A niacin primer

A reader of Life Extension reminded me of a piece I wrote about niacin a couple of years back.

Anyone desiring a primer on how and why to use niacin to correct lipid and lipoprotein patterns might find this useful.

While some people, no matter what they do, cannot tolerate niacin (about 10% of people), many others enjoy spectacular benefits.

Q: I recently had a cholesterol profile blood test and learned that I may be at risk of heart disease because my levels of beneficial HDL (high-density lipoprotein) are too low. I read that niacin could help increase my HDL, but my doctor said niacin is dangerous. Whom should I believe?

A: Your doctor would be right—if we were still living in 1985. Since then, however, we have learned how to use niacin (vitamin B3) safely and effectively. Unfortunately, many physicians have not yet caught up, or are still trapped by the idea that cholesterol-lowering statin drugs are the only way to decrease cardiovascular disease risk. I have personally prescribed niacin for thousands of patients as part of our program to reverse coronary disease. In fact, niacin is the closest thing we have available to a perfect treatment that corrects most of the causes of coronary heart disease.

Continued here.

Comments (19) -

  • Ganesh Kumar

    7/29/2009 7:20:35 PM |

    Do you therefore prescribe Niaspan since its considered to be the gold standard of niacin? If so, I urge you to look up user views on side effects at http://www.askapatient.com/viewrating.asp?drug=20381.  This was key reason why I chose NOT to take Niaspan and got the HDL, triglycerides level just with Vitamin D and Omega 3s

  • Kiwi

    7/30/2009 11:17:42 AM |

    Reading through some of the comments it seems to me people are starting on too higher dose.
    I've been on niacin for almost a year and started with just 50mg/day. Yes, half a tablet.
    Slowly worked up to 500mg standard niacin then switched to SloNiacin and increased to 750mg.
    I take 75mg aspirin at the same time.
    Any slight tingling I get I know the stuff is working and it makes me feel good.

    Only problem, SloNiacin is only available from the US, so I have to import it myself. I'm pretty sure it's not legal to do this as amounts over 100mg are considered a drug in this country (NZ).
    I've just had some vitamin D confiscated by Customs for the same reason. Capsules over 1000iu available only on prescription. Tough.

  • Anonymous

    7/30/2009 1:12:55 PM |

    The primer states that niacin blocks the release of fatty acids. So if I am trying to loose fat would taking niacin be counter productive to on trying to burn fat stores to lose weight?

  • trinkwasser

    7/30/2009 3:49:25 PM |

    I wish it had worked. Frown

    Maybe because it was inositol hexaniacinate, 1000mg niacin "equivalent"

    I had gotten my HDL up from 25 to 55 primarily through low carbing and adding more saturated fat, but that was with simvastatin 10mg

    As an experiment I dropped the statin and added the niacin and also pantethine (NOT pantothenic acid) 600mg.

    Previous results:
    HDL 55 trigs 62 LDL 94
    which is close enough for jazz to your 60-60-60

    Latest results
    HDL 47 trigs 115 LDL 156

    I have now restatinated myself. Either my funky familial genes or the damage from the years of undiagnosed diabetes have caught up with me. Still it was an interesting experiment in showing that the statin actually does have a benefit over and above the diet.

    It would be interesting to see what effect the statin *plus* the niacin and pantethine has but I suspect it will be several years before I am permitted another lipid panel. They prefer saving money to saving lives here.

  • billye

    7/30/2009 8:03:22 PM |

    Is supplementing with niacin the only way to raise HDL and lower LDL without taking Staten's?  Some other doctors are recommending a magnesium supplementation using a topical magnesium oil which can raise the magnesium levels to the top of the reference scale in as little as six weeks.  I quote Dr. Mildred S. Selig MD "most modern heart disease is caused by magnesium deficiency as reported in an article by Chris Jennings "what's all the buzz
    about magnesium oil?".  

    Magnesium in our food and water is drastically lower than it was 100 years ago.  I also understand that heart disease was practically non existent 100 years ago.  If true, what a coincidenc. Hmmm!  

    As you know I respect and honor your medical opinion, so, what say you?

  • billye

    7/30/2009 8:12:16 PM |

    I forgot to mention that I also supplement with high dose vitamin D3 and high dose fish oil.  My triglycerides level is now 66 mg/dl down from 115 mg/dl.  However, there has been no movement in my HDL and LDL level so far. I am waiting for a VAP test to come back.  Bottom line, I would not like to supplement with niacin.  Who wants the discomfort of flushes or itching.  I hope that magnesium supplementation works.

  • George

    7/30/2009 9:48:55 PM |

    Dr. Davis, always appreciate the great information on your blog. I have been taking 500mg of Slo-Niacin for a year with good results. Recently in a Prevention magazine I saw a quote by Dr. Angaston stating that you should only take niacin with a statin, that niacin by itself doesn't do anything. Your thoughts?

  • Dr. William Davis

    7/31/2009 12:42:29 AM |

    The form of niacin I use in 95% of cases is Upsher Smith's Sloniacin. It has a proven and published track record and is 1/20th the cost of prescription Niaspan.

  • Dr. William Davis

    7/31/2009 12:43:14 AM |

    Niacin works great by itself. There is absolutely no need for taking it with a statin.

    I can't imagine why Dr. Agatston would say such a thing. I wonder if it's a misquote.

  • Anonymous

    7/31/2009 12:57:28 PM |

    I recall reading that slow release niacin was the more hepatotoxic form of niacin, and that plain ol' niacin was best... is "sloniacin" the same thing as "slow release niacin?"

  • Dr. William Davis

    7/31/2009 2:49:59 PM |

    Niacin has confusing terminology.

    Sloniacin is closest in properties to "extended-release" niacin rather than "slow-relase," meaning niacin is trickled out over a briefer period with extended release, a property associated with reduced hepatic toxicity.

  • Anonymous

    8/1/2009 1:33:15 PM |

    Baylor college has a great resource if you want more medical study info.  The HATS study showed the staggering impact of Niacin/Statin combo but I don't think this should encourage statin use. If anything it points to a reduction in dose for those who must take statins ( http://www.lipidsonline.org/slides/slide01.cfm?q=niacin&dpg=9 )

    I take 2grms (Now brand)at night before I go to bed.  Sure occasionally I get a flush but the benefits far outweigh the occasional discomfort:-

    "In the group receiving niacin plus simvastatin without antioxidants, LDL-C levels were lowered by 42%; the LDL-C levels in the placebo groups were unaltered. HDL-C was increased by 26% in the niacin plus simvastatin group. The combination of niacin and simvastatin reduced CHD events by 60–90%, with about a 90% reduction seen in those subjects who did not take antioxidants, possibly because the treatment-induced increase in HDL particle size was blunted by antioxidants."


  • Anonymous

    8/7/2009 4:10:03 AM |

    The primer states that niacin blocks the release of fatty acids. So if I am trying to loose fat would taking niacin be counter productive to on trying to burn fat stores to lose weight?

  • cbatterman

    9/25/2009 5:09:59 PM |

    I read a 2002 paper by John A. Pieper in VOL. 8, NO. 12, SUP. THE AMERICAN JOURNAL OF MANAGED CARE that said Slo-niacin was hepatoxic where as IR Niacin was not...Are there more recent studies that support your use of slo-niacin over IR niacin?

  • Diane

    10/7/2009 5:13:56 PM |

    I have been battling slowly rising cholesterol since going through menopause, despite a great diet, ideal weight, and an active lifestyle. I resisted any suggestion of taking statins, especially after the February 2008 WSJ article and the NYTimes Well blog post "Do Statins Make You Stupid?"

    Luckily, I have a very conservative doctor, who is not so quick to prescribe statins. First she recommended fish oil capsules, (which raised HDL but also raised LDL). After that, I tried garlic (which I had to stop after my partner commented on the smell of my skin), plant sterols, (which didn't appear to have much effect), and finally niacin.

    In July I asked my doctor for instructions on using niacin. She recommended Slo-Niacin, starting with 500 mg once a day and increasing to 500 mg twice a day.

    I went back for my three-month visit this morning. My cholesterol has dropped from 220 to 175; HDL still high at 53, LDL down to 102 from 142, triglycerides down to 85 from 160.

    I usually avoid flushing by taking it immediately after a meal and drinking lots of water with the pill. If I eat too late in the evening and go right to bed, the flushing effect is worse - you have to move around for a while.

    I am very pleased and hope that this anecdotal evidence will encourage others.

  • steve

    10/23/2009 9:02:11 PM |

    I used  550 mg Niaspan for 3 months, It made no change in my Lipid Panel. Then I used 750 mg Slow-Niasin for 3 months . My Cholesterol fell from 182 to 174 . LDL dropped from 130 to 118. Triglycerides rose from 82 to 96, HDL went up 1 point from 35 to 36. Not happy with the results .
    I am mow trying 1,000 IU of D-3 and 2,400 mg of Fish oil Supplement along with 1 heaping TBS  each of oat bran and  pure cocoa in my oatmeal every morning along with 1/4 cup of walnuts. Will get checked again in April.
    I will post my results.

  • mongander

    11/16/2009 2:26:34 PM |

    "A small 208-person trial that used ultrasound to examine arteries found that Zetia was clearly inferior to a version of the old drug niacin in preventing clogged arteries. Moreover, in a surprise finding, patients on niacin appeared to have fewer heart attacks and were less likely to die from heart disease than those who got Zetia. It is unusual for such a small trial to show a difference in heart attack rates."

  • Lynn

    3/28/2010 1:26:20 PM |

    I would like to also follow up on the comment about niacin blocking the release of fatty acids.
    I have read elsewhere that nicotinic acid inhibits lipolyis.
    I cannot seem to determine how the recommended dosage (750 mg of SLO Niacin) might set me back in my current efforts to shed body fat?

    Any further reading available on this issue anywhere? Thanks

  • buy jeans

    11/2/2010 7:34:16 PM |

    While some people, no matter what they do, cannot tolerate niacin (about 10% of people), many others enjoy spectacular benefits.

The Perfect Carnivore

The Perfect Carnivore

People who carry the gene for lipoprotein(a), Lp(a), tend to be:

--Intelligent--The bell curve of IQ is shifted rightward by a substantial margin.
--Athletic--With unusual capacity for long-endurance effort, thus the many marathoners, triathletes, and long-distance bikers with Lp(a).
--Tolerant to dehydration
--Tolerant to starvation
--Resistant to tropical infections

In other words, people with Lp(a) have an evolutionary survival advantage. More than other people, they make clever, capable hunters who can run for hours to chase down prey, not requiring food or water, and less likely to succumb to the infections of the wild. In a primitive setting, people with Lp(a) are survivors. Evolution has likely served to select Lp(a) people for their superior survival characteristics.

But wait a minute: Isn't Lp(a) a risk for heart attack and stroke? Don't we call Lp(a) "the most aggressive known cause for heart disease and stroke that nobody gives a damn about"?

Yes. So what allows this evolutionary advantage for survival to become a survival disadvantage?

Carbohydrates, especially those from grains and sugars. Let me explain.

More so than other people, Lp(a) people express the small LDL pattern readily when they consume carbohydrates such as those from "healthy whole grains." Recall that the gene for Lp(a) is really the gene for apoprotein(a), the protein that, once produced by the liver and released into the bloodstream, binds to an available LDL particle to create the combination Lp(a) molecule. If the LDL particle component of Lp(a) is small, it confers greater atherogenicity (greater plaque-causing potential). Thus, carbohydrate consumption makes Lp(a) a more aggressive cause for atherosclerotic plaque. The situation can be made worse by exposure to vegetable oils, such as those from sunflower or corn, which increases production of apo(a).

Also, more than other people, Lp(a) people tend to show diabetic tendencies with consumption of carbohydrates. Eat "healthy whole grains," for instance, or if a marathoner carb-loads, he/she will show diabetic-range blood sugars. I have seen long-distance runners or triathletes, for instance, have a 6 ounce container of sugary yogurt and have blood sugars of 200 mg/dl or higher. The extreme exercise provides no protection from the diabetic potential.

Because carbohydrates are so destructive to the Lp(a) type, it means that people with this pattern do best by 1) absolutely minimizing exposure to carbohydrates and vegetable oils, ideally grain-free and sugar-free, and 2) rely on a diet rich in fats and proteins.

The perfect diet for the Lp(a) type? It would be a diet of feasting on the spoils of the hunt, devouring the wild boar captured and slaughtered and eating the snout, hindquarters, spleen, kidneys, heart, and bone marrow, then eating mushrooms, leaves, nuts, coconut, berries, small rodents, reptiles, fish, birds, and insects when the hunt is unproductive.

Capable hunter, survivor, consumer of muscle and organ meats: I call people with Lp(a) "The Perfect Carnivores."

Comments (19) -

  • BuckarooBanzai

    10/2/2012 7:07:35 PM |

    Then I suppose I am the imperfect carnivore-tendency towards high Lp(a) which is recently under control but also apoE3/4 which suggests limiting fat (or is it just saturated fat?).  Limit carbs...no, limit saturated fat.  OK, so that leaves lean meat, avocadoes, nuts and non-starchy veggies, right?

  • Dr. Davis

    10/3/2012 1:40:11 AM |

    Not necessarily, Buckaroo.

    The apo E4 introduces a trait of highly variable fat-sensitivity.

    Perhaps this is something worth discussing in future.

  • Ulrik

    10/3/2012 3:20:49 PM |

    I'll second a request for your opinions on what to do when you're ApoE ε3/ε4 or ε4/ε4! This is very interesting, but just the beginnings of personalized medicine.

  • Anand Natrajan

    10/3/2012 6:54:13 PM |

    Dr. Davis,
    I have extremely elevated Lp(a) (190 mg/dL) that hasn't budged despite 2 g niacin  and  4 g  fish oil daily.  I am seem to fit several of your descriptors, i.e. thin, premature CHD at. 47, LDL that is resistant to lowering beyond 85 mg/dL despite statin and niacin therapy, borderline fasting glucose etc. Always been very physically active and that hasn't changed despite one stent.

    However, I am not and don't want be to be a carnivore. Any other options?
    Thank you.


  • Bob

    10/3/2012 7:16:40 PM |

    What level of Lp(a) do we need to be concerned about?

  • BuckarooBanzai

    10/3/2012 9:43:10 PM |

    I would welcome a more in-depth discussion of the role of fat sensitivity in apoE4.  I've not been able to find anything remotely like a consensus on PubMed, and The Perfect Gene Diet which addresses was a big disappointment.

  • Susan

    10/4/2012 1:30:46 AM |

    Well, I just got my Lab Results back and I am the lucky carrier of Lp(a) as well as Apo E3/4 and probable FH or FDB. LDL-C Direct 205, HDL-C 95, Triglycerides 52, LDL-P1969, LP(a) Mass 64, LP(a) Cholesterol 13. I have been wheat free, sugar-free, low carb, high fat for about 3 years. Looks like I will have to make some changes, but feel uncertain because high fat is what has really helped me lose weight. Without the fat, I have cravings. Higher carbs are no good for me. Would coconut oil perhaps lead to better results?

  • Yet Another Kim

    10/4/2012 6:38:19 PM |

    Hmm, I've recently learned I have lipoprotein(a). I am definitely not an endurance athlete (I adore sports where I can go hard for a minute and then recover), but the rest of the sketched profile fits.

    I'm not sure how I feel about your assertions wrt carb tolerance as it applies to me, though. If I eat by preference with no effort to restrict, I get on average 100g carb/day (a bit less if there are no social demands), but higher or lower levels of carbohydrate don't seem to make too much difference in my blood glucose readings (or mood or ability to lose weight). I have had some wild effects from medication, though: the Mirena IUD (levonorgestrel) in particular caused a crazy post-prandial rollercoaster and elevated fasting glucose for a couple of months until I pulled the plug.

  • Gene K

    10/6/2012 1:21:32 PM |

    I am ApoE 3/4, and I have followed this issue closely. You may find some useful advice on Dr. Kruse's Optimal Living site, especially in his EpiPaleo diet - http://jackkruse.com/brain-gut-6-epi-paleo-rx/.

  • Haley Joel

    10/9/2012 10:14:20 AM |

    Hi Susan,

    Instead of coconut oil i would rather suggest to have some high calorie food, because oil makes you increase of cholesterol not fat , having high calorie food like cereals will also help in have some energy in the body

  • Celeste

    10/12/2012 7:51:31 PM |

    Dr. Davis,

    I am working on bringing my husband's Lp(a) 14 and apoB 109 down.  His current pattern is A/B smack in the middle.  What confuses me is saturated fat. How is this good for bringing down your numbers (assuming your not apoe4) when it is also highly inflammatory.  Perhaps this is in the book but it hasn't arrived yet.


  • Rick

    10/16/2012 10:46:29 AM |

    Look at this article on kidney failure in sugar cane workers...horribly fascinating.


  • Gene K

    10/21/2012 2:47:14 AM |

    It is hard to believe that regular readers of this blog will consider cereal in their diets.

  • Stephanie

    10/26/2012 2:36:07 PM |

    I just got my first VAP test results back and my Lp(a) is 12 mg/dL.  I probably fit your description pretty well, except I have no idea if I get diabetic if I eat lots of grains.  I used to be semi-vegan but I was a marathoner at the time.  I do know that back then I would get very hungry every 2 hours and I would gain weight pretty easily if I stopped doing so much cardio.  My LDL has gone up (116 now, pattern A, was 94 a year ago) since going paleo 1.5 years ago, but my HDL is also up (95, was 85) and my trigs are down (55 now, was 65).

    Thanks for the info!  I'll keep my carbs low as I can while keeping my energy up.  I know if I don't eat some starches I start to feel pretty awful, especially during certain times of the month.  I guess I should start using a glucometer!

  • RFM

    1/4/2013 4:15:47 PM |

    Dr. Davis,

    My VAP test showed that I have an Lp(a) of 12 on a normal scale of 1-10.  A specific Lp(a) blood test showed that I have an Lp(a) of 250 mg/dL.  Do you see such discrepancies often?  How can both tests possibly be right?


  • Richard

    2/3/2013 8:33:08 PM |

    Kinda disliked that the text encourages confirmation bias, but had a private test for lp(a) anyway ($50, pretty cheap info).  It was predictably, very high, which matched up to the NMRLipo derived suspicions I had, big numbers were all awesome, with a bajillion ldl-p and very near diabetic a1c & insulin resistant! lol.

    Needless to say, sugar and refined grains are now mostly deleted.    Keeping a <10% cap on carbs for now; not sure I can manage a smaller cap, but we'll know if that change was sufficient in a couple more months.

    If someone needs a reason why lp(a) and associates would be evolutionarily advantageous?   On a distance hunt, away from village support, quick repair is better than good repair; and a downed hunter may not have much meat, but will have some body fat, and will have dried fruit.   Sugar+injury+gobs of sticky things in the blood, good nuff to be back in the game quickly (if painfully).    No one cares if their hunters die at 55 instead of 75.

    nb... objectively measured, I fit your stated tendency characteristics exactly.   I'd kinda like to live past 55 though.

  • Mar

    8/19/2013 7:58:22 PM |

    Hi Dr. Davis,
    My husband has very high Lp(a) at 30 years old. We are trying to get on the right diet to help him so he can live a long life and not die of a heart attack at a young age like his mother, uncle and both grandfathers. You seem to be very knowledgeable in regards to Lp(a) levels in cardiac patients. His doctor is not and we are currently doing the Caldwell Esselstyn diet (plant-based, low-fat) to reverse plaque build-up. Reading your blog suggests to me that we are on the wrong track. Can you please point me to the research papers from which you derive your specific conclusion that high Lp(a) carriers should be carnivorous?
    I would greatly appreciate any help!
    Thank you so much,

  • R Shaffner

    11/20/2013 10:20:28 PM |

    How about eggs, dairy and fish?

    And be sure to take low-dose aspirin, which has been shown to "abolish" the incremental risk of having Lp(a).

  • R Shaffner

    11/20/2013 10:27:45 PM |

    Dr. Davis,

    I've had high Lp(a) readings in the past.  I've lost 35 pounds and dropped 4 meds, by eating low-carb, high-fat.  It's a now a lifestyle for me, not a temporary diet.  And I get plenty of fish oil, so I'll see what your recommendations do for my Lp(a).

    I'm curious what you think of this study:  http://www.atherosclerosis-journal.com/article/S0021-9150(08)00522-4/abstract .  For the women in this study, the incremental Lp(a) risk was from having a minor allele in the LPA genotype, and for those women in this large study, low-dose aspirin eliminated that incremental risk.

    I've been taking daily aspirin too, but now I think I know how it helps.

    Thanks for all you do!