Life extension had article recently about Metformin
Any comments about this med in the non diabetic to help with insulin

How long after eating?

Thanks for the post, Dr Davis. If blood glucose goes down after eating a meal, for instance 113 pre meal (fasting) and 97 1 hour after eating - is this an indication of insulin resistance, and excess release of insulin?

Maureen  I Love You and you need to stop eating wheat. Vince

I can't find this exact model in stock online.  What features do you recommend so I can look for an alternative?

I know you've been recommending this for some time.  I'm now at the point of being ready to act on it.  Do you have a brand of glucose monitor that you recommend or think works best?  I thought folks used to have to have a doctor's Rx to purchase these.  No longer true?

You don't need an Rx at all to buy a glucose meter, unless you're trying to get it reimbursed through insurance of some kind. What you do need is a fat budget for test strips if you're diabetic or plan to do lots of testing over the long run. The meters themselves are only $15-$50. One touch ultra seems to be decent. You want to look for the ones that only need a super small drop of blood, which allows you to stick your forearm or other places. The old type meters required a huge drop from a fingertip, and you really had to slaughter yourself with a needle to get a decent amount. Some of the new ones are also calibration-free and they're very compact - not much bigger than a stopwatch. I may pick up one myself. Where do we find info on what is a reasonable post-pranadial level to shoot for, say 1 or 2 hours after eating?

I think most meters now only need tiny drop. Walmart's Relion has lowest cost strips by far but it does suffer from some variability in readings.  My experience is AccuChek is excellent.

This study seems to indicate that the one hour sugar (I would think the absolute peak whenever it comes) is the best marker to follow:

http://care.diabetesjournals.org/content/33/3/557.abstract

Among upcoming posts will be how to use postprandial blood sugars to achieve all these benefits.

As one of the anonymous commenters suggested, OneTouch Ultra is a good device, as are Bayer Contour, Accuchek Aviva, and the Walmart device. We've had nothing but problems with the Walgreens' device.

I have a digital thermometer, a BP meter, a BG meter but with respect, without a home basal insulin meter we lack the single most important tool.

Hi jehane,
You want to know pre-1st meal of the day blood glucose. This is only called "fasting" blood sugar level since overnight went without food. You may know this;
maybe I've confused your phrasing.

That pre-prandial reading is your reference to see how after meal(post-prandial) blood sugar reacts. Since your data sounds unusual it would help responders to specify if 113 number is on an empty morning stomach (as opposed to between meals and pre-next meal).

There are 3 types of accuracy for blood glucose monitors: absolute, relative, consistent. Absolutely accurate means the reading is the same as a quality lab would give. Relatively accurate means the readings are always the same distance up or down from what a quality lab would give, so all you have to do is add or subtract a fixed amount to get the true readings. Consistent means the device gives the same readings when multiples samples are taken at the same time. A device might be consistent but not relatively accurate, if the deviation from the true readings is not constant but rather varies with the blood glucose level.

I have confirmed that my Walmart Reli-on Confirm model glucose tester is consistent. That is, if I take three samples within a space of 5 minutes, they will agree to within about 5 mg/L. The Reli-On Confirm test strips are $0.40 each, which is much cheaper than most meters. These strips requires only a tiny bit of blood, so the lancing device doesn't hurt much at all and the puncture quickly heals.

I ordered the control solution, to test whether the Reli-On is absolutely accurate, but it hasn't arrived yet. Another way to test absolute accuracy is to measure with the Reli-On within a few minutes of getting blood drawn at a laboratory.

Note that Reli-on also sells an inexpensive ($9) mail-in home H1Abc test.

I learned a lot from my Reli-On (assuming it is accurate). First, when I went on a paleo diet, my insulin sensitivity declined, so that my blood sugar was skyrocketing after eating a huge bowl of oats. Then when I went back to my usual high-carb diet, my insulin sensitivity returned to a reasonable level. Second, when I stepped up my exercise program ever slightly (10 minutes of one-legged squats in addition to my usual leisurely yoga), my insulin sensitivity rose to a very high level for the next few hours, so that eating a huge bowl of oats within that time had very little effect on blood sugar. This makes sense, since those squats probably deplete glycogen stores in the legs.

I wholeheartedly agree with measuring blood glucose.
I was, unbeknownst to me, on my way to Type 2 diabetes until I found this blog and read the doc's previous posts on blood glucose  levels.
If you all really like to get into the nitty gritty of cholesterol, blood glucose, etc. and relish numbers and stats like I do then join the TYP forum. It's a veritable bonanza of numbers, advice and data crunching.

What would you say is a good number to have as your postprandial glucose?

And would you say that the lower the better or is there a lower level people should try to stay above?

I've been trying to keep my glucose under 100 an hour after eating since you suggested it last summer.  Haven't lost any weight but my fasting blood sugar and HgA1c are both down a little after going up for years.  I like having a simple rule (don't eat meals that raise my blood sugar over 100) but I sure do miss rice and beans.

I don't think the cost of the strips is prohibitive since it doesn't take long to figure out which foods jerk your blood sugar around: whole grains being the main thing in my case.

Well I bought one an Accu Check blood sugar checker yesteday, but I do wonder.Yesterday I checked four hours after eating a MacD breakfast (but left the bread)so it was mainly egg and burger with some potato has thing. Got a reading of 82, however this morning after a 12 hour fast got 118 (which I thought a little high for a non diabetic). Its understanding whats going on. Is the body busy swilling insulin around to keep my sugar down to 118 or has the pancreas intervened overnight to pump in some glucagon to get my blood sugar up? Without knowing some of the other dynamics it can be difficult to fathom out. I'm sure some kind of insulin test would be better.

Sorry my fasting blood sugar was 97.2 or 5.4 mmol/l (I'm from the UK). It was indeed 118 two hours after a meal last night of steak chop and buttered roast parsnips last night plus a thin wedge of chocolate brownly with double cream and a sprinkling of walnuts. After reading this blog however will have to reduce my love for proper butter and roasting food too

Does whey protein isolate with unsweetened almond milk raise blood glucose levels?

Interesting. I'm looking through my screening results (I'm in Europe) and there is no mention of LDL, but I have two other values, P-Apo A1 (1.77 g/L) and P-Apo B (1.09 g/L). Is there a relation between these and LDL/HDL?

It is good to have positive feedback via blood testing to show changes one is making to their body. I wonder what is a good interval between tests to show cholesterol changes?

On a similar note, I have been eating low carb for 4 months using my blood meter to reduce both blood sugars and insulin resistance for pre-diabetes. I am still thinking about your slo-niacin suggestions and how the bad increase in blood sugar and insulin resistance vs the good cholesterol effects would affect me. I am waiting to get results from my first NMR lipoprofile to make a decision.

Indeed, restricting carbohydrates is more similar to taking statins than many people think. With the advantage that it does not have the side effects of statins, and is not costly at all.

Many people do not know that carbohydrates stimulate the production of VLDL, suppressing the production of free fatty acids and ketones. Our liver then pumps out small VLDL particles at a high rate, and these end up as small-dense LDL particles. The potentially atherogenic type, in the presence of other factors (e.g., chronic inflammation).

Low carbohydrate dieting stimulates the production and release of free fatty acids and ketones, suppressing the production of VLDL. Our liver then pumps fewer VLDL particles into the bloodstream (since FFAs and ketones are already doing a good job at feeding muscle and brain tissue), and when it does it lets out big VLDL particles, which end up as large-fluffy LDL particles prior to re-absorption by the liver.

If anyone wants to see what these particles look like, the figure in the post below may be useful:

http://healthcorrelator.blogspot.com/2010/02/large-ldl-and-small-hdl-particles-best.html

Ketones are not shown because they are water soluble:

http://healthcorrelator.blogspot.com/2010/04/ketones-and-ketosis-physiological-and.html

Do you have any comments on oatmeal? I've noticed that for me personally, it doesn't significantly spike my blood sugar, and I've heard a lot about how oatmeal can improve cholesterol -- but of course this is often just focused on total cholesterol or general LDL amount.

Hi Dr. Davis
I'm really hoping to hear your opinion on this study:
http://www.pnas.org/content/early/2009/08/21/0907995106.abstract?sid=

Hear, hear, Ned!

I agree: Carbohydrate restriction is the unsung hero of VLDL and LDL reduction, though actual measurements are required to appreciate this effect.

Oatmeal anonymous--

It's all about individualizing your food choices.

Checking postprandial blood sugars is an excellent way to know if these issues apply to you or not, or to what degree.

What are your thoughts on Amlamax for the reduction of LDL?

OK, so here's my question... I am young (late twenties), thin (BMI: <20.2), and active (run, bike).  However, I still have almost all small, dense LDL.   I'm an ApoE 3/4, which I understand means I need to limit the amount of fat in my diet.  However, if grains also contribute to small LDL, what am I supposed to eat?   I don't eat much wheat as it is (my husband is celiac), but I do enjoy oats, rice, and the occassional piece of bread when we eat out, etc.  Would cutting all grains from my diet and living on only vegetables, some fruits, and lean meats be acceptable? Sounds like a boring and sad diet...

Oatmeal reducing Cholestral is a joke. If I eat Oatmeal for breakfast( even a 1/2 cup) my BG numbers stay HIGH all day. Oatmeal is not a food I have on my breakfast table ever.

Over what time period were these
panels taken or in other words, how many weeks or months in-between test?
Love the blog!
CB

Who knows where to get an (NMR) lipoprotein panel in Toronto/Mississauga?

You say, "LDL particle number 2620 nmol/L (which I would equate to 262 mg/dl LDL cholesterol)"

Why would you equate 2620 nmol/L to 262 mg/dl? The conversion factor given at http://jama.ama-assn.org/content/vol295/issue1/images/data/103/DC6/JAMA_auinst_si.dtl is roughly 1mmol/l = 39mg/dl.

Holym--

I believe you are confusing Friedewald calculated LDL in nmol/L and LDL particle number--two entirely different things.

My simple conversion is meant to yield a "Friedewald-like" LDL cholesterol from LDL particle number.

I do agree!!

Where can I find the peer reviewed research upon which you base your advice? Thanks

My lab results are in, and they are,  on balance, not much improved. I think.

The changes I effected since my prior panel panel 3 months ago:
1) Lost 20 lbs
2) Ingest 6,000mg of fish oil for a total of 1200mg (total) of DHA and EPA/day
3) Ingest 500mg of Slo-Niacin/day (with 125oz of water/day)
4) Ingest 6,000mg of Vitamin D/day (Changed to the proper Vitamin D soy capsule from the powdered tablet)
5) Eat a large handful of almonds/day
6) Exercise hard (weight training and cardio intervals for a minimum of 90 minutes/day).

The (worsened) numbers:
1) Total Cholesterol: 269 (from 267)
2) LDL Cholesterol: 186 (from 175)

The (improved) numbers:
3) Triglycerides: 201 (from 280)
4) HDL Cholesterol: 43 (from 36)

Unfair to ask you, I know, but I am frustrated. What do I do wrong? What can I do more? I am VERY reluctant to take a statin, as I have tried many, all with terrible side-effects. And, fwiw, I started today on my wheat-free diet.

Thank you for your guidance,
David

The part of the study that caught my attention was "Current and former smokers had higher incident CAC rates than never smokers, but this difference was not statistically significant once other risk factors were considered. "

Dr Davis,

I recently came across your blog and it peaked my interest. I have been tracking my lipids for several years now.

Let me give you a little background. My dad had by-pass surgery when he was in his forties. He spent the rest of his life watching his diet and lipids and blood pressure. In 2005 he died from coronary failure a month after turing 71.

Because of my family history, and lipid levels (LDL 130, HDL <40), my physician wanted to start me on advicor. I resisted and tried to moderate my lipids through diet and exercise. I used the low fat diet approach and got nowhere. So I started on Advicor late in 2003. By March of 2004 my profile was right where my doctor wanted it: LDL 76, HDL 41, TriG 98. I continued on Advicor and had my lipid profile and liver enzymes checked every 6 months. I started keeping my scores in a spreadsheet and have been tracking them ever since.

After taking Advicor for a while I started reading about the side effects, about the additional predictors for heart disease, and the limitations of the physician "approved" diets.

After doing all this reading, I wanted to try once again to moderate my lipids through diet. In January 2006 I stopped taking advicor and changed my diet so as to reduce carbohydrate. I started eating cheese omlets cooked in butter for breakfast. I did not avoid red meat. I stopped eating rice, potatoes, and white flours, etc. As a result of these changed my HDL went up from 40 to 50. My TriG went down to a low of 73. Unfortunately, my LDL went up to 130-140. So after about a year I went back on Advicor but kept my diet similar (except I went back to whole grain cereal for breakfast). The other change I made last year is I started on an aggressive exercise program. I exercise 4-5 times a week for 50-60 minutes, keeping my heart rate at the 80% level. I also got a bicycle and started biking on the weekends (that has been quite fun and rewarding - I did an MS-150 ride this past October). I've only lost a few pounds 210 to 195. At 6'3" my BMI is barely in the "normal" range. I have recently switched Doctors due to other factors, but my new doctor wants to keep me on Advicor.

My questions are these. Am I just fooling myself into a false sense of security by taking Advicor and monitoring my lipids? Should I continue this plan or make some mods?

I anticipate that you will recommend a CT scan. Are they costly? Covered by insurance? Require a Dr's referral? What levels of radiation exposure do they impose?

I look forward to hearing your reply.

thats very interesting. The "conventional" risks only explain about 12% of plague increase and yet its well documented that statins reduce heart attack by somewhere between 30 and 40%.

Hi, Barry-


Thanks for your interest. However, I cannot answer direct medical questions, as good as they are.

I would invite you to look at the website that this blog accompanies, www.trackyourplaque.com.

Using conventional cholesterol as your index of risk is a fool's game. I could introduce you to hundreds of people who've had heart attacks and bypass surgery who thought they were being well served by conventional cholesterol. In my view, it is a model-T of medical testing.

I didn't find much value in this report because it doesn't look at percent changes in CAC, which seems to me to be the most important parameter to judge if plaque is growing at an unacceptable rate. Another thing about it, they didn't consider lipoprotein subclasses, but haven't most or all of the MESA subjects had NMR testing? Combining Otvos' NMR data on the MESA population with the CAC percent change data from this study could give some real insight into how and why plaque progresses. It looks like no one is going to do such a study. Is there any way a member of the public can get the raw data from the MESA studies, so we can do our own analysis? After all, MESA was funded by public funds, wasn't it?

To my knowledge, NMR lipoprotein analysis was not performed as part of this study, or at least used for this type of analysis to predict events or progression of calcium scoring.

Yes, NMR results were not used in the study, but the study was done on 5756 subjects who participated in the MESA test. Mora did a study of the NMR results 5538 MESA participants, but didn't look at CAC progression (Atherosclerosis, 2007 May;192(1):211-7) Isn't it a pretty good possibility that these studies were both done on the same basic group of MESA participants? If so, the data is out there to do a study of the effect of lipoprotein subclasses on CAC progression, it just hasn't been done yet.

Is it possible that the MESA data could be made available to us, or is the data totally  controlled by the people who collected it?

Hi, Harry--

I do believe that access is obtainable, though I am unsure how restricted. Go to http://www.mesa-nhlbi.org/default.aspx# for application information. I would like to do the same when some research time has been freed up.

Dr. Davis, from reading the MESA website, it looks like the MESA people aren't going to release the data except to qualified researchers working for established institutions or companies, and who will publish their results in a peer-reviewed journal. They aren't interested in making the data available to the general public, where it could be misinterpreted, thereby casting doubt on the overall MESA project.

That leaves people like me out, because I just want to play with the data and look for possible correlations that haven't yet been investigated, like the effect of lipoprotein subclasses on CAC progression. Unless some established research group becomes interested in doing such a study and publishing the results, it probably won't get done. It's a bit frustrating, because it looks like the data is all there to do such a study, but there is no way to get them to release the data.

It will probably take a fairly significant expenditure of time and analysis to investigate this and publish the results, so it will probably take a full time research group to do it. With all the other things you are doing, it may be difficult for you to take the time to do this kind of study. Perhaps with your contacts with clinical research people who might be interested in investigating this, (e.g., Otvos, Raggi, Budoff, Rumberger?) you could get the ball rolling.

Also, it looks like a person can't get the data unless they specify exactly what they are looking for, which sort of rules out looking for correlations that haven't been previously suspected. There is something to be said for shoveling all the data into a stepwise multiple regression program and seeing what pops up as the most significant parameters, but with the tight controls they have on releasing data, this isn't likely to happen, which is unfortunate for those of us who have a personal interested in prevention.

Hi, Harry--

All is not lost. It may take a while, but there may be some possibilities.

I've been giving it some thought. I can't give it high priority right now, given the need to get some of our own data analyzed and published. But I believe it is something we should explore in future.

--Conventional risk factors like LDL cholesterol, diabetes, and excess weight explain only a tiny fraction of why someone develops coronary atherosclerotic plaque as represented by a heart scan score.