High HbA1c: You're getting older . . . faster

Over the years, we all accumulate Advanced Glycation End-products, or AGEs.

AGEs are part of aging; they are part of human disease. AGEs are the result of modification of proteins by glucose. AGEs form the basis for many disease conditions.

Accumulated AGEs have been associated with aging, dementia, cataracts, osteoporosis, deafness, cancer, and atherosclerosis. Most of the complications of diabetes have been attributable to AGEs.

There's one readily available method to assess your recent AGE status: HbA1c.

Hemoglobin is the oxygen-carrying protein of red blood cells. Like other proteins, hemoglobin becomes glycated in the presence of glucose. Hemoglobin glycation increases linearly with glucose: The higher the serum or tissue glucose level, the more glycation of hemoglobin develops. Glycated hemoglobin is available as the common test, HbA1c.

Ideal HbA1c is 4.5% or less, i.e., 4.5% of hemoglobin molecules are glycated. Diabetics typically have HbA1c 7.0% or greater, not uncommonly greater than 10%.

In other words, repetitive and sustained high blood glucose leads to greater hemoglobin glycation, higher HbA1c, and indicates greater glycation of proteins in nerve cells, the lens of your eye, proteins lining arteries, and apoprotein B in LDL cholesterol particles.

If AGEs accumulate as a sign of aging, and high blood sugars lead to greater degrees of glycation, it only follows that higher HbA1c marks a tendency for accelerated aging and disease.

Indeed, that is what plays out in real life. People with diabetes, for instance, have kidney failure, heart disease, stroke, cataracts, etc. at a much higher rate than people without diabetes. People with pre-diabetes likewise.

The higher your HbA1c, the greater the degree of glycation of other proteins beyond hemoglobin, the faster you are aging and subject to all the phenomena that accompany aging. So that blood glucose of 175 mg/dl you experience after oatmeal is not a good idea. 

The lesson: Keep HbA1c really low. First, slash carbohydrates, the only foods that substantially increase blood glucose. Second, maintain ideal weight, since normal insulin responsiveness requires normal body weight. Third, stay physically active, since exercise and physical activity exerts a powerful glucose-reducing effect. Fourth, consider use of glucose-reducing supplements, an issue for another day.

While HbA1c cannot indicate cumulative AGE status, it can reflect your recent (preceding 60 to 90 days) exposure to this age-accelerating thing called glucose.

If your doctor refuses to accommodate your request for a HbA1c test, you can perform your own fingerstick test.

Comments (16) -

  • Dexter

    3/28/2010 3:08:24 AM |

    http://www.diabetesdaily.com/edelman/2010/03/interview-dr-bernstein-on-low-carb-diets-treatments-politics.php

    Dr Richard K. Berstein was interviewed on Mar 23 and was an eye opening regarding A1C and the incompetence of the mainstream medical community dealing with diabetics.  Author of many books for diabetics.

    http://www.amazon.com/gp/entity/Richard-K.-Bernstein/B001IOBDVW?ie=UTF8&ref_=s9_simh_gw_p14_al1

    Acceptable blood glucose levels of 250 and A1C levels of 7?  And not being accepted into diabetes clinics with A1C level less than 6.5  Criminal.

  • Denny Barnes

    3/28/2010 5:44:42 AM |

    HbA1c is a measurement of early glycation products which correlates with serum AGE levels, but is not a measure of advanced glycation end-products. For example, one Japanese study of cognitive decline in diabetes found, "Serum AGE levels were significantly associated with the impairment of complex psychomotor skills independent of HbA1c."

    You have written on the benefits of coffee.  While I share your love of coffee and believe coffee does not affect HbA1c, it clearly is one of the worst sources of AGEs.

  • Anonymous

    3/28/2010 1:12:09 PM |

    Use a BG meter to check effect of meals/foods on BG peaks, as described in this thread:
    http://www.imminst.org/forum/index.php?s=&showtopic=36724&view=findpost&p=373966

  • Anonymous

    3/28/2010 1:32:08 PM |

    btw, the case of high A1C with normal fasting BG is often due to high rates of gluconeogenesis (glucose from protein) that keeps BGs high between meals, but drops by morning as all remaining protein gets digested overnight.  A high rate of gluconeogenesis is often characteristic of insulin resistance, and is what forces many to eventually need the help of drugs to control BGs (i.e., reducing carb intake may not be enough to keep BGs low, and you're stuck consuming a certain amount of protein).

  • Carl M.

    3/28/2010 1:41:08 PM |

    Question: does this test measure just proteins reacted with glucose or also those reacted with fructose? I recall hearing somewhere that fructose was seven times as reactive.

  • Dr. William Davis

    3/28/2010 2:18:52 PM |

    Exactly right, Denny.

    HbA1c can only provide an indirect indicator, and only a short-term one at that. However, it's better than no indicator at all.

  • DrStrange

    3/28/2010 4:35:55 PM |

    " the case of high A1C with normal fasting BG is often due to high rates of gluconeogenesis (glucose from protein) that keeps BGs high between meals, but drops by morning as all remaining protein gets digested overnight."

    Also, can result from too frequent eating.  By adding a couple light, between meal snacks to my 3 meals per day I jumped my A1c from 5.1 to 6 in a few months.  Won't do that again!

  • Anonymous

    3/28/2010 9:11:18 PM |

    Dr. Davis,

    Have you ever looked into the potential for substances like taurine, benfotiamine, pyridoxamine, carnosine?  I've seen passing mention of these as potential glycation inhibitors.

    I've also seen sources that suggest that R-ALA and ALCAR can be of possible help in reducing glycation damage.

    While the comment in your post seems to point a bit more to the latter, I realize that you mentioned that glucose-reducing supplements are a topic for another day. But perhaps this can add to the mix for a possible future post on those topics.

    Doug Rafferty

  • Anonymous

    3/29/2010 12:59:45 AM |

    I've now gone back and read all the recent blog posts about BGs made by Dr. Davis, and would like to point out several issues:

    - first, it's great to see someone finally pushing BG measurements for non-diabetics; however, there's a lot to know about this, and I encourage others to read the imminst thread referred to in comment #3 above

    - for low-carb dieters with insulin resistance, their average BG (and A1C) will usually be dominated by glucose produced from protein digestion (i.e., it's not just about carb intake)

    - the most accurate and precise meter I've seen is AccuChek Aviva, where precision is mainly determined by strip quality, and crummy strips will cost you a lot more money and blood, since you'll need to make a lot of extra measurements (i.e., with crummy strips you may have to average 3 results to get an accurate number)

    - disease risk rises exponentially with BG levels, which is why peaks matter most

    - the time to your peak BG after meals depends on so many factors that you'll have to determine that yourself (i.e., don't assume 1 hour; mine is 30-60 minutes for most meals)

    - exercise after meals can reduce your BGs to fasting levels, but they will soon rise again due to continued protein digestion (or even low-glycemic carb digestion); so the benefit of regular exercise is mainly in a general lowering of insulin resistance, and greater glucose uptake by muscle mass when at rest

  • stcrim

    3/29/2010 1:09:07 AM |

    Cinnamon - a simple recipe with a double punch.  Take a couple of cups of almonds and wet them.  Shake them in a bag with a couple of teaspoons of Ceylon Cinnamon.  Make sure you use Ceylon for best Blood Sugar results.

    Preheat your oven to 350.  Spread the almonds on a cookie sheet.  Pop them in the oven and turn it off.  20 to 30 minutes later the Cinnamon will be dried to the almonds - let cool and enjoy.

    What was it they were eating in the 20s and 30s to cause heart disease?  My grandfather died in 1934 of quote, acute indigestion.

  • Anonymous

    3/29/2010 1:43:44 AM |

    With respect to weight loss and BG measurements, some of you may find my story encouraging:

    - starting at 205 lbs, I lost about 20 pounds basing decisions mainly on carb counts and low glycemic index

    - after getting a meter and eliminating foods causing high-post meal BGs (such as oatmeal!), I dropped another 10 pounds

    - after fixing a testosterone deficiency (andropause), I dropped another 10 pounds

    which puts me at about 165 and BMI near 22.  (All that was done over the course of about 5 years, but it took me that long to figure out this stuff!)

  • stcrim

    3/29/2010 1:43:44 AM |

    Oops! I forgot to mention I use a little Stevia with the Ceylon Cinnamon and almonds.  It also works great with walnuts.

    Steve

  • Anonymous

    3/29/2010 2:33:34 PM |

    To my above list, I'd like to add a few points about "grazing":

    - from the plots in the blog, it appears that evidence of "stacking" comes mainly from excessive fructose consumption; my own experience with a TG meter does not show stacking of TGs when grazing on fat-rich mini-meals

    - it's irrelevant whether grazing is "self-indulgent"; diet needn't be torture, and you're unlikely to stick with something you don't enjoy doing

    - it's also irrelevant whether grazing is "unnatural", since the optimal diet (to reach, for example, age 100) is unlikely to be one followed by people who rarely lived beyond age 50; to reach extraordinary ages, you'll likely need to do extraordinary things (niacin? fish oil capsules? D3 capsules? etc.)

    - peaks matter, and fewer meals means larger peaks (as well as increased acid reflux, esp. bad when large meals are consumed late in day)

    imho, i don't think the data currently exists to prove the case one way or the other, and suspect that the optimal solution will turn out to be very person-specific

  • Anonymous

    3/29/2010 6:50:12 PM |

    More thoughts on "stacking": If one spread one's consumption across 24 hours, then food would be being burned at exactly the same rate as it was being consumed, and no significant stacking would occur. Thus stacking results from compressing consumption into smaller time frames. In fact, the ultimate "stack" is formed by consuming a single meal per day (i.e., all the TG and BG is forced to pile up over a very short time frame).

    The caveat to this is that it may be the case that larger TG and BG peaks create more efficient processing (i.e., ice cream is somehow better handled after a big meal than when consumed in isolation), or that the benifits from lows between meals outweigh all the highs during meals. But I remain skeptical that such stress (high peaks, high insulin, etc.) is ultimately a good thing (esp. since I've already taken the trouble to control acid reflux by spreading intake across the day).

    But wouldn't be surprised either way. There's already a camp that believes that BG spikes are necessary for optimum bone formation, etc., so who knows?

  • Anonymous

    3/30/2010 9:38:06 PM |

    I've found every article in this blog really interesting and helpful and everything seems to make a lot of sense.
    But I still fail to see how it fits for people that don't want/need to loose weight.
    Say a 190pound healthy athlete with a very active live.
    How do you feed him without gazing, only two meals per day, 50g carbohidrates per day and 40g of fat per meal?
    How would you feed Michael Phelps?

  • Anonymous

    3/31/2010 3:55:27 PM |

    Dr. Davis,

    In this latest post, you said "Fourth, consider use of glucose-reducing supplements, an issue for another day."

    I would very much like to read your thoughts on these supplements and would look forward to a blog post on this topic.

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Are you more like a dog or a rabbit?

Are you more like a dog or a rabbit?

Dr. William Roberts, editor of the American Journal of Cardiology and cardiovascular pathologist, is a perennial source of clever ideas on heart disease.
In a recent editorial, Dr. Roberts comments:








"Because humans get atherosclerosis, and atherosclerosis is a disease only of herbivorers, humans also must be herbivores. Most humans, of course, eat flesh, but that act does not make us carnivores. Carnivores and herbivores have different characteristics. (1) The teeth of carnivores are sharp; those of herbivores, flat (humans have some sharp teeth but most are flat for grinding the fruits, vegetables, and grains we are built to eat). (2) The intestinal tract of carnivores is short (about 3 times body length); that of herbivores, long (about 12 times body length). (Since I am 6 feet tall my intestinal tract should be about 60 feet long. As a consequence, if I eat bovine muscle [steak], it could take 5 days to course through those 20 yards.) (3) Body cooling for carnivores is done by panting because they have no ability to seat; although herbivores also can pant, they cool their bodies mainly by sweating. (4) Drinking fluids is by lapping them for the carnivore; it is by sipping them for the herbivore. (5) Vitamin C is made by the carnivore's own body; herbivores obtain their ascorbic acid only from their diet. Thus, although most human beings think we are carnivores or at least conduct their lives as if we were, basically humans are herbivores. If we could decrease our flesh intake to as few as 5 to 7 meals a week our health would improve substantially."



You can always count on Dr. Bill Roberts to come up with some clever observations.

I think he's right. Some of the most unhealthy people I've known have been serious meat eaters. Most of the vegetarians have been among the healthiest. (I say most because if a vegetarian still indulges in plenty of junk foods like chips, crackers, breakfast cereals, breads, etc., then they can be every bit as unhealthy as a meat eater.)

Should you become a vegetarian to gain control over coronary plaque and other aspects of health? I don't believe you have to. However, modern livestock raising practices have substantially modified the composition of meats. A steak in 2006, for instance, is not the same thing as a steak in 1896. The saturated and monounsaturated fat content are different, the pattern of fat "marbling" is different, the lean protein content is different. Meat is less healthy today than 100 years ago.

Take a lesson from Dr. Roberts' tongue-in-cheek but nonetheless provocative thoughts. Pardon me while I chew on some carrots.

Comments (11) -

  • Jeff

    12/20/2006 4:48:00 AM |

    Fascinating and funny. Thanks for the post. I'm glad I found your blog

    Jeff Brailey
    http://wordworks2001.blogspot.com

    Check my blog and find out why I refused to have a quintuple coronary artery bypass in the spring of 2004 and am alive to tell about it almost three years later.

  • Regina Wilshire

    12/20/2006 8:52:00 PM |

    Dr. William Roberts, editor of the American Journal of Cardiology and cardiovascular pathologist, is a perennial source of clever ideas on heart disease.


    He's also on the advisory board of the Physicians Committee for Responsible Medicine (PCRM) - an organization with a very clear agenda.

  • Anonymous

    12/21/2006 11:06:00 PM |

    (2) The intestinal tract of carnivores is short (about 3 times body length); that of herbivores, long (about 12 times body length). (Since I am 6 feet tall my intestinal tract should be about 60 feet long. As a consequence, if I eat bovine muscle [steak], it could take 5 days to course through those 20 yards.)

    I can't believe a physician thinks the human intestine is "about 60 feet long". At most, it's about 25 feet long.

  • Terri

    12/22/2006 3:00:00 PM |

    Provocative thoughts, yes....

    By way of full disclosure, the leadership and advisory board of the Physicians Committee for Responsible Medicine (PCRM) includes:

    PCRM Board of Directors: Neal D. Barnard, M.D., President; Roger Galvin, Esq., Secretary; Andrew Nicholson, M.D., Director.

    PCRM’s advisory board includes 11 health care professionals from a broad range of specialties:

    T. Colin Campbell, Ph.D. Cornell University
    Caldwell B. Esselstyn, Jr., M.D. The Cleveland Clinic
    Suzanne Havala Hobbs, Dr.PH., M.S., R.D. The Vegetarian Resource Group
    Henry J. Heimlich, M.D., Sc.D. The Heimlich Institute
    Lawrence Kushi, Sc.D. Division of Research, Kaiser Permanente
    Virginia Messina, M.P.H., R.D. Nutrition Matters, Inc.
    John McDougall, M.D. McDougall Program, St. Helena Hospital
    Milton Mills, M.D. Gilead Medical Group
    Myriam Parham, R.D., L.D., C.D.E. East Pasco Medical Center
    William Roberts, M.D. Baylor Cardiovascular Institute
    Andrew Weil, M.D. University of Arizona

    Clearly, as a comment mentioned, they have a viewpoint or agenda, however that doesn't mean they are wrong, anymore than carnivore-type programs may be right for everyone.

    In my opinion, there's plenty of room for 'novel' thoughts in the field of preventive cardiology and I appreciate Dr. Davis bringing them forward.

    And most clearly of all, there's plenty wrong with the conventional "standard American diet" no matter which end of the dietary spectrum one embraces.

    Whatever WORKS to help with plaque reversal!

  • petite américaine

    12/31/2006 3:08:00 AM |

    "However, modern livestock raising practices have substantially modified the composition of meats."

    Is patient education difficult on such subject matter?  Curious; had to ask.

  • Sue

    1/5/2007 1:38:00 AM |

    And how about the flesh of grass fed beef and wild game?  Is that good, better, more acceptable but still bad?  How about the folks who believe anthropologically we were meant to to eat a hunters and gatherers diet?

  • d.rosart

    11/15/2007 5:42:00 PM |

    Polar bears have the longest intestine of all the bears. I'm like a polar bear.

  • Anonymous

    6/22/2008 8:38:00 PM |

    Hi Dr. Davis,
    Your favorite internet TYP promoter checking in. : )  Thought to mention a possible opportunity - a friend of mine mentioned that he printed out and passed on a copy of your latest blog posting, the Big Squeeze, to his friend, Congressman Jim Marshall.  http://en.wikipedia.org/wiki/Jim_Marshall_%28U.S._politician%29
    Don't know if much will come of it, but being an opportunity thought to bring to your attention.  
    You might want to delete my mentioning of this.

  • Anonymous

    4/4/2009 5:53:00 AM |

    Just found your blog and am enjoying it.

    On this topic, I read such a comparison by a veterinarian who had cared for sheep, dogs and cows for 30 years.  Unfortunately I can't find it at the moment

    His take was the opposite.  

    Some things I remember were that humans, like carnivores, can swallow very large chunks of food that would kill a herbivore.

    Humans don't have 4 stomachs and don't chew cud.

    Human stereo vision is much more like all types of predators (eagles, cats, dogs, hawks, predatory fish) than almost any herbivore (eyes almost on the sides of the head)

    If you look at human hands, they look a lot like the Bonobo monkey's hands and NOT at all like a gorilla's hands.  Bonobos eat a lot of meat - insects, rodents, birds, and gorillas eat a lot of fruit and vegetables.

    That's basically what I remember.

    I'll post a link later to the fill thing if I can find it.

    Sam in Toronto

  • Anonymous

    4/5/2009 5:04:00 AM |

    Another thing I remember - the intestine length argument goes both ways - some carnivores do have long intestines.

    Something that does not go both ways - human intestines have the enzyme systems needed to degest lots of chemicals that ONLY exist in MEAT.

    As far as I know, you cannot get these from plants, or from only 1 or 2 plants in the world  

    Heme iron (not a big deal these days, but this was huge in the past, where every human, even kings, had dozens of blood-extracting parasites on the skin, in the hair and intestines)

    creatine (vegetarians can be synthesize this out of plant methionine)

    EPA/DHA (from fish oil - in ancient times, in meat - none in vegetables - there's no plant source for EPA, and only seaweed for DHA)

    B12

    also, as an efficiency measure over and above the efficiency of digesting individual amino acids, human digestion can grab large chunks of protein, many of which occur only in meat ( very, very large peptices -  but I forget what these are called - globulins or antigens)  

    Sam in Toronto (that's me, the author, not a chemical that humans can digest and that does not occur in vegetables)

  • Tuck

    7/2/2010 1:39:24 AM |

    Robert's comment is interesting, it's also grossly in error.  

    We're not rabbits or dogs, we're humans, and we're omnivores.

    The anthropological record is quite clear at this point.  We evolved large brains to hunt prey, and the fat of that prey allowed our brain to get larger, making us better hunters.  We sweat because we could outrun our herbivorous prey, using our naked skin as a superior cooing mechanism.  We have smaller teeth because we've been cooking our food for 1.5 million years, or so.

    We do seem to need some vegetable matter in our diets.  Even the Eskimos eat some.  But we do fine on a primarily animal diet.  A cow would not.

    It'd be nice if a physician was a little more familiar with the species he's treating.  A veterinarian couldn't get away with this degree of ignorance.

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Letter from the insurance company

Letter from the insurance company

Claudia got this letter from her health insurance company:

Dear Ms. ------,

Based on a recent review of your cholesterol panel of January 12, 2011, we feel that you should strongly consider speaking to your doctor about cholesterol treatment.

Reducing cholesterol values to healthy levels has been shown to reduce heart attack risk . . .


Okay. So the health insurer wants Claudia to take a cholesterol drug in the hopes that it will reduce their exposure to the costs for her future heart catheterization, angioplasty and stent, or bypass surgery. This is understandable, given the extraordinary costs of such hospital services, typically running from $40,000 for a several hour-long outpatient catheterization procedure, to as much as $200,000 for a several day long stay for coronary bypass surgery.

So what's the problem?

Here are Claudia's most recent lipid values:

LDL cholesterol 196 mg/dl
HDL 88 mg/dl
Triglycerides 37 mg/dl
Total cholesterol 291 mg/dl

By the criteria followed by her health insurer, both total and LDL cholesterol are much too high. Note, of course, that LDL cholesterol was a calculated value, not measured.

Here are Claudia's lipoproteins, drawn simultaneously with her lipids:

LDL particle number 898 nmol/L
Small LDL particle number less than 90 nmol/L (Values less than 90 are not reported by Liposcience)

LDL particle number is, by far and away, the best measure of LDL particles, an actual count of particles, rather than a guesstimate of LDL particles gauged by measuring cholesterol in the low-density fraction of lipoproteins (i.e., LDL cholesterol). It is also measured and is highly reproducible.

To convert LDL particle number in nmol/L to an LDL cholesterol-like value in mg/dl, divide by ten (or just drop the last digit).

Claudia's measured LDL is therefore 89 mg/dl--54% lower than the crude calculated LDL suggests.

This is because virtually all of Claudia's LDL particles are large, with little or no small. This situation throws off the crude assumptions built into the LDL calculation, making it appear that she has very high LDL cholesterol.

Do you think that Big Pharma advertises this phenomenon?

Comments (24) -

  • Anonymous

    3/18/2011 1:49:34 AM |

    Dr. Davis,

    I think total cholesterol should be 290, perhaps, and not 29?

    I have started using the lipoprofile in my practice.  Patients with relatively normal lipid profiles are startled with the results.  Getting them to make any changes is another thing, but I will keep trying.

    Teresa

  • Anne

    3/18/2011 7:42:37 AM |

    I live in the UK under the National Health Service but I also  have private medical insurance. I know that neither my private medical insurance company, nor the NHS itself, know my cholesterol numbers - they are known only to the lab, my doctors and me. How is it that patient information, which should be confidential, is given to insurance companies ? I find that a very worrisome aspect of this.

  • Kris @ Health Blog

    3/18/2011 8:08:05 AM |

    I find it kind of strange how obsessed american doctors are with cholesterol levels, in my country (Iceland) this is not such a big deal.

    It's almost as if the doctors in America are going out of their way to find something wrong with their patient so that they can treat it.

    For example high cholesterol, thyroid disorders. I pretty much never hear people talk about those things here.

  • Anonymous

    3/18/2011 11:55:23 AM |

    and when she refuses to do as ordered, her insurance company will find out about that, and will then terminate her coverage. Anybody want to make a bet? So much for privilege and confidentiality in the ole US of A.

  • Peter

    3/18/2011 1:29:41 PM |

    Seems very odd, I've had health insurance fornforty years, and they've never given me any advice or indication that they read my lab results.

  • Marg

    3/18/2011 2:22:16 PM |

    Some insurance companies routinely require physical examinations before they will write life insurance and are happy to find any reason not to write the insurance. Could this have been a life insurance company?

  • Galina L.

    3/18/2011 2:33:23 PM |

    What do you think is the best line of defense for the patient? My husband has similar calculated LDL - 181, the rest of numbers are excellent and he is in a very good health at 50 years old. Blood pressure is excellent(115/65), pulse is 45 at rest, fasting BS is 76. Our doctor admits it, but recommends Lipitor anyway. Our health insurance is about to be changed and it makes me worry about perspective pressure from insurance people on my husband to take that Lipitor.

  • Anonymous

    3/18/2011 2:37:48 PM |

    How does an individual give honest answers on health questionaires when applying for new or additional life or health insurance?  If they ask my PCP they would be told that I am low risk for heart attack.   If they look at my CT scan score they would see that I am in the 90th percentile - high risk.
    These are hypothetical questions at this point but my inclination would be to base my answer on my PCP's opinion rather than my calcium score, in part because medical insurance does not cover CT scans (apparently because they don't consider them to be a reliable predictor of risk) and in part because I have taken steps to significantly reduce my risk.

  • Anonymous

    3/18/2011 2:41:21 PM |

    Let's name names!  I have coverage by United Health Care through an employer.  I have gotten several letters in the past couple of years telling me I NEED this test, or that that test, to maintain my good health!  [However, never anything about the value of lipoprofile testing!]

    I consider this an abhorrent practice, an invasion of my privacy, and totally reject their "advice".  Advice should be coming from my doctor, and in fact it is.  I don't need their nurse "case manager" nor this advocacy for excessive testing.

    There's nothing like a letter from an insurance company to raise blood pressure!

    madcook

  • Barbara

    3/18/2011 4:35:25 PM |

    It is very disturbing to me that 1) her health insurance has access to her medical records and 2) that a for-profit organization is getting involved in her healthcare. Having moved from Australia about five years ago, everything about American health care disturbs me. I trust no one; they all seem to be desiring a profit and therefore paperwork is their main concern, not patient care, health, or longevity.

  • Jonathan

    3/18/2011 6:31:50 PM |

    My last test showed calculate LDL at 208, however the one from three months ago was "directly measured lipid" and showed 263 LDL direct, so might the calculated version be wrong in either direction?  I have pattern A and am FH.

  • susan

    3/18/2011 6:53:21 PM |

    I'm for naming names too!  I have Aetna health insurance through my employer. I don't get letters from them, but I get emails. Just today, I told my email program to automatically delete any further emails from the "Simple Steps to a Healthier Life" program. Plus whenever I sign into the online portal, I get nagged to have all kinds of tests, fill out questionnaires, and join health improvement programs.  I got so tired of the demand that I "fill out a health assessment questionnaire" I finally gave in, hoping it would be removed from the page. It just opened a new can of worms: now I have a half dozen new "suggestions" on my "to do list". Bah humbug!

    I'm of the "live and let live" school.  Why go looking for trouble?  As long as I'm not having symptoms, I feel no need to undergo all of these tests.

    Thank God my doctor is beginning to understand that I'm not going to be taking any of those Pharma-pushed poisons just because my lab results don't meet someone's criteria. Once again, I say Bah humbug!

  • Dr. William Davis

    3/18/2011 7:15:53 PM |

    Thanks for catching that, Teresa.

    It is indeed an eye-opener, isn't it?

  • Dr. William Davis

    3/18/2011 7:17:42 PM |

    Anne and Kris--

    Fascinating non-American perspectives.

    Insurance companies have incredible info on us. I'm always surprised more is not made of this issue.

    Remember: The more they know, the better they are at denying coverage.

  • Anonymous

    3/18/2011 8:19:22 PM |

    Dr. Davis,

    I didn't want to put this here (not sure if I could post it elsewhere) , but I thought you would find this interesting if you haven't seen it yet.

    http://www.psychologytoday.com/blog/p-nu/201103/cardio-may-cause-heart-disease-part-i

    RyanH

  • Anonymous

    3/18/2011 8:25:47 PM |

    Anonymous1 said:
    "I have coverage by United Health Care through an employer"
    Ah, United. I have Oxford/United. '
    Several years ago, when everyone at Oxford (and patients) worked toward a noble goal of "salary" for their CEO of 1.6 Billion a year, they sent me several letters suggesting that I have basic check up. I followed their suggestion. Then, I started to receive letters ... refusing to pay - 100% refusal. Each time, I had to call and ask nicely and politely: "Are you nuts?" They paid.

  • Dr. William Davis

    3/18/2011 10:52:16 PM |

    Though I am not in the habit of defending health insurers, I have found that they tend to provide a benign "you should speak to your doctor about . . ." kind of approach.

    I often wonder, however, if at some point they start to be more coercive. Something like: "You should strongly consider a cholesterol-reducing drug. We anticipate that your premiums may be higher if you do not."

    That would be scary.

  • Anonymous

    3/19/2011 12:50:53 AM |

    Ah, I should have continued.
    In a way, Oxford achieved their goal. What they paid was minimal, but they avoided bigger cost at that time.
    They scared me to death - if they don't pay for what they send to ( with letters firmly printed) which is basic, stated officially in some book as my right, they probably won't pay for anything else. I neglected all symptoms and asked for medical attention when I really didn't have any choice (and in a slightly new climate)
    I was diagnosed with two quite serious conditions - neither curable, but one was preventable and the other was at this time preventable to a degree. I mean the condition would be one only (the result of "bad" accumulation +genes?), less serious and correctable.

  • Contemplationist

    3/19/2011 3:16:40 AM |

    An insurance company has a tremendous incentive to reduce its costs and hence a great incentive to find out the truth. If they are not, it means that something is fishy. Why are insurers not commissioning their own studies? Are they not allowed to? Is it the regulators who are holding them back? Or are they actually stupid?

  • Anonymous

    3/19/2011 3:59:39 AM |

    I have not had any insurers say they know what a patient's lipid numbers are, but they can pretty well tell from claims data what tests have been done, and what medications are prescribed.

    We get faxes all the time recommending that meds be changed or weaned or made as needed rather than routine.  Yes, I know Mrs. Jones has been on an ulcer medicine for 6 months, and we should try to wean it.  What they don't know is that she won't change her diet and lose some weight, so maybe her symptoms would stop, and her symptoms get horribly worse without her ulcer medication.

    Teresa

  • jkim

    3/19/2011 2:57:41 PM |

    Dr. Davis,

    Based on Claudia's numbers, I guess I should expect a letter from my insurance company and a prescription from my doc for a statin. I won't fill the scrip.

    I'm 65, slim, eat VLC, and haven't been afraid of  saturated fat. But I just got my labs and TC was 476, HDL 146, Triglycerides 79 (I'd had wine with dinner--they're usually in the 30s), and LDL 314!!!

    How worried should I be about these numbers?

  • susan

    3/21/2011 1:57:39 AM |

    Hey Dr. Davis,

    At my last visit, my doctor mentioned my lipid numbers; but even he had to admit that my LDL (157) and TC (234) had improved (from 177 and 255), and the rest of my labs were all WNL. I generally eat low carb -- other than my recent indulgence in mini PB cups -- so I suspect that, as you indicated, the actual numbers are better than the official calculated numbers.

    My doc didn’t try to prescribe any meds this time. But at other visits he’s tried to guilt me into following the accepted guidelines by telling me his “performance score” is determined by how well he adheres to those guidelines, including prescribing all the meds and tests recommended by the so-called experts for a patient of my age with my lab results.

    I also fear that things are changing in this regard – and not for the better. Our government has now decided that we all must have insurance or pay a fine. If I refuse to follow the recommended guidelines, either my insurance company or my doctor, or both, may “fire” me. The truth is, I really don’t give a fig which entity it is (doctor, insurance company, or government panel) that tries to hector me into following guidelines promulgated by “experts” who believe in the lipid hypothesis. I simply choose to believe that I’m in charge of my body and that I get to determine whether to take a recommended med or have a recommended test.

    As for insurance companies getting lab results, I don’t know whether the doctor’s office or Quest Labs has been feeding my results to my insurance company, but when I look at my online health info on the insurance company’s web site, all my lab results are listed. And I’m sure the company is basing at least some of its many recommendations on those results.

    I must admit, having the results online makes it easy for me to keep track of them; but given the ease with which records can be hacked, I fear for my health privacy. And I resent the big brother attitude of the insurance company. I'm a well-informed, healthy adult. Treat me like one.

  • ShottleBop

    3/21/2011 4:50:53 AM |

    Just this past week, my insurance company (Aetna), which has paying for my test strips for the past year and a half, sent me a letter suggesting that I might have diabetes, and should talk to my doctor.

  • jkim

    3/21/2011 1:39:31 PM |

    Hi Dr. Davis,

    I spent the weekend reading your older posts about LDL. I guess I need to get a test done to determine my LDL particle number before my doc and I have a discussion. Thanks for posting that info in such detail on your blog.

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"Average amount of heart disease for age"

"Average amount of heart disease for age"

A 72-year old woman came to my office after a complicated hospital stay (unrelated to heart disease). She'd undergone a CT coronary angiogram and heart scan as part of a pre-operative evaluation prior to a surgery for a non-heart related condition.

The heart scan portion of the test (I was impressed they even did this) yielded a heart scan score of 212. The CT coronary angiogram portion of the test revealed a 50% blockage in one artery, a lesser blockage in one other artery.

The cardiologist consulting on the case advised her that the amount of coronary disease detected was insufficient to pose risk during her surgical procedure. He also advised her that she had "an average amount of disease for age." He thought that nothing further was necessary since she was "average."

Say what?  

What if I told you that you have an average amount of cancer for your age? After all, cancers become more common the older we get. Who would find that acceptable?

Then why should ANY amount of coronary atherosclerotic plaque be "acceptable for age"? Coronary plaque is a degenerative disease that poses risk for rupture. While it is indeed common, by no means should it be acceptable.

I would bet that this same cardiologist would be from the same school of thought that would be eager to advise heart catheterization, stent, and other procedures--revenue-generating procedures--should she have a heart attack appropriate for age.

I wish that I could tell you that this silly comment was provided by some peculiar, "everyone-knows-he's-crazy" doctor. But it was not. It was a solidly mainstream physician. He pooh-poohs nutrition, laughs when asked about nutritional supplements, thinks anyone complaining about symptoms less than a full-blown heart attack is a baby. He is respected by the primary care physicians, lectures on the advantages of prescription medications. In short, he is your typical conventional cardiologist.

This is the way they think. I know, because I was one of them. Thankfully, something banged me upside my head one day (my Mother's sudden cardiac death) and tipped me off to the painful irony of the conventional approach to heart disease.

There is NO amount of coronary disease appropriate for age. This notion is a remnant of the paternalistic, "I-know-better-than-you" attitude of the last century of medicine.

The 21st century promises a new age.

Comments (4) -

  • Anonymous

    7/2/2008 11:58:00 AM |

    Thank you for writing about this. Thank you for thinking and acting like you do.

    Best regards

  • ethyl d

    7/2/2008 4:51:00 PM |

    Dr. Davis: this sentence that ended your blog--"This notion is a remnant of the paternalistic, 'I-know-better-than-you' attitude of the last century of medicine"--brought to mind something I read recently in Angie's List, which apparently in a previous issue had asked readers to rate the care received by their doctors, and reported the ratings in an article. In the next issue Angie's List published the letters of several doctors who wrote in to express their outrage that patients would have the audacity to critique the care they received, since they believe said patients are incapable of accurately evaluating whether they received competent care or not. The attitude conveyed in their letters dripped with contempt for people who in their estimation are too stupid to assess the care they receive. I fear a lot of doctors really do believe they are an elite breed apart, towering over the ignorant rabble. All I can say is that, thanks to you and to Dr. Eades, I am a lot better prepared to assess the care of my own doctor, and counter her assimilated commonplaces about nutrition and heart disease. I wish I had known when my parents were still alive what I know now. I couldn't save them from their doctors, but maybe I can save my husband and myself.

  • Anonymous

    7/2/2008 10:23:00 PM |

    "The 21st century promises a new age."
    Taking into mind what ethyl d said: what are the med schools teaching nowadays? Last time I worked in a hospital it was same old, same old. That was eight years ago. The med schools' resistance to change (or not) will make the difference, I think.
    And thank you for this blog. It is an invaluable service.

  • Anonymous

    7/4/2008 6:10:00 AM |

    an old joke:

    Q: What do you call the guy at the bottom of his medical school class?

    A: Doctor.

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Are there any alternatives to niacin?

Are there any alternatives to niacin?

In the Track Your Plaque program, we tend to rely a great deal on niacin. When used properly, 90-95% of people will do just fine and achieve their lipid and lipoprotein goals with the help of niacin, along with their other efforts.

Unfortunately, around 5% of people simply can't take niacin without intolerable "hot flush" effects, or occasionally excessive skin sensitivity--itching, burning, etc.

Why does this happen? These 5% tend to be "rapid metabolizers" of niacin, i.e. they convert niacin (nicotinic acid, or vitamin B3) into a metabolite called nicotinuric acid. Nicotinuric acid is the compound responsible for the skin flush. Most people can slow or reduce the effects of nicotinuric acid by:

--Taking niacin with dinner, so that food slow tablet dissolution.

--Taking with plenty of water. Two 8-12 oz glasses usually eliminates the flush entirely in most people.

--Taking with an uncoated 325 mg tablet of aspirin in the first few weeks or months. Eventually, you will need to revert back to a better stomach tolerated dose of 81 mg, preferably enteric coated. But a full 325 mg uncoated can really help in the beginning, or when you have any niacin dose increases, e.g., 500 mg to 1000 mg.

But even with these very effective strategies, some people still struggle. That's when the question arises: Are there any alternatives to niacin?

Well, it depends on why niacin is being used. If you and your doctor are using niacin for:

Raising HDL--Then weight loss to your ideal weight; reduction of processed carbohydrates, especially wheat products; avoidance of hydrogenated ("trans") fats; a glass or two of red wine per day; dark chocolates (make sure first ingredient is chocolate or cocoa, not sugar), 40 gm per day; fish oil; exercise; other prescription agents (fibrates like Tricor; TZD agents for diabetes; cilostazol (Pletal)). Niacin is by far the most effective agent of all, but, if you're intolerant, raising HDL is still possible through a multi-faceted effort.

Reduction of small LDL--The list of effective strategies is the same as for raising HDL, but add raw almonds (1/4-1/2 cup per day), oat bran and other beta-glucan rich foods like oatmeal. Reduction of processed carbohydrates is especially important to reduce small LDL.

Reduction of Lipoprotein(a)--This is a tricky one. For men, testosterone and DHEA are effective alternatives; for women, estrogen and perhaps DHEA. Hormonal preparations of testosterone and estrogen are stricly prescription; DHEA is OTC. I have not seen the outsized benefits on lipoprotein(a) claimed by Rath et al by using high-dose vitamin C, lysine, and profile, unfortunately. We are clearly in need of better alternatives to treat this difficult and high-risk disorder.

Reduction of triglycerides/VLDL/IDL--I lump these three together since they all respond together. If you're niacin intolerant, maximixing your fish oil can be crucial for reduction of these patterns using doses above the usual starting 4000 mg per day (providing 1200 mg EPA+DHA). Reduction of processed carbohydrates, eimination of processed foods that contain high-fructose corn syrup, and weight loss to ideal weight are also very effective. "Soft" strategies with modest effects include green tea (>6 cups per day) or theaflavin 600-900 mg/day; raw nuts like almonds, walnuts, and pecans; exercise; soy protein.

Reduction of LDL--Lots of alternatives here including oat bran (3 tbsp per day), ground flaxseed (3 tbsp per day), soy protein (25 grams per day), Benecol butter substitute (for stanol esters), soluble fibers like pectin, psyllium, glucomannan; raw nuts like almonds, walnuts, and pecans.

In future, should torcetrapib become available (by prescription), this will add to our available tools for these areas when niacin can't be used. Until now, the alternatives to niacin depend on what you and your doctor are trying to achieve. In the vast majority of cases, HDL, small LDL, triglyceride, etc. goals for heart scan score control can be achieved, even when niacin is not well tolerated.
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Marathoners, triathletes, and heart disease

Marathoners, triathletes, and heart disease

Curious thing: People with lipoprotein(a) gravitate towards elite levels of exercise.

I tell my lipoprotein(a) patients that, if they want to see a lot of other people with lipoprotein(a), go to a marathon or triathlon.

This effect applies more to males than to females, just as the fascination with numbers seems to be confined to men, too. That's why I've posted in past about the "prototypical" lipoprotein(a) male.

I believe this is a big part, perhaps the only, reason why there seems to be a modest increased risk for cardiovascular events despite high exercise levels in marathoners. It has nothing to do with the exercise itself; it has to do with the kind of people who choose to exercise at this level.
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Call me when you're having chest pain

Call me when you're having chest pain


I met a patient, Anna, yesterday. She was quite frustrated and frightened.

At age 50, Anna suffered a heart attack and received a stent to her left anterior descending coronary artery. What she found upsetting is that, because several members of her family had suffered heart attacks in their 40s (Dad--heart attack at age 45, paternal uncle--heart attack age 40, and even another uncle with heart attack in his late 20s), she had repeatedly asked her doctor whether she was okay.

She received the usual array of false assurances: "You're feeling fine, right? Then don't worry about it." "Look. Your cholesterol is in the normal range. Even your cholesterol/HDL ratio is fine." "Women don't get heart disease until later in life."

All proved absolutely false. As we talked, Anna exclaimed, "I think what I've been told all along is that we'll take you seriously when you finally have a heart attack!"

She's exactly right. The vast majority of times, heart disease is discovered by accident, usually because of an "event" like heart attack. This is like changing the oil in your car when it finally breaks down--it's too late.

CT heart scan, followed by lipoprotein testing and associated values, then correction of your specific causes. It's that simple.
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If you have hypertension, think Lp(a)

If you have hypertension, think Lp(a)

Clair has coronary disease.

Clair first came to attention at age 57 when she suffered a large heart attack involving the front of her heart (the "anterior wall") two years ago. Her cardiologist implanted a drug-coated stent. Her doctors advised her to "cut the fat" in her diet, exercise, and take Lipitor.

One year later, she required a stent to another artery (circumflex). At this point, Clair was thoroughly demoralized and terrified for her future. Her first heart attack left her heart muscle with only 50% of normal strength.

She came to my office for another opinion. Of course, one of the first things we did was to identify all causes of her heart disease. No surprise, Clair had 7 new causes not previously identified, including low HDL (37 mg/dl), a severe small LDL particle pattern (75% of all particles were small), and Lp(a).

Her blood pressure was also 190/88, despite her relatively slender build and 3 medications that reduced blood pressure. That's a Lp(a) effect: Exagerrated coronary risk along with unexpected hypertension that often seems inappropriate.

In fact, I saw several patients just this week with lipoprotein(a), Lp(a), and exagerrated high blood pressure (hypertension). It's not that uncommon.

Though it has not been described in the medical literature, our experience is that hypertension is a prominent part of the entire Lp(a) "syndrome".

Lp(a) is responsible for much-increased potential for coronary disease (coronary plaque). It increases in importance as estrogen recedes in a woman (pre-menopause and menopause) and testosterone in a man, since both hormones powerful suppress Lp(a) expression (though why and how nobody knows).

I believe that Lp(a) is also responsible for hypertension that most commonly develops in a persons mid-50s and onwards, often with a vengeance. 3 or 4 anti-hypertensive medications and still not controlled.



Role of l-arginine

L-arginine may be more helpful in this situation than others. L-arginine, recall, is the supply for your body's nitric oxide, a powerful dilator of the body's arteries and thereby reduces blood pressure. We use 6000 mg twice a day, a large dose that requires use of powder preparations rather than capsules.

More reading about l-arginine and nitric oxide is available through Nobel laureate, Dr. Louis Ignarro's book, NO More Heart Disease : How Nitric Oxide Can Prevent--Even Reverse--Heart Disease and Stroke, available at Amazon.com ( http://www.amazon.com/gp/product/0312335814/104-1247258-6443909?v=glance&n=283155).




Will l-arginine truly reverse heart disease on its own? No, I don't believe so. Contrary to Dr. Ignarro's extravagant claims, I find l-arginine a facilitator of plaque regression, i.e, it helps other strategies achieve regression, but it does not achieve regression or reversal by itself. (Note that Dr. Ignarro is a lab researcher who studies rats and has never treated a human being.)

But l-arginine may have special application in the person with lp(a), particularly if hypertension is part of the syndrome.


Note: As always, please note that I talk frankly about l-arginine and other supplements and medications but have no hidden agenda: I am not selling anything, nor am I affiliated with any source/website/store etc. that sells these products. If I advocate something, I do so because I truly believe it, not because I'm trying to sell something. I make this point because so much nonsense is propagated in the media because of profit-motive. That's not true here.
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Omega-3 fatty acids likely NOT associated with prostate cancer

Omega-3 fatty acids likely NOT associated with prostate cancer

A weakly constructed study was reported recently that purportedly associated higher levels of omega-3 fatty acid blood levels and prostate cancer. See this CBS News report, for instance.

Lipid and omega-3 fat expert, Dr. William Harris, posted this concise critique of the study, exposing some fundamental problems:

First, the reported EPA+DHA level in the plasma phospholipids in this study was 3.62% in the no-cancer control group, 3.66% in the total cancer group, 3.67% in the low grade cancer group, and 3.74% in the high-grade group. These differences between cases and controls are very small and would have no meaning clinically as they are within the normal variation. Based on experiments in our lab, the lowest quartile would correspond to an HS-Omega-3 Index of <3.16% and the highest to an Index of >4.77%). These values are obviously low, and virtually none of the subjects was in “danger” of having an HS-Omega-3 Index of >8%. So to conclude that regular consumption of 2 oily fish meals a week or taking fish oil supplements (both of which would result in an Index above the observed range) would increase risk for prostate cancer is extrapolating beyond the data.

This study did not test the question of whether giving fish oil supplements (or eating more oily fish) increased PC risk; it looked only a blood levels of omega-3 which are determined by intake, other dietary factors, metabolism and genetics.


The authors also failed to present the fuller story taught by the literature. The same team reported in 2010 that the use of fish oil supplements was not associated with any increased risk for prostate cancer. A 2010 meta-analysis of fish consumption and prostate cancer reported a reduction in late stage or fatal cancer among cohort studies, but no overall relationship between prostate cancer and fish intake. Terry et al. in 2001 reported higher fish intake was associated with lower risk for prostate cancer incidence and death, and Leitzmann et al. in 2004 reported similar findings. Higher intakes of canned, preserved fish were reported to be associated with reduced risk for prostate cancer. Epstein et al found that a higher omega-3 fatty acid intake predicted better survival for men who already had prostate cancer, and increased fish intake was associated with a 63% reduction in risk for aggressive prostate cancer in a case-control study by Fradet et al). So there is considerable evidence actually FAVORING an increase in fish intake for prostate cancer risk reduction.

Another piece of the picture is to compare prostate cancer rates in Japan vs the US. Here is a quote from the World Foundation of Urology:


"[Prostate cancer] incidence is really high in North America and Northern Europe (e.g., 63 X 100,000 white men and 102 X 100,000 Afro-Americans in the United States), but very low in Asia (e.g., 10 X 100,000 men in Japan).”

Since the Japanese typically eat about 8x more omega-3 fatty acids than Americans do and their
blood levels are twice as high, you’d think their prostate cancer risk would be much higher...
but the opposite is the case.


Omega-3 fatty acids are physiologically necessary, normalizing multiple metabolic phenomena including augmentation of parasympathetic tone, reductions of postprandial (after-meal) lipoprotein excursions, and endothelial function. It would indeed make no sense that nutrients that are necessary for life and health exert an adverse effect such as prostate cancer at such low blood levels. (Recall that an omega-3 RBC index of 6.0% or greater is associated with reduced potential for sudden cardiac death.)

I personally take 3600 mg per day of EPA + DHA in highly-purified, non-oxidized triglyceride form (Ascenta Nutrasea liquid) that yields an RBC omega-3 index of just over 10%, the level that I believe the overwhelming bulk of data suggest is the ideal level for humans.

Comments (6) -

  • Jeff

    7/23/2013 10:56:11 PM |

    Can you advise where you get the Nutrasea Liquid that you mention you personally use above?.  I'm not finding any in the 3600mg range.  I couldn't find any where 2 doses equals that amount either.  Looking for high quality Omega 3's that are not sourced from Krill due to shell fish allergy.  Currently taking fish oil gel caplets of dubious quality.  Thanks in advance.

  • pickinthefive

    7/29/2013 5:58:45 PM |

    Hi Dr. Davis,
    A question I would have.  If you are at a known risk for prostate cancer, i.e. father or uncle's already have it, or in my case a reletively high PSA and symptoms of BPH, would it be wise to avoid the Omega 3's ?
    Thank you,
    Monty

  • Edwin

    8/14/2013 9:27:43 AM |

    So my eating a canned salmon sandwich for lunch most days which has about 1g of Omega3 (I take no supplements) should be safe?

  • Stephen in Anaheim

    8/15/2013 5:29:38 AM |

    I have to say that this is a great thing to read! In most dietary articles that I stumble across nowadays, I can find at least a paragraph or more on why people should be adding more Omega-3 fatty acids to your diet. In fact, I have read that Omega-3 can be quite beneficial for a number of medical conditions ranging from childhood asthma to fibromyalgia. It is scary to think that it could associated with a higher risk of prostate cancer, even though the underlying study was not well constructed.

  • Edward

    8/16/2013 3:08:29 AM |

    Dr. Davis,
    I take fish oil from a brand called "Carlson fish oil" it contains omega 3 fish oil 1,600. What would be the highest safest amount a person can take in Omega 3 in your experience from your patients and practice? What are your thoughts on the Linus Pauling Heart therapy which calls for a person taking at least 10 grams of vitamin C and 3-5 grams of Lysine in order to reverse plaque and heart disease? I have read the two time Nobel prize winner's books and his writings on heart disease are compelling. I would love the insight from an actual cardiologist with a practice to confirm what works and doesn't work.

  • Edward

    8/16/2013 1:19:06 PM |

    Dr. Davis,
    How much fish oil would you consider the highest and safest dosage for a person to take for heart disease and would the dosage a person who is healthy or heart problems differ?

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