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.
The best artificial sweeteners

The best artificial sweeteners

13. August 2011 William Davis (23)
Our new recipes, such as New York Style Cheesecake and Chocolate Coconut Bread, are wheat-free and low- or no-carbohydrate. They fit perfectly into the New Track Your Plaque Diet for gaining control over coronary atherosclerotic plaque, not to mention diabetes, pre-diabetes, hypertension, small LDL particles, high triglycerides, high inflammation (c-reactive protein) and other distortions of metabolism.

However, there's one compromise: We include use of non-nutritive sweeteners. It's therefore important to know that artificial sweeteners are not all created equal.

One common tripping point: maltodextrin.

Maltodextrin is composed of polymers (repeating subunits) of glucose, as few as 3 or as many as 20 or more glucose subunits. So maltodextrin is glucose sugar. While it lacks the especially destructive pentose sugar, fructose, maltodextrin is metabolized to glucose and thereby increases blood sugar substantially.

Many artificial sweeteners are bulked up with maltodextrin. For instance, granulated Splenda and Stevia in the Raw, two sweeteners billed as low-calorie and sugar-free that is used on a cup-for-cup basis like sugar, are primarily maltodextrin--with only a teensy bit of Splenda or stevia.

The best artificial sweeteners, i.e., the most benign without a load of maltodextrin, are:

Liquid stevia--Just the extract from stevia leaves and water. It can be a bit pricey, e.g., $10 for a 2 oz bottle, but a little goes a long way.

Truvia--While I'm not too fond of the manufacturer (Cargill), I believe that Truvia is among the better sweeteners around. It is a mixture of the natural sugar, erythritol, that generates little to no blood sugar effects and rebiana (rebaudioside), an isolate of stevia. Some people aren't too fond of the mild menthol-like cooling effect of the erythritol nor the slight aftertaste. I find it works pretty well in most recipes.

Be aware that, no matter which artificial sweetener you use, it has the potential to stimulate appetite. I therefore like to not eat foods sweetened with liquid stevia or Truvia in isolation but as part of a meal. That way, any appetite stimulation that results is substantially quelled by the proteins and fats ingested.
Tags :

Comments (23) -

  • Princess Dieter

    8/12/2011 11:53:20 PM |

    Thank you for the link. I was just talking with hubby last night about finding a recipe for cheesecake that had no wheat/gluten and would be good for us for special treats/occasions (like an upcoming family birthday). Yay.

  • pjnoir

    8/13/2011 2:52:19 AM |

    I never use Truvia. The best stavia hands down is SweetLeaf, either the liquid or the powder. BUT Stevia acts like insulin, in fact, Asia has been using it as an insulin substitute and comes with a warning to diabetics about using it with one’s daily  insulin shots.   I stopped using it as I don’t need to rev up by insulin production.  I’m diabetic. I still go with local honey and get the benefits of having local pollen in my body.

  • Shreela

    8/13/2011 3:27:35 AM |

    Both DH and I noticed the aftertaste. I figured out how to use half stevia/half sugar for a few days, then 1/4 each, then all stevia, which solved the aftertaste problem for me. I then tried one teaspoon of sugar to a quart of stevia-sweetened tea with DH - he didn't notice any weird taste. So hopefully just adding a tiny bit of sugar for 1-2 weeks will get your taste buds used to stevia.

  • Gabriella Kadar

    8/13/2011 3:29:15 AM |

    Why do people feel the need to eat desserts?  Doesn't adherence to a consistent low carb diet eventually curb most of the craving for sweets?  One teaspoon of fruit jam should be able to quell any overweening desire.  Or is the socio-cultural programming for eating confections so deeply ingrained that people just can't live without?

  • Michia

    8/13/2011 9:06:53 AM |

    I agree.  In our house (LC for years), the same logic applies to low carb "treats" that applies to low carb Frankenfoods.  Don't eat foods that are trying to be foods that you know you can no longer have.  

    There is a real danger in continuing to eat really sweet foods, even artificially sweetened.  "Low carb" needs to be "low sweet".  If you hang in there, you do eventually lose your taste for it.  

    As for Splenda, you can find the liquid if  you try.  And the mini tablets are minimally carby.

  • cancerclasses

    8/13/2011 6:13:31 PM |

    Both cancer & systemic fungi make energy by means of glycolysis and create demands for large amounts of sugars.  People with continuing carb cravings that won't resolve may have one or the other condition.  Otherwise I'm with you, people hanging onto sweets are still living to eat rather than eating to live.

  • Might-o'chondri-AL

    8/13/2011 7:27:21 PM |

    Hi Dr. Davis,
    Server blocked me elsewhere, so writing this here.
    Amazake data when made from white rice (brown, short & long may each differ) =
    30 - 70 % complex carbohydrate saccharides
    20 - 45 % maltose (not amylose)
    3 - 5 % glucose
    5 - 9 % protein
    3 - 5% fat
    1 - 7 % fiber
    0.3 - 0.4 % mineral ash
    iron, niacin & thiamine

    Sample 1 liter (1 quart) sauce pan Amazake home kitchen batch:
    200 ml ( 7 ounce volume, +/- 200 grams) short grain brown rice rinsed and drained
    bring to boil  in 2.5 times the volume water
    reduce heat to low and, covered,  cook 50 - 60 minutes (until not wet)
    transfer cooked rice to an incubation vessel & let cool
    when cooled to  60* Celcius (140 * F) mix with 400 ml (14 ounce volume) of Koji innoculant
    cover with aluminum foil (or somehow) and put where can keep warm
    incubation ideal temperature is 57 - 60 * C  (with leeway)
    ferment for  desired time , 12 hours sweeter and I use 22 hours
    when time up pan boil the Amazake (stir) 3- 5 minutes to inactivate Koji fungi
    refrigerated covered keeps weeks

    Dosages mentioned previously (for 165 pound adult, and Amazake was eaten with protein and fat):
    (a) " low" dose with 2 hour blood glucose ending up being same as pre-prandial blood glucose was 1/8th (by volume) of the above Amazake (rough calculation would thus be ingesting 1/8th  of  +/- 600 grams  total of original dry rice and Koji rice)
    (b) "high" dose with 2 hour blood glucose rebound (suggested for athletes carbs) was 1/4 (by volume) of the above Amazake recipe (rough calculation  would in this case be ingesting 1/4 of +/- 600 grams total of original dry rice and Koji rice)

    Koji innoculant ( steamed white glutinous rice infused with Aspergillus oryzae and then dessicated) used was wholesale direct from L.A. producer Miyako Oriental Foods 626-962-9633; call for your local retailer of their Koji under the "Cold Mountain" brand. They recommend double their Koji for any volume of rice substrate. Other makers of Koji proportions may be less if the Koji is less dehydrated; family business G.E.M. Cultures in Wash. mail orders their Koji and it may (?) be suitable for using less (GEM also sells spores with instructions to make your own Koji).

  • Might-o'chondri-AL

    8/13/2011 7:43:26 PM |

    Dr. Davis,
    Orientation for those athletes interested in experimenting with Amazake:
    Innoculant of rice is Aspergillus oryzae fungal infused rice grains, called Koji; Koji has alpha-amylase, glyco-amylase, acid protease, lipase, amylo-glucosidase , acid carboxy-peptidase , chitosinase and citric acid.
    Incubation lets fungal penetrate new rice substrate and fungal hyphal tip performs hydrolytic enzyme secretion.

    Cooking the rice first gelatinizes the starch held in granules inside of organelles with lipoprotein membranes (amyloplasts) into 16 - 30% amylose and 65 - 85 % amylopectin which are ammenable to hyphal hydrolytic action. Koji's amylo-glucosidase enzyme digests the gel &  Koji's alpha amylase enzyme reduces molecular size of amylose, which makes it less viscous and more fluidly mobile. It is glyco-amylase enzyme that turns amylose and some of the amylo-pectin chains  into glucose.
    Incubation lets the fungi grow and their mycellial cell wall builds up with the amino mono-saccharide glucosamine (a.k.a. chitosan); fungi generally have 67 - 126 mg mycelial glucosamine per 1 gram dry weight mycellium. Amazake is well tolerated by most since glucosamine is useful in colitis. Glucosamine (chitosan) is a poly-cationic bio-polymer formed when chitosanase I enzyme de-acetylates chitin (in fiber); with optimal enzymatic pH being 5.5 - 6.5. Chitosan is more acid pH soluble than chitin and under chitosanase II enzyme (working from pH 3.8 -8.5) some chitin is de-acetylated to form more oligo-saccharides.

    Amazake may have biologically active high molecular weight immunological poly-anionic polysaccharide
    derivatives like the poly-acetyl carboxylic acid  COAM (chlorite oxidase oxy-amylose). COAM comes about when a saccharide chain is oxidatively cleaved between 2 carbon atoms resulting in oxy-amylose, a polymer of 2 aldehyde functions;  when these aldehydes gets further oxidized they produce functional carboxyls.  Rice has aldehydes like the volatile aldehyde hexanal we smell as stored rice &/or from rice bran.

    Rice, like most bean & grain carbohydrate polysaccharides, include the following in both the soluble and insoluble form: arabinoxylan, beta-glucan, cellulose, mannose, galactose, xylose and uronic acid. For us these non-starch  polysaccharides are not digestible;  as neither is fiber (made up of cellulose, hemicellulose, pectin and lignan ) since 90% of our dietary fiber is linked together by beta-glycosides that our digestive enzymes can't cleave. Arabinoxylan, mannan, galacto-mannan and xylan are considered anti-nutritional since can lower intestinal uptake of nutrients; while mannose reacts with amino groups in dietary protein to reduce the amount of certain aminos properly digested.

    Koji's fungal hyphal hydrolytic enzymes include mannosidase enzymes; beta mannanase catalyses the mannosidic links in insoluble mannan polysacharides where there are galactosyl residual features.  The  so-called endo-mannanase (a manno -hydrolase) cleaves mannan and galactomannan to free up molecules like manno-triose, manno-biose and manno-tetraose that human gut Bifidobacteria can then feed on. This may be part of why a substantial dose of Amazake seems to yield more delivery of  sustained energy beyond what one would get from the usual amount of short chain fatty acids put out by gut bacteria.

    Amazake incubation is a solid state fermentation, since want the minimal free fluid when culturing;  too much water and the substrate porosity is diminished and resultant depressed oxygen transport in substrate  causes fungal cell numbers to decline. A  submerged fungal ferment, when cooked rice with koji substrate is set out  too soupy can result in 3.5 times less enzymatic activity. Using  too much rice substrate mixed with too sparse koji innoculant and the fermentation won't proceed promptly due to low oxygen. Also do not stir the blend while incubating to avoid damaging mature fungal hyphae or breaking new growth.

    Mannanase enzyme development in 1st day is less than 50 units/gram and this goes to a maximum of 100 units/gram after 2 days; a peak mannanase content seems to be +/- 250 units/gram on days 3-5. I incubate short grain brown rice Amazake for 22 hours; while most commercial Amazake products and home producers probably do not incubate more than 12 hours. The longer incubation is allowed to go on for the more llikely bitter flavors develop from oxidation of the bran's oil content;  yet the bran is desired for it affords better beta- mannanase and beta-mannosidase enzymatic formation.

    Amazake has exceptional anti-oxidant properties; with longer incubation time this activity increases. Amazake also raises the bodies ability to inhibit lipid peroxidation; so concern over any of rice bran's oil oxidation is probably moot.
    END

  • Elenor

    8/14/2011 5:13:52 PM |

    You don't mention liquid surcralose (Splenda)  -- which has all the 'benefits' of sucralose without the maltodextrin.  I use it and nothing else.

  • Dr. William Davis

    8/15/2011 12:51:28 PM |

    Wow, Might. You are a walking Wikipedia!

    Thanks for the incredible insights.

  • Marlene

    8/15/2011 5:44:10 PM |

    I have never been able to find liquid Splenda in stores in the U.S.  If it's there, what brand name is it sold under?

  • ibh

    8/15/2011 8:36:23 PM |

    I use Sweet Leaf as well. It is in the powder from. the box states no chemicals,no alcohols, no erythritol, no ethanol or menthol,, no aspartame, no sucralose, no maltodextrin, no dextrose or additivees. Seems clean to me. Any thoughts as to problems with this product.

  • Anonymous

    8/15/2011 8:36:54 PM |

    Doc, also notice the removal of all of Might's comments from Guyenet's site. This speaks for itself, as to where the truth lies. Might is truly a wonder and knows what he's talking about.

  • Jack Kronk

    8/15/2011 9:57:54 PM |

    What does that mean, that the comments from Guyenet's site are removed? Stephan removed them, or Might removed them? I've traded comments with Might over there dozens of times.

  • Jack Kronk

    8/15/2011 10:00:22 PM |

    I just use pure Stevia powder, which is gauranteed to be at least 95% pure stevia crystals (like the liquid stevia, on in teh form of powder. The brand I use is Stevita. A tiny little 0.7 ounce conainer lasts FOREVER! You only need a tiny pinhc of it for coffee. It doesn't exchange well versus sugar as a substitute, but adding a little to whatever you might be baking or making can help with using less of whatever other sweetener you may need to use.

  • Janmar Delicana

    8/16/2011 12:13:10 AM |

    Dear Dr. Davis,
    It’s a great pleasure to read your blog. I find your post very informative. Thank you for sharing.
    As a reader, I consider your writing to be a great example of a quality and globally competitive output.
    As a moderator for Physician Nexus (a community for physicians) I would like to share your genuine ideas and knowledge. With this you can gain 1000 physician readers on Nexus.
    We would love for you to visit our community. It's free, takes seconds, and is designed for physicians only - completely free of industry bias and commercial interests.
    Best,
    Janmar Delicana
    On behalf of the Physician Nexus Team
    www.PhysicianNexus.com

  • Might-o'chondri-AL

    8/17/2011 12:33:07 AM |

    Stephan who hosts the WholeHealth blog is smarter than me &  the removal of my comments there came from someone using my computer. These days I do not have the time to follow Stephan's blog, which has nothing to do with validity of his approach.

  • Stefan

    8/31/2011 1:46:14 AM |

    Marlene,
    I buy it at SuperSupplements or at Whole Foods. Any nutritional supplements &vitamins stores should carry it. If you live in a place whch doesn't havenay -> use Amazon. It's simple Smile.

  • Stefan

    8/31/2011 1:50:21 AM |

    Whoops - I thought you meant Stevia. Liquid Splenda is at amazon as well

  • Serge

    9/2/2011 11:27:16 PM |

    Dr. Davis--

    I'd like to recommend ZSweet.  It's a stevia/erythritol blend but isn't a Big Ag product like Cargill/Coca-Cola's Truvia or Pepsico/Monsanto-er-Merisant's PureVia.

    It's funny how Stevia was banned by the FDA in the 80s, only to be given the GRAS label in 2008, which just happened to be the same year that Truvia was launched.  Coincidence?

  • Dr. William Davis

    9/2/2011 11:40:52 PM |

    Hi, Serge-

    I have no doubt that the clout of Cargill pushed Truvia through. I wasn't aware of ZSweet--thanks!

  • Susan

    12/18/2011 6:10:37 AM |

    I am absolutely thrilled to have found this blog.  I've been extremely cautious of sugar and sweets since my mother was diagnosed with diabetes when I was a child.  Unfortunately I did fall into the "healthy whole grains" trap for a while, but have kept my daily carbs between 50-100 for many years now.  I like Stevia products, but unfortunately they leave me with a slight headache.  I've been (sparingly) using Volcanic Agave Nectar for years, mostly in tea and for the occasional baked good.  I understand that due to the rich soil in which it's grown, and minimal processing, volcanic blue agave has a lower glycemic index-load than other traditional agave nectars, at 27.  

    Am I doing myself harm by using it?  I'd like to try the liquid Splenda, that contains no maltodextrin.  Thank you Elenor and Stefan for mentioning it, but should I be concerned about its processing?

  • jpatti

    5/27/2012 6:58:29 PM |

    I'm not big on Truvia.  

    From what I've heard from other diabetics erthyritol doesn't have the GI side effects of most sugar alcohols and has a lesser effect on bg, but even so... I prefer a plain stevia powder.

    I don't think erthyritol has been around long enough to know what it's side effects may be, that it doesn't raise bg much and doesn't cause GI distress isn't good enough. There's any number of other bad side effects that exist in the world besides those two.

    Stevia is food.  Granted, the plain white stuff is relatively refined, but I still feel better about it than erthryitol.  

    Susan, agave nectar has almost no GI effect because it is fructose, not glucose.  It has MUCH more fructose than HFCS.  Search this blog for a long list of the bad stuff that fructose causes.  I'm a diabetic, and I'd seriously rather eat sugar than agave.

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