Prevention: Bad news in bits and pieces

Jan clearly did not want to talk about her heart scan. Her score of 502 came as a shock to her. After all, she'd survived breast cancer just a year earlier, having been through dozens of radiation treatments, chemotherapy, not the mention the emotional upheaval.

Now I was telling Jan that she had a very high heart scan score with a heart attack risk of 5% per year. Then we got to her lipoprotein patterns: Jan had several striking abnormalities, including a misleading LDL cholesterol that underestimated her true LDL by nearly 100% (LDL particle number), small LDL, and the dreaded lipoprotein(a).

"I can't handle this! Why did I get the stupid scan in the first place?!"

Giving her a chance to collect her emotions, I discussed how, even though this business can be frightening, it's far--FAR--better than the alternative: heart attack at 3 am, rush to the hospital, stents, bypass surgery, etc. Or, death for the >30% of people who don't make it to the hospital in time.

That's why I often tell people that prevention of disease is bad news in bits and pieces. But it's a lot more manageable this way. Coronary plaque is a controllable process. You don't have much control in the midst of a heart attack.

Comments (1) -

  • fanatic cook

    10/2/2006 11:38:00 AM |

    I find it curious why people don't want to know or talk about their numbers ... blood sugar, blood pressure, blood fats.  My brain tells me it's a form of denial, but choosing not to see it won't make it go away.  I know it's not easy quitting smoking or starting an exercise program, but at least you're alive.
    That's all, don't mean to sound bleak  Smile

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The lipid distorting effects of weight loss

The lipid distorting effects of weight loss

Roger experienced a near-fatal heart attack 6 years ago. He survived thanks to the quick action of bystanders who initiated CPR and called 911. An emergency catheterization was performed and a stent implanted into the closed right coronary artery. But that's not why I tell Roger's story.

Since then, Roger has become comfortable with the idea that he has heart disease. His initial commitment to good nutrition and exercise has waned, as it often does in us distractable humans. So Roger gained about 30 lbs through a long winter, inactivity, eating frozen dinners, and the cookies and baked goodies his daughters made him.

As a result of the weight gain and inactivity, Roger's HDL dropped to 32 mg/dl, triglycerides rose to 211 mg/dl, blood sugar crept up into the pre-diabetic range of 116 mg/dl. Undoubtedly, small LDL was out of control beneath the surface. His tummy reflected the weight gain, flaccid and overhanging his belt.

I read Roger the riot act. I reminded him of what he had experienced and nearly didn't survive. Weight loss and a re-invigoration of his nutrition and exercise efforts was going to be crucial.

Roger listened and took it to heart. Over three months, he lost 24 lbs, a phenomenal result. However, his repeat lipid panel showed an HDL of 28 mg/dl, triglycerides 234 mg/dl, blood sugar unchanged.

"I don't get it! I lose all this weight and the number get worse?!" Roger was understandably upset after his enormous effort.

I told Roger that after a profound weight loss, lipids can go berserk for up to two months after weight has stabilized. Typically, HDL drops and triglycerides rise--the opposite of what we want. But wait another two or so months after weight has stabilized and the numbers begin to look beautiful.

Why does this crazy effect happen? I really don't know and I've never heard a satisfactory explanation for it. But it is very real and quite predictable.

The lesson: after a substantial weight loss, be patient. Check your lipid numbers too soon and you might be confused or disappointed. If you do check them, bear in mind that additional time may need to pass before you see the weight loss fully reflected.
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Where do you find fructose?

Where do you find fructose?

Apple, 1 medium: Fructose 10.74 g




Honey: Fructose 17.19 grams per 2 tablespoons



Barbecue Sauce: HFCS number 1 ingredient
Ingredients: High Fructose Corn Syrup, Vinegar, Concentrated Tomato Juice (Water, Tomato Paste), Water, Modified Food Starch, Salt, Honey, Contains Less Than 2% of Molasses, Natural Flavor, Paprika, Spice, Mustard Flour, Guar Gum, Red 40.



A1 Steak Sauce: HFCS number 2 ingredient
Ingredients: Tomato puree (water, tomato paste), high fructose corn syrup, vinegar, salt, water dried onions, contains less than 2% of black pepper, modified food starch, citric acid, dried parsley, dried garlic, xanthan gum, caramel color, potassium sorbate and calcium disodium EDTA as preservatives, molasses, corn syrup, sugar, spices, tamarind, natural flavor

Comments (25) -

  • Gretchen

    7/15/2009 1:04:39 PM |

    You forgot agave syrup, which a lot of people are using as an "all natural" low-glycemic replacement for HFCS. In fact, it contains more fructose than HFCS.

    One manufacturer's products include “low glycemic monosacharide.” Gosh, I wonder what that is.

  • PERKDOUG

    7/15/2009 3:10:43 PM |

    It would be a service, if you (or someone) posted a "fructose" content list which includes all the common fruits and berries. I eat a lot of berries and have wondered if that is such a good idea. A list would help us define "good calories" regarding these possible fructose bombs.

  • Anonymous

    7/15/2009 4:23:16 PM |

    Thanks for the visuals and labels on fructose...I am very aware of fructose contents and fruit -- especially since I have experience with fruit and gout attacks that may or may not be supported in literature.  I will only add that every time you purchase a product DO NOT ASSUME CONTENTS ARE THE SAME as when you last purchased.  For example, Classico pasta sauces which I used as base for soups and stews (all LC) has started adding sugar.  CostCo Kirkland brand marinated artichoke hearts (again LC) started out using olive oil, now uses cannola oil. My experience as label-reading shopper is food producers are now adding sugars including fructose to just about everything because the buying public perceives sugar to be tastier...even the rotisserie chickens most grocery delis have now...be careful if you very LC to whether the spice rub has sugar in it.

  • Anonymous

    7/15/2009 4:38:34 PM |

    What don't you find it in?

  • Anonymous

    7/15/2009 5:11:25 PM |

    Finding it hard to believe that an apple wouldn't have some other redeeming value that counteracts or balances the fructose content: soluble fiber, fiber, vitamins, minerals, etc.  Hopefully this is not an indictment of all fresh fruits?

  • GK

    7/15/2009 5:30:00 PM |

    It's all very well to measure fructose content, but it is meaningless unless we know what intake levels have to be before they become problematic.

    In my own case, when I went "paleo" a couple of years ago, I swore off sugar, grain, and processed foods.  I lost 15 lbs over six months without trying.  Now this was before I heard about the fructose issue, and I was eating fruit like I never had before in my life, 3 to 4 pieces a day, and the sweet ones, too:  apples, bananas, grapes, dates, etc.  Surely I was ingesting more fructose than I had been before with a blob of ketchup here, steak sauce there...

  • Anonymous

    7/15/2009 9:49:50 PM |

    Not to put too fine a point on it, but what you show as A.1. Steak Sauce is actually their marinade. Real A.1. Steak Sauce (at least my bottle) contains no HFCS, but does have 2g sugar per serving. Thank you for spending the time you do on this blog; you, along with some others, have given me the intellectual and scientific basis I needed to change my diet. The improvements, physical and mental, have been astounding.

  • Nameless

    7/16/2009 12:01:15 AM |

    The fructose info is interesting, but I agree with GK. We really need to know what is considered a safe level before condemning all fructose sources.

    Fruits do have certain health benefits, some more than others, especially berries. There is also the possibility that by becoming super fructose-phobic and avoiding all fruits/berries,  that one could decrease their chances of heart disease, just to succumb to cancer instead.

  • Laura in Arizona

    7/16/2009 2:19:25 AM |

    Perkdoug, I have found that the web site "nutrition data" has a breakdown of sugars for things. Go to nutritiondata.com and type in the food you are interested in. Choose the right food and quantity and then go down to the section on carbohydrate and click the see more details. When I did that for dates, 1 medjool has about 7.6 grams of fructose (eek!). Like many folks I am cutting down on my fructose consumption so use this table a lot.

  • Anonymous

    7/16/2009 3:01:42 PM |

    How about the king of HFCS--Soft drinks and candy.

  • pmpctek

    7/17/2009 3:22:57 AM |

    As someone else asked, "what don't you find it in?"

    Fructose can be found in many vegetables too.  One sweet onion has 6.69 grams, a half head of cabbage has 6.58 grams, a head of lettuce has 5 grams, a cup of chopped red peppers has 3.37 grams, a medium sized cucumber has 2.62 grams.  In fact nutritiondata.com lists 138 vegetables which have some amount of fructose in them (albeit many having very small amounts.)

    So, if one's goal is to avoid all sources of fructose and still maintain any semblance of good health, well good luck.

  • Anonymous

    7/17/2009 5:00:37 PM |

    @Nameless: Well put!

  • country mouse

    7/17/2009 6:56:16 PM |

    I think tossing fruit is a bit of the baby out with the bathwater.Fruit has the most wonderful spectrum of bright tastes and flavors of any food we have on the planet. "Healthy" vegetables encompassed the bitter, the flat, and the algae like part of the flavor spectrum. Me, is meet and nice in small to medium quantities but when eaten in low-carb volumes, it just becomes something you shovel in to make hunger go way.

    Fruit is a wonderful gift. Adding a little sugar and heating some berries produces this wonderful sauce you can pour over pancakes or creps (if my diabetes let me have crepes). Some fat, flour, and salt makes a wonderful crust that you wrap around sliced and spiced fruit. Cold cherries crunch between your teeth dribble juice around your tongue while you roll the stone around your mouth cleaning off the last of the fruit meat. Peaches with ginger, peach blackberry, blueberry pie. Sliced and cored apples cooked in red-hot cinnamon sauce on the stove and then chilled before serving on Christmas Eve. On a hot August day, wandering through an orchard and dodging Yellowjackets when picking a beautifully ripe peach off the tree.  Pulling a crisp apple out of winter store in November and tasting what will become cider.

    On a more practical level, I also need to make the decision on how much fruit versus how much bulk  laxative? If I eat one piece every days, I'm looking 8+ tablespoons of Metamucil.  bleck.  I'd rather starve myself in  other areas to make room for the delightful sweetness of fruit.

  • Dr. William Davis

    7/18/2009 2:50:28 AM |

    Who said throw fruit out?

    I believe you are reading things that aren't there.

  • country mouse

    7/18/2009 4:51:08 AM |

    I disagree.  without giving a threshold of "bad", your presentation implies that all fructose at any level is bad.  I read some comments as expressing fear or doubt that they were eating too much fruit.  others like me what to know the threshold of bad.

    just between you and me, I'd give up living before I gave up fruit.  no joke.  the flavours of fruit are that important to me.  I've already lost enough food ground with diabetes, I'm not giving up any more.

  • Anne

    7/18/2009 12:51:34 PM |

    According to Dr. Richard Bernstein, fruit does not have to be a part of a healthy diet. Here is what he says in his book, Diabetes Solution:

    "Although eliminating fruit and fruit juices from the diet can initially be a big sacrifice for many of my patients, they usually get use to this rapidly, and they appreciate the effect upon blood sugar control. I haven't eaten fruit in almost forty years and I haven't suffered in any respect. Some people fear that they will lose important nutrients by eliminating fruit, but that shouldn't be a worry. Nutrients found in fruits are also present in the vegetables you can safely eat."

    Dr. Bernstein has had T1DM for about 50 years and advocates a very low carb diet to help normalize blood sugars. http://www.diabetes-book.com/

    Because of blood sugar problems I have eliminated all sources of HFCS and have greatly limited my fruits. I find I can eat a few berries or a bite or two of other fruits without raising my blood glucose, but I mostly stick with colorful low carb veges.

  • Nameless

    7/18/2009 6:28:10 PM |

    Dr: Davis -- "Who said throw fruit out? I believe you are reading things that aren't there."

    Yet you start this post with a photo of an apple. Although perhaps it wasn't  your intention, it certainly implies that fruit is bad.

  • TedHutchinson

    7/19/2009 8:44:44 AM |

    National estimates of dietary fructose intake increased from 1977 to 2004 in the United States.
    high-fructose corn syrup percentage of sweeteners increased from 16% in 1978 to 42% in 1998
    Since 1978, mean daily intakes of added and total fructose increased in all gender and age groups, whereas naturally occurring fructose intake decreased or remained constant.
    If you can't get the full text at least read the abstract. The full text has some interesting charts presenting the data more clearly.
    It isn't eating naturally sourced fructose from whole fruit driving increased obesity. Increases in fruit consumption are dwarfed by greater increases in total daily energy and carbohydrate intakes.

  • Anonymous

    7/20/2009 9:20:21 PM |

    RE: Comment by Nameless (“Yet you start this post with a photo of an apple. Although perhaps it wasn't your intention, it certainly implies that fruit is bad”)
    -------------------------------------------------------------------------------------------

    The good doctor is merely demonstrating in effective graphic terms that
    too much of a good thing is not good. The numbers (ie gms of fructose)
    are important guidelines. There’s no point in getting your nuts in wringer over it!

  • Anonymous

    8/4/2009 11:19:11 PM |

    Bernstein developed Diabetes at age 12. He was born in 1934, so at age 75, he has been diabetic for 63 years. No diabetic complications. Normal blood sugar for all!!

  • David Gillespie

    8/23/2009 10:35:41 PM |

    I think its more helpful to express sugar content (and fructose if known) as a percentage rather than an amount per (varying) serve.  It makes it easier to compare apples to apples (scuse pun).  I've prepared a few listings of various food groups (several hundred items in each) on this basis at www.howmuchsugar.com if you are interested.

  • Anonymous

    8/30/2009 8:58:49 PM |

    Some people suffer from fructose malabsorption. One source states that it is found in approximately 30-40% of the population of Central Europe. If one has that condition, then it would be prudent to avoid all fructose, even the fructose found in fruit. I love the taste of fruit, but it is destroying my health due to malabsorption issues. Fortunately, we know that some cultures lived very healthy lives without eating fruit (e.g. Eskimos).

  • John

    12/1/2009 7:17:24 PM |

    I don't get it. What am I not seeing?

    How much high fructose corn syrup is in a serving of the BBQ sauce? How much in a serving of the steak marinade?

    You state such figures for a serving of apple (1 medium), and for a serving of honey (2 Tablespoons).

  • Anonymous

    10/19/2010 10:53:28 PM |

    I had to give up fruit to prevent further beta cell damage (above 140 apparently for pre-diabetics, and maybe everyone, I don't know). Fruit and many veggies are toxic to people with glucose intolerance. I had to give up veggies for now, until I can find one that I can tolerate. Cabbage was too hard on my blood sugar. I am slowly trying to figure out what I can eat and how to minimize the glycemic impact. Unfortunately, I might have to damage my beta cells to find out what works. The system told me I was fine, even though I told them I had sugar problems. I gave up on doctors 10 years ago, since they were useless. I finally bought a meter and started testing, and the truth is painful.

  • buy jeans

    11/3/2010 6:47:15 PM |

    In addition, since I have been involved with cardiac CT for now nearly 24 years, the PLC also affords me an opportunity to develop a CT coronary angiography training program for cardiologists and radiologists (www.cardiaccta.us). Together, these new efforts are merely an extension of my interests in prevention, patient care, and teaching.

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Lipoprotein(a), menopause, and andropause

Lipoprotein(a), menopause, and andropause

Lipoprotein(a) is a curious lipoprotein. Not only is it a genetic pattern with numerous variations, it is also one that shows a predictable age-dependent rise.

Women in particular are prone to this effect, men to a lesser degree. As we age, many hormones recede, particularly growth hormone, testosterone, the estrogens (estradiol, estriol, estrone), progesterone, and DHEA, among others. This is not a disease but the process of senescence, or aging.

When we're young, estrogens, testosterone, and DHEA all exert suppressive effects to keep lipoprotein(a), Lp(a), at bay. But as a woman proceeds through her pre-menopausal and menopausal years, and as a male passes through his fourth decade, there is an accelerated decline of these hormones. As a result, Lp(a) crawls out of its cave and starts to sniff around.

Typically, a woman might have a Lp(a) of 75 nmol/l (approximately 30 mg/dl) at age 38. Ten years later, at age 48, her Lp(a) might be 125 nmol/l (app. 50 mg/dl), all due to the decline of estrogens and DHEA. A parallel situation develops in males due to the drop in testosterone. For this reason, it may be necessary to re-check Lp(a) once after the fourth decade of life if you've had a level checked in your younger years.

This opens up some interesting therapeutic possibilities. If receding hormones are responsible for unleashing Lp(a), hormones can be replenished to reduce it. In males, this is relatively straightforward: supplement human testosterone and Lp(a) drops about 25%.

In women, however, it's a bit murkier, thanks to the negative experince reported using horse estrogens (AKA Premarin) in the HERS Trial and Women's Health Initiative. You'll recall that women who take horse estrogens and progestins (synthetic progesterone) do not experience less heart attack and develop a slightly increased risk of endometrial and breast cancer. There was, however, a poorly-publicized sub-study that showed that women with Lp(a) experience up to 50% fewer heart attacks on the horse/synthetic combination.

Wouldn't it be nice to have a large trial examining the safety/advisability of human estrogens and progesterone? To my knowledge, no such confident study in a significant number of women exists, since there's so little money to be made with human hormonal preparations.

For these reasons, we use lots of DHEA, generally at doses of 25 to 50 mg per day. It makes most people feel good, boosts energy modestly, increases muscle, and reduces Lp(a) up to 18% in women, a lesser quantity in men.
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