davis (13)
Here's my 12-year old standing next to dwarf wheat grown near my house. The wheat is full-grown, harvested about 2 weeks after I took this photo.

Wheat is no longer the 4-foot tall "amber waves of grain" of the 20th century. Over 99% of all wheat grown worldwide is now the 18- to 24-inch tall dwarf. New size, new biochemistry, new effects on humans. I call it dwarf "mutant" wheat despite its lack of extra limbs or eyes because of the dramatic transformation required to breed this unique synthetic plant. 

Short-stature means less stalk, faster growing. The stockier stalk also means that the heavy seed head won't cause the plant to "buckle," as 4-foot tall wheat used to. 





The thousand-plus proteins of wheat that have been transformed to generate this dwarf mutant also changed wheat's relationship to consuming humans.

Medical education in the days of Big Pharma

30. October 2010 William Davis (43)
I received this detailed email from an unexpected source: a 3rd-year medical student.

In her email, Theresa describes her frustrations in what she is witnessing for the first time, proceeding through her training and getting exposed to the realities of medical life.

Medical training, particularly clinical training from the 3rd and 4th years of medical school, onwards through internship, residency, and fellowship training, consists largely of bullying, "pimping" (meaning rapid-fire grilling of questions at trainees), and sleep deprivation. It is an extended hazing period meant to demoralize and inculcate the trainee into following the lead of superiors. Buck the system and you're . . . out. Imagine you've just sunk $190,000 and 8 years of college into getting to your internship. You are not going to chance being thrown out on principle. So you just swallow your pride, go along with the game, and echo all the answers they want you to repeat.

While Theresa laments the sad state of modern American pharmaceutical- and procedure-obsessed medicine, she provides me with hope that some young people training to practice medicine today will carve out their own paths, not the one laid for them by the pharmaceutical industry, nor fall for the temptation of higher-paying procedural specialties like orthopedics and cardiology. I am impressed with her ability to see this so early in her career.


Dr. Davis,

I am a 3rd year medical student at ________ University. I came across
your blog today, and I'm very glad I did. I appreciate the value of your time,
so I want to be as succinct as possible while still getting across what I'm
really thinking and feeling:

From what I gathered exploring your blog for a while this afternoon, the
wellness strategies you incorporate into your practice are some of the exact
things I want to do with my future patients. Personally, I strongly believe in
staying healthy by eating right, staying active, etc. For instance, I don't eat
grains or much in the way of starches and sugars. So I love the fact that you
are helping your patients make these powerful and foundational changes in their
lives.

As I'm sure was your experience, a full appreciation of nutrition and lifestyle
as a first-line health strategy is not something that was taught to me in
medical school. I came to school with this deep conviction already in my heart
and mind, and now, on my 3rd year rotations, I am still conflicted and at a loss
as to how I'm going to be able to practice medicine the way I want to, which is
to incorporate these all-important principles into the care of my patients.

What I've come to understand about the medical field today is that the
information that exists is primarily subsidized by the pharmaceutical industry,
and dictated to medical professionals as "evidence-based" treatment guidelines
and recommendations by organizations with sincere and official sounding names
like American Heart Association and American Cancer Society. Add to that the
pressure of potential malpractice litigation and the complexities of the
insurance reimbursement game, and it seems to me like what you get is a bunch of
diagnostic and medication management algorithms that any half-trained monkey
could follow. In his sleep. Which I guess would be alright if at least they
weren't algorithms based on misguided, self-serving, profit-seeking Big Pharma,
Food Inc, insurance conglomerates, and agri-politics (I think I just made that
word up.)

A lot of well-intentioned physicians are just parroting the party
line, as their patients dutifully and gratefully chomp down their statins and
diabetes drugs and blood pressure pills. And I'm sorry, but "diabetes
education" programs with curriculum put together by drug companies? How is that
even legal? Massive corporations raking in massive profits that are dependent
on uncontrolled blood sugars telling people how to best control their blood
sugars?!

Anyway, forgive my rant. What I'm getting at is this: How can I practice
medicine, with the freedom to educate/coach/treat my patients with diet and
lifestyle changes to mitigate/reverse their chronic health conditions? Without
feeling like I automatically have to first and foremost prescribe the litany of
drugs dictated by "evidence-based" guidelines? Without excessive fear of
litigation or loss of credibility among my peers? Without having to lie through
my teeth to my patients, and tell them that eating low-fat and heart-healthy
whole grains is the best way (implication also being the only scientifically
proven way) to control their diabetes, lower their cholesterol, etc, etc, etc?

I want my patients to have the full benefit of honest nutrition and lifestyle
information, and medications and surgery as necessary. I'm afraid that there
isn't room for this kind of holistic emphasis in the medical profession today.
Are there residencies that include this kind of training or at least respect
these "unconventional" philosophies? Are there clinics or practice groups that
would allow me to practice with this emphasis, or is there a bias against docs
who do not necessarily conform to the party position? Will I have no other
option but to go it alone under the auspices of my own shingle? How do you
handle these kinds of issues in your professional life?

Sincerely,
Theresa M.


A ray of hope! Perhaps Theresa is just the first among many more medical students who refuse to submit to the brainwashing practices of the pharmaceutical industry, the same mind manipulation that has hopelessly turned most of my colleagues into their unwitting puppets.

I'll be interested in watching how Theresa's experience unfolds. I've asked her to keep us informed every so often.

The Great Low-Carb Connector

28. October 2010 William Davis (15)
The effusive Jimmy Moore of Livin' La Vida Low-Carb asked me to help get the word out about his new podcast subscription service, The Livin' La Vida Low-Carb Show Fan Club.

Jimmy has been The Great Connector for the low-carb discussion, from his ubiquitous online and social media presence, to his annual low-carb cruise. He has also broadcast first class interviews of nutritional notables like Gary Taubes, Dr. Robert Lustig, and blogger Stephan Guyenet. His Fan Club expands listener involvement in the podcast process and, potentially, greater access to his guests:

My faithful listeners have long been asking me about how they can become even more engaged in the behind-the-scenes workings of the show to get the inside scoop about what’s coming next. I’ve heard people ask specifically for access to transcripts of the most popular podcasts, a listing of the interviews I’m currently working on with the ability to ask questions of those guests, to have sneak peek of audio from not-yet-released interviews and more. My amazing podcast producer, Kevin Kennedy-Spaein, and I have been discussing how to best do this for a while in an effort to meet the demands of our biggest fans and we think we’ve got just the answer for you. Introducing The Livin’ La Vida Low-Carb Show Fan Club!

This is for all intents and purposes the quintessential destination for people who can’t get enough of this podcast that goes much deeper than discussion about the low-carb lifestyle. Yes, I speak with a lot of people who are supporters of carbohydrate-restricted diets, but I also talk with fitness gurus, people who support alternative eating plans, those who have interesting theories and beliefs regarding health and much more. Wouldn’t you love to have a chance to know who’s coming up in my schedule to be able to ask them questions BEFORE I interview them? Keep in mind that my interviews are pre-recorded and air sometimes as much as 5-6 months afterwards. Members of the “fan club” would know all about who’s coming and likely will have their question asked on the air just for signing up to be a part of this exciting new addition to “The Livin’ La Vida Low-Carb Show.”

Jimmy is the guy who is bringing this disparate and widely-spread community together. He's the guy we all know, he knows "everybody." I'm looking forward to seeing how this new project makes a more involved, personal delivery of interaction possible.

New Track Your Plaque record!

27. October 2010 William Davis (19)
The record for the largest drop in heart scan score (by percentage of starting score) has been held for around three years, with 63% reduction in score.

Well, the longstanding record was broken this week: 75% reduction in score.

At the start, Freddie has disastrous lipid values:

LDL cholesterol 263 mg/dl
HDL 26 mg/dl
Triglycerides 323 mg/dl
Total cholesterol 354 mg/dl

Lipoproteins (NMR) were worse:

LDL particle number 3360 nmol/L
Small LDL 2677 nmol/L

Heart scan score: 732

Interestingly, Freddie had virtually no vitamin D in his body, with a 25-hydroxy vitamin D level that was unmeasurable.

Freddie was miserably intolerant to statin drugs, with even the smallest dose resulting in intolerable muscle aches. That's when his doctor sent him to me.

Because I felt that the dominant abnormality in Freddie's lipids and lipoproteins was small LDL particles, representing 80% of total LDL particle number, we focused his program on correcting this parameter. Freddie's program was therefore focused elimination of wheat, cornstarch, oats, and sugars, along with an eventual vitamin D dose of 20,000 units to finally achieve a 25-hydroxy vitamin D level of 66 ng/ml. No statin drug in sight.

43 lbs of weight loss and 18 months later, a second heart scan score: 183--a 75% reduction.

While the rest of the world continues to insist that coronary calcium (heart scan) scores cannot be reduced, I am seeing records being broken. I add Freddie's experience to the rapidly growing list of people who have not just stopped coronary plaque from growing, but are seizing control and reducing it, sometimes to dramatic degrees.

The Anti-AGEing Diet

22. October 2010 William Davis (36)
Advanced Glycation End-products, AGEs, are a diverse collection of compounds that have been associated with endothelial dysfunction, cataracts, kidney disease, and atherosclerosis in both animal models and human studies. Not all involve glycation nor glucose, but the catch-all name has stuck.

There are a number of actively-held theories of aging, such as the idea that aging is the result of accumulated products of oxidative injury; a genetically pre-programmed script of declining hormones and other phenomena; genetic "mis-reading" that results in disordered gene expression, debris, and uncontrolled cell proliferation (e.g., cancer); among others.

One of the fascinating theories of aging is, cutely, the AGEing theory of aging, i.e., the accumulation of AGE debris in various tissues. Such AGEs have been recovered in lenses from the eyes, atherosclerotic plaque in arteries, kidney and liver tissue, even brain tissue of people with Alzheimer's dementia. AGEs perform no known useful physiologic function: They are relatively inert once formed (especially polymeric AGEs), they do not participate in communication, they make no contribution of significance. They simply gum up the works--debris. (AGEs are to health as the USDA food pyramid is to dietary advice: material for the junkyard.)

There are two general ways to develop AGEs:

1) Endogenous--High blood glucose (any blood sugar above 100 mg/dl) will permit glycation of the various proteins of the body. The higher the blood glucose, the more glycation will proceed. Glycation also occurs at low velocity at blood glucose levels below 100 mg/dl, though this would therefore represent the "normal," expected rate of glycation. Endogenous glycation explains why people with diabetes appear to age and develop all the phenomena of aging faster than non-diabetics (kidney disease, eye diseases, atherosclerosis, dementia, etc.). Hemoglobin A1c, HbA1c, is a readily-obtainable blood test that can show how enthusiastically you have been glycating proteins (hemoglobin, in this case) over the last 2 to 3 months.

A low-carbohydrate diet is the nutritional path that limits endogenous glycation leading to AGE formation. Restricting the most obnoxious carbohydrates, the ones that increase blood sugar the most, such as wheat, cornstarch, rice starch, potato starch, tapioca starch, and sucrose, will limit endogenous AGE formation.

2) Exogenous--AGEs (here especially is where the "AGE" label is misleading, since many other reactions besides glycation lead to such compounds) are formed with cooking at high temperatures, especially meats and animal products. Therefore, a rare steak will have far less than a well-done steak. A thoroughly baked piece of salmon will have greater AGE content than sashimi.

The forms of cooking that increase AGE content the most: roasting,deep-frying, and barbecuing. Temperatures of 350 degrees Fahrenheit and greater increase AGE formation.

Therefore, cooking foods at lower temperature (e.g., baking, sauteeing, or boiling), eating meats rare whenever possible (not chicken or pork, of course), eating raw foods whenever possible (e.g., nuts) are all strategies that limit exogenous AGE exposure. And minimize or avoid butter use, if we are to believe the data that suggest that it contains the highest exogenous AGE content of any known food.

If we connect the dots and limit exposure to both endogenous and exogenous AGEs, we will therefore not trigger this collection of debris that is likely associated with disease and aging. So following a low-AGE diet may also be an anti-aging strategy.

The New Track Your Plaque Diet, soon to be released on the Track Your Plaque website, has incorporated strategies to limit both endogenous as well as exogenous AGEs.

Butter: Just because it's low-carb doesn't mean it's good

21. October 2010 William Davis (59)
The diet I advocate in the Track Your Plaque program to gain control over the factors that lead us to coronary plaque and heart attack is a low-carbohydrate diet. We begin with elimination of wheat, cornstarch, oats, and sugars in the context of an overall carbohydrate-reduced diet. We refine the program by monitoring postprandial (after-meal) glucoses.

But not everything low-carb is good for you. Fried sausages, for instance, are exceptionally unhealthy, despite having little to no carbohydrates.

An emerging but potentially very powerful issue is that of Advanced Glycation End-products, or AGEs. There are two general varieties of AGEs: endogenous (formed within the body) and exogenous (formed in food that is consumed).

Endogenous AGEs form in the body as a result of high blood glucose, i.e., glycation. When exposed to any blood glucose level of 100 mg/dl or greater, some measure of glycation will develop due to a reaction between glucose and various proteins, e.g., proteins in the lens of the eye, forming cataracts over time.

Exogenous AGEs form in food, generally as a result of heating to high-temperature. (AGEs is really a catch-all term; there are actually a number of reactions that occur in foods, not all of them involving sugars. However, the "AGE" label is used to signify all the various related compounds. The values quoted here are from Dr. Helen Vlassara's Mt. Sinai Hospital laboratory; reference below.)

Beef cooked to high-temperature yields plentiful AGEs. One gram of roast beef, for instance, contains 306,238 units. This means that an 8-oz serving yields 13.8 million units AGEs. Compare this to a boiled egg with 573 units per gram, raw tomato with 234 units per gram.

Butter contains an impressive 264,873 units AGEs per gram, the highest content per gram in the entire list of 250 foods tested in the Mt. Sinai study. A couple pats of butter (10 g) therefore contains 2.64 million units. A stick of butter that you might add to cake batter to make a cake therefore yields 30 million units of AGEs.

So there's nothing wrong with the fat of butter. It's AGEs that appear to be responsible for the endothelial dysfunction/artery-constricting, insulin-blocking, oxidation and inflammation reactions that are triggered. Among all of our food choices, butter is among the worst from this viewpoint.

Throw in the peculiar "insulinotrophic" effect of butter, and you have potent distortion of metabolic pathways, courtesy of the butter on your lobster.

(AGE data from Goldberg 2004. In this analysis, carboxymethyllysine was the marker used for AGE content.)

Incidentally, the new Track Your Plaque diet will soon be released as chapter 9 of the new Track Your Plaque book on the website.

Einkorn now in Whole Foods

16. October 2010 William Davis (19)
I just saw this at Whole Foods: einkorn pasta.

In my einkorn bread experience (In search of wheat: We bake einkorn bread), I was spared the high blood glucose and neurologic and gastrointestinal effects of conventional whole wheat grain (dwarf Triticum aestivum). I shared the einkorn bread  with four other people with histories of acute wheat sensitivities, only one of whom experienced a mild diffuse joint reaction, the other three not experiencing any symptoms.

Anyone wishing to try einkorn can now obtain commercial pasta from Jovial, an Italy-based manufacturer. It comes in spaghetti, linguine, rigatoni, fusilli, and penne rigate shapes.

Eli Rogosa, founder of The Heritage Wheat Conservancy, tells me that, in her experience, celiac suffers seem to not experience immunologic phenomena triggered by conventional wheat.

However, we've got to be careful here. The so-called ("diploid") "A" genome of einkorn shares many of the same genes as the ("hexaploid") "ABD" genomes of modern wheat, including overlap in the sequences coding for the 50-or so different glutens and glutenins. Most of the genes that code for the glutens that cause celiac and related illnesses reside in the "D" genome that are absent in the einkorn "A" genome. However, the "A" genome still codes for glutens. So there is potential for activating celiac disease in some people. Insufficient research has been devoted to this question. It is a question of extreme importance to people with celiac and other immune-mediated conditions, since re-exposure to the wrong form of gluten can increase risk of intestinal lymphoma 77-fold, as well as risk of other gastrointestinal cancers.

So einkorn should not be viewed as a cure-all for all things wheat, but as something to consider for a carbohydrate indulgence. Yes, indeed: It is a carbohydrate, with 61 grams ("net") carbs per 4 oz (uncooked) serving.
Should anyone give it a try, please be sure to report back your experience, especially if you have a history of wheat intolerance. If you have a glucose meter, pre- and 1-hour post values are the ones to measure to gauge the blood sugar effects of consumption. Because pasta tends to cause long sustained blood sugar rises, another value at 2-4 hours might be interesting.

Noodles without the headaches

14. October 2010 William Davis (26)
If you are looking for a wheat-free noodle or pasta, shirataki noodles are worth a try.

Shirataki noodles are low-carbohydrate (less than 3 g per 8 oz package) and, of course, do not trigger all the unhealthy effects of wheat--no blood sugar/insulin provocation, no addictive brain effects (exorphins), no gluten-mediated inflammatory effects.

(I advise avoiding gluten-free pasta alternatives made with rice flour and other common gluten alternatives, since they trigger blood sugar, small LDL, and growth of visceral fat just like wheat.)

I made a stir-fry using the shirataki-tofu noodles, shown below. (Tofu is added to make the noodles more noodly in consistency, as opposed to the chewier non-tofu variety.) The noodles were a lot like the ramen I used to eat as a kid. They were filling and tasted great in the sesame oil, soy sauce, tofu, and vegetables I used.


The noodles are easy to use. Just drain liquid out of package. (The noodles come in water.) Rinse in collander 30 seconds, then boil for 3 minutes. Add to your stir-fry or other dish. Some manufacturers, such as House Foods, also have angel hair and fettucine style noodles.

You're fried

13. October 2010 William Davis (26)
If I could invent a food that illustrates nearly all of the shortcomings of the American diet, it would be French fries, the familiar fixture of fast food.

What we have come to view as French fries contain just about every one of the unhealthy ingredients that lead us down the path of obesity, diabetes, heart disease, high blood pressure, etc.

Let's take them one by one:

Potato starch--Potato starch exerts an effect on blood sugar similar to that of table sugar, only worse. (Glycemic index french fries 75; glycemic index sucrose 65.)

Advanced Glycation End-products (AGEs)--AGEs form when proteins and fats are subjected to high temperature cooking; the longer the high temperature, the more the food reaction creating AGEs proceeds. AGEs are the likely culprit in roasted and fried foods that made it appear that saturated fats were bad, when it was really AGEs all along. AGEs have been shown to block insulin's effects, increase blood sugar, cause endothelial dysfunction and high blood pressure.

Acrylamides--Acrylamides, like AGEs, are created through high-temperature heating. French fries are unusually rich in AGEs. Brewed coffee also contains a small quantity, while French fries contain 82-fold greater quantities, among the highest of all known sources of acrylamides.

Oxidized oils--The amount of oxidized oils will depend on what sort of oil was used for frying. As more restaurants are trying to get away from hydrogenated oils, many are turning back to polyunsaturates. Others are turning to commercial-grade oils that contain both hydrogenated and polyunsaturates. If oils are permitted to oxidize, then they will trigger oxidative phenomena in your body upon consumptions, e.g., LDL oxidation (Staprans 1994).

In other words, the innocent appearing French fry unavoidably triggers oxidation, all the phenomena triggered by high blood glucose (high insulin, glycation, visceral fat accumulation), along with the cascade of effects arising from AGEs and acrylamides.

Top your French fries with some ketchup made with high-fructose corn syrup that exagerrates AGE formation, visceral fat, and distorts postprandial (after-eating) effects.

Is it any wonder that we've lost control over diet?
"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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