What vitamin D form?

In response to questions regarding why don't vitamin D tablets work, here are my observations.

When I first started correcting vitamin D levels around 3 1/2 years ago, people would begin with starting 25-hydroxy vitamin D blood levels of around 20 ng/ml.

Taking, say, 6000 units vitamin D as tablets over 3 months yielded blood levels of 24-30 ng/ml. Taking 6000 units in an oil-based form, and blood levels would commonly be 60-70 ng/ml.

In other words, tablets are very poorly absorbed. I also saw very erratic absorption with tablets, with tremendous variation in blood levels.

I witnessed this effect many times. I finally began telling patients to avoid the tablets altogether. It's simply not worth it. Taking dose X of tablets, you cannot predict what the blood level of vitamin D will be.

Now, you can sometimes make the tablets get absorbed by either taking with a teaspoon of oil (e.g., olive, flaxseed) or taking with an oil-rich meal. However, I am uncertain just how consistent the absorption is under these circumstances, not having done this enough times to know.

Oil-filled gelcaps are no more expensive than tablets (or perhaps a dollar more). Health food store employees and pharmacists don't know this. I have had many patients come to the office claiming they changed to tablets because that's all their health food store or pharmacy carried and the person behind the counter assured them it was the same. Blood level of vitamin D to confirm: right back down to the starting level or near it--little or no absorption.

The only way to know whether a preparation is absorbed is to check a blood level. But, in my experience, having checked vitamin D blood levels thousands of times, gelcaps never fail; tablets fail over 80% of the time.

Comments (36) -

  • TedHutchinson

    2/16/2009 9:13:00 AM |

    Effective strength D3 is not available over the counter in the UK. UK readers have to buy from the USA.
    http://tinyurl.com/8znjue
    Iherb do Now foods 5000iu D3 in olive oil capsules very cheap.
    Orders £18 or over are not only subject to Customs duty but our Post Office charges £8 extra to collect the tax.
    Using Iherb $5 discount code such as WAB666 reduces the price of 360 to under the tax threshold. Leaving the daily cost including P&P to 5.25p daily

  • TedHutchinson

    2/16/2009 12:01:00 PM |

    http://tinyurl.com/ch5262
    May I also draw readers attention to this half hour video from Cedric Garland about Vitamin D status and cancer incidence and progression.
    You will note Garland suggests 60ng 150nmol/l for lowest cancer incidence.

  • fritz

    2/16/2009 1:48:00 PM |

    Is the vitamin D from cod liver oil effective?

  • Anonymous

    2/16/2009 2:10:00 PM |

    Slightly off topic, but I just read that congress is going to vote on a bill to cut medicare coverage of vitamin D levels, so now we will have to rely on private insurance, or simply pay ourselves.

    Jeanne shepard

    By the way, I prefer not to be "anonymous" but the Google Blogger doesn't remember my password, and won't let me select a new one.

  • Anne

    2/17/2009 3:28:00 AM |

    Some of the vitamin D experts warn against using cod liver oil. http://www.vitamindcouncil.org/newsletter/2008-december.shtml

    One concern is too much vitamin A if you took enough of the cod liver oil to get the D you need. Another is that vitamin A and D compete with each other.

  • TedHutchinson

    2/17/2009 10:18:00 AM |

    fritz
    Read what Dr Cannell says about Cod liver oil here
    http://tinyurl.com/dh9b6k

    A typical 5ml tsp of CLO contains roughly 400iu. Most people require on average 5000iu/daily so the amount from CLO is insufficient.

    Jeanne
    Twice yearly $30, 25(OH)D blood spot tests, available by post from this source
    www.grassrootshealth.org/daction/index.php

  • Rick

    2/17/2009 10:49:00 AM |

    iHerb.com also has Country Life Vitamin D3 2500 IU (200 softgels).

    Thanks for answering the questions about tablets so quickly, by the way.

  • Tom

    2/17/2009 11:38:00 AM |

    For the benefit of UK readers, I'd like to second TedHutchinson's informative comment. I use the same product from the same supplier Smile

    It's worth noting that postage and packing cost from the US does not contribute to the value of the order for the purposes of taxes and extortionate 'fees'.

  • Matthew

    2/17/2009 1:08:00 PM |

    I don't understand why taking a vitamin D3 capsule will not raise level of 25(OH)D when consuming it with fat or meal containing fat. Should get the same results...

  • Anonymous

    2/17/2009 5:43:00 PM |

    First, let me say that I really love your blog.  I learn so much every time I come here.

    I do have a question for you.  What do you make of this site:

    http://bacteriality.com/2007/09/15/vitamind/

    On the surface, she appears to be a competent scientist, but she blames everything (and I do mean everything from macular degeneration to brain lesions) on too much Vitamin D and claims that the road to universal health should begin with driving one's Vitaman D levels to below 20 ng/mL.  A friend of mine just sent this to me in a panic.  Please let us know what you think.

    Thanks so much!
    Isabella

  • Steve L.

    2/17/2009 7:39:00 PM |

    The Costco effect.  I had been wondering why so many people use the tablet form.  Just noticed yesterday that tablet is the form of Vitamin D that Costco carries.

  • Diana Hsieh

    2/17/2009 8:54:00 PM |

    All of the vitamin D capsules that I checked in Whole Foods yesterday were composed of some kind of frankenfood oil in them, most notably soybean oil.  Can anyone recommend any brands that use something better?  

    (I have the same problem with my vitamin E complex, but I'm not convinced that I should be taking that anyway -- although it does seem to help the inevitable dry skin in winter here in Colorado.)

    BTW, my husband and I got our levels tested thanks to your recommendations.  Mine were excellent (probably thanks to many months of good supplementation), but his need some work (despite some more moderate supplementation).  Thanks for the info!

  • David

    2/18/2009 4:37:00 AM |

    Re: the http://bacteriality.com/2007/09/15/vitamind article...

    Anonymous,

    Dr. Davis wrote about this issue (more or less) last year: http://heartscanblog.blogspot.com/2008/03/marshall-protocol-and-other-fairy-tales.html

    David

  • Michael

    2/18/2009 5:55:00 AM |

    @ Diana Hsieh
    Don't know if this is available where you are (I'm in Australia) but I use this brand of D3 for this very reason. It's in fish oil, of reasonable potency.

    THOMPSON'S Vitamin D (1000mg) with Fish Oil (500mg) - 60 gelatin-free caps

    http://www.thompsons.co.nz/afa.asp?idWebPage=8403&ID=163&SID=663632930&Type=Products

    Product made in New Zealand. Hope this helps.

  • Anna

    2/18/2009 6:40:00 AM |

    Diana,

    Our family likes Carlson Vit D products.  They are definitely absorbable, because the whole family went from the low end fo the reference range to around 70-86 ng/ml in the past few months).

    Mostly we use Solar D Gems in the 2000 or 4000iU capsules.  There is a bit of Norwegian CLO & EPA?DHA in them, and lemon flavor.  They chew up easily, too, but can also be swallowed.

    The non-chewable capsules are much tinier and are made with sunflower oil, but even that is a very tiny amount in this very small capsule.

    The Carlson D drops in the 2000iU/drop dose is made with coconut oil (though it is fractionated, to keep it liquid).  But it's only a drop.

    I find very good prices at www.vitaminshoppe,com, usually for about 2-4 ¢ per each 1000iU (that's how I make price comparisons).  Plus Vitamin Shoppe has a frequent buyer program so purchases earn points toward fairly generous coupons (such as $5 off a $15+ purchase), and shipping is reasonable (sometimes free).  

    Or I buy Carlson Vit D3 at the local store when they are on sale (stores that sell a lot of Carlson product often pass along "mfg discounts" or "special buys").

  • TedHutchinson

    2/18/2009 11:09:00 AM |

    Isabella
    Mark London  MRL@PSFC.MIT.EDU has provided a detailed scientific rebuttal of the Marshall Protocol here
    http://tinyurl.com/cfod57
    Is the MP Treatment for Sarcoidosis Helpful for Other Chronic Diseases?

    MP’s Vitamin D Theories Are Not Supported by Lab Studies.
    Updated July 2, 2008

    Dr Davis has previously addressed this issue in the blog entitled
    The Marshall Protocol and other fairy tales

    Diana Hsieh
    The capsules I suggested are dissolved in olive oil.
    http://tinyurl.com/abbagz
    Carlson 2000iu sunflower oil $12.22
    http://tinyurl.com/abbagz
    Carlson also do Solar Gems in Cod liver oil.
    http://tinyurl.com/bclzom

  • Anonymous

    2/18/2009 1:35:00 PM |

    Diana Hsieh,

    I believe the NOW foods brand D3 formulations are suspended in olive oil.

    Carlson's Vitamin D3, 2,000 IU is suspended in sunflower oil.

    That being said, most of these D3 capsules are quite tiny, so I am not sure that they contain a huge amount of oil, unless you are taking more than 10,000 IU's daily (i.e., 5 capsules).

    As to sources, iHerb is the best and most user friendly, and I won't even give you my $5. discount code, as previous poster did.  You can sign up for your own discount number at the iHerb website.

    Hope that helps!

  • Sam

    2/18/2009 3:30:00 PM |

    Diana,

    I'm currently using Carlson 2000IU gelcaps which contain sunflower oil (omega-6, even if small quantities) and a few other more benign ingredients.

    When these are exhausted I'm switching to Carlson D-drops in which D3 is dissolved into medium chain triglycerides (MCT).

  • Anonymous

    2/18/2009 4:50:00 PM |

    Thanks everyone for the input.  I feel much better now and am off to take my gel-capped Vitamin D3.

    All my best,
    Isabella

  • TedHutchinson

    2/18/2009 9:21:00 PM |

    When researching Carlson Solar Gems earlier I mentioned they contain Cod liver oil but no Vitamin A Content is listed on the Carlson's website.
    So I emailed Carlson's to confirm the vitamin a content. They replied
    total Vitamin A is below 2% of the daily value which is the threshold above which the FDA requires you to list the Vitamin A content.
    As adult RDA for vitamin A is 700~900iu, below 2% of that is below 14~18iu. So there is really is no reason to avoid Solar Gems because of their potential Vitamin A content.

  • Anonymous

    2/19/2009 12:52:00 AM |

    Dr. Davis,

    Appreciate your elaborating the tablets vs. capsules point and thank you for continuing to take the time to write such informative posts!

  • Anonymous

    2/19/2009 7:46:00 PM |

    "Heart disease was once thought to be less of a problem for women than for men. Research now indicates that heart disease is the No. 1 cause of death among women in the US, while confirming that women with an intact uterus have a lower incidence of heart disease because they benefit from the uterine advantage." Visit http://www.truthout.org/021609R for the full article.

  • Anonymous

    2/20/2009 12:01:00 PM |

    Dr. Davis,
    Are gelcaps with dried powdered form of vitamin d3 as effective as oil filled gelcaps?

  • Ricardo

    3/26/2009 12:58:00 AM |

    Dr. Davis, "Americans Low on Vitamin D" - http://www.webmd.com/news/20090325/americans-low-on-vitamin-d

  • Anonymous

    4/22/2009 6:37:00 PM |

    I've had great results from powdered gelcap from D-Max (5000 IU) from Nature's health Supply, but a bit less from NOW olive oil gelcaps (5000 IU). Just a hunch, because I have an autoimmune disease and I'm trying to work out my symptoms. So no 25(OH)D test here.

    I'll try those Carlson's next.

    Great blog by the way!

  • Anna

    4/22/2009 8:49:00 PM |

    I just ordered some D3 to send to my 81 yo MIL and 46 yo SIL in London.  I'm quite sure they are going to very deficient (they just ordered the www.grassrootshealth.net home testing kit as it's a pain to get NHS to agree to test).  

    I found Bio-Tech D3-5 (5000iU cholecalciferol capsules  - powder in a tiny gelatin capsule) offered on Drs. Eades's Protein Power website at a great price, 100 qty for $8.  Shipping via UPS was $6.45 to my location for up to 10 bottles.  That makes the price per 1000iu incredibly low.  I bought a year's supply (8 bottles) to mail to my in-laws, plus two bottles for me.  Note I was very surprised at the small size of the box, but it did contain the 10 bottles I ordered, but the capsules and bottles are small and light, which is nice when ordering so much at once and mailing it again.  Fast delivery, even with UPS ground service.

    I just had another 25 (OH)D test drawn last week; I'll get the results tomorrow at my endo appt for my thyroid.  I was averaging 5000iU/day  supplementation with various Carlson D3 products, based on previous 25 (OH)D test results and supplementation levels.  So I'll switch to the Eades' Bio-Tech formula now and see how my 25 (OH)D is in late summer/early fall.

  • David

    4/22/2009 9:40:00 PM |

    Anna,

    I'd be very interested to hear a follow up from you when you retest after being on the Bio-Tech D3 for awhile. I'm of the mind that D3 in softgel form is more absorbable and hence more efficacious for raising and maintaining 25(OH)D levels, but I see many of the "big guns" (e.g. Cannell, Eades, etc.)promoting/selling the powdered Bio-Tech formula. Perhaps you could report back here with your results?

    David

  • Anna

    4/23/2009 6:27:00 PM |

    Dave,
    Sure.  I'll be retesting  thru my endo in 6 mo.  But I might do a mail-in test via www.grassrootshealth.net before that.  

    I'm guessing a gelatin capsule filled with a powder (might be an oily powder,too) is more absorbable than a hard tablet form.

    Btw, I just got my lab result for 25(oh)d---a nice 68ng/mL (after months of 5000iU D3 carlson oil gelcaps and/or oil drops .  Also was an easier winter than i've had in years, which I think might be due to more sunlight and Vit D.

  • David

    4/23/2009 7:59:00 PM |

    Thanks, Anna. 68 ng/ml-- Good for you! You know, all my life, I've had tough winters. I would always get very sluggish and depressed. I mean I would get really, really down. But ever since I've started the vitamin D, the winter blues are a thing of the past. This alone is probably the most noticeable effect I've ever had from taking any supplement. It's a very dramatic and welcomed change.

  • Herry

    5/27/2009 9:41:31 AM |

    I will read from time to time for that.

    http://allnutri.com/bid970/now+foods.aspx

  • Anonymous

    8/26/2009 6:34:03 PM |

    That means D3 in Calcium tablets like Citrical is probably poorly absorbed  too, am I correct?

  • David

    8/27/2009 10:27:06 PM |

    Yep.

  • Anonymous

    11/11/2009 8:42:39 PM |

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  • Anonymous

    12/13/2009 2:00:04 AM |

    yoo... amazing thread!

  • Anonymous

    5/4/2010 2:15:47 AM |

    GNC has Vit D drops.....do you feel this is good?

  • buy jeans

    11/3/2010 12:30:44 PM |

    Oil-filled gelcaps are no more expensive than tablets (or perhaps a dollar more). Health food store employees and pharmacists don't know this. I have had many patients come to the office claiming they changed to tablets because that's all their health food store or pharmacy carried and the person behind the counter assured them it was the same. Blood level of vitamin D to confirm: right back down to the starting level or near it--little or no absorption.

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Diet: One size does NOT fit all

Diet: One size does NOT fit all

Heart Scan Blog reader, Frustrated, posted this comment:

Dr. Davis,
I have spent the last 5 months eating a diet that completely eliminated all wheat products. It was very low carb, and consisted of relatively high protein (eggs, grass fed beef, grass fed raw cheese, oily fish, chicken), good level of olive oil, walnuts, fish oil (3 mg per day), raw vegetables, little bit of fruit. So I had good amount of monounsaturated fat as well as saturated fat from eggs and grass fed products.

My recent NMR showed:
LDL-p. 2,800
Small LDL particle 1700
Small HDL particle 20
HDL-C 40
LDL-C 114
Trigs. 224
Total chol 208

So I was disappointed. Where have I gone wrong? No wheat and sky-high LDL-p and 1700 small LDL particles.


This is indeed unusual. I see this perhaps 5 or 6 times over a year's time, while thousands of other people show the usual expected respone. I don't have Frustrated's lipoprotein panel prior to starting the diet, but I'll bet the starting panel was similar to this "after" panel.

The overwhelming majority of people who follow a diet like the one described--no wheat, limited carbohydrate, grass fed beef, fish, chicken, vegetables, limited fruit--obtain extravagant reductions in small LDL, increased HDL, and reduced triglycerides. So why did Frustrated end up with such disappointing results, values that potentially provide for high risk for heart disease?

There are several possibilities:

1) He/she is in the midst of substantial weight loss. When labs are drawn in the midst of weight loss, stored energy is being mobilized into the blood stream. This energy is mobilized as fatty acids and triglycerides which, upon entering the blood stream, cause increased triglycerides, reduced HDL, chaotic or unpredictable small LDL patterns, and increased blood sugar sufficient to be in the diabetic or pre-diabetic range. This all subsides and settles down to better values around 2 months after weight loss has plateaued.

2) Apo E4--If Frustrated has one or two apo E4 genes, then increased dietary fat will serve to exaggerate measures like small LDL despite the reduction in carbohydrates, LDL particle number, and triglycerides. This is a tough situation, since small LDL particles and high triglycerides signal carbohydrate sensitivity, while apo E4 makes this person, in effect, unable to deal with fats and dietary cholesterol. It gives me the creeps to talk about reducing fat intake, but this becomes necessary along with carbohydrate restriction, else statin drugs will come to the "rescue."

3) Apo E2 + Apo E4--It's possible that an apo E2 is present along with apo E4. Apo E2 makes this person extremely carbohydrate-sensitive and diabetes-prone with awful postprandial (after-meal) persistence of dietary byproducts, alongside the hyperabsorption of fats and dietary cholesterol from apo E4. This is a genuine nutritional rock and a hard place.

4) Other variants--There are probably a dozen or more other genetic variants, thankfully rare, such as apo B and apo C2 variants, that are not generally available for us to measure that could influence Frustrated's response.

5) The low-carb diet is not truly low-carb--Frustrated sounds like a pretty sharp cookie. But it's not uncommon for someone to overlook a substantial source of carbohydrate exposure that triggers these patterns. Fruit is a very common tripping point, since people generally regard unlimited fruit as a healthy thing. This does not seem to be Frustrated's problem. Others indulge in quinoa, sweet potatoes, millet or other carbohydrate sources that look and sound healthy but, in sufficient quantities, can still trigger this pattern.

6) Other--Hypothyroidism, kidney disease, nephrotic syndrome, hypercortisolism and some other relatively rare conditions are worth considering if none of the above apply.

Anyway, that's the list I use when this peculiar situation arises. If obvious weight loss is not the culprit, the next step is apo E testing. However, the wrong response is to reject the low-carbohydrate notion altogether and just limit fat, since this typically leads to uncontrolled small LDL, high triglycerides, and diabetes. It can often mean limiting carbohydrates while also limiting fats. Just as with the combination of apo E4 with Lipoprotein(a), I lump many of these patterns into the emerging world of genetic incompatibilities, genetic traits that code for incompatible metabolic phenomena.


Comments (33) -

  • David Horry

    8/24/2011 6:03:44 AM |

    Hi Dr Davis,
    I am an apoe4 carrier. My trig=62, HDL=69; LDL-C=175 after 16 months on a carbohydrate restricted, gluten free diet. Wondering whether I need to also reduce my fat intake. But then what is left to eat? Making up the calorie difference with protein does not sound too healthy.

    David

  • Dr. William Davis

    8/24/2011 12:24:19 PM |

    Hi, David--

    I would urge you to NOT rely on the calculated LDL value, since on a low-carb diet with potential conversion of small to large LDL particles calculated LDL can substantially overestimate true LDL.

    The best: LDL particle number through NMR lipoprotein analysis. The next best: apoprotein B, widely available from nearly all labs.

    When you're armed with this information, then you can make an intelligent decision about diet changes.

  • Paul

    8/24/2011 1:43:34 PM |

    Regarding Item 6

    There was some traffic between Chris Kresser and Jimmy Moore on Twitter yesterday regarding whether low carb caused low T3 in susceptible individuals. Clearly bad news for heart health.

    I am a treated hypothyroid and this was my recent experience - I had gone low carb and ended up with an abscess in the roof of my mouth that needed antibiotics.  When tested, my T3 had fallen from 5.5 to 3.8 (RR 4 - 6.8) - however, my TSH was 0.672 (RR 0.35-4.5).  In the UK, this low T3 would normally would have been missed as there is a TSH only testing policy here unless the TSH is found to be outside the reference range - I elected to pay privately for the T3 test.

    I remain on low-carb (and wheat free of course) as it is the only approach which allows me to lose weight, and have increased my meds from 75T4+20T3 to 100T4+40T3.

    I would query whether you consider hypothyroidism to be rare. I suspect it is very common.

  • steve

    8/24/2011 6:52:16 PM |

    Hi Dr. Davis:
    What if the patient  followed the above diet, had a particle count of 2,100, but only 200 were small and HDL 69 and Trgs 66.  Would this be acceptable, and better than a particle count of 640, less than 90 small, HDL 64, Trgs 45, but on statin and Zetia?  Assume thyroid and D all normal, and Apo E3/3
    Thanks for all the input

  • Chris

    8/24/2011 7:26:24 PM |

    Hi Dr Davis,
    This post really hit home with me (and ironically this is my first visit to your site).  I had a heart attack 2 years ago (34 years old, ate well or so I thought, in great physical condition at 5'9" 150 lbs).  My cardiologist advised the usual low fat diet and pravastatin, and while my lipids are better than they were, I'm still very concerned they are not near where they should be.

    About 5 weeks ago I found the primal diet and began eating that diet.  Last week I had another lipid test and my numbers actually got worse (not by much).  Would you mind reviewing my numbers and if you have any suggestions I would appreciate it.

    8/31/2009 heart attack
    total chol 115
    LDL 74
    HDL 16
    Triglycerides 126
    VLDL 25

    07/19/2010 checkup
    total chol 138
    LDL 64
    HDL 33
    Triglycerides 203
    VLDL 41

    03/21/2011 Healthfair
    total chol 122
    LDL 69
    HDL 31
    Triglycerides 111
    VLDL 22

    8/19/2011 walk in lab:
    total chol 159
    LDL 98
    HDL 34
    Triglycerides 135
    VLDL 27

    Glucose 97
    hsCRP 1.2
    A1c 5.5

    Do you suggest giving the "primal" diet more time or do you suspect I may have another condition causing this?

  • Chris

    8/24/2011 7:36:33 PM |

    Also in May of this year I had the following tests done at the cardiologists:
    Date of service: May 13, 2011
    CAT Scan MRI & NMR
    Diagnostic Radiology X-Ray
    Cardiovascular Stress Test

    I was told everything was fine.

  • Might-o'chondri-AL

    8/25/2011 2:28:51 AM |

    Track Your Plaque once gave a desirable level of ApoB  as under 70 mg.dl as surrogate marker for the desirable LDL particle number (which is less than 700 nm/l) if one only has ApoB testing.  Maybe some one else can recall the conversion ratio of ApoB into LDL particle numbers.

    A cholesterol fractions normal transfer from HDL to ApoB is governed by  the cholesterol ester transfer protein (CETP). Genetic variants of CETP can cause differences in the numbers of  small LDL and sparse CETP can cause cholesterol to stay stuck in HDL  ( CETP has little impact on numerical % of HDL). So genetic variants of ApoB can influence the levels of cholesterol shunting around.

    In  the liver ApoB normally gets it's lipids when ApoB goes into a cell's endoplasmic reticulum. And if the ApoB doesn't improperly degrade ( ApoB needs "enough" microsomal triglyceride transfer protein SREBP-1c, the sterol regulatory element binding protein, to avoid degrading) then ApoB can pick up triglycerides to form VLDL molecules. So, if there is not enough liver SREBP-1c  then lipids can't be transferred over to make triglyceride rich VLDL; conversely lots of liver SREBP-1c provokes extra VLDL.

    Doc says carbohydrate related  post-prandial high glucose not only induces  more VLDL output  from the liver but that this is part of the mechanism whereby carbs can boost body fat. High carbohydrate intake causes extra lipo-genesis in the liver because a significant  reflex of high post -prandial liver insulin is a signal that upregulates SREBP-1c. Then SREBP-1c expression rises and that in turn activates genes for the lipogenic enzymes (ex: fatty acid synthesase & acetyl CoA carboxylase),

    Rogue readings of VLDL may be due to viral hepatitis proteins, flavivirus and pestivirus, which can decrease VLDL formation and secretion while dropping levels of ApoB. Viral proteins "smear" onto lipids and this blocks SREBP-1c action and viral proteins can also "stick" on to the HDL protein fraction ApoA1 inside of the  liver cells' Golgi Apparatus. Thus in chronic liver disease and hepatitis circulating VLDL associated triglycerides eventually decreases so there are more non-VLDL  triglycerides in play.

  • Jack Daniels

    8/25/2011 11:49:38 AM |

    Hi Dr. Davis,

    I was just wondering, due to many healthy cultures including the kitava, okinawan's...etc, who indulge in rather high carb intakes and retain rather pristine health, is it possible that high trigs, low hdl..etc may just be a lipid profile reflecting high carb* intake rather than suggesting atherogenic buildup ?

    *when based on safe starchy type carbs

  • Dr. William Davis

    8/25/2011 3:42:09 PM |

    Hi, Paul--
    In the population I see, hypothyroidism is exceptionally common, both in people on low-carb but also in people prior to initiating their low-carb efforts. So, without a formal analysis, I'm skeptical that low-carb in and of itself causes free T3 to drop.
    There are also numerous inhibitors of the 5'-deiodinase enzyme that converts T4 to T3, including perchlorate residues from fertilizers in vegetables and polyfluorooctanoic acid, the residue of non-stick cookware, just to name a couple.

  • Dr. William Davis

    8/25/2011 3:43:29 PM |

    This is the BIG unanswered question. Sadly, there are next to no data that speaks to this question.
    My day to day answer has been to 1) eliminate small LDL, then 2) maintain LDL particle number 1500 nmol/L or less. But that is pure speculation on my part.

  • Dr. William Davis

    8/25/2011 3:45:22 PM |

    Hi, Chris--
    Something doesn't compute: Every panel you list is the pattern of excessive carbohydrate consumption and/or sensitivity. So something is sneaking through. There is no question that a "primal" or low-carbohydrate approach works for this pattern.  

    You might also have an Apo E2 gene that amplifies carbohydrate sensitivity.

  • Dr. William Davis

    8/25/2011 3:47:01 PM |

    Hi, Might--
    As always, you are an incredible fountain of unique insights!

  • Dr. William Davis

    8/25/2011 3:47:44 PM |

    Sorry, Jack, I didn't understand your question. Could you rephrase?

  • Chris

    8/25/2011 4:28:55 PM |

    Thanks.  I've only been eating primal/paleo for about five weeks, so only the last panel would reflect this (if thats enough time to be reflected in my lipid panel).  I will re-test after another few months.

  • Jack Kronk

    8/25/2011 4:53:55 PM |

    Dr Davis. Jeez. This sounds similar to my story (Frustrated's #s). I have eaten Paleo for over a year now, I have done exceedingly well with body composition in that time. See my "Share You Paleo Before and After" here ---> http://paleohacks.com/questions/7058/share-your-paleo-before-and-after/28493#28493. But this only adds to the confusion for me (and others).

    For some reason, my labs came back on July 8, 2011 with small dense LDL and pathetic HDL at 40, despite a diet rich in GF beef, pastured eggs, bacon, pasture butter, coconut oil, ghee, veggies, starch and fruits only for carb sources, etc etc. I spend mega money to eat well. We don't mess around. I posted my VAP panel results on PaleoHacks last month and it has resulted in a lot of attention on this very subject. Chris Masterjohn weighed in with his thoughts. Dr Kruse wrote a blog all about it.

    http://paleohacks.com/questions/50347/hack-jack-kronks-vap-test-results

    I will be retesting again in about a month, as I have made some changes, like eliminating bananas, less heavy cream and pasture butter, etc.

    My lab said it's $390 just to do the ApoE test. Is this a normal price? If not, where do you recommend people get the testing done?

    I'm genuinely confused. It's like my body is saying... "Yes Jack. Good job. I am very happy with what you are eating. I will continue to keep fat off and pack on muscle." But then my heart is saying "Nooooo. Stop!!"

    How can this be?

  • Jack Daniels

    8/25/2011 5:29:06 PM |

    I was questioning if your pathological interpretation of a blood lipid profile that exhibits low hdl and high triglycerides, could instead just be a reflection of a high carb diet rather than suggesting an increased risk for CVD. I was referencing a couple high carb cultures, such as the Okinawa and the kitava, who exhibit a similar lipid profile but have very small incidence of CVD. Compared to other cultures with similar lipid profiles, such as the Swedes and Americans, who have much higher rates of CVD would suggest it's more about quality of blood lipids rather than their certain partitioning. Hopefully that's a better re-phrasal?

  • steve

    8/25/2011 5:57:08 PM |

    This is the BIG unanswered question. Sadly, there are next to no data that speaks to this question.
    My day to day answer has been to 1) eliminate small LDL, then 2) maintain LDL particle number 1500 nmol/L or less. But that is pure speculation on my part.

    My understanding related to your above comment is that large LDL is nearly as athrogenic as small LDL and that you want the particle number low with mix between largle and small LDL taking secondary importance.  Of course, that is based on a diet that the avg american consumes,  and not on the low carb with wheat sugar and cornstarch elimination you advocate.
    Am i under a correct understanding regarding large LDL being dangerous as well and therefore the need to minimize this even with your dietary recommendations?  Also, i thought you advocated a total LDL particle number to approach 600?  Is your 1500 number a revised viewpoint based on newer diet or clinical observations?
    Thank you again.

  • Might-o'chondri-AL

    8/25/2011 7:53:36 PM |

    Server error blocking me again ... testing after hour passed.

  • Might-o'chondri-AL

    8/25/2011 8:49:34 PM |

    ApoE is crucial to VLDL & chylomicron formation. Variant ApoE 2 less efficient at transfering lipids to liver and is binding lipids up an extra +/- 2%; result is that lipids take longer to clear from circulation and more can go wrong. From my notes, here is the rate some ancestral populations have at least 1 copy of ApoE2: 2-4% of Mexican-american & American Indian, also  3-4% of Japanese & West African. There is 0% of South American Indians with ApoE2 and one wonders which variation of  ApoE  might be in Kitava melanesians. .
    ApoE4 degrades easiest of all ApoE forms, leaving protein fragments in cell's cytosol which then can affect a mitochondria's lipid binding region impairing the performing of  tasks. In addition ApoE4 fragments diminish gene PPAR gamma expression; and this depresses the desirable bio-genesis of mitochondria. The affects on mitochondria may be why high levels of dietary fat is problematic for ApoE4 individuals; there may be too sparse output of viable mitochondria and mitochondria membranes are involved in how efficiently we burn fat or glucose.  .
    In light of these ApoE4 nuances it is interesting to know that fasting raises free fatty acid levels (from fats in the body and not loose fats from recent food); and then those free fatty acids upregulate  gene for PPAR gamma in the liver. Fasting makes one put out ketones  because of the extra PPAR gamma programing and this ketogenesis is also one way that activating more PPAR gamma improves insulin sensitivity. This suggests to me that individuals with ApoE4 may (?) find some benefit from modified fasting; possibly something like decidedly fewer meals in a day and also simply not grazing on snacks (ie: in addition to just trying to select what foods to eat) between meals that are regularly spaced apart (ie: very early breakfast to let meal times spread put more evenly) .

    Finally again from my notes, here is the rate some ancestral population have at least 1 copy of ApoE4: .14-19% Germans & Finns, also 7-12%  French & Italians. Of course America is one of the world's melting pots so an individual's propensity for ApoE 4 & ApoE 2 is hard to pin point.

  • Jack Kronk

    8/25/2011 9:02:36 PM |

    This is fascintaing Might. I have been guilty of snacking too much. All healthy snacks, but still the concept of grabbing bites of delicious foods between meals might be messing with my liver. For my VAP test, I did not fast. Chris Masterjohn believes this was the reason (or at least the reason for dismissal) of my increase in triglycerides in the blood. I am most concerned about my low HDL, because if I raise my HDL, I believe my LDL will become more dominantly pattern A.

  • Paul

    8/25/2011 11:04:33 PM |

    Thank you for the reply.  I would like to share a speculation.  Strict low carb means gluconeogenesis means an increased cortisol demand? OK in young fit Paleo men, but what about long-term un(der)treated hypothyroid individuals?

    In "Safe Uses of Cortisol", Dr William Mck Jefferies (p. 183/4) observes that low dose (20mg/day) of hydrocortisone taken by a patient with hypothyroidism increases T3,  lowers T4 and improves patient energy levels suggesting such low dose cortisol enhances T4 to T3 conversion.

    Could VLC, by putting demands on potentially weakened adrenals, have the opposite effect?

  • Might-o'chondri-AL

    8/26/2011 12:10:58 AM |

    HDL molecules hold triglycerides (there are 45 different variations of triglycerides in circulation, which are based on what their esterified fatty acid component is), cholesterol esters (about 13 - 27% of the HDL surface particles), shingomyelins and glycerophospholipids. HDL's principle proteins are +/- 70% ApoA1 and +/- 20% ApoA2;  yet any changes in the ratio of ApoA2 from genetics (Kitavans?, I propose so) or drugs (ex:fibrates) can have effects.  

    Usually people with low levels of  HDL have more trigs on their HDL surface (compared to those with high levels of HDL) and low HDL is associated with the passing of more cholesterol esters to VLDL & chylomicrons. Also, when HDL trig levels go up that makes it easier for the liver enzyme hepatic lipase to cleave off more ApoA1 for the kidneys to clear away; and that further tends to keep HDL levels low.  

    In comparison people with high levels of HDL have more cholesterol esters on their HDL; which may be due in part to cholesterol esters affinity for ApoA1 in HDL. And statisticly high levels of HDL are usually associated with bigger ("large") HDL molecule size. Both large HDL and ApoA1 are considered to be more protective factors against atherosclerosis.

    I suspect that Kitavan melanesians' low HDL fortuitously correlates with a geneticly higher than normal % of ApoA2; and ApoA2 configures more deeply nestled into the HDL complex than ApoA1. It (ApoA2) influences molecular  interactions all the way to the HDL surface and limits certain lipid dynamics.

    ApoA2 holds ApoA1 off of mature HDL molecules and this results in a shunting of ApoA1 into forming up the pre-Beta HDL; these lipid poor ApoA1 configurations are great at doing reverse cholesterol transport that brings back cholesterol  to the liver for excreting as bile acids. Those pre-Beta HDL are small, yet notably excellent at taking cholesterol away from nefarious macrophage foam cells (the large HDL  molecule also picks cholesterol nicely from foam cells).

    Experiments see that preceeding type of change with fibrate drug doses, which only minimally raise HDL & ApoA1 yet increase the ApoA2 amount in HDL by over 25%. Since fibrates are agonists activating the peroxisome proliferator activiated receptor PPAR alpha it might be instructive to see if anything in the Kitavan diet is a similar agonist, such as heirloom tuber roots derived from wild yam with high diosgenin content (diosgenin is well known to affect PPAR gamma).

  • Dr. William Davis

    8/26/2011 5:15:14 PM |

    Hi, Steve--
    There really is no final word on what the desired endpoint is when small LDl has been eliminated and you have pure large LDL. In a perfect world, I'd wish for a particle number of 600 nmol/L with pure large LDL. But I'm no longer entirely sure this is necessary. But this remains anecdotal. There are no formal data, nor do I have any formal analysis of our own data on this question.

  • Dr. William Davis

    8/26/2011 5:17:32 PM |

    Hi, Jack--
    Don't know, since I've never seen any genuine lipoprotein data on these populations. Most of the data I've seen has been total cholesterol, which is far too crude to draw any conclusions from.

    Have you seen lipoprotein data on these populations?

  • Jack Kronk

    8/26/2011 5:33:12 PM |

    Might. Do you suspect that I have low HDL and highish Trigs/VLDL in the blood for this reason? I do take in a fair amount of protein (including a whey isolate daily). Also, plenty of eggs. Does dietary protein consumption have any actual affect on HDL's principle protein and/or surface cholesterol esters?

  • The Surgical Blog

    8/27/2011 3:52:44 AM |

    Yes Jack Kronk, it seems that you have low HDL and highish Trigs, I do also think.

  • Nancy Milligan

    8/28/2011 7:51:57 PM |

    Just wanted to comment. I've been a long time low carb person, gluten-free too. I also had my thyroid ablated with RAI many years ago. I have found, as have many low carbers, that my reverse T3 is very high and Free T3 is scraping the bottom or below the range.

    Unfortunately this does seem to be a common side-effect of low carb eating. It's even documented in studies on the topic.

    We had a low carb eater recently watching his LDL climb to very high levels after he began eating low carb. He started taking cytomel and his LDL is coming down very nicely.

    Did he get a sudden onset of hypothyroidism that just coincided with low carb eating? I suppose that's possible, but I do think there's something more going on.

    I'm taking Armour thyroid myself, but I still have the tendency to turn T4 into reverse T3 and I suppose that means the Free T3 can't get to the receptors. I'm going to experiment with raising my carbs a little higher and sticking to things like yams and squash for my carbs.

  • Espen Rostrup

    8/31/2011 12:33:45 PM |

    Dear dr. Davis,
    I just attended the annual cardiology congress of the European Society of Cardiology. Amongst others, the new guidelines on dyslipidemia were presented and I had the opportunity to ask the working group the question you mention above in your first of opportunities : What about measuring lipids during an ongoing substantial weight loss? The were not able to give me a proper answer.
    Do you have any scientific references saying that weight loss induce a temporary dyslipidemia or is it based on your experience?
    I would be most thankful for your comment on this.
    Best regards
    Espen Rostrup, MD, PhD-fellow
    Bergen, Norway

  • Dr. William Davis

    9/2/2011 2:56:29 AM |

    Dr. Rostrup--

    Unfortunately, I know of no published data documenting this effect. However, I have seen it hundreds of times. It is, in fact, quite predictable: drop in HDL, rise in triglycerides, variable small LDL effects, increased blood glucose. It all subsides and improves over time.

    It would indeed be an interesting study to chronicle the changes serially in a small number of people.

  • Dana

    9/8/2011 8:28:14 PM |

    I am also seeing a heck of a lot of omega-6 intake there.  Also, the healthfulness of monounsaturated fats is a bit overstated.  I've heard of studies where they had 3 groups of people.  One got their normal saturated fat, one group replaced the saturated fat with olive oil and the third group replaced the sat-fat with corn oil.  The corn oil eaters did the worst in health outcomes, but the olive oil group wasn't great either--both groups that replaced the sat-fat did more poorly.  I've heard of other studies where lard was compared with olive oil and the lard-eaters turned out better.  Bottom line, the human body seems to like saturated fat best.  (Lard is not as saturated as butter, but it is more saturated than olive oil.)  If I were in a position to make medical recommendations (I'm not), I'd tell someone like this to ixnay on the plant oils for a while and see what happens.

    It should be noted that one of the more dubious selling points of grass-finished meat is that it is lower in saturated fat.  To me, this is not a selling point.  If this person were only getting PUFAs from their grass-finished meat it would be one thing--at least then it'd be closer to a 1:1 omega-6/omega-3 ratio.  But that's not what's going on here.  If they were just eating the fish they might still be OK (depends on the fish--cold-water is better).  But they're adding in walnut oil and chicken consumption and those are going to add more omega-6, even if the chicken's pastured.

    I'm curious what this person's inflammation markers are.  If they're off the map the LDL may still be high because the body's trying to repair the inflammation.  That would explain the low HDL too; LDL takes cholesterol out to the body from the liver, and HDL returns it to the liver.  If the cholesterol is *needed* elsewhere in the body then of course it won't be returned to the liver.

    Even if inflammation markers are normal, this person's diet may not be meeting their needs for saturated fats in the cell membranes, which may mean they need more cholesterol in their cell membranes to try to make up the deficit.  Not an ideal situation.

    Get the PUFA reduced, get the inflammation down if any, see what the lipids do and then we can talk about weird genes.  Absent the necessary DNA profile we really don't know, anyway.

  • Dana

    9/8/2011 8:31:06 PM |

    "just eating the fish" = in addition to the pastured beef.  I would not drop beef in favor of fish, there's too much good nutrition a person would be giving up, but fish in addition to beef's not bad.  Chicken used to be a luxury food, you had it on Sundays if then.  Best that it's relegated to that role again.  The white meat is too dry and the dark meat's rife with PUFAs.  Other fowl are not much better.  A foray into the USDA's nutritional database is an eye-opener.

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