This is scary! One bad day sets you back a week.
I limit my carbohydrates (zero grains, no more than 25 grams of sugar) to no more than 100 per day. How low should I go?

Dr. Davis, I think we need some clarification on "carbohydrates" -such as which sub-group, sugars (of which there are also sub-groups), starches (more sub-groups), and fiber (more sub groups) need limits. Obviously, sugars are of top concern, with starches following close behind. But arent some of the fiber carbohydrates desirable?

I think your website clock is off by twelve hours.....

How would this affect triglycerides, Dr. Davis.

Hi All-
Got server error where this belongs, so...about lamestream media hype of vitamin D & fibrilation here is the study's own press release - they only worry about D over 100ng/ml.
Quote:  "... Dr. Bunch and his colleagues examined blood tests from 132,000 patients in the Intermountain Healthcare database.Patients did not have any known history of atrial fibrillation, and all had previously received a vitamin D assessment as part of their routine care. Patients were then placed into categories to compare levels of vitamin D: low (less than 20 nanograms per decilter), low/normal (21-40 ng/dl), normal (41-80 ng/dl), high/normal (81-100 ng/dl), and excess (more than 100).Patients with vitamin D levels in the normal range were compared with other groups to assess their risk of developing atrial fibrillation.
In patients with low, low-normal, normal and high-normal levels of vitamin D there was no increased risk of atrial fibrillation.  However, in those with excess levels of vitamin D there was a significant increased risk of atrial fibrillation.  Atrial fibrillation risk was two and a half times greater in patients with excess levels of vitamin D compared to those with normal levels."

Thanks for bringing that up, Al.  I had heard of the study, but hadn't gotten around to looking it up.  

Two and a half times higher risk of atrial fibrillation may not be as much of an increase as it sounds.  It depends on how many people were in the group, and what the real numbers are.  I found this on WebMD:  http://www.webmd.boots.com/heart-disease/news/20111118/high-vitamin-d-levels-linked-to-heart-condition

The risk of a-fib in those with normal levels of vit D was 1.4%.  With high levels, it was 3.8%.  It isn't that much of a difference, and not as significant as it would be if the risk went from say 10% to 25%.  It is also not as significant if the group number is very small, but we don't have that information.  

I also found this note on a case study in which a-fib stopped after starting vit D.  Go figure.  http://www.ncbi.nlm.nih.gov/pubmed/2379840

Triglycerides tend to go up, Mary, though not with the same magnitude as small LDL particles.

Hi, Jeff--

The problem with the fiber is that it comes with digestible carbohydrate. It means that a slice of white Wonder bread triggers small LDL, but so does a cup of quinoa, millet, or buckwheat, all fiber-rich grains.

Got to be careful: We can't fall for the same logic that has fooled generations of nutritionists: If something bad for you is replaced by something less bad and there is apparent benefit, lots of the less bad thing is good for you.

Wow, that's a lot, Yuma.

It varies with individual carbohydrate sensitivity, but most people tolerate 15 grams per meal well without postprandial rises in blood glucose or triggering of small LDL.

Dr. Davis:
It amazes me how some nutritionists  (e.g., ADA or AHA  based) and diet book writers encourage people to cheat on their diets without considering the health impacts. Clearly a mixed message when one is told to make changes, but then told that they can ignore the dietary changes once a week or on special occasions or holidays.

Hi doc, are you sure you have the right units (nmol/l)? Hwere in  Europe, the target for LDL is less than 3 mmol/l which would equal to 3000 µg/l (not nmol/l).

Hi, STG--

Yes, it is amazing. I have done so many lipoprotein panels (tens of thousands) that I see patterns that a casual observer would not see. This is a substantial, though underappreciated, effect.

Great post Doc! That really brings the message home.

Actually, I am questioning how much do we ned to be concerned about the carbohydrate content of things like green peppers or onions? Flax seed has a nearly all-fiber carb content, doesn't it? What's a safe daily target for total carbohydrate intake, and how should we do the math, if any?

Knowing that high postprandial glucose levels cause an increase in small ldl particles. And we know that carbohydrates, especially wheat, significantly raise post prandial glucose levels. Would it make sense that Ted could cheat on Fridays with a carb load and still drop his particle score just by exercising after being bad if it kept his glucose levels from spiking?

Kent,
exercising after "cheating" (eating carbs) MAY work, especially for people who still have enough residual beta cells left in their pancreas and not much insulin resistance. But often exercise is counterproductive because the exercise raises cortisol levels which in turn release blood sugar from the liver. This can only be determined by tight blood sugar measuring (pre/post exercise).
Renfrew

Hi, Jeff--

It varies, but most people can do well with around 15 grams carbohydrate grams ("net" carbs, meaning total carbs minus fiber) per meal.

This has never been studied, Kent, but I suspect that exercising will only partially blunt the effect, not eliminate it.

Dr Davis:
Where do you come out regarding the "safe starch" debate on the Jimmy Moore website?

Can anyone (or Dr. Davis)  tell me what they include in their 15 gr. carb meals?  how many carbs per day total,,,,SNACKS ETC? does this cause ketosis?  I've been trying to eat right,  however, at 8:30 PM my blood sugar was 112. is that bad or ok?  I'm a 61 year old woman. my calcium score 4/11 was 206. thank you

Sorry, Steve, I'm not familiar with that term.

If you are referring to amylose, the form of carbohydrate that is less efficiently digested, it will boil down to blood sugar consequences of a specific amylose-containing food.

Hi, Lindas--

I aim for blood sugar to stay below 100 mg/dl--all the time, including after meals.

Ketosis can occur, though usually not. Eat vegetables, nuts and nut meals, oils, olives, avocados, meats, cheese. Plenty to eat without wheat and limited carbs.

Can I add vegetables does not include potatoes, corn, and rice - just to be clear.

Yes, correct. They will trigger small LDL if consumed in anything but the smallest portion size (e.g., more than 1/2 cup).

Dr Davis:
The "safe starch" discussion is related to rice and potatoes being "safe starch" according to the writers of the Perfect Health Diet, The Jaminets.

1/2 cup serving per meal X3 = 1.5 cups per day.  If three meals consumed in a day and zero at one meal could you eat 1 cup at one meal, and 1/2 cup at another and still be ok from an overall perspective?
Are you advocating zero rice, potatoes as well as wheat and other starches?
How is the level of acceptable maximum small LDL?
Which would you find more acceptable for a person with CAD with normal weight, thryroid, D?
LDL 2200
small 200
HDL 69
The above with no statins; or
LDL 650
small <90
HDL 60
The above with statins
Both with virtually zero starch
Is zero starch healthy?  Will zero starch induce thyroid issues?
Meat, chesse, fish, veggie diet healthy ok for those who cannot eat nuts?

Thanks,
Wheat Belly sound advice; I have recommended it to several who have  gotten the book

Dr. Davis:
What population develops small LDL--your patients, anyone who eats carbohydrates, individuals with defective glucose metabolism (e.g., prediabetic, diabetic, insulin resistant)?

Yes and yes. It is truly ubiquitous with few modern people escaping it.

Hi, Steve--

The triggering of small LDL tends to be dependent on the contents of a single meal. It does not necessarily mean zero carbohydrates, but staying below the threshold for provocation, which can be approximated by checking a 1-hour postprandial glucose: If any rise above the pre-prandial level is seen, then there is potential for provoking small LDL.

There is no confident answer to which is better. But, given the apo E4-driven or other abnormal metabolic pattern with the LDL particle number of 2200, I would opt for statin, much as I hate to say it.

I'm not familiar with American blood sugar levels....what on earth would it mean to keep blood sugar under 100, in Canadian terms?  (I've been given a target of 4-7 before meals, and 7-9 after meals....)

I'm so interested in the post ! I live in the UK where we don't get much sun, even in the summer. I'm in my mid 50s and am pale skinned and slim. Because I have osteoporosis and a heart valve defect I guessed I needed some vitamin D to help these conditions, and, after doing much research, started to take 4,000 ius of D3 per day last January. A blood test, four months later, at the beginning of May revealed that my blood level of 25-hydroxy vitamin D was 153 ng/ml (384 nmol/L), more than twice the 'normal level ! Certainly not the kind of level that 4,000 ius of D3 per day should produce ! I stopped taking the D3 and a couple of months later my 25-hydroxy vitamin D had dropped down to 64.8 ng/ml (162 nmol/L). My endocrinologist has now advised me to resume taking D3 but at 2,000 ius per day and I will have another blood test in two weeks time and then review the amount I should take based on those results. This shows how important it is to get tested !

Anne

If we do have known level from testing, do you have a formula or algorithm for calculating how much more we should add to raise blood levels of Vitamin D by a specific amount?

I found one such formula in a book touting Vitamin D but the whole tone of the book was pretty snake-oil like and low on information for intelligent people so I did not have complete confidence in his tables.

You said "the ability to activate Vitamin D is lost by the majority of us by age 40".

Did you mean to say it declines after age 40?

Dr Cannel has some interesting points to make on the accuracy of some Vitamin D test results here.
http://www.vitamindcouncil.org/newsletter/2008-july.shtml

I am a 64yr old male living in the UK. My skin is fairly tanned as I try to get as much full body sun exposure as is available here however I have also been taking 5000iu/daily for a couple of years now. When I was last tested my score was 147.5nmol/l 59ng/ml. I wonder if Anne's numbers are the result of a faulty test.

where do we get enough vitamin D wihout worring about laboratory tests? What about the good old cod liver oil spoon some mothers used to give us when we were children? And what about getting of the sofa and start walking half an hour every day? I live in sunny Portugal. In the summer we eat a lot of sardines and other fish, and also spend hollidays in the beach. Instead of worring about things science or medicine may never understand, we could start looking back to our healthy paleolithic ancestors and ask what changes civilization has brought that made diabetic 7% of the total population. Excelent blog, Dr.!

I am the other Anne. I will add GF to my name for "gluten free" so you can tell us apart.

I think it important to stress that vitamin D supplementation needs to be continued long term. I have met too many people who have been prescribed 50,000 IU of D2 for 8-12 weeks and then told to stop because their 23(OH)D went over 30ng/ml. I know one person who's doctor stopped and started the D2 3 times.

I agree that testing is important. I have had a difficult time raising my vitamin D to an optimal level. I am hoping my next test will be good. I have to wonder what role my low vitamin D played in my CAD.
AnneGF

Jenny-
Vitamin D dosage effects appear to be quite idiosyncratic.  I started out at a 25OH-vD level of 21 ng/ml, and currently have to take 10,000 IU (softgel) daily to keep my 25OH-vD level at 66 ng/ml.

I'm male, and a big guy, plus T2 diabetic, so I probably need a larger dose.

Take a look at the Vitamin D Council web site below. Search for the string "rule of thumb" in either of the links below, in which it is mentioned as a rule of thumb to increase 25OH-vD levels by 10 ng/ml would require 1000 IU vitD.

http://www.vitamindcouncil.org/newsletter/2008-may.shtml
-- or --
http://heartscanblog.blogspot.com/2008/04/vitamin-d-newsletter-reprinted.html

BTW:  I bought your recently-published “Diabetes 101”  book (great job!). I want to give it to some of my poorly-managed diabetic friends, which tends to be most people, due to the poor level of diabetic care.

I was a patient of Dr. Richard Bernstein, who I hear complimented your book.  He is quite a character, but taught me more about diabetes than all of my doctors forgot. I owe to him my current state of relatively good health in spite of diabetes.

I personally went from 30ng to  60ng in 3 months by taking 8,000 ius of D per day.
Any opinion from anyone on how often this blood level should be tested to regulate dosage?

Another interesting post, thank you. I'm wondering about your opinion on how often you think Vit. D levels should be tested after the initial test is done, especially if the levels are drastically low.

Excellent, excellent, excellent post.

I, too, often get asked how much D someone should take.

People tend to want to take it prior to checking (or in lieu of checking) blood levels. Often times, they're afraid to ask their doctor to order the test since many in our community have flat out refused to order it.

My doctor says, "taking vitamin d without checking blood levels is like baking a cake without knowing the temperature of the oven."

It's true. Without knowing your level, you don't know how much to take or for how long to take that dose.

You may also need more at different times of year.

I take 10,000 IU daily starting in mid November and continue until mid-May or so.

I get my 25(OH) and serum calcium levels checked every 3 months.

What drives me nuts is the media and other health professionals "warnings" against taking too much and/or their suggestion that you get more D through sunlight.

Almost every article on D has some disclaimer from a medical professional warning against too much D. But, they fail to really communicate how RARE D toxicity is and how the risks of NOT taking enough D FAR outweigh the risks of taking too much D.

And, to suggest that people get their D by spending time in the sun is irresponsible. As you know, the bodies ability to activate D from the sun decreases with age.

We should be measuring levels and then managing levels through supplementation.

Do you also check serum calcium levels?

Jessica,

I get my serum calcium, serum inorganic phosphate and alkaline phosphatase measured at the same time as my 25(OH)D level. So far, even when my D was much too high, the levels of calcium and inorganic phosphate have been normal but the alkaline phosphtase was above normal. I think I'm lucky that my GP and endocrinologist will measure my levels judging from the problems other people have getting tested. My endocrinologist told me that he fully supports me having D3 supplementation so maybe that's why.

Anne

Jessica,

Don't forget to check Magnesium -- as we build stronger bones and drive mineralization there, Mag can get depleted from the blood and intracellular stores.

Have you read the Magnesium report at TYP?

-G

Jessica,

Don't forget to check Magnesium -- as we build stronger bones and drive mineralization there, Mag can get depleted from the blood and intracellular stores.

Have you read the Magnesium report at TYP?

-G

Great book on this topic is The Vitamin D Cure.  It has a table that shows how much you individually need to take based on your weight and current level to reach your goal vitamin D amount...p49.  The average American needs 20 to 25 iu per pound to raise their level to 50 - 70.

here is a good site on vitamin D, www.vitaminD3world.com The site also has links to a neat micro tablet form of vitamin D

It all makes sense when vitamin D is viewed as a hormone, a steroid hormone, not a vitamin. Vitamin─no, steroid hormone─D exerts potent effects in tiny quantities with hormone-like action in cells, including activation of nuclear receptors.

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