Fortune teller

25. November 2006 William Davis (0)
Whenever your doctor uses your cholesterol values--total, LDL, HDL, triglycerides--to judge your heart disease risk, he/she is trying to act as your fortune teller.

In some states, fortune telling is illegal, a misdemeanor. The New York State lawbooks say:

A person is guilty of fortune telling when, for a fee or compensation which he directly or indirectly solicits or receives, he claims or pretends to tell fortunes, or holds himself out as being able, by claimed or pretended use of occult powers, to answer questions or give advice on personal matters or to exorcise, influence or affect evil spirits or curses; except that this section does not apply to a person who engages in the aforedescribed conduct as part of a show or exhibition solely for the purpose of entertainment or amusement.
(Source : Wikipedia)

Rather than occult powers, your physician claims to use "medical judgement" to tell your fortune. Except for that distinction, it might be construed as a misdemeanor.


Let's take three typical examples:

58-year old Laura has a high LDL of 195 mg/dl. Her HDL is 52 mg/dl, triglycerides 197 mg/dl. Does she have heart disease?

51-year old Jonathan has an LDL of 174 mg/dl, HDL 34 mg/dl, triglycerides 156 mg/dl. Does Jonathan have heart disease?

71-year old Marian has an LDL cholesterol of 135 mg/dl, HDL 84 mg/dl, triglycerides of 67 mg/dl.

None of the three have symptoms. They all feel well. Nobody is taking a statin cholesterol drug or other agent that would modify the numbers. Jonathan is around 30 lbs overweight. Nobody has an impressive family history of heart disease.

Can you tell who has heart disease and who doesn't? If you can, you're smarter than I am, because I certainly can't tell. But your doctor tries to divine your future by looking at these numbers.

Do they know something that we don't know? No. It's a crude odds game, a guessing game. A guessing game that frequently comes up on the losing end.

These are three real people. Laura, despite her high LDL, has no identifiable coronary heart disease. Jonathan has advanced coronary disease. These were his numbers just prior to his stent. Marian has a moderate quantity revealed by a CT heart scan score of 419.

Don't even try predicting your future from your cholesterol numbers--it simply can't be done. Every day, I see patients and physicians beating their heads over this dilemma. Telling your fortune using pretended occult powers is illegal. Telling your fortune using cholesterol numbers should be, too.

If you want to know if you have coronary plaque, that's the role of the CT heart scan. Plain and simple.
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Do stents kill?

Do stents kill?

6. February 2007 William Davis (5)
There's apparently a lively conversation going on at the HeartHawk Blog (www.hearthawk.blogspot.com). Among the hot topics raised was just how bad it is to have a stent.

I think that my comments some time back may have started this controversy. I've lately noticed that having a stent screws up your heart scan scoring in the vicinity of the stent. I was referring to the fact that I've now seen several people in the Track Your Plaque program do everything right and then show what I call "regional reversal": unstented arteries show dramatic drops in score of 18-30%, but the artery with a stent shows significant increase in score.

This is consistent with what we observe in the world outside Track Your Plaque when stents are inserted. Someone will get a stent, for instance, in the left anterior descending artery. A year later, there will be a "new" plaque at the mouth of the stent or just beyond the far end. This is generally treated by inserting another stent. Use of a drug-coated stent seems to have no effect on this issue.

Now, my smart friends in the Track Your Plaque program would immediately ask, "Does this mean you continually end up chasing these plaques that arise as a result of stents? Do you create an endless loop of procedures?"

Thankfully, the majority of times you do not. Rarely, this does happen and can lead to need for bypass surgery to circumvent the response. But it is unusual. The tissue that grows above and below stents does seem to be unusually impervious to the preventive efforts we institute.

Perhaps there's some new supplement, medication, or other strategy that will address this curious new brand of plaque growth. Until then, you and I can only take advantage of what is known. If it's any consolation, the plaque that seems to grow because of a previously inserted stent seems to lack the plaque "rupture" capacity of "naturally-occuring" plaque. It is, indeed, somehow different. It is more benign, less likely to cause heart attack. It's always been my feeling that this tissue behaves more like the "scar" tissue that grows within stents, causing "re-stenosis", a more benign, less rupture-prone kind of tissue.
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  • madcook

    2/6/2007 5:17:00 AM |

    "If it's any consolation, the plaque that seems to grow because of a previously inserted stent seems to lack the plaque "rupture" capacity of "naturally-occuring" plaque. It is, indeed, somehow different. It is more benign, less likely to cause heart attack."

    Dr. Davis:

    You'll pardon my obvious question:  Has anybody actually looked at this phenomenon both in structure and composition at (pardon the word) autopsy?  I would wonder if it's a hyper-reaction to a foreign object, a kind of 'normal' scarring, as you mentioned, or something else.  Obviously there is calcium in this plaque, else it wouldn't be visible on scan. Very curious...

    madcook

  • Dr. Davis

    2/6/2007 8:46:00 PM |

    Madcook--
    The phenomenon is known as "edge restenosis". When examined at autopsy, or in years past when plaque was actually extracted by procedures like directional atherectomy, the material is the same as that occuring within the stent, known as "neointimal hyperplasia."

    The million dollar question is: Can anything modify neointimal hyperplasia? This is the whole dilemma of stent restenosis, the growth of tissue into stents. Of course, the procedural answer tends to involve drug coated stents. However, I know of no specific preventive strategy that has demonstrated substantial impact on the edge restenosis phemenonon. I've tried several agents, including cilostazol, which holds modest promise.

  • madcook

    2/6/2007 11:14:00 PM |

    Thank you for that information... I look forward to hearing more about the use of these agents as time goes by.

    "Of course, the procedural answer tends to involve drug coated stents."

    I just wonder how many people, who 'flunk' a treadmill test, or having an 'equivocal' result, end up in the cath lab and emerge with stent(s)... Are they _really_ aware beforehand that a lot of stent use is "off label" and they just might end up with a year or two (or a lifetime) on Plavix and aspirin?

    I lasted a week on Plavix before I refused anymore... after nearly bleeding to death in the kitchen from a cut (where else would a madcook hang out?).  But then I was very lucky, too as I escaped the cath lab without needing stenting.  A rare event I understand... and aspirin will always be my daily friend (along with most of the other TYP recommendations).

    Regards and thank you for the Heart Scan Blog.  It is a tremendous resource and very informative.

    madcook

  • John Townsend

    2/7/2007 9:15:00 PM |

    RE: "A year later, there will be a "new" plaque at the mouth of the stent or just beyond the far end."

    I'm curious whether or not this is a regular or typical occurrence and if there are symptoms one should be sensitive to that indicate such a development. Also does the size of the stent have a baring on the condition? Does vigorous exercise exasperate the condition?

    I appreciate your blog. It's very informative and helpful.

  • Dr. Davis

    2/7/2007 9:42:00 PM |

    John--
    It is, unfortunately, a very common occurrence, though the majority of times it does not result in any specific symptom or clinical consequence. Among the 30% or so of people who do re-develop chest pain, breathlessness, or have a new abnormality on a stress test, most of the time another stent is implanted at the area of tissue growth.

    Though this is really outside the realm of the Track Your Plaque program, it is yielding confusing results for people who engage in the program yet have a stent or two. It's my believe that the stent modifies the process of scoring in the stented artery. That's why we can see score reduction in arteries without stents, while the artery with a stent shows substantial increase in score.

    The larger the artery, the less likely this occurs. Large means 3.5 mm or greater in diameter.

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"I hate fish oil!"

"I hate fish oil!"

9. October 2006 William Davis (1)
I get this comment occasionally, usually from the fishy belching that can occur, rarely because of other crazy effects like rash, fishy body odor, etc.

In the vast majority, fish oil is a benign but wonderfully effective agent. Track Your Plaque followers know that fish oil, starting at 4000 mg per day of a standard 1000 mg capsule preparation, dramatically reduces triglycerides and thereby raises HDL, partially suppresses small LDL, and is the best agent available for reducing postprandial (after eating) abnormalities like IDL and certain VLDL fractions.

However, an occasional person (about 1 in 20) just doesn't like the effects. Are there alternatives? Fish oil packs such a wallop of beneficial effects that can not be replaced by any other single agent or lifestyle practice. For this reason, we have a number of easy strategies to enhance your tolerance for fish oil. (Of course, if your and/or you doctor determine that you're allergic to fish oil, then you should indeed avoid it; thankfully, this is rare.)

Helpful strategies include:

--Refrigerate fish oil capsules--this cuts back on fish belching.
--Take only with meals. This also may increase fish oil's benefits on suppressing after-eating lipoprotein abnormalities.
--Take an enteric-coated preparation--this delays breakdown of the tablet/capsule, making fishy belching less of an issue. Sam's Club has an inexpensive preparation.
--Take liquid fish oil. Usually orange or lemon flavored, liquid fish oil may be a faint fishy taste and odor, but usually not as prominent as the capsules. There's also less stomach upset.
--Coromega--a paste form of fish oil available at health food stores or through http://www.coromega.com. Coromega tastes fruity and comes in little squeeze envelopes.
--Frutol--Pharmax, a British company, makes another fruity fish oil that is non-oily and tastes like apricot. It's actually fairly reasonably priced, too. However, it is hard to find. The only way I know to get is to go online at www.pharmaxllc.com. You may have to actually order through a health care provider.

When using any preparation of fish oil, the best way to determine your dose is to add up the EPA and DHA content. For instance, if you use a fish oil liquid that contains 320 mg EPA and 240 mg DHA per teaspoon, you will need two teaspoons a day to achieve the equivalent of our starting dose of 1200 mg of EPA+DHA, usually provided by 4000 mg total in 4 capsules. Note that some lipid and lipoprotein disorders will require higher doses, e.g., 1800 mg EPA+DHA for high triglycerides (>200 mg/dl) or high IDL.
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  • buy jeans

    11/3/2010 3:43:43 PM |

    However, an occasional person (about 1 in 20) just doesn't like the effects. Are there alternatives? Fish oil packs such a wallop of beneficial effects that can not be replaced by any other single agent or lifestyle practice. For this reason, we have a number of easy strategies to enhance your tolerance for fish oil. (Of course, if your and/or you doctor determine that you're allergic to fish oil, then you should indeed avoid it; thankfully, this is rare.)

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Honeydew melon

Honeydew melon

18. July 2009 William Davis (4)

Honeydew melon:

Sugars, total 51.97 g

Sucrose 15.87 g

Glucose 17.15 g

Fructose 18.94 g

Because sucrose is half fructose (the other half is glucose), there are approximately 26 grams of fructose per one-half honeydew melon.



Image courtesy Wikipedia
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  • Ed

    7/18/2009 7:09:07 PM |

    Dr Davis: what is your recommended daily limit of fructose? I have read elsewhere a recommendation of 20 grams max per day.

  • Sifter

    7/19/2009 10:49:42 PM |

    I understand staying away from high fructose corn syrup in refined carbohydrates. But citing natural occuring fructose in natural God-given fruits? as dangerous?!  I don't believe it.

  • Anna

    7/21/2009 2:48:53 PM |

    "natural occuring fructose in natural God-given fruits"

    The modern fruits now available are *nothing* like "God-given" fruits.  

    The fruit that humans eat today has been altered (by humans) for various traits, especially large size and high sugar content.  In the industrial age, selection sped up and favored longer shelf life and size/shape uniformity over flavor in the human preferences.

    Prior to human manipulation, the fruits we currently eat were far smaller, less sweet, and not very abundant.

  • buy jeans

    11/2/2010 7:49:41 PM |

    The fruit that humans eat today has been altered (by humans) for various traits, especially large size and high sugar content. In the industrial age, selection sped up and favored longer shelf life and size/shape uniformity over flavor in the human preferences.

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