Apo E4 and sterols: Lethal combination?

11. February 2011 William Davis (24)
Phytosterols, or just "sterols" to its friends and neighbors, are a group of cholesterol-like compounds that are abundant in the plant world. Lately, however, sterols have proliferated in the processed food supply, thanks to the observation that sterols reduce LDL cholesterol when ingested by humans.

This must mean that sterols are good for you.

Uh oh. Wait a minute: There is a rare disease called sitosterolemia in which there is unimpeded intestinal absorption of all sterols ingested through diet. They must have really low LDL cholesterols! Nope. They develop coronary disease--heart attacks, angina, etc.--in their late teens and 20s. In other words, if sterols gain access to your bloodstream, they are bad. Very bad.

Conventional thinking is that only a modest quantity of dietary sterols gain access to the bloodstream. But there are two potentially fatal flaws in this overly simplistic line of thinking:

1) What happens when you load up your diet with "heart healthy" sterols, such as those in "heart healthy" margarines, mayonnaise, and yogurt, effectively increasing sterol intake 10-fold?

2) What happens in people with the genetic pattern, apo E4, that is carried by 25% of the general population that permits much greater intestinal absorption of sterols?

My prediction: Despite the fact that sterols reduce LDL, they may, in certain genetically-susceptible people, such as those with apo E4, increase risk for heart disease: heart unhealthy.

Here are two studies that suggest that greater sterol absorption in people without sitosterolemia are at higher risk for heart disease:

Alterations in cholesterol absorption/synthesis markers characterize Framingham offspring study participants with CHD

Plasma sitosterol elevations are associated with an increased incidence of coronary events in men: results of a nested case-control analysis of the Prospective Cardiovascular Münster (PROCAM) study

Glucomania

8. February 2011 William Davis (52)
As I suggested in a previous Heart Scan Blog post, a glucose meter is your best tool to:

1) Lose weight
2) Cure diabetes
3) Reduce or eliminate small LDL particles
4) Achieve anti-aging or age-slowing effects

But it means getting hold of a glucose meter and applying it in a very different way.

Diabetics typically check fasting morning glucose and again several times during the day to assess medication effects. But you and I can measure blood glucose to assess the immediate effects of food choices--two very different approaches.

The concept is simple: Check a blood glucose just prior to a food or meal of interest, then one hour after finishing.

Let's take two hypothetical breakfasts. First, oatmeal, a so-called "low-glycemic index" food. Slow-cooked, stone ground oatmeal with skim milk, a handful of walnuts, just a few blueberries.

Blood glucose just prior: 95 mg/dl
Blood glucose one hour after finish: 175 mg/dl

I made those numbers up, but this is a fairly typical response for many adults. (This is why "low-glycemic index" is an absurd notion.) This kind of response causes 1) glycation, the adverse effects of glucose modification of proteins that leads to cataracts, kidney disease, cartilage damage and arthritis, atherosclerosis, skin wrinkles, etc., 2) high insulin response that cascades into fat deposition, especially visceral fat ("wheat belly"), and 3) glucotoxicity, i.e., direct damage to the pancreas that can, over years, lead to diabetes.

Next day, let's try a breakfast of 3-egg omelet made with green peppers, sundried tomatoes, and olive oil.

Blood glucose just prior: 95 mg/dl
Blood glucose one hour after finish: 93 mg/dl

This is a meal of virtually zero-glycemic index. This kind of response triggers none of the effects experienced following the oatmeal. Repeated over time and you fail to trigger glycation, you stop provoking insulin, and visceral fat mobilizes rather than accumulates: you lose weight, particularly around the middle.

We therefore aim to keep the one-hour blood glucose 100 mg/dl or less. If you start with a high fasting blood glucose of, say, 118 mg/dl, then we aim to keep the one-hour after-eating blood glucose no higher than the pre-meal.

It works. Plain and simple.

This makes the primary care docs crazy: "How dare you check your blood sugar! You're not diabetic." In truth, blood glucose meters are relatively simple devices to use. The test strips and lancets will cost a few bucks. (The meters themselves are either low-cost or free, just like Gillette sometimes sends you a beautiful new razor for free but expects you to buy the blades). These are direct-to-consumer products. While a prescription written by your doctor for a glucose meter and supplies helps insurance cover the costs, you can easily get these devices without a prescription. Some stores, like Target, keep their devices out on the shelves with the shampoo and bath soap.

Warning: Anyone taking diabetes drugs will have to consult with their doctors about the safety of such an approach. Because this approach can actually cure diabetes in some people, if you are taking some diabetes drugs, especially glyburide, glipidize, and glimepiride, you can experience dangerously low blood sugars, just as any non-diabetic taking these drugs would.

Diarrhea, runny noses, and rage: Poll results

6. February 2011 William Davis (19)
Here are the results of the week-long poll asking the question:

Have you experienced a wheat re-exposure syndrome?
Yes, undesirable gastrointestinal effects 223 (41%)
Yes, asthma or sinus problems 51 (9%)

Yes, joint pains and/or swelling 85 (15%)

Yes, emotional or other nervous system effects 59 (10%)
No, nothing, nada  107 (19%)

No. Wheat is sacred and you're all nuts  13 (2%)


There are several interesting observations to make from this informal poll. First, as I have observed, the most common wheat re-exposure syndrome is gastrointestinal, usually involving cramps, diarrhea, and lame explanations to your dinner partner.

Second most common: joint pains and/or swelling.

Third: asthma or sinus congestion.

The incidence of emotional or nervous system effects surprised me a bit. I didn't expect 10% of people to share this effect. This is an effect I also experience personally, along with the gastrointestinal consequences.

To be sure, this is a skewed poll, since many people likely come to this blog in the first place because of such issues. But I was nonetheless impressed with the relatively modest proportion of people who did not share such a re-exposure syndrome: only 19%.

Beyond the interesting numbers provided by readers, a good many also provided some fascinating and graphic comments. Here's a sample:




Sassy said:

Reflux -- starts a day later and goes for up to a week. And Bloat:2-5 inches on my waistline in a day, lasting up to three. Miserable. And why, having experienced this once, have I done it often enough to verify the connection with certainty? I am working on that one.
Anonymous said:
Wheat increased hunger with even with only a small amount. Crackers in soup was enough to set it off.

Also, when I was trying to get off wheat, I noticed that 2 eggs and 2 bacon and I could go 5 hours before hunger, or 2 eggs and 2 bacon and toast was good for three hours before hunger. That was the final step to giving up wheat. Now three years and 59 Kg [130 lbs!] loss later, there is no doubt in my mind that wheat is evil, and I do not regard it as suitable for human food. I speculate that it increases ghrelin or cortisol.

Anna said:
For me, in the two years since I began eating Gluten-Free (Low Carb for 6 years), the few times I've had re-exposure to wheat, I've experienced fast onset and intense abdominal pain (known exposure during the daytime) and heartburn, indigestion, intense nausea, and disrupted sleep (exposures during evening meal not discovered until the next day).

My husband wants to think he's fine with wheat (though I know that he has at least one gene that predisposes to celiac), but IMO, he isn't. He eats no wheat at home because that's the default, and he's OK with that. But if he goes out to dinner at a restaurant that serves "good" artisan bread, he will indulge in a few bites (he does restrict his carb intake, so it's still a limited amount). More often than not, he will sleep fitfully on those nights, snore more, and wake in the night with indigestion. He wants to bury his head in the sand and will only acknowledge the discomfort being due to eating too many carbs, not the wheat itself. I notice he sleeps fine if he eats a small amount of potato or rice. Go figure.

Our 12 yo son has been eating GF for two years also. About 6 months into GF, he unknowingly ate wheat a number of times (licorice candy laces at a friend's house), which resulted in outbreaks of canker sores in his mouth each time. He also exhibits mood and behavior changes when he eats wheat, which is what prompted me to test him for gluten intolerance in the first place.

Mark said:
If I go for 3-4 days without wheat, grains or sugar and then go out and binge on a pizza and ice cream or something like that I become explosive within 20 minutes to an hour. It's like a wheat and sugar rage.(I'm not saying this is an excuse for rage, I'm saying it has happened to me and I believe partly do to re-exposure) It seems the combination of the wheat plus sugar can be the worst.

I get red rashes around my neck sometimes right away and sometimes up to a day or later and sometimes get bad diarrhea. 
I think it can be almost dangerous to cut things like gluten and sugar suddenly out of the diet without being very serious about keeping them out. I have found it very hard to cut out wheat without binging on it later after 4 or 5 days. I don't believe that my symptoms are just psychological either.
I was also diagnosed with ADHD as a young kid and then rediagnosed with adult ADHD by 3 different doctors. I also have bouts of mania at times too. I am considering trying to go completely gluten/refined carbohydrate free to see if it helps with the symptoms and gives me some relief.

I have never been tested for celiac or gluten intolerance but I would like to be. I think it would help explain to my girlfriend, family and friends why I can't go out and eat pizza or have a beer or ice cream. Right now they all think I'm a hypochondriac. At times I have experienced an intense fatigue the next day like I can't wake up and also sharp pains in my body and headaches.
Anonymous said:
I ditched wheat a year ago after my wife was diagnosed celiac. I immediately experienced a number of health improvements (blood lipids, sleep, allergies, etc.).

Fast forward: We all suffered some inadvertent wheat exposure yesterday via some chocolate covered Brazil nuts (of all things). This accidental A-B-A experimental design resulted in the following:

1. My celiac wife experienced what she calls "the flip" within an hour of exposure (i.e., intense GI distress).
2. My five-year old son went to bed with some wicked reflux.
3. I woke up with some twinges in my lower back and an ache in my football-weary left shoulder. I was also complaining to my wife about fuzzy-headedness that refused to respond to caffeine or hydration. I could only describe it as "carb flu"...

And then I read your post!

Anne said:
Depression, agitation and brain fog if I get glutened. Some times this comes with abdominal pain and a rash on my back - I think it is dose dependent. Cross contamination with wheat is a big issue when eating out. Needless to say, I eat out infrequently and then try to stick with the restaurants that are the most aware of gluten issues.
Terrence said:
Several weeks ago, I started Robb Wolf's 30 day challenge.

The first two weeks were brutal - calling it a withdrawal flu was a massive understatement. So, I thought I would try some wheat and see what happened (could not be worse, I thought). Well, it was.

I still felt extremely crappy, but I was now MASSIVELY GASSY - AMAZINGLY GASSY, for about 48 hours - flatulence on wheels, in spades. I did not go out at all in those 48 hours - when the gas came on, it went out, LONG, and QUICKLY and LOUDLY.

I am easing back into wheat and grain free. I am gluten free today and tomorrow (Sunday and Monday). I expect to try a small amount of wheat on Thursday, then maybe a little more the following Thursday.

Donald said:
I have limited wheat consumption severely over the last 8 months. I have lost 120 pounds, no longer have bouts of illness, asthma, depression, or low energy. I also take vitamin D and other supplements that have helped (many are from your blog recommendations).

Last week I ate a small piece of cake and dessert pizza. Shortly thereafter I started sneezing, had a scratchy throat, and runny nose. I called off sick the next day for fear of being contagious. My symptoms subsided quickly and I am now attributing them to the processed flour eaten at my work luncheon. I think it was an allergic reaction since I recall having much more severe symptoms fairly regularly in my wheat eating days. Those were attributed to an "allergy" of unknown origin back then.

John said:
I suffered from Ankylosing Spondylitis, Iritis, Plantar Fasciits, etc for a number of years. I restricted carbs, especially wheat and I've been symptom free for the past two years now.
Lori said:
I found wheat to be one of the worst things for giving me gas bloating and acid reflux, and I'd had sinus and nasal congestion my whole life. When I ate that cookie, it just re-introduced old problems. I can occasionally eat a gluten-free, grainy goody at my party place without any side effects. I also have a little sprouted rice protein powder every day.

Another odd thing about wheat: it was hard for me to stop eating it once I started. I could go through a whole box of cookies in one sitting, even though I wasn't a binge eater. But I can have a couple of gluten-free cookies and stop.

Paul said:
Except for one slip up this recently past holiday season, I've been sugar-grain-starch free since July 2008. Mental fog was the most noticable re-exposure symptom I had.

My mom has had the worst acid-reflux for 40-plus years. It had become so bad that she was on three medications just to deal with the symptoms. After much training and coaxing, I finally got across to her  how to totally get off wheat. Not at all to my surprise, after being wheat free for a few weeks, she lost weight and her acid reflux was GONE!

But she had been addicted to wheat for so long, she relapsed, and the reflux fire soon returned. Wheat must be akin to heroin with some people. Even though they know it's very bad for them, they can't help themselves.

Onschedule said:
Re-exposure often leads to diarrhea for me, or such a heavy feeling of tiredness that all I can do is lay down and pass out. A local pizzeria makes a darn good pie, but since I started practicing wheat-avoidance, I can't keep my eyes open after eating there. I can't say for sure that it's the wheat causing it, but definitely something in the crust. Diarrhea, on the other hand, is definitely triggered by the wheat for me.

My mom complained of gastric reflux for years, but never filled the prescriptions that her doctors would give her. I suggested wheat-avoidance- gastric reflux disappeared within 3 days and hasn't returned (has been 6 months now). I've already commented elsewhere on this blog about how much weight and bloating she has lost...

Steve said:
Interesting that I should sit down, turn on my computer and find your poll. Having gone several weeks, maybe months, avoiding gluten, I took my daughter and her boyfriend out to eat because my wife has been working late at the office lately. Although I was thinking I would just eat my steak and chicken, I succumbed to the temptation of eating about a dozen greasy, breaded shrimp that my daughter and her boyfriend ordered. It's 1:39am and I still do not feel sleepy. My left nostril is completely blocked, my stomach feels bloated, really, really full and I've been burping. In your poll I checked sinus problems but could have chose gastrointestinal or nervous problems just as well. 
A few weeks ago my daughter brought home a pizza and, once again, despite my knowing that I shouldn't, I ate a couple of pieces. I was sick for two days. The pain in what I think was my transverse colon was so bad I thought I might have to go to ther emergency room. Before I ate the pizza I had never gone grain-free that long before. I did this after reading Robb Wolf's book. 
I AM CONVINCED. No more wheat for me! Please, Lord, give me strength.
LV said:
What don't I experience! I typically avoid wheat (and gluten for that matter) as I'm pretty sure it makes me sick, but when I slip (or someone else slips me some) I end up with massive amounts of joint swelling and tenderness, diarhea, cramping, gas, bloating and brain fog. I'm absolutely miserable. Just that alone is enough to keep me off gluten. I have RA, so if I have repeated exposures I'll have a flare which SUCKS!

The perfect Frankengrain

4. February 2011 William Davis (25)
Pretend I'm a mad food scientist. I'd like to create a food that:

1) Wreaks gastrointestinal havoc and cause intractable diarrhea, cramps, and anemia.
2) Kills some people who consume it after a long, painful course of illness.
3) Damages the brain and nervous system such that some people wet their pants, lose balance, and lose the ability to feel their feet and legs.
4) Brings out the mania of bipolar illness.
5) Amplifies auditory hallucinations in people with paranoid schizophrenia.
6) Makes people diabetic by increasing blood sugars.
7) Worsens arthritis, such as osteoarthritis and rheumatoid arthritis.
8) Triggers addictive eating behavior.
9) Punishes you with a withdrawal process if you try to remove it from your diet.

I will develop a strain that is exceptionally hardy and tolerates diverse conditions so that it can grow in just about any climate. It should also be an exceptionally high yield crop, so that I can sell it cheaply to the masses.

Now, if my evil scheme goes as planned, I will then persuade the USDA that not only is my food harmless, but it is good for health. If they really take the bait, they might even endorse it, create a diet program around it.

Dag nabit! Such a plan has already been implemented. Another evil food scientist already beat me to the punch. The food is called wheat.

Diabetes: A study in aging

3. February 2011 William Davis (0)
Diabetics experience long-term health difficulties, including atherosclerosis/heart attacks, peripheral vascular disease, hypertension, cataracts, kidney disease, neuropathies, male erectile dysfunction, osteoarthritis, and colorectal cancer. They also die, on average, 10 years earlier than non-diabetics.

In effect, diabetics compress their lives into a shorter period of time. They experience all the "complications" of aging at a younger age. People without diabetes, of course, can develop atherosclerosis, cataracts, kidney disease, etc., but they tend to do so later in life compared to diabetics.

One index of the rate of aging (but not chronologic age itself) is hemoglobin A1c, or HbA1c, a "moving average" of glycated hemoglobin, i.e., glucose-modified hemoglobin. Blood glucose glycates hemoglobin linearly and irreversibly; measuring HbA1c thereby provides an index of the last 60 or so days average blood glucose.

To put HbA1c values into perspective:

Average HbA1c of hunter-gatherers: 4.5%
Average HbA1c for Americans: 5.6%
American Diabetes Association definition of diabetes: 6.5% or greater
American Diabetes Association definition of adequate control of diabetes: 7.0% or less

Why do diabetics age faster? There are likely several reasons. One important reason is glycation, as indexed by HbA1c. Glycated proteins in the lens of the eye causes cataracts. Glycated proteins in cartilage leads to arthritis. Glycated LDL particles (apo B) leads to atherosclerosis. Glycated nerve cells causes neuropathy. And so on.

If glycation underlies many of the phenomena of aging, then we might surmise that:

1) The less you glycate, the slower you age.
2) The more you glycate, the faster you age.

Therefore, the higher the HbA1c, the faster you are aging.

What foods increase HbA1c? Carbohydrates. That bowl of slow-cooked, stone ground oatmeal? A one-hour after-eating blood sugar of 170 mg/dl is common. Your doctor says that's okay because it's below 200 mg/dl and you don't "need" medication yet.

Fish oil: The natural triglyceride form is better

2. February 2011 William Davis (43)
If you have a choice, the triglyceride form of fish oil is preferable. The triglyceride form, i.e., 3 omega-3 fatty acids on a glycerol "backbone," is the form found in the body of fish that protects them from cold temperatures (i.e., they remain liquid at low ambient temperatures).

Most fish oils on the market are the ethyl ester form. This means that the omega-3 fatty acids have been removed from the glycerol backbone; the fatty acids are then reacted with ethanol to form the ethyl ester.

If the form is not specified on your fish oil bottle, it is likely ethyl ester, since the triglyceride form is more costly to process and most manufacturers therefore boast about it. Also, prescription Lovaza--nearly 20 times more costly than the most expensive fish oil triglyceride liquid on a milligram for milligram basis--is the ethyl ester form. That's not even factoring in reduced absorption of ethyl esters compared to triglyceride forms. Remember: FDA approval is not necessarily a stamp of superiority. It just means somebody had the money and ambition to pursue FDA approval. Period.

Taking any kind of fish oil, provided it is not overly oxidized (and thereby yields a smelly fish odor), is better than taking none at all. All fish oil will reduce triglycerides, accelerate clearance of postprandial (after-eating) lipoprotein byproducts of a meal (via activation of lipoprotein lipase), enhance endothelial responsiveness, reduce small LDL particles, and provide a physical stabilizing effect on atherosclerotic plaque.

But if you desire enhanced absorption and potentially lower dose to achieve equivalent RBC omega-3 levels, then triglyceride forms are better.

Here are cut-and-pasted abstracts of two of the studies comparing forms of fish oil.

Bioavailability of marine n-3 fatty acid formulations.

Dyerberg J, Madsen P, Moller JM et al. 
Department of Human Nutrition, Faculty of Life Sciences, University of Copenhagen, Copenhagen, Denmark.

Abstract

The use of marine n-3 polyunsaturated fatty acids (n-3 PUFA) as supplements has prompted the development of concentrated formulations to overcome compliance problems. The present study compares three concentrated preparations - ethyl esters, free fatty acids and re-esterified triglycerides - with placebo oil in a double-blinded design, and with fish body oil and cod liver oil in single-blinded arms. Seventy-two volunteers were given approximately 3.3g of eicosapentaenoic acid (EPA) plus docosahexaenoic acid (DHA) daily for 2 weeks. Increases in absolute amounts of EPA and DHA in fasting serum triglycerides, cholesterol esters and phospholipids were examined. Bioavailability of EPA+DHA from re-esterified triglycerides was superior (124%) compared with natural fish oil, whereas the bioavailability from ethyl esters was inferior (73%). Free fatty acid bioavailability (91%) did not differ significantly from natural triglycerides. The stereochemistry of fatty acid in acylglycerols did not influence the bioavailability of EPA and DHA.
(Full text of the Dyerberg et al study made available at the Nordic Naturals website here.)



Eur J Clin Nutr 2010 Nov 10. 

Enhanced increase of omega-3 index in response to long-term n-3 fatty acid supplementation from triacylglycerides versus ethyl esters.

Neubronner J, Schuchardt JP, Kressel G et al. 
Institute of Food Science and Human Nutrition, Leibniz Universität Hannover, Am Kleinen Felde 30, Hannover, Germany.

Abstract

There is a debate currently about whether different chemical forms of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are absorbed in an identical way. The objective of this study was to investigate the response of the omega-3 index, the percentage of EPA+DHA in red blood cell membranes, to supplementation with two different omega-3 fatty acid (n-3 FA) formulations in humans. The study was conducted as a double-blinded placebo-controlled trial. A total of 150 volunteers was randomly assigned to one of the three groups: (1) fish oil concentrate with EPA+DHA (1.01?g+0.67?g) given as reesterified triacylglycerides (rTAG group); (2) corn oil (placebo group) or (3) fish oil concentrate with EPA+DHA (1.01?g+0.67?g) given as ethyl ester (EE group). Volunteers consumed four gelatine-coated soft capsules daily over a period of six months. The omega-3 index was determined at baseline (t(0)) after three months (t(3)) and at the end of the intervention period (t(6)). The omega-3 index increased significantly in both groups treated with n-3 FAs from baseline to t(3) and t(6) (P < 0.001). The omega-3 index increased to a greater extent in the rTAG group than in the EE group (t(3): 186 versus 161% (P < 0.001); t(6): 197 versus 171% (P < 0.01)). Conclusion: A six-month supplementation of identical doses of EPA+DHA led to a faster and higher increase in the omega-3 index when consumed as triacylglycerides than when consumed as ethyl esters.

Diarrhea, asthma, arthritis--What is your wheat re-exposure syndrome?

30. January 2011 William Davis (52)
Have you experienced a wheat re-exposure syndrome?

As I recently discussed, gastrointestinal distress--cramps, gas, diarrhea--is the most common "syndrome" that results from re-exposure to wheat after a period of elimination.

Others experience asthma, sinus congestion and infections, mental "fogginess" and difficulty concentrating, or joint pains and/or overt swelling.

Still others say there is no such thing.

Let's take a poll and find out what readers say.

Marathoners, triathletes, and heart disease

30. January 2011 William Davis (0)
Curious thing: People with lipoprotein(a) gravitate towards elite levels of exercise.

I tell my lipoprotein(a) patients that, if they want to see a lot of other people with lipoprotein(a), go to a marathon or triathlon.

This effect applies more to males than to females, just as the fascination with numbers seems to be confined to men, too. That's why I've posted in past about the "prototypical" lipoprotein(a) male.

I believe this is a big part, perhaps the only, reason why there seems to be a modest increased risk for cardiovascular events despite high exercise levels in marathoners. It has nothing to do with the exercise itself; it has to do with the kind of people who choose to exercise at this level.

The best fish oil

29. January 2011 William Davis (30)
The best fish oils available are the liquid forms. Contrary to many people's expectations, the best liquid fish oils have no fishy odor or taste.

I use a lot of liquid fish oils because of the higher doses we use in the Track Your Plaque program, as well as our strategy of high-dose fish oil to reduce lipoprotein(a). Women, in particular, don't like taking the oodles of capsules required to achieve the higher doses we need. So the ladies really like the liquid forms.

The best liquid fish oils are non-fishy, highly-concentrated, and come in the better absorbed triglyceride form. Many capsules, including prescription Lovaza, are the less well-absorbed ethyl ester form. Several studies, such as this one, have now demonstrated that the naturally-occurring triglyceride form yields higher blood (RBC) levels of omega-3 fatty acids, likely due to more efficient digestion via pancreatic lipase.

While there are many good forms of fish oil and only a few bad, these are the best of the best:

Pharmax
The Pharmax Finest Pure Fish Oil with Essential Oil of Orange contains 1800 mg EPA + DHA per teaspoon. This is the preparation I've been taking.

Nordic Naturals
The Nordic Naturals lemon-flavored ProOmega Liquid contains 2752 mg EPA + DHA per teaspoon, the most concentrated of any fish oil I've seen.

(This list is not exclusive. These are just two brands I've used extensively with good results.)

These highly-concentrated, triglyceride forms are more expensive, due to their concentrated nature. 1 teaspoon Pharmax fish oil, for example, provides an equivalent quantity of omega-3 fatty acids as 6 standard fish oil capsules on a milligram for milligram basis, but more like 8 to 9 capsules when absorption efficiency is factored in. The triglyceride form is also more laborious to manufacture. On our Track Your Plaque Marketplace, our Pharmax 500 ml runs $58.95 list. (500 ml provides 100 teaspoons or 600-capsule equivalent.)

Note that, minus the protection of the capsule, liquid fish oils will oxidize if not refrigerated. So be sure to keep your liquid fish oil in the fridge.
Fat is not the demon

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.
Tags :

Comments (36) -

  • Matt Stone

    4/16/2010 1:09:27 PM |

    You might wanna revise the last statement in parenthesis about a low-carb diet causing small LDL to skyrocket Smile  I assume you meant low-fat.

  • Eloise

    4/16/2010 1:23:10 PM |

    I´ve been a low fat healthy anything victim myself for over 12 years and know exactly that it is a difference to SAD - but as you said only at the beginning. But maybe it´s easier to take those first changing steps into the right direction even if it´s the wrong way.
    Low fat, tons of fruits and whole grains are not the solution.
    Now I´m VLC for over one year, keto the last half got rid of eczema, asthma, mood issues and much more. Laboratory always repeat the tests because they can´t believe it: HDL 199, triglyceride 35. That´s high fat.

  • Dr. John Mitchell

    4/16/2010 1:26:29 PM |

    Dr. D
    You are on the mark with the last paragraph...it's more than one "magic pill" to solve the health problem. The solution appears to be a combination of many aspects of human existence...diet exercise and mental state.
    Eat right, exercise right, and think right...making the right choices for a healthier lifestyle.

  • Anonymous

    4/16/2010 2:08:30 PM |

    (something that is unlikely in Ornish, since small LDL particles skyrocket on a low-carb diet)

    Should this not read either

    "Low-Fat" or "High-Carb" diet?

  • John

    4/16/2010 4:07:42 PM |

    I applaud Dane--I don't know how long I'd be able to contain my frustration if I had to not only watch the Dr. Oz show, but actually receive direct advice from Ornish and Oz about low fat...

  • Chuck

    4/16/2010 4:33:16 PM |

    You mean "skyrocket on a *low fat* diet", right?

  • Anna

    4/16/2010 4:37:00 PM |

    "since small LDL particles skyrocket on a low-carb diet"

    I think this is a typo that was meant to say "high-carb diet", right?  Or perhaps it was large LDL particles skyrocket on a LC diet.

  • Nigel Kinbrum

    4/16/2010 5:31:01 PM |

    "since small LDL particles skyrocket on a low-carb diet"
    I think you meant high-carb diet

  • Anonymous

    4/16/2010 5:56:34 PM |

    I think you have a mistype here:

    (something that is unlikely in Ornish, since small LDL particles skyrocket on a low-carb diet)

  • Anonymous

    4/16/2010 7:38:14 PM |

    Dr. Davis,

    I watched Dr. Oz's show on reversing heart disease and it was interesting to read your comments.  

    Regarding the reversal of heart disease, while I admittedly haven't read your publication, do you have Heart Scans/Calcium Scores, angiograms or PET Scans that show the same results Dr. Oz (and other MDs like Dr. Caldwell Esselstein or K. Lance Gould) that show the same results with your program?  

    Thank you again and look forward to your feedback.

  • Anonymous

    4/16/2010 7:46:00 PM |

    maybe I am reading into this wrong but " (something that is unlikely in Ornish, since small LDL particles skyrocket on a low-carb diet)"

  • Anonymous

    4/16/2010 8:27:32 PM |

    ''something that is unlikely in Ornish, since small LDL particles skyrocket on a low-carb diet''   You surely meant low-fat diet.

  • jd

    4/16/2010 8:45:38 PM |

    Thanks as always.  Please fix third line from bottom, after skyrocket,"low-carb," to help the newbies.

  • pjnoir

    4/16/2010 8:53:34 PM |

    See- it was an AMBUSH. They write the rules and that is that. WE, the low carb HIGH fat diet, community must be the grass roots driving force. We are like Galileo committing hiFat heresy among an antiFat, Whole grain Inquisition. Fight on and screw tv talk shows.

  • Drs. Cynthia and David

    4/16/2010 10:51:34 PM |

    I will be curious to see how this goes down on the Oz show, but am afraid we'll be left wanting to bang our heads on the wall.  Does this mean that Dane did not get a chance to respond at all to their advice or that he must agree to follow their advice (maybe with a  follow up to show improvement, or NOT).

    I agree with you that their diet advice is probably better than what most of their featured patients eat.  And you probably can show improvements to a degree that way in many people.  Just cutting the enormous glycemic load in conjunction with omega-6 rich oils should help a lot.  But that doesn't make it optimal for health.

    What's it going to take to shut up the low fat dogmatists?  A class action lawsuit?

    Why don't you have a show of your own?  I think it would be a good thing.

    BTW, I think you meant to say "small LDL particles skyrocket on a low-FAT diet" in your penultimate sentence.

    Cynthia

  • Phil

    4/16/2010 11:32:21 PM |

    Dr. Davis,
    Should the next-to-last sentence read "...small LDL particles skyrocket on a low-fat diet..."?  I thought low-carb diets reduced small LDL.

  • Steve

    4/17/2010 12:42:09 AM |

    Typo should be fat
    "small LDL particles skyrocket on a low-carb diet"

    I've enjoyed reading your blog.

    Other ideas...
    Niacin and phosophorous suppression causal for insulin resistance?

    Fibrates?

  • Dr. William Davis

    4/17/2010 4:41:10 AM |

    Ooops!

    Thanks, all for catching the typo.

    The sentence should have read:

    . . . small LDL particles skyrocket on a low-FAT diet.

    I guess everyone is paying attention!

  • Gys de Jongh

    4/17/2010 8:55:20 AM |

    not every body agrees ....

    Am J Clin Nutr. 2010 Mar;91(3):578-85.

    Lack of suppression of circulating free fatty acids and hypercholesterolemia during weight loss on a high-fat, low-carbohydrate diet.

    Abstract
    BACKGROUND: Little is known about the comparative effect of weight-loss diets on metabolic profiles during dieting. OBJECTIVE: The purpose of this study was to compare the effect of a low-carbohydrate diet (< or =20 g/d) with a high-carbohydrate diet (55% of total energy intake) on fasting and hourly metabolic variables during active weight loss. DESIGN: Healthy, obese adults (n = 32; 22 women, 10 men) were randomly assigned to receive either a carbohydrate-restricted diet [High Fat; mean +/- SD body mass index (BMI; in kg/m(2)): 35.8 +/- 2.9] or a calorie-restricted, low-fat diet (High Carb; BMI: 36.7 +/- 4.6) for 6 wk. A 24-h in-patient feeding study was performed at baseline and after 6 wk. Glucose, insulin, free fatty acids (FFAs), and triglycerides were measured hourly during meals, at regimented times. Remnant lipoprotein cholesterol was measured every 4 h. RESULTS: Patients lost a similar amount of weight in both groups (P = 0.57). There was an absence of any diet treatment effect between groups on fasting triglycerides or on remnant lipoprotein cholesterol, which was the main outcome. Fasting insulin decreased (P = 0.03), and both fasting (P = 0.040) and 24-h FFAs (P < 0.0001) increased within the High Fat group. Twenty-four-hour insulin decreased (P < 0.05 for both groups). Fasting LDL cholesterol decreased in the High Carb group only (P = 0.003). In both groups, the differences in fasting and 24-h FFAs at 6 wk were significantly correlated with the change in LDL cholesterol (fasting FFA: r = 0.41, P = 0.02; 24-h FFA: r = 0.52, P = 0.002). CONCLUSIONS: Weight loss was similar between diets, but only the high-fat diet increased LDL-cholesterol concentrations. This effect was related to the lack of suppression of both fasting and 24-h FFAs.

    PMID: 20107198

  • Fred Hahn

    4/17/2010 2:15:57 PM |

    If I'm correct, the study cited in the comments section fails to reflect LDL particle size. IOW, your total LDL can go up and still result in a superior outcome.

    Also, weight loss isn't the issue - fat loss is. We want to know which group lost the most fat, not weight.

    Additionally, A calorie restricted, low fat diet that places carb intake at only 55% (FAR lower the the USRDA recc's) is still a relatively low carb diet.

  • Lou

    4/17/2010 3:28:45 PM |

    Gys de Jongh,

    I've seen that study before. I can't access to the whole study but did they use NMR lipid test or traditional lipid test? Huge difference! I'd bet the study was flawed.

  • TedHutchinson

    4/17/2010 8:38:20 PM |

    @ Gys de Jongh
    In this study Subjects were told that polyunsaturated fats
    and monounsaturated fats were healthier sources of dietary fatty acids than were saturated fats,
    readers here know Dr Davis makes his recommendations on the basis every effort is made to improve omega 3 status while avoiding omega-6-rich sources like corn oil, vegetable oils, sunflower or safflower oils.

    Similarly New Atkins devotes a lot of time explaining the importance of raising omega 3 while reducing omega 6 sources.

    It is a pity these researchers didn't make similar recommendations.

    I would also like to point out that  in this study, concentrations of LDL cholesterol were estimated by using the Friedewald equation
    You may be interested in Dr Davis's  previous comments on Making Dr. Friedewald an honest man

    The point is that in the context of  high omega3 ~ low omega6 intakes, we would normally expect to see a low carbohydrate diet produce a beneficial effect on triglycerides and free fatty acids without reducing TOTAL cholesterol but this may seriously throw Friedewald off target.

    Without any positive recommendations to address the omega3<>omega6 ratio, the low carb diet used in this research is not a low carb diet that either Atkins proponents or Dr Davis would support.

  • donny

    4/17/2010 11:03:08 PM |

    Gys--

    So how much did the high carb group eat? The abstract only says that calories were restricted, it doesn't say to what extent.

    What was the composition of the weight loss?

    "There was an absence of any diet treatment effect between groups on fasting triglycerides or on remnant lipoprotein cholesterol, which was the main outcome."

    Triglycerides at the same level probably means different things, depending on the overall picture.

    A particular triglyceride level in a high carb diet might be a measure of the continuous production of triglycerides in the liver. In a low carb diet,  triglycerides might be at a similar level, and if this comes alongside a higher level of free fatty acids, those free fatty acids will be in competition for takeup with the triglycerides; so the same level of serum triglycerides could be reached, even though triglyceride production itself might be decidedly lower.

  • marshall

    4/17/2010 11:04:44 PM |

    Gys,

    It would be interesting to see if it was the large, fluffy LDL or the small, dense LDL that increased. Were the high fat diets consisting of a lot of Omega 6 or PUFAs? Or did the high fat come from coconut, grass fed meats, and omega 3 fatty acids?

  • Bobby

    4/18/2010 12:02:18 AM |

    I know lots of folks on a low fat high carb diet who flourish and do not have your experience. I know folks who are on a diet you recommend who also flourish. This whole subject must be more complex than currently understood. Either folks are different or we are missing some variables. The oriental cultures flourish on a high carb diet and they do well (until the SAD influences them).

  • nightrite

    4/18/2010 4:01:27 PM |

    It's not uncommon for LDL to increase with a high-fat diet. This increase however is in the large fluffy LDL subparticles and not in the small, dense type LDL.
    Small LDL is the real "bad guy" in the cholesterol story.

  • Jan-Peter

    4/18/2010 4:26:54 PM |

    I recently had the Berkley Heart panel done and found out I was a 3/4 APO E carrier.  Their recommendation of a 20% low fat diet I found misguided.  Instead I went on a restricted calorie (1,700/day I'm 5' 11") diet consisting of no grains, some limited fruit (mostly berries)and lots of veggies (daily carbs 110g), lean protein (grass fed if red meat) about 125g. And I eat a ratio of fats (80g) mostly from avacado, olive oil, nuts, and yes some saturated (20g).
    The Macro ratio is 46% fat/30 % protein/24% carbs.
    By being high fat I am able to maintain this low calorie diet without feeling depreived.
    After 2 months on this diet I lost 24 pounds my LDL went from 130 to 91, my HDL went from 45 to 54, and my triglycerides from 230 to 94.

    DESPITE THESE #'S MY PHSYCIAN AND THE DIETIAN FROM BERKLEY WARNED ME THAT MY GENOTYPE DOES NOT METABOLIZE FATS WELL!
    I know there are conflicting studies (Krauss). I would love Dr. D to take on this APO E subject.  I can't believe from an evolutionary standpoint that 20 % of the population can't eat high fat diets, something is wrong with this hypothesis.

  • Norm

    4/18/2010 9:41:03 PM |

    Gys de Jongh, maybe you should read this interpretation of the study on Dr. Eades' blog.

  • Gys de Jongh

    4/19/2010 11:11:00 PM |

    @ TedHutchinson :
    The Friedewald equation works fine in this case because the baseline Trig's were 117 mg/dl

    If Trig's < 100 mg/dl, LDL is over estimated by 12.17 mg/dL or if you have a (very) good lipid panel your LDL might be over estimated by 10% . Nothing to worry about I would say Smile

    The article is free :
    Arch Iran Med. 2008 May;11(3):318-21.
    The impact of low serum triglyceride on LDL-cholesterol estimation.

    PMID: 18426324

  • Gys de Jongh

    4/19/2010 11:17:49 PM |

    @Lou
    Total cholesterol and triglycerides were measured enzymatically with a colorimetric endpoint (Roche Diagnostic Systems, Indianapolis, IN), as were HDL-cholesterol concentrations (Diagnostic Chemicals Ltd, Oxford, CT). LDL cholesterol was calculated from plasma total and HDL cholesterol and triglyceride concentrations

  • Gys de Jongh

    4/19/2010 11:23:07 PM |

    @donny
    Suggested caloric intakes for women initially were set at 1200–1500 kcal/d, with the higher intakes recommended for those with a BMI > 36. Men were instructed to eat 1500–1800 kcal/d, again with the higher intakes recommended for those with a BMI > 36. Subjects were encouraged to consume about 30% of calories from fat, 15% from protein, and 55% from carbohydrate.

  • Gys de Jongh

    4/19/2010 11:30:30 PM |

    @Bobby
    The best "diet" for you depends on what your genes do with the food after you eat it  Smile
    Int J Circumpolar Health. 2007 Dec;66(5):390-400.
    Common variants APOC3, APOA5, APOE and PON1 are associated with variation in plasma lipoprotein traits in Greenlanders.
    Abstract
    OBJECTIVES: We undertook studies of the association between common genomic variations in APOC3, APOA5, APOE and PON1 genes and variation in biochemical phenotypes in a sample of Greenlanders. STUDY DESIGN: Genetic association study of quantitative lipoprotein traits. METHODS: In a sample of 1,310 adult Greenlanders, fasting plasma lipid, lipoprotein and apolipoprotein (apo) concentrations were assessed for association with known functional genomic variants of APOC3, APOA5, APOE and PON1. For significantly associated polymorphisms, between-genotype differences were examined in closer detail. RESULTS: We found that (1) the APOE restriction isotype was associated with variation in plasma total and LDL cholesterol and apo B (all p < .0001); (2) the APOC3 promoter genotype was associated with variation in plasma triglycerides, HDL cholesterol and apo A-I (all p < .002); (3) the APOA5 codon 19 genotype was associated with variation in plasma triglycerides (p = .027); and (4) the PON1 codon 192 genotype was associated with variation in total and LDL cholesterol and apo B (all p < .05). CONCLUSIONS: Taken together, our results suggest that common genetic variations in APOC3, APOA5, APOE and PON1 are associated with significant variation in intermediate traits in plasma lipoprotein metabolism in Greenlanders; the associations are similar to those observed for these variants in other populations.

    PMID: 18274205

  • Gys de Jongh

    4/19/2010 11:35:35 PM |

    @marshall
    High-fat/low-carbohydrate-diet treatment
    Participants in the high-fat condition were instructed to consume a diet that was low in carbohydrate and thus higher in percentage fat and/or protein (13). The central feature of this approach is carbohydrate restriction with unlimited consumption of fat and protein. Subjects were told that polyunsaturated fats and monounsaturated fats were healthier sources of dietary fatty acids than were saturated fats, but it was clear that the primary goal was to limit carbohydrate by whatever means were required. Participants were provided a treatment manual, which described the rationale for a low-carbohydrate diet as well as numerous suggestions for meal plans. The treatment manual for the highcarbohydrate diet plan was modified to make it parallel to the high-fat (low-carbohydrate) recommendations. This substudy took place during the first phase (“induction”) of the intervention. During this phase, participants were instructed to consume ’20 g carbohydrate/d. They were told to eat until full while remaining within the carbohydrate limit.

  • Lou

    4/20/2010 10:38:22 PM |

    Gys,

    What about small LDL particle vs large LDL particle? Did they use vegetable oil? What kind of carbohydrates?

    How do you explain this clincal study - http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=17583796&dopt=AbstractPlus?

    I rapidly lost a lot of viseral fat past month after cutting most of wheat flour based food AND adding more healthy fat like avacado, coconut milk, olive oil, egg yolk and plenty of various meat. I feel better. I tried low fat high carbs diet and it was not sustainable because I go hungry all the time.

    Unless I have full access to that study, I'm going to write it off as flawed misleading study. The author was clearly trying to promote high carbs and low fat diet. I'll have to see where they got grants from to do the study.

  • Catatonic Eyes

    4/22/2010 3:15:12 PM |

    Dr. Davis what brand of fish oil do you recommend? I have been taking Flameout by Biotest but am feeling it may not be the best choice. I am hopeful to find something reasonably priced that works well. When my Vit d tested at nine in December when I was admitted to the hospital, I started taking the NOW brand of Vit d 3 and mid March was at 53.....my new doctor is having me increase my dose as he wants it higher. Any brand recommendations for someone struggling on one income for the family for fish oil? Thanks for all of your articles. I am learning so much and will regain my health in time!

  • wendys

    4/26/2010 9:42:26 PM |

    Did they do a full colesteral work-up and will they show the results if it shows that Dane's numbers got worse instead or better?

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