Yup.  "Hammers and nails"!

I am 65 years old.  I had a stent inserted in the "widow-maker" artery (80% blockage) a year ago.  I had passed out a couple of times (heart rate dangerously low - 30s).  I rode to the hospital in an ambulance.  Tests revealed short LBBB episodes; mild mitral regurgitation, mild tricuspid regurgitation. Catherization showed 3 vessel CAD. I was told that a medicated stent was absolutely necessary given the situation; regardless, I have to accept that.   A pacemaker was installed to prevent bradycardia and keeps heart rate from dropping below 60.   I have 20% L distal main blockage and 90% lesion of the high first obtuse marginal at the takeoff.  The right coronary had 60% posterior lateral branch stenosis.  

Since then I have reduced TG from 360 to 60,  LDL from 89 to 82 (although a few months ago it was in the mid-70s), and increased HDL from 30 to 46.  I went from 365lbs to 190lbs and hope to eventually get to 180lb this Spring.  I did it by progressing from walking to trotting (slow run) and dietstyle changes (low-GI veggies, fruits, etc.) .

On a recent visit the cardiologist said the the LDL needs to be 70 or below to "freeze" the 90% blockage and gave me a prescription for Lipitor.  I asked if there were alternatives, like diet, supplements, etc.  He admitted that he did not know about those alternative but did know Lipitor.   When the only tool you have is a hammer then everything is a nail.  I understand that the 90% blockage is important but will not take the Lipitor to achieve the 12 points reduction.  Seems like an overkill.  

I asked him if there was a way to evaluate my current condition.  I was told there was no way.  Basically, if I have no symptoms, good.  If I have symptoms then it will have to be evaluated.  Death could be the only symptom.   I swear he was about to say bypass surgery ($$$$$$!) was inevitable.  Something is wrong with this "fly-in-the-fog-and-hope-you-don't- hit-a-mountain" approach. Hope is not a strategy!

I am confident that I can reduce LDL to below 70 based on eliminating wheat-products in my diet plus increasing oat bran in my diet.  I also take fish oil daily (EPA/DHA-2g).  I am looking for a new cardiologist.  I just recently purchased your book and find it very instructive.  In the meantime I have an appointment with my primary care physician to discuss implementing the Track Your Plaque program.  I realize that the one stent will skew the scan numbers but can be used as a baseline number.

Anyway, onward . . .

As an ancient engineer, I often use your aphorism.
Your publicly expressed viewpoint must earn a lot of criticism from your colleagues, and undoubtedly there have been financial and other sacrifices on your part.
I would like to offer heart felt appreciation for what you do.
I assume that many colleagues share your point of view. Are there others who have the 'cojones' to speak out?  Is there any degree of cooperation?

I would like to know something of your perspective on potential solutions for cardiology in particular, and healthcare in general. In fact, on the whole "medical-pharmaceutical-insurance-government complex" (to paraphrase the warnings of Dwight Eisenhower).
I grew up under British socialized medicine, and while the delivery to the people is more even, it is not a  solution. Do you foresee some kind of compromise as workable? Should the solution be patient driven? Business driven? Govt. driven?
I recall that in the UK, doctors and the system tend to be viewed as almost god like in their authority, although a few individual Dr. rebels such as. Malcolm Kendrick come to mind.

Yes, I know. This is far too big a topic for your blog, but with the elections coming up, my curiosity just got the better of me!
Note: I promise not to ask any more difficult questions until next Feruary 29!
MikeV

I'd like to echo the comment by Mike V.  The current health care situation in the US is so "unsustainable", to borrow an agricultural phrase, yet having a good view of the UK's NHS (I have English in-laws) doesn't inspire me to wish all of that on myself or the US public, either.  My in-laws in Norway seem to have it better in many ways, but I see some dangerous aspects creeping in over there, too.  We need better options for our nations's healthcare, but I only seem to hear about how well our current system works (for some people) with all the costly high-tech procedures and diagnostics or else warmed-over versions of the UK and Canadian systems, which has some serious flaws, too.

I want healthcare that takes prevention and health promotion into account, not just "disease care" that catches disease "just in time".  I don't want "checkbook science" or "concensus science" dictating what options I have or what information is available to me.  I don't want a "nanny" nor do I want my care determined by healthcare industry lobbyists.  

There must be something better, that does a better job of balancing promotion of good health with treatment of disease, with balancing good intentions without nannyism, with balancing  access to care without over treatment.  We need a system that allows medical personnel to make the best decisions for each individual patient, with a better way of managing the associated costs and compensation for all participants.   It is very hard for physicians to "buck the trends" these days.

As an insider with an insightful view from the trenches of the healthcare industry, I'd love to read more of your thoughts on these issues in future posts, Dr. Davis (your busy schedule allowing, of course).  How can we reform healthcare without pushing the pendulum too far into another harmful direction, in a way that it beneficial to all - patients, medical personnel, medical institutions, medical research, etc?

And then, how do we make it happen?

Webmaster, I love your site. Thank you sooo much for working on it.

I recently had a discussion with a relative who got a prescription for Vitamin D.  (This after I bought her a Vitamin D test from Grassroots showing a level of 19.)  I told her the prescription was a bad idea as it was surely Vitamin D2.  She looked into it and came back and told me, no, it was D3.  I have not seen it, but I am asking now - is it really true that prescriptions are invariably D2?  She claimed it was 50k IU of D3, once a week.

Separately, I see it stated here and there that the Vitamin D added to milk is D2.  Most milk labels I see show it as D3.

A bit of information that the drug reps don't tell the physician is people need to be on a maintenance dose. I have seen so many people who were prescribed D2 for a few months. Once the vitamin D level rose to over 30, they were told they could discontinue taking the D2.

One person told me that she had started and stopped D2 three times. She said her doctor could not figure out why her vitamin D level keeps dropping when the D is stopped. At least she was retested. The other people who were told to stop taking D2, were never retested once their D hit "normal".  

I have a friend who told her doctor she would get her vitamin D as D3 OTC. She said he expressed surprise that it could be bought without a prescription.

The study you site appears to use the dry form of vitamin D3.

So is D2 a prescription medicine?

Here is an abstract providing an example of the total lack of effect of D2 in a patient.
The lack of vitamin D toxicity with megadose of daily ergocalciferol (D2) therapy:
The maximum daily dose of vitamin D currently recommended is 2000 IU. Ergocalciferol (D2) 50,000 IU orally weekly for 8-12 weeks is often used to treat vitamin D deficient patients (25(OH) vitamin D <20 ng/mL).
The lack of vitamin D toxicity after massive doses of ergocalciferol has yet to be reported in the literature.
We report a case of a 56-year-old woman who received supratherapeutic doses of ergocalciferol (150,000 IU orally daily) for 28 years without toxicity. We discuss the possible mechanisms which may account for a lack of toxicity despite intake of massive daily doses of ergocalciferol in this patient.

The sad aspect to this story is that as Vitamin D2 at that ridiculously high intake didn't do her harm, it's also probable that her body did not recognise it at all, so it probably didn't do her any good either. As there have been other accounts of people taking large (but not as huge as this case) amounts of D2 and it not having any noticeable effect on Vitamin d deficiency symptoms it seems just pointless to risk using it, when there is a cheaper, more reliable, alternative readily available.

I think it is up to the patient who is tuned in to this fine blog and several other like minded blogs who preach as you do, such  as "nephropal.blogspot.com" to bring your information to their primary doctors.  My primary doctor still takes a Staten drug even though he knows and marvels at the health gains that I have achieved through supplementation with high dose vitamin D3 and high dose omega 3fish oil, along with a cave man like diet.  I asked him why he take a Staten drug when they work by increasing his vitamin D level? I said just take vitamin D3 instead of the Staten drug.  His answer was that he only takes a little Staten drug.  When he found my wife to be vitamin D deficient, he in fact ordered a script for vitamin D2.  I insisted that she take OTC vitamin D3 and after a tussle he gave in.  

I am sorry to say that only we the patients can change the system.  I don't blame the very over worked primary care physicians who have no time to read the necessary science.  We the patients have to bring the relevant data to them.  After all it's our health that is being impacted.

Bark--

There is indeed a prescription D3.

Now, why a prescription form is necessary is beyond me. I suppose we could make prescription vitamin C, too, and charge $120 per month.

Hi, Anne-

Yes, I also see this incredible blunder occuring around me.

I'm not sure what they're thinking.

Vitamin D3 1000 IU 240 tablets per bottle x 2 bottles purchased from Costco is dirt cheap.  $5.20 Cdn.  Very cheap $ U.S. dollars.

I take 3,000 to 5,000 IU daily and associate it with stopping hot flashes.

Inadvertently 'experiments' by running out of D3 for several weeks at a time resulted in really terrific hot flashes. Nothing is quite as unpleasant as having a hot flash as soon as I wake up, for example. Clearly I have not done double blind studies.  I am (sort of) menopausal.  No periods from September 2008 to June 2009.  Now, back.

No vitamin D3 intake during summer of 2008:  terrible terrible hot flahses. Then started taking D3 3000 IU in August 2008. Ran out of D3 sometime in Januray.  Hot flashes started up sometime later.  However, no hot flashes since end of March 2009.  No hot flashes from September to January.  Stopped taking D3 because too lazy to go to Costco to buy more.  Then started taking D3 and then stopped with the hot flashes and have not had another one in months even though obviously the hormones are fluctuating.

I used to think that HRT would stop hot flashes.  HRT does nothing for the hot flashes.  Vitamin D3 appears to work much more effectively.  

Dr. G. Kadar
Toronto, Canada

Dr. Kadar--

Fascinating observation!

Any other ladies who've made similar observations? Or perhaps taken vitamin D yet continued to experience hot flashes?

Tony ~ D2 can be bought as an OTC too.

Dr. Kader ~ I have a co-worker who says her hot flashes disappear when she takes vitamin D.
Anne

I wonder if there is any research on your view that the tablets don't work, only the gelcaps, for raising vitamin D levles.  It seems like it would be very easy to show whether or not this is true, and very important since lots of people take the tablets.

Hi, Peter-

To my knowledge, there is no research on this topic. However, having tested vitamin D blood levels thousands of times, I can say with confidence that the tablets are inconsistently absorbed--sometimes they work, often they don't, or they increase blood levels less effectively. Levels also vary widely, due to inconsistent absorption.

Gelcaps--i.e.,oil-based--are absorbed consistently.

What are some good brands of OTC D3?  I see the Costco mentioned, but has it been independently tested?  I know the Costco brand fish oil is supposedly decent, so it would make since that the D3 is as well.

I usually order online (vitacost.com) and I like the NSI brands.  Are they good?

Dr. Kadar

Thanks for sharing about your success with vitamin D3 bringing relief for your hot flashes.  I have a daughter who was suffering with hot flashes and refused to take the dangerous medically recommended hormones to alleviate the problem.  Instead she started to take black cohosh. when I pulled a negative study from Pub Med she stopped. She continued to suffer and not in silence.  In the meantime, understanding the health benefits, I convinced her to start taking 6000 IU of vitamin D3 soft gels.  It never dawned on me that this could be so positive relative to hot flashes.  This morning I asked her how come I don't hear any hot flash complaints and she answered that she hasn't had an episode in a very very long time.  It seems likely that we now can put a face on the reason why.  Yet another use for the miracle health supporting hormone vitamin D3.  

It truly is a fascinating observation,as Dr. Davis remarked.  Thanks for solving this mystery.

It's just a guess, but the inconsistent absorption of dry  D3 sounds like it's due to fats (or lack of fats) consumed when dosing. So if patients take it with fish oil, or right after a fatty meal, it may work.

But I see no reason to stay on dry anyway as gels are very cheap. There are also liquid drops (usually with a fat carrier) for those who dislike pills.

I'm just waiting for a company to put out a D3/K2 gel next. They seem like logical partners.

I have a blogsite where I am tracking successes regarding the usage of vitamin D.  Will you tell your success story?  I am an advocate and educator for using Vitamin D3.  I personally take 6000-8000 to keep my levels of D3 at the appropriate level.  

I will never stop!  It manages the SAD disorder that I had without knowing for over 25 years.  It has changed my life.  My sense of wellbeing has increased to 100%.  Before, it was always a struggle to shake off the feeling that something always felt off, or wrong. It never felt like depression, and my outlook has always been upbeat.  But I still carried around, what I only know how to discribe as almost a sadness, or a feeling that something was wrong but I couldn't put my finger on it.  After taking the Vitamin D3, it just disappeared.  So, now I am an advocate, and believe firmly that this information must be disemminated out into the communities.  

If you have a story to tell I would appreciate it if you would add it to my blog site:

http://dactionhealth.ning.com/

Best~Diana~

There are also D3 available in liquid form.  It is great for those who can't swallow pills.  I believe it is through Biotics Research.  It is 2000U a drop.  I put 3 to 4 on my finger, and it is done. Nice to have the option and works better for children.

I recently discovered while shopping for my D3 that there is also a D3 version made from sheep lanolin.  Is this as effective as the D3 from fish oil?  Is there any reason why one would be preferred over the other?  I go for the fish oil source because I just don't know anything about the other.

I've been taking anywhere from 4,000 iu to 10,000 iu per day since February 2009 when my test revealed a level of 27 ng/dl. Last month I asked my dr for another test and he said they normally don't test again, which I just don't understand!(kaiser insurance). I still have my hot flashes but now that I think about it they are few and far between and less intense.
Nancy

Probably taking vitamin D3 tablets with a meal containing fat helps with absorption.

I've got patients using the drops.  They butter their toast and add the relevent number of drops of D3 1000 IU per drop to their buttered toast. (I recommend 100% rye sourdough bread for those patients who must eat their bread.)

I am now asking female patients experiencing intrusive hot flashes to take vitamin D3.  I'll wait for feedback from them.  Also for perimenopausal mood fluctuations.

Looked at another way:  D3 is a hormone replacement therapy.  

I do also tell patients about vitamin K2 and how it is also necessary for bone metabolism.  If they take therapeutic doses of
vitamin D3, then they also must eat eggs (and cheese, liver, etc.)  But minimally, they must eat egg yolks.  In Canada, K2 is not available in any serious way as a supplement.  

Dr. G. Kadar
Toronto, Canada

I would love to take my D3 in gelcap form, but have thus far been unable to find any here in Canada.  I sometimes take the liquid, but get hung up on what constitutes 'a drop,'  so usually settle for tablets along with fish or krill oil.  Anyone know of a Canadian source for gelcaps?

Dr. William Davis said...

"I can say with confidence that the tablets are inconsistently absorbed--sometimes they work, often they don't, or they increase blood levels less effectively. Levels also vary widely, due to inconsistent absorption.

Gelcaps--i.e.,oil-based--are absorbed consistently."


I cannot say anything about hot flashes since I'm a man (but can and will tell these interesting observations to PMP women I know), yet I have something to say about tablet versus powder versus gelcaps issue that may be of interest.

I have moderate level Crohn's disease and got great help from D3 supplements for over 7 months now. I started with gelcaps (dosage 25-75 µg/d), then abruptly moved into powder form (Vit D Max, dosage 125 µg/d) and observed GREAT improvement in a couple of weeks. Even my BP dropped so much - from 145/95 to 115/75 and I even got dizzy during daytime. (I also took some melatonin to be fair).

Then - after about 4 months - I changed back to gelcap form and kept the dosage and experienced somewhat more symptoms - if only for a while.

Is it possible that powder form may work more quickly, or did my powder D3 contain more D3 than mentioned? I honestly don't know.

I wrote for Dr B G about my Crohn improvement a while ago but she seems to be on holiday as we're speaking?

- Neo

I buy small easy to dissolve capsules of D3 (dry powder, not oil) made by Bio-Tech from Dr. Eades' Protein Power site (no affliation other than as a reader).  The cost for the dose is very, very good ($8 for 100 capsules) and the bottles are small.  I was able to buy 11 bottles for the same shipping price as 1 bottle, so I stocked up and shared with family members (my experience is that middle aged adults need at least 5000iu per day year round to keep 25 (OH)D levels above 50 ng/mL).  I test at least twice a year, so I know that the D3 is absorbing.  

I also usually take the D3 around the same time I am consuming some fat, which probably helps with absorption.  Other family members take Carlson's oil capsules with good results.  We avoid hard tablets.

Bio-tech also makes a non-prescription D3 in a 50,000iU dose, 12 capsules for about $18 (plus shipping), which is a very competitive price compared to high dose Rx D2.

Hi
Really a nice blog!
Needs stuff to to!

Readers who are using Vitamin D3 for cancer prevention may be interested in this new paper from Vieth
How to Optimize Vitamin D Supplementation
to Prevent Cancer, Based on Cellular
Adaptation and Hydroxylase Enzymology
The hypothesis seeks to answer some of the Dilemmas that challenge the vitamin D/Cancer hypothesis regarding prostate/pancreatic cancers.
1)How can the vitamin D hypothesis explain the U-shaped risk curve for prostate cancer when the data suggest that the average 25(OH)D
concentrations in countries with relatively high rates of prostate cancer are apparently the optimal concentrations for preventing prostate
cancer?
2 What plausible mechanism, other than vitamin D, could account for the association between greater lifetime sun exposure and diminished risk of prostate cancer ?
3 How can latitude and environmental ultraviolet light be associated with increased risk of prostate cancer, and pancreatic cancer, yet not be a significant contributor to the lower average 25(OH)D concentrations theorized to be the key component of the mechanism that relates latitude to cancer risk?
4 Why is summer season of diagnosis, or a higher serum 25(OH)D associated with better prognosis of prostate cancer?
5 If vitamin D is adverse for prostate cancer, then why is the rate of rise in prostate-specific antigen (PSA) slower in summer  than in other seasons and why would vitamin D supplementation slow the rate of rise in PSA ?
6 Why, in regions of the United States where environmental UVB is low, is there a positive association between pancreatic cancer versus serum 25(OH)D, while at the same time, in regions where UVB is high (presumably providing even higher serum 25(OH)D levels), is there no relationship with 25(OH)D ?
7 If 25(OH)D is antiproliferative in cell cultures of prostate cells in vitro  and pancreatic cells, then why would it contribute to the development of cancer in vivo?

Vieth suggests that as circulating 25(OH)D levels rise and fall, 1,25-dihydroxyvitamin D  concentrations  need to be adjusted and the balance between 25(OH)D-1-hydroxylase [CYP27B1](tumor surpressing) and the catabolic enzyme, 1,25(OH)2D-24-hydroxylase [CYP24](oncogene) may for a while become disrupted.

Any time there is a delay in cellular adaptation, or lag time in the fine tuning of  1,25(OH)2D  in response to fluctuating 25(OH)d concentrations there is the potential for too little of the tumor suppressor enzyme and too much of the oncogene CYP24.

Regular daily supplementation with D3 keeps levels high.
Regular 25(OH)D testing will enable you to see your levels are remaining steady.
It may be  sensible for people living further North to have a lower summer intake and higher winter amount in order to reduce the amplitude between summer highs and winter low 25(OH)D levels.

Those who go for Winter sunshine breaks may want to think about increasing D3 intakes before they fly off, reducing supplement intake while under the tropical sunshine and resuming supplementing immediately on returning home to prevent sudden changes in status and limit the extent of gains/losses.

25(OH)D levels need to be both high and stable.

The graph Dr Davis shows how D2 levels dropped steeply (indeed levels at the end of the month were  lower than before supplementing started) so the fact that D2 increases the rate at which 25(OH)D depletes making the fluctuation in level more acute, is a further reason to avoid it.

Dr. Davis,
I just got my labs back after 7 months on low-carb, high-fat diet.  Chol was 337 (my labs are here).
I was wondering if you or readers could point me to 5 or 6 links that would help educate me on this issue so I can see if I need to make any changes in the next 7 months.  Thank you for your time.

Why do doctors prescribe Vitamin D2?
They don't very often. Calcitriol (most common brand, Rocaltrol) is the most often prescribed Vitamin D around here (near Philadelphia).

Why do we need a prescription Vitamin D when OTC Vitamin D is just as good?
Two reasons:
1. Without a prescription, patients take medicine less reliably,
2. More importantly, many of my patients are poor, and OTC meds are not paid for, but prescriptions are.

I take D2 (and get as much midday sun as is safe) because of the horrible way the sheep are treated.

http://www.savethesheep.com/animals.asp

I know a nurse practitioner who practices in Phoenix, Arizona. She has done hundreds of blood draws for nutrient levels and has noted that some 99% of people were vitamin D deficient.

She went on to explain that a lot of these people were construction workers and did not even wear sunscreen. Again, this is in Phoenix where the sun shines intensely nearly every single day of the year. If those people are not getting enough D, I think it's pretty safe to say that you are at least at risk.

D2 comes from plant sources. D3 comes from animal sources, primarily animal skins. If you are vegetarian you would not want to take D3.

The primary reason the prescription form is D2 is because D2 is much safer. Too much vitamin D is worse than too little. The standard prescription dose is very high, 50,000 units. High doses like that of D3 would be extremely dangerous. Your body is much better able to regulate it's absorbtion of D2.

I would never take D3. It might take a bit higher dose of D2  to achieve the same result (studies do not agree on this) but I am never going to poison myself. I expect sereous negative health consequences in the future as a result of the marketing of D3. D3 is pretty much all you can find over the counter these days. I assume that it is more about promoting animal agriculture than human health.

It is true that the pharmaceutical industry has at times had undue sway over the medical profession.  To say that physicians are educated by "pretty representatives" is insulting and undermines the credibility of the author.  I agree that vitamin D3 is more "natural" and technically more potent.  The reason why vitamin D2 is more often prescribed is at least three-fold.
1. Vitamin D2 is available in a prescription strength that allows for a more rapid repletion of vitamin D levels.  (It is hard to find a prescription vitamin D3)  In other words, it would take longer to replete vitamin D with over-the-counter doses of vitamin D3.  So why not just take a bunch of D3 capsules?  The dosing schedule for repletion of vitamin D with D3 is not as well worked out as it is with vitamin D2.  As soon as someone does a large scale study using vitamin D3, we will all be willing to switch.  Doctors are hesitant to make up regimens where effective ones already exist (re: risk of patient harm/legal liabilities)  
2. Vitamin D2 has been prescribed for decades. We as physicians are more familiar with its effect on patients.  
3.  Finally, vitamin D3 used to be more expensive--another reason D2 was preferred over D3.  Doctors, like everyone else, are often resistant to change.
One thing is certain.  The author's assertion that physicians are not guided by science is false.  What we need is large scale clinical trial with vitamin D3.  The problem here is funding.  Who will pay for it?  Until then, the most we can say is that vitamin D3 is more "natural" and more potent.  Vitamin D2 however is effective and has not been shown to be injurious.

Dr. J--

Allow me to insult you again: It has been my experience that many of our colleagues are miserably susceptible to the smile of a pretty representative. Perhaps you are not, but I see it all the time.

I'm afraid that I believe you are way off base on the D2. I recommend that you read the existing literature. I believe that there's only one conclusion: D2 is markedly inferior. While better than nothing, why would anyone take a non-human form over a human form?

Having replaced vitamin D in approximately 2000 patients using D3, I can tell you it is safe and reliable. In the handful of patients taking D2, I've seen everything from modest increases in blood level so 25-hydroxy vitamin D to no increase at all.

Twice I have been on prescription strength Vit d2(50,000 units first for 8 weeks since my level was 30  and then rose to 66 with RxI took good quality Vit D3 in between 2000 units daily faithfully,eat a good diet (also take ERT age 65) and after serveral months^ my level again fell to 33 now have beenplaced on Vit D2 for 12 weeks, blood level 64 and will repeat test in 6 months.I am now taking 4000 units of D3. I DO NOT seem to be absorbing Vit D3 and wonder why or if I need even more daily

Why wouldn't you just obtain your Vit D through food sources? sardines, salmon, tuna, liver, egg yolk, cod liver oil, fatty fish, dairy

I HAVE to say something.  There are some valid health related reasons why some people/children have to take D2.  My daughter has to take D2 (her levels are at 33) so her DAN doc wants her D supplemented.  She also has some gastritis/EE he is hoping to heal in her tummy w it.  He wishes and we all wish she could take D3--I know its way better than D2.  BUT--she can't take D3--she is allergic to both fish and lanolin . . . so . . . therefore she has to take D2 right?  No other D3 option out there for her right--please answer if there is another option for her.  She is allergic to all the natural foods with D3 as well--egg etc.  D2 is all thats left.  I PRAY its helping her a little. We use a local company in WI called Cty Line Pharmaceuticals--the D2 is liquid, its D2 dissolved in propylene gycol with NOTHING else added.  Its a bit spicy but my daughter "Gags" it down as she  surely be allergic to anything added to flavor it.

There is no such nutritional supplement representative in the waiting room. This preference for the "drug" D2 over the supplement D3 also stems from the inherent preference of physicians for things they can control, whether or not there is proof of superiority.

I was vit D deficient at a level 12. I was told to take over the counter D3 1,000 a day for 5 mths, retest. It raised to only 23. I was told to take Vit D 3 at 2,000 a day for another 4 mths and the result was I went back down to 18. Finally took the presciption D2 at 50,000 a wk and I am mid normal. My 2 daughters were recently diagnosed with D deficiency as well. I walk a dog daily yet my 85 yr old mother who does not really see the sun and when does wears sunscreen takes no Vit D and is not deficient. Go figure.

P.S. Yes Vit D did reduce hot flashes as well.

In 1972, one year after starting my Medical Education {Psychology}, I attended the yearly "National Health Federation" {Monrovia, California} Convention. I was already prescribing High Doses of Vitamin D, and I attended a lecture by a  Physician who was already known as THE EXPERT in Vitamin D research!! To this day, I don't remember his Name. The Subject of this particular presentation,  was that Vitamin D2 was toxic to the Kidneys & caused Kidney Damage; Primarily Kidney Stones! His Research was solid and alarming! I bought the 90-minute Tape of his entire Presentation, but misplaced it approximately 5 years later. His presentation  was a Classic, and I'd pay $50.00 to $100.00 for a copy of the Tape today! If anyone has this tape, PLEASE contact me!!
Meanwhile, NEVER take any amount of Vitamin D2. He proved that Vitamin D3 was safe, and that Vitamin D2 should never be ingested!

I find this very interesting because on the one hand they are giving up control over what their advertisement says, but on the other hand the ads that people come up with are probably even more relevant to the readers.

Very good blog, support, only the future health!

Great Article.  As I'm sure you know by now, I've been kind of a lipidpanelaholic since having a MI 2 yrs ago.  The hardest information to find is that of how long it takes for lipids to respond to diet changes and how sensitive they can be to even the smallest amount of carbs.

Are you sure that sort of response is not due to gluten/gliadin/lectin/transfat? Four crackers doesn't sound to me like much of a carb load, but for a gluten-sensitive person like me, that could set off some inflammation.

Dr. Davis,
How does alcohol fit in to the above "equation"? Specifically wine.

Marc

I have been on a wheat-free and carb restricted diet for about 7 weeks, and being concerned that I might be Apo E4, and therefor need to also limit saturate fat as you explained in an earlier blog, I asked my doctor to order a small LDL test.  No independent lab here that I consulted knew what that was, nor obviously did my doctor, since he just ordered "small LDL".  The local hospital lab finally found the following, which is what I will have blood drawn for tomorrow:
Lipoprotein Fractionation Panel 1, Ion Mobility
Which includes:
Choesterol; HDL Cholesterol; Triglicerides; :Lipoprotein (a); Lipoprotein Fractionation Panel 2, Ion Mobility (LDL, Total; LDL, Medium and Small; LDL, VerySmall; HDL, Large; LDL Peak Diameter, LDL Phenotype)

I hope that this is what I need.  Probably it is overkill, but in this case apparently my Medicare Advantage plan will cover it since it has been more than 3 months, since I had a simple panel done.

Is there a simpler test for small LDL?  By the way the CPT codes are 80061, 83695, 83704

Sounds like cheat days may not be that good of an idea...

Yes, it does cast cheat days in a new light!

That's it, Sam.

It shouldn't be that hard. The information is actually fairly straightforward and provides crucial information.

Hi, Marc--

Alcohol does indeed slow or stop weight loss, especially if more than a serving or two are consumed. So it pays to minimize during a weight loss effort.

Probably not, Howard, since those components have not been associated with triggering of small LDL. The trans fat component can indeed trigger small LDL, but it seems to occur even with foods minus trans fats.

However, I am impressed that gluten/gliadin/lectin rolled off your tongue!

The problem is carb creep. I experienced this a few months ago when I received the results of my HbA1c test. I was still in the prediabetic range and it was higher than the HbA1c test I had a few years earlier. I didn't get it? I thought I was consuming less carbs then I was. When I actually looked at my diet there were carbs creeping in: dark chocolate and small "safe starches" (e.g, potatoes, yams). Another factor that may have impacted my blood sugar was the stress of travel/visiting family during that three month time period. My understanding is that elevated cortisol levels can raise blood sugar. In any case, my recent HbA1c is in normal range. I think this is because I eliminated even small amounts of dark chocolate and "safe starches" (see Jimmy Moore's comments about safe starches).

How low should we go in carbohydrates to avoid increasing small LDL?

I'm not sure that wheat has this acute effect on everybody. In fact, I know it doesn't happen with me. I keep a close eye on my lipids and my small LDL particles remain "relatively" low despite the fact that I consume wheat/sugar products. Then again,  my blood sugar does not significantly rise after carbohydrates, so maybe that's why. If I eat a massive plate of pasta, a glass of fruit juice, and dessert, my blood sugar may (keyword, "may") rise to 120, if that, but then it goes down to about 80 about 45 minutes after the meal. No joke. In other words, I'm thinking this effect may have to do with the degree of people's volatility to rising blood sugars. Just a guess.

Fyi, I'm the apo E/4 person who's LDL amount/particle number (226, 2,000) is extremely sensitive to saturated fats and thus I'm always lost in the conundrum of balancing fats with carbs. Difficult!

I know that if weight loss is involved, it can take a few months after weight stabilizes for lipids to normalize.  If minimal or no weight loss is involved, how long does it take?

With the example about 4 crackers would be as low as 10g carbs.  Curious of the overall effects of say 10g carbs of sweet potatoes....

Then it depends on which parameter you are talking about, Teresa.

Small LDL requires just days to respond, while triglycerides require weeks to months, while HDL requires months to years.

Hi, Davide--

No doubt: Individual tolerances to various foods, including carbohydrates, can differ. And the apo E4 person has a tougher time of it.

Unfortunately, Jethro, there's no quick and easy way to decide this, since individual sensitivity varies.

Although imperfect, you can use HbA1c, an index of glucose and not of small LDL, to gauge whether you've been triggering higher blood sugars that often parallel the triggering of small LDL particles. You could, of course, obtain lipoprotein testing 48 hours after ingesting a known amount of carbohydrates, e.g., 20 grams, but that is logistically difficult.

That all said, most people can get away with 15 grams carbohydrates per meal, while some can't tolerate more than 10, yet others do fine with 30+ grams.

Excellent point, STG! And I like the "carb creep"!

Did you see this, Dr. Davis?

http://medicalxpress.com/news/2011-10-common-link-autism-diabetes.html

And it takes years to unlearn all the inaccurate stuff learned in school, and to find and learn the good stuff that is out there.  Thanks.

How does one check to see if they are apo E4?

How does it affect lipid results?

Dr Davis:  What is the small LDL profile for native populations that consume tons of of carbs and no signs of heart disease; also, the Japanese consume lots of carbs- easily 3 cups of rice per day which is about 120 carbs from rice alone.  Low level of CAD; what are their levels of small LDL.  I know for myself ApoE 3/3 that carbs do affect the small LDL level i have and in any event in the absence of a statin i produce tons of LDL particles large or small depending upon carb levels.  I believe genetics plays a large role.
Thanks

No doubt, Steve.

However, I'm unaware of lipoprotein assessment done to answer these questions. That would be interesting, however.

Easy, Stephanie: Have an Apo E test run.

Yes, agreed, Teresa: New lessons to learn every day in this Information Age!

Thanks, Barbara. No, I hadn't seen this. But I'm not the least bit surprised!

I find it wonderfully satisfying that the puzzle pieces are falling in place, just like that 1000-piece jigsaw puzzle we struggled to put together, with the last few pieces fit just perfectly!

Dr. Davis,
Have you heard or read about Lumbrokinase helping to lower small "a" particles?
Just wondering.
Dee

Dr. Davis,

There seems to be a lot of mention of the E4 ApoE genotype.  What about those of us that are E2/E4?  Any different instructions for us?

Thanks.

With this very tough pattern, you are best following lipoproteins and glucose measures like HbA1c to gauge response to various dietary manipulations. The basic diet approach, however, is largely the same; it just may require some adjustments, e.g., fat intake.

Sorry, Dee, no info.

Where did you hear this?

Here is the quote.  Appently it just helps lower the LP[a]  and does not have any terrrble side effects.  I may try it, nothing else is working.  My little a is 43 and rising in spite of all I do.

"The one nutraceutical that has shown promising clinical results in actually lowering Lp(a) is a lumbrokinase product made by Canada RNA Biochemical called Boluoke. Like its chemical cousin nattokinase, lumbrokinase is an enzyme that helps break up fibrin—a fibrous protein that helps form blood clots—to avoid too much clotting and keep blood flowing optimally."

:

Dee

I have my results.  My PCP reported these to me "for my records" with no further comment.  Maybe he can't interpret them?
Total Cholesterol: 231 (My PCP surely would think this is high.)
I find it strange that they did not report LDL direct, though perhaps it is not done because of the breakdown below.  
Calculated LDL: 133 H MG/DL
HDL: 85 Mg/dl  This is higher than I have ever had measured.
Triglycerides: 64 Mg/Dl  Even Simvastatin only got it down to 84.  I conclude that I am not Apo E4.
The range after \ below  is the range they cite, I presume, as normal.
Lipoprotein : <10  NMOL/L \ <75  I presume this is a good result.
LDL, Total: 2268 H NMOL/L  \ 440-1600
LDL, medium and small: 651 NMOL/L \ 144-787
LDL, Very Small: 277 NMOL/L \ 75-419
HDL large: 9315 H NMOL/L  \ 469-5258
LDL Peak Diameter: 227.5 Angstrom  \216.-234.3
LDL Phenotype A  Pattern A     I believe this to be the preferred pattern, low small LD and Triglycerides.  Ref: Obesity (2009) 17 9, 1768–1775. doi:10.1038/oby.2009.146--Reversal of Small, Dense LDL Subclass Phenotype by Normalization of Adiposity
Patty W. Siri-Tarino1, Paul T. Williams2, Harriet S. Fernstrom1, Robin S. Rawlings1 and Ronald M. Krauss1

Does this calculate to large LDL = 2268-651 =1617 (Not including medium)?
When should I do this test again?
Comment?

Hi, Sam--

The "pattern A" comment is misleading. About 40% of your LDL particles are small, too much.

It means going back to the strategies to reduce small LDL, such as wheat elimination and limiting carbohydrate exposure. It is worth repeating about 2 months after weight has stabilized following a diet change.

I have been on a no-wheat, limited, very-low carb, diet now for 6 to 7 weeks already.  I cringe to think of what the numbers may have been before.  I initially lost about 12 pounds in less than 2 weeks to get to 148, I am 72-in tall, and have stabalized there by eating more high-fat non-carb stuff.  You say 40% small.  You must be using the medium and small (640) over total (2268) to get 40%.  Apparently medium and small includes the very small, which must be a fraction of small?  How long should it take for the very small to approach zero?  Isn't that the more important number?  I will be out of the country for 2 weeks.

Thanks

Yes, exactly, Sam: Combine medium and small.

Dietary and weight changes usually exert effects on small LDL within a few weeks, much faster than most other parameters.

Get a VAP test....this measures your small particle/large particle LDL.
labcorp code 804500

I am going to try to get a VAP test.  No doctors know of it....only folks on the web.  Why?  It seems like a very important test to measure your LDL properly.  Can someone elaborate on this further?

Easy, Pb: There are no drugs--read: "no financial incentive"--to treat the abnormalities generally uncovered by lipoprotein testing like VAP. Thus, no push to get it tested.