Talking diet with your doctor

I’m always amazed at the number of comments this blog gets from readers who are worried about discussing health issues with their doctors.  Most are a variant of this composite of many comments I’ve read:

I’ve been on a low-carb diet, and I’m afraid my cholesterol is going to be up a little and my doctor will want to put me on a statin.  How can I show him/her that I’m really on the right track?

Another common variant:

I want to go on a low-carb diet, but I’m sure my doctor will be against it.  What should I tell him/her?

I’m always puzzled by these comments.  I’ve been on the other side of countless doctor-patient conversations, so I know how doctors (at least this one) think.  And I’ve been in countless doctor-doctor conversations, so I know how doctors think about their patients.  While there are a few old, crusty it’s-my-way-or-the-highway types still out there, it’s been my experience that most doctors are willing to work with their patients.

The important thing to remember is that you – not your doctor – are the one ultimately in control of your health.  I can guarantee you that if you have been reading this blog for any length of time or have roamed through and read in the archives, you are much more nutritionally savvy than the vast majority of doctors out there.  The old saw is absolutely true: doctors get very, very little nutritional training in medical school and even less in their post-graduate training.  In my own case, I got exactly one lecture on nutrition in medical school, and that was from a registered dietitian, which should tell you all you need to know.  And it wasn’t even a lecture on nutrition; it was a lecture on how to write orders for various diets for hospitalized patients.

Virtually all of my nutritional knowledge was self taught.  And most doctors don’t bother – I didn’t bother for the first five years of my practice.  I said all the same ignorant things and gave the same terrible advice that most doctors still give today.  Had statins been available then, I would have been giving them to everyone who walked through the door with elevated cholesterol levels.  I would have been telling patients that these drugs were a gift from the gods and that the evidence was conclusive that they worked.  And I would have been dead wrong.

Which brings me back to my first point.  You are in control of your own health.  And you likely know at least as much about nutrition as your doctor does.  So, why worry about what he/she thinks or says about nutritional issues? Besides, he/she is working for you, not the other way around.

But, it’s pretty apparent that many people are concerned about this issue, so let me tell you how to go about discussing diet with your doctor.

First, don’t bring a copy of Protein Power or some other diet book in and tell your doc to read it.  Just seeing a diet book makes the ‘fad diet’ warnings go off in a doctor’s head.  Plus, your doctor will never read it, so you’ll be wasting a perfectly good book. And don’t bring in magazine articles or copies of posts from this blog because they will scream the same ‘fad diet’ message.

Instead, bring in a short medical article.  I’m going to give you one you can print and use.  I’ll describe it a little later.  I’m going to provide you with a published case report, which is about all most physicians can read.  It will probably surprise you to learn that most practicing physicians don’t know how to and virtually never do search the medical literature.  (Academic physicians do know how to use the medical literature, but for the most part, don’t know how to take care of patients.)  So, if you bring in a long New England Journal of Medicine article, it will never get read.  A case report is what you want.

Then tell your physician that you’ve had friends or family that have been successful on this diet and that you are planning on giving it a short-term try.  And that you want your physician to monitor you.

If it’s a statin issue, you can do the Nancy Reagan and just say no.  Or you can say that you’ve done so well on your diet in other respects that you want to give it a little more time.  Or you can leave with the prescription and simply not get it filled if you don’t want to take the drug.  If you continue on the diet, your cholesterol will probably fall before your next visit anyway, and you can say that you decided to give your diet a little more time to work.  (If you want a lot of information to really discuss statins with your doctor, simply enter ‘statin’ or ‘statins’ in the search function of this blog and you’ll find plenty.)

I’ve got an interesting (and short) case report in my files that was published in the journal Aviation, Space, and Environmental Medicine, the official journal of the Aerospace Medical Society and sort of the unofficial NASA journal. Here is a downloadable pdf file of this paper suitable for presentation to your physician.pp-diet-in-an-aviator-av-spc-envir-med-2001

The paper presents the case of a 54-year-old army helicopter pilot with high-blood pressure (controlled with medications), obesity, diabetes, and elevated cholesterol.  When he presented for his annual flight physical, his blood sugar problems had worsened from glucose intolerance to diabetic proportions, and he was removed from flying status.  This pilot decided to go on Protein Power, and his flight physicians monitored him. Here is the brief history of his dietary journey:

After documenting normal renal function, that patient adopted a recovery plan of exercise and a high-protein diet.  His exercise consisted of walking 2 mi 3-4 times per week.  He kept his daily carbohydrate intake below 30 gms, but otherwise did not count calories.  In a 3-mo period of time, he lost 35 lbs.  His cholesterol was lowered to 204, his triglycerides [which had been greater than 500] lowered to 238, his fasting blood sugar lowered to 100, a 2-h post glucose load lowered to 122, and he discontinued his hypertension medication and remained normotensive.  The patient has continued the high-protein, low-carbohydrate diet with a gradual increase in the amount of calories from carbohydrates and for 1 yr has maintained quarterly hemoglobin A1C in the low 5 range.  He reports feeling better than he has in many years and has successfully returned to flying.

The article goes on to describe specifically the Protein Power diet in a comprehensive way.  It’s a much better short description of our own diet than one I could have probably written.  The paper then confirms the data we presented on the superiority of the low-carb approach with one other paper (there were more out there at the time, so I don’t know why they quit with just this one) that you can read in full text or download in pdf here.

This is the kind of case report you can simply give your physician and tell him/her that you are going to try this diet.  Your doc probably will read this one since it’s only two pages and reads like one doc writing to another, which is what a case report really is.

When you do go on the diet, your results should speak for themselves.  Your physician will then be as surprised as the docs were who wrote this case report.  Why do I know they were surprised?  Because you only write case reports on unusual or surprising findings.  You’ll never see a case report that says the patient came in with strep throat, we treated him with antibiotics, and he got well.  That’s an everyday occurrence.  It’s only the stuff that makes you sit up and take notice that inspires a written case report.  Your doc will be pleasantly surprised at your outcome just as these doctors were surprised at this aviator’s outcome.

Then maybe, just maybe, your doctor will want to know more.  And then you can give him or her the book.

Please note: I reserve the right to delete comments that are offensive or off-topic.

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73 thoughts on “Talking diet with your doctor

  1. Dr. Mike:
    I have printed the 2 pages which I will copy and whip out when necessary. Thanks!

    I see it was published in 2001. Not much has noticeably changed since then unfortunately.

  2. Doc —

    I have already printed the pdf and will give it to my hubby tonight, his blood numbers are very similar to the man in the case (Especially triglycerides of 500!). His doctor wants him to take statins which I’m VERY against.

    We have two PP books and we follow the guidelines, except for a once a month “carb” meal.

    In two months, my 6 foot tall hubby has lost 30 plus pounds and I’ve lost 9. He’s due to have his blood retested next month.

    Thank you for your blog and your books!

    –Sandi

  3. It was attributed to Rich Burton (Taffy nutter and buyer of very large diamonds) but who knows if he said it ?
    Actually its a perfect example if i understand correctly which i might not of a fat tailed power law
    “Drs are like a actors, there’s a few good ones and the rest are rubbish”

    Also status in us great apes seems to literally send us bezonkers right and well look at Senor Bray..as ‘silly as a sack o snakes’

    What was attributed to Richard Burton? I’m lost.

  4. Thanks for the report.

    I never use books or magazines as references when trying to prove a point anymore. After reading something interesting in a book, I usually now just try to go back to the original source by going back in references as far as I can and validate them. Then people won’t tell me that I am “on” some diet or doing something because an author says so. Although, I recommend your book whenever I get the chance.

  5. Dr. Mike,

    I think this is your most practical and useful post yet. I hope you realize how helpful this is going to be. I know quite a few folks who would like to give a restricted carb diet a try but are very worried about what their physicians will say. Unless you really know your stuff, it is hard to imagine yourself “debating” with the one who has greater intelligence (at least percieved) and years of experience far beyond we mere laymen.

    However, what you have presented here is a game plan so pragmatic and reasonable (tell your physician that you’ve had friends or family that have been successful on this diet and that you are planning on giving it a short-term try. And that you want your physician to monitor you.), yikes who could argue with that?

    I have sent this to everyone I know it would help. Thanks so much for your work on your books and this blog. I can’t tell you how excited I become when my blog reader shows a new post from you.

    Keep up the good work!

    Thanks. I’m glad you enjoyed the post.

    Cheers–

    MRE

  6. Great post! I have a comment and a question. I kind of experienced same ordeal with my doctor after embarking on a low carb lifestyle. Even though he is relatively young and relatively open-minded, he still got a traditional medical education in a traditional medical school. I am relatively young guy, 36 years old. In ten years that I have been seing my doctor he diagnosed me with many things, including post-traumatic stress disorder, post september 11, anxiety disorder to hyperinsulinoma to ADD. Even though I am and have always been an upbeat, positive guy, he said my symptoms of near syncope, extreame fatigue, debilitating energy spikes were attributed to some kind of mental route. All tests kept coming back negative, except I felt non-functional and prematurily old. Until one day I read Protein Power book. Then it hit me, could all symptoms be as simple as hypoglycemia cause by hyperinsulinimia. No wonder I could have easily swallow a gallon of ice cream to only be hungry two hours later for pizza, pasta and canoli. No I am not Italian, but I worked in a nice Italian restaurant back then. But my doctor kept insisting it was my underlying anxiety that caused me to eat carb for emotional pleasure. And having formal degree in nutrition it did make sense. I kept justifying the doctor theory by saying well it might be emotional eating to fill some kind of void. But I had a very good , there seemed to be no void. Then I insisted to have glucose intolerance test done and boom there it was, a horrible parade of my old symptoms, from almost fainting to cold sweats to tachycardia to anxiety. So it wasnt anxiety after all I said to myself. I took my self off Paxil and put myself on low carb diet. But my doctor was terrified. He didnt want any part of my journey on a low carb diet. He kept insisting that I was on a destructive path and he warned me about it. But this time I knew deep down he was wrong. Now I am down from 270 to 210 with still soem weight to loose, total cholesterol 150, HDL 65, tryglecerides 40 and blood pressure 110/60. So I always believe that if you change the way you look at things , things you look at change! Or as my best Russian friend sais Life is like a toilet paper, seems long but gets wasted on lots of …… So I decided to change my mind and stop wasting time looking for approval, even from my doctor. I love and respect medical professionals, especially doctors, but when it comes to your health and diets, you be the captain of thart ship! Dr Eades, I am sorry for a long email but it is an emotional subject. I have a question though.I have done great on LC, however quiting smoking few years back made me crave sweets once in a while. I do believe in emotional eating and subconscious comfort food. I am sure many people experience sweet cravings in a time of stress. After all my grandmother fed me candy every time I cried when I was little. So my brain still associates sweets with comfort. What is the best way to teach your brain to disassociate sweets with comfort? I do eat berries and sugar free chocolate a lot when it hits me, but it seems I cant loose weight because of it. And when i do eat a lot of sugar free chocolate my weight stalls for weeks, no matter how much I exercise. What do you think is the best way to avoid sweets or to have them to the minimum on a low carb diet? Thank u for your patience!

    You might want to try some magnesium. Many people who have a craving for sweets seem to reduce such cravings when they take magnesium. Plus, the health problems you have had tend to deplete magnesium, so you probably have low levels. I recommend about 300 mg at bedtime. Give it a try and let me know how it works.

  7. Good timing. I was just pondering this very question myself.

    At the start of the year I did some experimentation with low carb, but in a very haphazard and unstructured way. I saw some of the benefits that we all know about, and particularly I found that my asthma disappeared, which I didn’t understand until later when I read about ecosanoids in PP. During that time I also tested the idea (which I’d seen on a bulletin board) that any amount of fatty food can be eaten without weight gain and proved this to my own satisfaction. I didn’t get any blood work done though.

    But then I had some negative life events and reverted to comfort food – in your pithy phrase, I went “face down in the carbs”.

    Having now read PP and most of the archives of this blog (still working through them), I’m waiting for my copy of PPLP to arrive, and once I’ve digested that I’ll make a concerted and disciplined effort to follow the plan, with or without my doctor’s support.

    Good luck. Keep me posted.

    Cheers–

    MRE

  8. I agree with almost everything you said. People need to remember that M.D. Doesn’t stand for “medical deity” (referring of course to the medical abbreviation, not your lovely wife). Doctors should be thought approachable, not intmidating. The one time I encountered resistance on doing Protein Power, I told my doctor who wanted me to go low fat that I had other plans. She was very skeptical, but told me to check back in a month and then 3 to see how I was doing. You should have seen her face when I came back 30 lbs lighter in 3 months and reduced cholesterol (not that this means much in the big picture). The last time I saw her was a year after that and she was recommending Protein Power herself by that time.

    On the other hand, irony. I am about to ditch my current family doctor because of her low fat dietary recommendations for my kids. My kids who are not even overweight. How long before they say, “here give your kids these statins because they might get fat and then get high cholesterol.”

    The way you persuaded your doctor to take the low-carb diet seriously is the same way most are persuaded. Good work!

    Cheers–

    MRE

  9. ME: “You might want to try some magnesium. Many people who have a craving for sweets seem to reduce such cravings when they take magnesium. Plus, the health problems you have had tend to deplete magnesium, so you probably have low levels. I recommend about 300 mg at bedtime.”

    It is absolutely amazing (or maybe not) how many medical professionals would not recognize a magnesium deficiency even if it jumped up at them and kicked in their front teeth. This, despite the fact that magnesium deficiency is common in our society. Good on you Dr. Eades!

    I have experienced great benefit from magnesium supplementation with a low carb diet. But the form of magnesium seems to make a big difference. I am currently using magnesium aspartates or orotates. I also supplement with potassium. I have recently come across some articles on magnesium chloride that claim it is better utilized than other forms of magnesium especially when taken in liquid form. Could you please comment on this. Thanks.

    I’ve had no experience with magnesium chloride. But I have had much success with magnesium chelates such as the magnesium aspartate you mentioned. The one I ended up using for myself and my patients is magnesium citrimate. The chelates are nice because you don’t have to worry about interference with the absorption of other mineral ions. The problem with magnesium chelates is in the labeling of them. The chelating agent – aspartate, for example – is required in large amounts, and sometime manufacturers list the total weight of the magnesium plus the chelate, giving a weight for a dosage that many people assume is the weight of the magnesium alone. These are the magnesium supplements that say each capsule contains 1000 mg of magnesium aspartate. It does contain 1000 mg of magnesium aspartate, but only 150 mg of that might be magnesium. As a consequence, the best way to evaluate magnesium supplements is to look at the RDI (recommended daily intake). The RDI is a measure of only the magnesium. If you’re getting 150-200 percent of the RDI, you’ve got an adequate supplement.

  10. see the quote 3 lines up from yr line.

    Ah, I see. I thought the quote was referrring to something else, and I hadn’t a clue as to what.

    It’s all clear to me now. The comment was about the quote. The quote wasn’t about something I had written earlier. It’s late here, so I’ll claim fatigue.

  11. Thanks Mr Eades – a very handy thing to have up one’s sleeve. Personally I have got way beyond the point where I would bother trying to explain this to any of the doctors I see, but then I am in the fortunate position of being relatively young and healthy and therefore not having to engage with any physicians on the subject if I don’t want to. I have great sympathy for people battling with conventionally-minded doctors whose well-intentioned prescriptions are at odds with what the enlightened know to be optimum nutrition.

  12. Excellent post! I too have been dreading going to the doctor for a regular check up since eating low-carb. I lost 35 lbs but have no idea about my blood work. What tests should I ask them to perform on an otherwise healthy adult (and are there specific types that are better)? Iron ferritin? Magnesium? What method of blood sugar test?

    Guy

    You can get just the general run of the mill types of lab tests to see how you’re doing. On my own patients, in addition to the regular labs, I like to get a fasting insulin level, a C-reactive protein and a ferritin. I’ll add additional tests if a given patient has other problems. Serum magnesium doesn’t tell squat – you’ve got to get a intracellular magnesium level tested, which is fairly expensive. I only get these tests if I really think there is a problem.

  13. My doctor told me the other day I had the highest HDL (good cholesterol) value he’d ever seen. I told him I’d been low carb for 3+ years. He said it must be ‘genetic’.

    That’s always the explanation of last resort by the ignorant.

  14. Comment warning – I’m going to talk about constipation. Ok, so this is a problem I have had most of my life. For many years, I took various psyllium products. Since being a low carber of 9 months and reading about how fibre actually works to keep the system moving, I have not taken any psyllium. I have heard that many low carbers have constipation problems at first (even if they didn’t have it before) but that it works itself out with the additional fat. Unfortunately for me, that hasn’t been the case. So I was excited to see your comments about magnesium – that my problem might have been a magnesium deficiency all along. I made sure to get one of the forms of magnsium that you suggest, Magnesium Citrate. Unfortunately, I didn’t take it long enough to find out if it would solve the internal problems as I found it had the opposite effect on my sleep as it is suggested it would – I found I couldn’t sleep. Did you have any patients that had this experience – of magnesium keeping them from sleeping, rather than helping? I have found I generally sleep better as a low carber so this was very distressing. I was also disappointed that it appeared magnesium wasn’t going to solve the consipation problem – ok, it might have, but I would have been severally sleep deprived instead. Do you think that another form of magnesium would make a difference?

    I’ve never heard of magnesium keeping a person awake, but I guess there’s always a first time for everything. You could try another brand of magnesium or you could try taking it in the morning. I generally tell patients to take in before bed because of its sleep-inducing properties, but it doesn’t have to be taken at bedtime.

  15. I’m not exactly afraid to talk to my doctor, but I don’t waste my breath either. After my last checkup, his nurse called to tell me I need to go on a lowfat diet and come back in six months for a follow-up because my cholesterol is “slightly elevated.” When I pressed for actual numbers, they were: TC: 203, HDL: 61, TG: 62. No point having a discussion with someone who thinks those numbers require a change in diet.

    My kid’s pediatrician also told my wife that since my (thin, healthy) daughter is three years old, it’s time to switch her to skim milk. My wife knows better, but also knew it wasn’t worth arguing the point.

    The attitude most of us get from our doctors if we dare question their advice reminds me of an old joke:

    Two doctors are killed in a car crash and find themselves in a very long line to get into heaven. They walk up to St. Peter, who’s in charge of processing souls, and suggest that since they were doctors during their time on earth and saved a lot of lives, perhaps they could go to the front of the line. Peter replies, “Up here, everyone’s the same. Get back in line.” They do so, grumbling all the while.

    A few minutes later, a guy in a white coat with a stethoscope around his neck walks past everyone, waves to Peter, and goes through the Pearly Gates. The two doctors stride angrily back to Peter and demand to know why that particular doctor was able to skip past everyone else.

    Peter replies, “No, no, no, that wasn’t a doctor. That was God. He just thinks he’s a doctor.”

  16. Such a helpful, useful, and practical post!

    It would be of great assistance if you could do a similar post supporting prescriptions for unlimited diabetes testing strips for Type 1 diabetics and a high number of daily strips for Type 2 diabetics. There is a real need for this information because insurance companies and government-funded programs are pressuring doctors to reduce testing strip availability for their own economic reasons — which are excessively short-sighted, given the cost-savings when diabetics are enabled to reduce complications.

    This issue comes up a lot on diabetic forums …

    I’m not sure that a post by me will do much to persuade the powers that be to change the insurance regulations, but I’ll add it to my list of posts to contemplate.

  17. MRE:As a consequence, the best way to evaluate magnesium supplements is to look at the RDI (recommended daily intake). The RDI is a measure of only the magnesium. If you’re getting 150-200 percent of the RDI, you’ve got an adequate supplement.

    In its wisdom, the govt. seems to have changed the labeling requirements yet again…now DV appears where RDI was. DV seems to be what RDI used to be, which used to be U.S. RDA (not to be confused with RDA, something completely different!) Our govt. dollars at work.

    Thanks for the heads-up on magnesium. Pubmed makes for interesting reading on the subject. Here are a couple of studies from the past few months:

    Magnesium deficiency accelerates cellular senescence in cultured human fibroblasts:
    the long-term consequence of inadequate magnesium availability in human fibroblast cultures was accelerated cellular senescence, which may be a mechanism through which chronic magnesium inadequacy could promote or exacerbate age-related disease.
    (http://tinyurl.com/3gfs7c)

    And here’s an interesting study that seems to show that strenuous exercise can cause you to get an upper respiratory infection if you’re not getting enough magnesium: Exercise, magnesium and immune function
    http://tinyurl.com/4n57es

    One last one:
    Is magnesium deficiency widespread? http://tinyurl.com/4mrodn

    There are numerous studies showing that strenous exercise depletes magnesium and that magnesium deficiency is widespread. The last study I read on this stated that 72 percent of Americans don’t even get the RDI of magnesium. There is an entire school of thought that posits that a magnesium deficiency is the root cause of the metabolic syndrome. You’ve just scratched the surface of the vast quantity of magnesium studies.

  18. Mike, this post comes at a great time for me as I’m trying to find a doctor that will have an open mind so our first encounter won’t end in an ‘okay then… have a nice day!” with no future appointment. I myself have been thinking on how to approach a doctor about this without sparking the comment “…and how many years did you spend in med school…?” when a person seems to know more than the doctor about nutrition. I confess that I have little patience with people like that because, though I’m not a doctor but a biochemist, I do have a better grasp of what goes on in the body when different macronutrients are metabolized.

    Your post just gave me a different idea on how to approach the next doctor I’ll visit and hopefully he’ll want to work with me on this.

    I hope it works, Gabe. Keep me posted.

    Best–

    Mike

  19. ME: “These are the magnesium supplements that say each capsule contains 1000 mg of magnesium aspartate. It does contain 1000 mg of magnesium aspartate, but only 150 mg of that might be magnesium.”

    Or less – 770 mg orfmagnesium orotate contains only 50 mg of elemental magnesium.

    Insofar as talking with your doctor, it has been observation that, with few exceptions, doctors are driven by numbers in terms of treatment initiatives. In other words, most doctors are not proactive. They are reactive. Thus, a patient with a fasting blood glucose of 120 would not be treated, but a patient whose FBG was 127 would suddenly become a diabetic patient.

    A new study just posted today reveals what many of us have probably suspected for some time; fatty liver is common in diabetics. But while the study acknowledges that fatty liver is associated with an accumulation of abdominal fat, it doesn’t specifically state that fatty liver is probably much more common than is believed in anyone with insulin resistance which judging by the huge guts I am seeing is a lot of people. But it is unlikely that your family doctor will clue into this even if you have a 60 inch waist.

    “People With Type 2 Diabetes Can Put Fatty Livers On A Diet With Moderate Exercise

    According to researchers, who will present their findings on Sept. 18 at the annual meeting of the American Association of Cardiovascular and Pulmonary Rehabilitation, in Indianapolis, high liver fat levels are common among people with type 2 diabetes and contribute to heart disease risk.”

    The study which claims to be the first of its kind to discover this, found that aerobic exercise reduced fatty liver. Reducing carbs and eliminating HFCS would probably also go a long way toward reducing fat in the liver. But this study was concerned with exercise. The article goes on to say:

    “In addition (to aerobics), they lifted stacked weights for about 20 minutes, also three times a week, and not at a heavy-duty pace.”

    Hmmm, sounds like Slow Burn to me. I would put my money on this as the big factor in reducing the accumulation of fat in the liver and not the aerobic exercise component.

    http://www.sciencedaily.com/releases/2008/09/080919142356.htm

    Fatty liver disease (which is one of the subjects we cover in detail in the new book) is rampant. I just read a study showing that over a third of adults have fatty liver disease. It’s a real epidemic. Even in kids, which is truly unfortunate.

  20. Hi Mike.

    My doctor (but I think he’s not alone in that) would say it was the walking 2 mi 3-4 times a week that did the job with the aviator, “DESPITE” his wrong diet…

    Re magnesium and mineral supplementations, Mike, I’d like to know your thought about hair tissue mineral analysis and its relationship with the imbalance between Sympathetic and Parasympathetic System. Did you write anything on this subject on this blog?

    Thanks a lot.

    Marco

    Hey Marco–

    I haven’t written anything on mineral analysis as determined from hair samples. I really need to read up on that issue before I comment. I’ve always gotten intracellular magnesium levels on my own patients whom I thought needed them.

    Cheers–

    MRE

  21. Dr Eades there are so many companies out there to consider for supplementation. What do you recommend for multivitamin supplementation, is there a particular company do you like personally?

    I like Thorne, but their products are sold only to healthcare professionals, although I have seen them on the internet. Also, Life Extension Foundation makes pretty good supplements, and they can easily be bought online. And Douglas Labs makes good supplements. These aren’t the only three that are decent, however. There are a lot of good supplement companies out there – these are simply the three that I use a lot.

  22. Hi Dr. Mike,

    Haven’t posted in awhile. here’s an interesting one: earlier today, i spoke with a man in his 40s at the bar in my local golf club. He was wearing shorts and a T-shirt. He looked to be in great shape. What did he order to eat: bacon, eggs, sausage and a little tomatoe, all washed down with two pints of beer. I questioned the man about his meal. He said he has been eating a low-carb diet for about fifteen years. He also said that he gets the overwhelming majority of his carbs from alcohol, namely beer and rye. One thing that i found really interesting is his suggestion that beer contains more chromium than almost any other food or beverage. This is one of the main reasons, he said, that he drinks several pints of beer a day, that and its calming effects and of course its taste. I had no idea beer was a great source of chromium. Is this true?

    It is indeed true that beer contains a fair amount of chromium, but not nearly as much as a chromium supplement contains. And beer contains a lot of carbs. Especially two or three pints per day.

  23. Nice post!I was reading my mail at yahoo and i saw thems healt articel it was about high cholesterol and the article was sponsored by Lipitor,what do you give me???
    Jostein

  24. OK, I don’t mean to be obnoxious, but a case report? Seriously? I know they don’t teach nutrition to doctors, but what about basic statistics? Would anyone seriously make a medical decision based on an n of 1? Isn’t there a guy who can bend spoons with his mind (n=1)? Or that dude from back in the day that walked on water (n=1)? My understanding, Dr. Mike, is that you don’t use statins because they produce no statistically significant reduction in mortality in most populations, right? From what I can make out, the medical/nutritional establishment endorses low fat because the powers that be couldn’t figure out how to properly analyze and interpret the available data on how diet relates to health. Have all MDs really gotten so far away from any scientific training that they’re willing to be swayed by a case report? This really really scares me. Good thing I know how to read a methods section…

    On another note, when I dropped 15 pounds on Protein Power, my internist was convinced I’d developed anorexia. Not a chance! And now my poor dad’s on a statin (he’s 60, never had a heart attack, thin, and does triathalons). What’s the old saw about new ideas becoming accepted not by convincing the establishment but by waiting for them to die?

    If you think your average doctor understands statistics and reads actual scientific journal articles, you don’t know much about the average doctor. Doctors by and large don’t read the medical literature, nor do they understand statistics. Most are spoon fed information on drugs and the results of studies by drug reps. Sad but true. And when most doctors discuss patients, they relate interesting cases to one another, which are basically oral case reports. Doctors love to read case reports and understand them much better than they do scientific papers.

  25. Thanks for this post! When my old gp retired I switched to a very large Family practice. When i was asked which Doctor I wanted I said I’d like someone either in his mid 50s or someone who recently started tp practice. Since all the mid 50s Doctors weren’t taking new patients I ended up with a Doctor who was practicing family medicine for 2 months. When I told him I was on a low car diet he seemed startled for a second but didn’t even comment. abiout 10 months later I had my cholesterol test. He saw my numbers had improved markedly. hdl almost doubled and ldl down 60 points. I said to him this is what happens on a low carb diet. He just looked at me and said well you drink red wine. That will do it. I took this two ways. i was a =tiny bit annoyed because of his probable low fat prejudice but mostly I was happy with him. He never lectured me to go off low carb. He let me make my own decisions.

  26. Also thought you’d be interested in this post on HyperLipid…he’s commenting on a paper in which wild mice, given a choice of what to eat, ate very low carb/high fat — and maintained the same weight as carb-fed controls despite eating considerably more calories:

    http://high-fat-nutrition.blogspot.com/2008/09/physiological-insulin-resistance-wild.html

    I had read this paper already. It’s very interesting. It’s pretty clear that rodents experience a metabolic advantage.

  27. As Dr Eades said you are in control of your own health. Who cares if your physician doesn’t agree. I would never let a physician force me into doing something I didn’t want to like taking statins. We need to be truthful with our physicians, especially when doing low carb so they become accustomed to seeing good results from their patients who are low carbing. Everytime they see good results from low carbing it may start peaking their interest and get them questioning their low fat advice.

  28. I’m hopeful that a hundred years from now (maybe even sooner) the medical community then will look back on the majority of doctors during the latter half of the 20th-early 21st century and shake their heads at their ridulous theories about cholesterol and low-fat diets and laugh at statin prescriptions as the snake oil of the period. I had no idea when I first decided to give a low-carb diet a try that it would burgeon into a whole new way of looking at the medical field, but now that I’ve read a bit on it through blogs and books (PPLP, GCBC, etc.) my trust of doctors to know what they are talking about has drastically changed. Now I would do a whole lot more independent research if faced with any diagnosis rather than just assuming my doctor really knows what she is talking about. I hate to be so skeptical, but it’s become increasingly clear that many doctors often don’t know what they think they know. Which wouldn’t be so bad if they had some humility about the limitations of current scientifc knowledge, but I wouldn’t say humility is the most apparent virtue of most of the doctors I have encountered.

    My son-in-law (in his early 30’s) was recently diagnosed with diabetes and I immediately began sending him all the internet information I know of about low-carb nutrition to control blood sugar (which he welcomes). But I also felt obligated to warn him that his doctor might give him different advice, that if listened to, was likely to excerbate his diabetes and lead into all its complications. Fortunately, his doctor is willing to wait a bit and see how he does on low-carb, although she told him it would only slow down the progression of the disease and he would still eventually need medication and would suffer all consequences concomitant with diabetes. At least she knows low-carb is of some benefit, but based on what I have been reading, diabetes, if nutrition is controlled properly, can be kept in check, yes? Are there not diabetics who do succeed in keeping their blood glucose within a normal range through diet alone? Anyway, I’ve warned him to educate himself and not just blindly obey his doctor, or any dietician she recommends.

    Type II diabetes, especially if caught early on can almost always be controlled by diet only. It always stuns me, though, to discover how many people would rather takes the meds so that they can continue eating carbs.

  29. Hey Mike,

    Good idea and good example, although I’m a bit dismayed to see a triglyceride reading of 423 described as “mildly elevated”! I agree their summary of your approach covers it well but I think the paragraph on the ADA lunacy should be highlighted before handing it over! Masterful understatement but powerful nonetheless.

    You might think of a companion post about what to say in social situations – something that seems to trouble people almost as much if not more. One of my suggestions, if the truth is too complicated/embarrassing or might lead to a diet argument, has been simple dishonesty. “I’m a diabetic” is after all only the whitest of lies since health and/or weight problems associated with any degree of insulin resistance is just one small step away. This approach has the advantage of simplicity, guaranteeing a sympathetic and helpful response and also allows for some simple education in a non threatening manner ( “No, starchy foods are just as bad as sugar because sugar is what they become”).

    The other side to this embarrassment to ask for different food (or just saying “no”) is that if the roles were reversed and any guest couldn’t or wouldn’t eat something offered for health, ethical or religious reasons we would all without exception, bend over backwards to accommodate their needs.

    Cheers,

    Malcolm

    Hey Malcolm–

    I’ll ponder the social situation problem. The way I deal with it is to simply say I don’t like whatever the starchy food is. I say, yeah, I’ve always been weird. Even as a kid I didn’t like French fries, or whatever. Usually does the trick without having to get into the diet discussion.

    Cheers–

    MRE

  30. Just a quick question on blood pressure and doctors. I seem to have “white coat hypertension.”

    I have an automatic BP cuff at home, and when I measure at home, I’m always hovering around 118/82. When I go to a doctor, though, it can be very high. At my most recent appoint, it was 150/110. Granted, this was at the wacky women’s center we’ve discussed before and I was keyed up by the time I got there. With good cause, too. They wanted me to go on their new weight loss program based on Kevin Trudeau’s “The WeightLoss Cure.” They said I should do Phase 1, which is to have 15 colon cleanses in 30 days, calories around 500 per day, lots of steam baths, etc. Then you start going in weekly to have human growth hormone sprayed up your nose.

    I knew this was coming (as they had mentioned it at the previous appointment), so you can imagine how keyed up I was. At the end of the appointment, I said I’d think about it. And I did. I thought how idiotic it was.

    BUT, I also noticed that they had indicated on my chart that I had high blood pressure. This is after just one test.

    So, my question is this. How do you overcome “white coat hypertension”? Do I simply have to take my BP at home, keep records, and then show them at each appointment? Would they actually believe my records after **seeing for themselves** that I had high blood pressure?

    Maine must be getting wacky. Now my DENTIST insists on taking your blood pressure at each appointment. The last two times they tried, I politely declined, but then had to firmly decline in no uncertain terms because they said “they like doing it and there was a real need to do so.”

    Sheesh. I’ve already run screaming from the women’s center and will not return. Now I have to find a new dentist, too.

    Sounds like the Women’s Center has gone off the deep end. I wonder how many colon cleanses Paleolithic man performed. And the notion that any physician would be promoting a program developed by Kevin Trudeau is beyond the pale.

    It’s tough to overcome white-coat hypertension. But before you can say that’s what it is for sure, you’ve got to get your own equipment calibrated so you’ll know it’s accurate. If it is, then you don’t have anything to worry about. You could take a few magnesium capsules before you go and suffer the bowel consequences later. Or you could tell the doctor that you were treated for HBP before very successfully with a beta blocker. When you get the prescription for a beta blocker, put it in the cabinet and take one before every doctor’s visit. That will do the trick nicely.

  31. Seems odd that no doctor I’ve ever been to has any kind systematic way to get feedback from patients, the way most restaurants, college teachers, etc have evaluation forms.

    I don’t think lawyers or accountants do either. And I don’t know why. Maybe they’re afraid to find out what they would find out. And I guess they assume that most patients/clients will vote with their feet.

  32. Sorry, but I have one more question, this one on magnesium. I’m taking the Thorne Magnesium Citramate recommended and sold on your site. The “Supplement Facts” table shows that 1 capsule provides 150 mg of Magnesium (as Magnesium Citrate-Malate), which is 37.5% DV.

    I’m taking 1 capsule each morning, and 2 each evening. That means I’m getting 450 mg of Magnesium Citrate-Malate, which works out to be 112.5%.

    So, is this an appropriate dosage or not? In a response above, you said, “If you’re getting 150-200 percent of the RDI, you’ve got an adequate supplement.” It sounds like 3 of these specific capsules are NOT enough.

    If I take 2 morning and 2 evening, though, I get what my husband affectionately refers to as the “Hershey Squirts.” Gross, I know!

    Following up from my last response regarding blood pressure, I want to be sure to get enough magnesium to help lower my blood pressure and do all those other wonderful things magnesium does for my body.

    Thanks again!

    I give my own patients two capsules at bedtime. In patients whom I felt were really magnesium deficient, I told them to keep increasing their dosage until they got diarrhea, then to back off one capsule. In other words, titrate to tolerance. Which it looks like you have done on your own without my sage counsel.

    Cheers

    MRE

  33. As a nurse, one of the things that has always bugged me is this attitude that people have to do what their doc tells them to do. “My doc said he’d give me 3 months to lower my cholesterol and then I’d have to go on statins”, “My doc said I had to…..”

    As an avid support forums user, I have probably posted a dozen times noting that the doc cannot make you take anything, it’s your choice to follow a doc’s suggestions, etc….and what I’ve been hearing lately is a fear, especially from those in areas where docs are busier, is that the doc is going to refuse to care for them if they don’t follow “orders”. With so much in the news about standards of care, paying for results, etc I’m not surprised people are scared. My own doc “fired” me because I refused statins and then insisted on getting a correct test that she wouldn’t order (it was a cancer rule out and I’d consulted with a specialist!). At the time I was looking for a new doc, which I eventually found, so I wasn’t concerned….but I can imagine people being worried! It seems to me that most people simply lie to their docs, which to me is NOT a good idea!

    So….any ideas on what I can use to convince people that even with the pay for results, etc they still should be honest with their docs and remember that they make the decisions, and the docs make recommendations?

    For me, I now have a great doc. First appointment I went in with my history all nicely typed out for him (I’m 54 and have a few issues). I also made it very clear that I would never go on a statin and didn’t believe the cholesterol theory was accurate. I told him up-front that I would research everything and make my own decisions, but I respected him and would listen to his professional advice….may not follow it, but would listen. He’s ok with this! (This is after 4 other docs who essentially showed me the door!) The one thing I chuckled about was when I said I was on a low carb diet, he said “low carb, good, good”. One of my current problems is a diagnosis of a form of rheumatoid arthritis (palindromic RA), but my inflammation markers are almost normal! My RF and anti-CCP are “wildly positive”, but only my sed rate was mildly elevated…both PCP and rheumy agree it’s likely the diet that is keeping CRP, etc down.

    I think that the way you approached your current doc is perfect. If you do this, and the doc shows you the door, you’re probably the better for it. If the doc accepts you as you are and respects your opinion and wants to join forces with you to keep you in the best health possible, then you’ve found a good one.

  34. Dr. Eades said: If you think your average doctor understands statistics and reads actual scientific journal articles, you don’t know much about the average doctor. Doctors by and large don’t read the medical literature, nor do they understand statistics. Most are spoon fed information on drugs and the results of studies by drug reps. Sad but true. And when most doctors discuss patients, they relate interesting cases to one another, which are basically oral case reports. Doctors love to read case reports and understand them much better than they do scientific papers.

    It’s true. I’ve been married to a physician for 38 years, and this is how it works. Thanks, Dr. Eades, for explaining it to those whose live outside the medical community.

    I know it’s true. I used to be a doctor. :-)

  35. Sorry to be an arse and go comp. off topic but can anyone out there give me some brand names of really good/high quality Magnesium supplement manufacturers PLEASUM ?….
    There are seemingly so many and here in Can-Ardour it seems that RDA’s don’t have to be put on vit and mins and so as a percentile one can only guess.
    supachramp at yahoo dot come if anyone can lead me and show me the light..yah, yah and thrice yah (idea’d from Frankie Howard)

    Maybe a reader can come through for you. I am totally unfamiliar with the supplement scene in Canada. And I don’t know which US manufacturers ship to Canada.

  36. Hi Doc,
    Re: magnesium. One study found magnesium citrate the most bio-available (even better than chelated forms). Mg citrate is very cheap and available everywhere so isn’t this the best choice? Study:^ Walker AF, Marakis G, Christie S, Byng M (September 2003). “Mg citrate found more bioavailable than other Mg preparations in a randomised, double-blind study”. Magnes Res 16 (3): 183–91. PMID 14596323.

    There is more to magnesium supplementation than simply which is most bioavailable. Most mineral supplements are absorbed through the same pathways, and when you load up on one, you can decrease the absorption of another. For instance, taking zinc reduces the absorption of copper. The nice thing about chelated minerals is that they are absorbed in a different way and don’t compete for absorption. I’m willing to forgo a little absorption to not have to worry about absorption of other minerals.

  37. Take the magnesium in the morning then its not a problem if it keeps you awake! Surely the alertness/wakefulness (presumably) caused by the magnesium will wear off by bedtime.

  38. “Maybe a reader can come through for you. I am totally unfamiliar with the supplement scene in Canada.”

    This is a valuable dialogue. It would be great if there were a thread where we could post on this subject on an ongoing basis.

    Which company whose products I buy in Canada or order from the US depends on the nature of the product. I tend to be especially particular about mineral supplements. One company whose chelated mineral supplements I trust is Applied Orthomolecular Research (www.aor.ca) based out of Calgary, Alberta. Many health food stores in my area (greater Vancouver) carry this product. I also use NOW for some of their mineral supplements and for their ChromeMate (chromium polynicotinate). Organika (Richmond, BC) is another company I use for their chelated minerals. Some supplements such as R+ lipoic acid as ‘Glucorelle’ I order from Anafit in the US because I can not find a comparable product in Canada that is complexed with biotin.

    I am always looking to learn more about supplements. So I am very appreciative of any knowledge others have to offer. Thanks to Dr Eades as always for his valuable advice and insights.

  39. “The nice thing about chelated minerals is that they are absorbed in a different way and don’t compete for absorption.”

    So would chelated iron be a better choice too??

    Yep. But, if you are on a low-carb diet that is high in meat, you should be getting plenty of hene iron, which is the most absorbable of all.

  40. Do you have any experience with magnesium oil?

    http://www.mfcd.net/depot/magoil.asp

    I have no experience with magnesium oil, but a lot of experience with epsom salts, which is another trans dermal kind of magnesium. If you want to go to sleep, take a good long epsom salts bath. The magnesium oil probably does the same thing.

  41. “Yep. But, if you are on a low-carb diet that is high in meat, you should be getting plenty of hene iron, which is the most absorbable of all.”

    I am, but have RA and apparently anemia is a side effect. My ferritin was very low too. I donate (or try to) every 2 months at work and started showing anemia right around the time I started with RA symptoms. No change in diet, but during a flare I become anemic.

    Red meat is my favorite….I rarely eat chicken.

  42. Mike G wrote : “Re: magnesium. One study found magnesium citrate the most bio-available (even better than chelated forms). Mg citrate is very cheap and available everywhere so isn’t this the best choice?”

    Isn’t Magnesium citrate a chelated form? That’s my understanding from pg. 223 of the new testament (Protein Power Lifeplan) discussing magnesium. I just wanted clarification because I wasn’t so sure after reading Dr. Mike’s response to Mike G’s question. Thanks.

    Also, those looking for other forms might consider liquid trace minerals. The Vitamin Shoppe bottle of Trace Mineral Liquid contains 250 mg of magnesium in 1/2 tsp. It has a funky salt taste, though. The last line in the ingredients states “and other elements found in sea water,” which might explain the taste.

    I don’t have a copy of the PPLP with me, so I don’t know what’s on page 223. But magnesium citrate is a salt of magnesium, not a chelate. Chelates are amino acids attached to a magnesium in a different type of linkage than a salt linkage. Chelates have amino acid kinds of endings, i.e., magnesium aspartate, which is a magnesium and aspartic acid.

  43. Carolyn Dean in her book, The Miracle of Magnesium, mentions that for some people magnesium is so energizing that it keeps them awake at night (p. 228). Others find just the opposite, that it relaxes them and helps them sleep. She attributes this to the fact that there are so many different ways magnesium works on the body. She suggests experimenting with different times and different brands and types.

  44. Dr Mike,

    I have a different take on why one should not be too open with one’s doctor.

    I went through a time recently where I had to purchase individual health insurance (as opposed to group insurance). In order to get this policy, I had to agree to let the insurance company review all my medical records. This includes concerns I had expressed to my doctor that were not necessarily actual problems. But it’s right there on the medical record. Same goes for blood tests and prescription history. There is NO privacy.

    I was amazed that the interviewer from the insurance company knew about what prescriptions I had taken in the past. It’s in a database that the insurers have access to. She asked me why I took malaria medication. I was confused for a minute about how she knew about it and I explained that I was travelling overseas and my doctor recommended it as a preventative but I decided to not take it.

    If anyone sees the possibility in the future of having individual health insurance, I would recommend not telling your doctor anything unless you’re nearing death. Sad but true.

    You’re right. This openness can pose problems later on. When patients tell something like what you told your doctor and ask me not to put it in their chart, I always oblige. Other doctors should, too. But if you don’t ask, in it often goes.

  45. Long time reader, first time comment.
    Dr. Eades, thank you for your amazing blog. Thank you for the time you dedicate to it.

    ” it’s been my experience that most doctors are willing to work with their patients.”

    I agree with this statement. But I do want to share the following;
    Recently had a flu/virus that knocked me on my behind for 2 days. Then strangely came back for another 2-3 days about a week later. I wanted to make sure all was ok so went to see my Dr.
    Bloodwork was perfect (in his words, like that of a teenager)
    He knows of “your way of eating” as he calls it and all my stats are proof of my lifestyle.
    Proud to say I’m 41 with a very different physique then my friends and college classmates.
    However after the visit, my Dr. asked me to come in soon, to discuss my family history and to see what risks maybe be lying ahead. Making sure to point out that I’m over 40 now.
    I tried to get into a discussion about gene expression, but stopped myself. Told him my parents are both in their mid 70’s and leading wonderful active lives (mom is on lipitor).
    Leaving there I felt strange. Just like my pediatrician for my kids, there seems to be this “attitude/opinion” that something is wrong, they just need to find it.
    I’m now looking for a new Dr. with an upbeat positive out look,. Am I being naive?

    Marc

    No, you’re not being naive. Sadly, that’s the way it is in all too many cases. Good luck in finding a doc that will work with you.

  46. What’s really sad is that someone like me, mid 50s with no so-called risk factors for heart disease other than high cholesterol, can really get socked when it comes to purchasing health insurance on my own. Either higher rates or downright refusal. So I face the real possibility that I can’t afford to retire early because of a high cholesterol reading–I need my employer’s group insurance.

    It is sad. Especially since cholesterol is a ‘putative’ risk factor, in other words, an imagined one. We’re in your shoes, I might get a script somewhere – a walk-in clinic, maybe – for a statin, and God knows, they’re easy to get. Take it for a bit just before my next regular blood test, and say, Voila! cholesterol is down. I’ve been following a low-fat diet. That should do the trick. It’s a sorry state of affairs when one has to turn to chicanery just to pretend that a problem that really isn’t a problem doesn’t exist.

  47. Hi Doc,
    Do you prefer the VAP test or the NMR Lipoprofile or other(s)? Wonder if taking some annatto tocotrienols would “push” a persons numbers into more acceptable health insurer ranges? They look pretty good on paper but then so did policosanol and flush-free niacin.

    Thanks,
    Robert

    I’ve always used a lab profile that I set up with whatever clinical lab I use most. As long as I get the parameters I need, I’m happy. I’ve had no experience with the annato tocotrienols as lipid-lowering agents, so I can’t say. I’ve always pretty much been able to control lipids with the low-carb diet, so I haven’t worried about using other agents. When I can’t get them down and the patients are worried, I get a direct LDL test (instead of the calculated one that all the labs typically use) and a particle size determination, which usually does the trick in terms of assuaging patient worry.

  48. “If anyone sees the possibility in the future of having individual health insurance, I would recommend not telling your doctor anything unless you’re nearing death. Sad but true.”

    There is another reason why it is not a good idea to tell your doctor some things no matter what insurance plan you are on. I have been to seminars supposedly intended to ‘help patients work with their doctor’. One of the things that is part of these program in addition to the “take your meds” mantra is for patients to make a detailed list of everything they take including all vitamin and mineral supplements and anything else intended for health and give a copy to their doctor. Now, I doubt this information is of any interest to your doctor. But the pharmaceutical industry would probably love to get their hands on it. And your doctor would only be too glad give it to them.

    On a similar vein, I can see a day not far away where health care plans will charge premiums or even refuse to insure those who refuse to be treated according to official medical protocols meaning statins if one has high cholesterol, BG medications no matter what diet you follow etc. At the present time we can choose to take responsibility for our health and make our own decisions as to treatment. But for how long?

  49. I agree that ultimately it’s all in our own hands, but sometimes it can feel like you’re not on the same team as your doctor which can be a bad feeling.

    I think part of the problem is just how much some of this in ingrained to these guys and how hard they’ll fight over it. I go see a nutritionist a few times a year. He’s a great guy, very intelligent, knowledgeable, even well versed in supplements and many topics. And treats people with very weird intestinal diseases like Crohns and Celiacs (which is how I got to him originally as my GI thought I had celiac disease). I’ve seen the head of Hospitals bring their kids to see him, and I’ve seen some real turnarounds in his patients. He was part of the Harvard Panel of Health on the Mediterranean Diet. and Chairs the NYS regents for Nutrition. So all in all a smart guy, good hearted, and helps people…

    But he loathes my diet. I mean LOATHES my diet. The fact that I cook with Extra Virgin coconut oil and butter, all the meat, the eggs, etc.. it really makes him angry. Makes him argue with me over it everytime I see him. It shocks me just how much he almost takes it personally. He pours over my cholesterol numbers everytime they test me, hoping that this will be the time that my cholesterol is out of whack and that he’ll be proven right, that’s there no way all that meat and butter and saturated fat could give me such optimal numbers and it’s all a fluke. But no it’s always perfect, and it cheeses him off because it goes against his whole grain, veggie heavy, lots of chicken and fish, little red meat eating philosophy.

    It’s really kinda scary (and sad) watching someone who is (or is suppose to be) very very smart and someone you look up to just blow up over what you put in your mouth. Good guy and someone I respect, but like you said, A lot of these guys just cling to what they’ve been taught and refused to look at new evidence even when it’s staring them in the face. And it can get pretty tiring arguing with him. I still get good advice from him on other things, but I’ve learned just to skirt around the diet issue and since he finds it such a touchy subject.

    Get a copy of this book and read it. You will learn why your nutritionist reacts the way he does. He fell on the low-fat side of the decision pyramid and is using everything at his command to justify his decision. What’s worse, for a lot of these people it’s not just a matter of coming to the wrong conclusion via faulty reasoning, the idea of low-fat, whole grains, and the rest of the drill has become a religion.

  50. I just wanted to post some info regarding Brian’s post about high cholesterol and getting private health insurance. I went through this exact issue last year, and posted it on this blog.

    I had been on low carb for well over a year at the time. The insurance company took a blood sample and found total cholesterol of 221, HDL of 112, and LDL of 98.

    They rejected me for “high” cholesterol of 221, regardless of such optimal HDL and LDL numbers. I thought it was a futile effort, but I wrote them a letter explaining that high HDL is good and low LDL is good, and total cholesterol doesn’t matter. I sent them a link to the AHA’s website showing these were both optimal numbers.

    Lo and behold they wrote back and said I was right! I got the policy at a low rate. Maybe they’re finally learning what the numbers mean.

    Congratulations! I guess there are still a few people out there who aren’t brain dead on this issue.

  51. LDL = low density lipoprotien (LDL is NOT cholesterol. LDL is a lipoprotein PARTICLE)
    LDL-C = the amount of cholesterol inside LDL particles (usually calculated, can be direct)
    LDL-P = the number (or concentration) of LDL particles

    Cholesterol is an oil and blood is water-based. Oil and water do not mix, so for cholesterol to be transported in the blood stream it must be carried inside lipoprotein particles. It is useful to think of the cholesterol as “passengers” and the lipoprotein particles as “vehicles.”

    If I have an LDL-C of 100 mg/dL (100 passengers), how many vehicles (LDL particles) do I have? I could have 10 vehicles with 10 people each, 20 vehicles with 5 people each, 50 vehicles with 2 people each, 100 vehicles with 1 person each, etc. I have NO IDEA what my LDL-P is just because I know my LDL-C.

    This simple analogy is biologically accurate because atherosclerosis works just like a traffic jam — it is a gradient driven process. Just as it is the number of cars on the road that causes a traffic jam, it is the number of LDL particles in circulation that drives the disease process — NOT the amount of cholesterol the particles contain inside them.

    Dr. Eades says he is using a “direct LDL test” rather than a calculation, but all this test does is directly measure cholesterol “passengers.” If you want to predict the risk of a traffic jam, wouldn’t you rather know the number of VEHICLES instead of just a more accurate measurement of the number of passengers?

    Furthermore, LDL particle size is greatly misunderstood by many people. Lots of folks think that small LDL particles are terribly bad, and that large “fluffy” particles are much safer. As a group, patients with diabetes tend to have a HIGH NUMBER of SMALL particles, and they have a lot of risk, but guess what? As a group, people with Familial Hypercholesterolemia tend to have a HIGH NUMBER of LARGE particles, and they, too, have a lot of risk. I don’t care if your cholesterol is being transported in Mazda Miatas or Chevy Suburbans — if you have too many vehicles on the road you’re at risk of a traffic jam (cardiovascular disease). It’s particle NUMBER that is driving this process — particle size just helps influence therapeutic decision-making.

    The American Diabetes Association and the American College of Cardiology issued new Lipoprotein Management recommendations in April (see Diabetes Care and the Journal of the American College of Cardiology April editions). In a nutshell, the ADA & ACC are now recommending that high risk patients be treated to both cholesterol AND particle number goals of therapy, and the two means of measuring particle number that the ADA/ACC recognize are a test called apoB and LDL-P by NMR (the NMR LipoProfile test).

    Note: Atherotech (VAP) is now reported a calculated apoB. The ADA/ACC recommendation is for a MEASURED apoB utlizing standardized assays. VAP’s apoB calculation has NOT been recognized and some laboratories will not even report this value because it has not been scientifically vetted. In other words, the two choices are a standardized, MEASURED apoB, or the NMR LipoProfile test.

    Best Regards,

    Marc
    marcwgarber@comcast.net

    Thanks for the didactic. These issues have all been covered in various posts throughout this blog. And they matter, I suppose, to people who have bought into the lipid hypothesis of heart disease. Those who are convinced that cholesterol in whatever form is the driving force behind the development of cardiovascular disease will continue to develop ad hoc hypotheses to confirm their beliefs. I happen to fall into a group who believe that cholesterol has very little, if anything, to do with cardiovascular disease, so I tend to not follow all the latest developments in new lab tests that continue to slice cholesterol more and more thinly in an effort to give some credence to the lipid hypothesis.

  52. Dr. Mike:

    I agree with you that cholesterol is not “the” answer it has been presented to be, and I am not advancing the “cholesterol hypothesis.” As a point of clarification, tests such as apoB and the NMR LipoProfile test are NOT cholesterol tests, and therefore they do not “slice cholesterol more and more thinly.” Rather, these tests are direct lipoprotein assays (not direct measurements of the cholesterol inside the lipoproteins, but a direct measurement of the lipoprotein particle numbers themselves).

    I agree with you that cholesterol is not a causal agent in atherosclerosis. There are correlations between cholesterol levels and atherosclerosis, but correlation does not equal causation, and two people with identical cholesterol levels can have VERY different numbers of lipoprotein particles transporting that cholesterol, and VERY different levels of cardiovascular risk.

    Furthermore, the correlations between lipids and cardiovascular disease become progressively weaker as lipid levels drop, so using lipid measurements in an attempt to predict and manage cardiovascular risk is especially dicey for people with low levels of LDL-C and non-HDL-C (the two guideline goals of therapy). The inverse is generally true for HDL-C (although HDL is an extremely complex topic).

    The fact remains, however, that when we dissect an atherosclerotic plaque, it’s full of cholesterol. The ONLY way for cholesterol to penetrate the endothelial lining of the arterial wall is for a lipoprotein particle to carry it inside, and when the number of lipoproteins (especially LDL particles) is high, the risk of this penetration occuring is higher. A growing number of studies around the world (including some truly enormous ones -i.e. AMORIS followed 175,000 patients for 5 years) have shown that the number of lipoprotein particles is a stronger predictor of cardiovascular endpoints than cholesterol.

    So has cholesterol been “the” answer? No. Can we do better with lipoproteins? Yes (which is why guidelines are starting to slowly move towards lipoprotein particle numbers).

    Will lipoprotein particle numbers be “the” answer. No. Atherosclerosis is a multi-factorial disease, with a host of contributory factors. But lipoprotein particle numbers DO work better than cholesterol, and I hope we can agree that having tests which allow us to assess and manage cardiovascular risk better than we can with cholesterol tests is a good thing.

    Best Regards,

    Marc

    I didn’t mean to literally slice cholesterol thinner and thinner. I was using ‘cholesterol’ as a metaphor for the lipid hypothesis. As far as I’m concerned, lipoproteins are a component of the overall category of lipids. I know they are proteins, but their job is to transport lipids. Some factor being a putative risk factor because it correlates with disease is not proof of cause. Many people with low levels of LDL and low particle numbers develop coronary artery disease. You tell me how the cholesterol gets there in their lesions.

    All I’m saying is that the idea that lipids and their carriers are the causitive factors for heart disease is simply an hypothesis at this point. When one part of the hypothesis fails – as has the total cholesterol as risk factor part has – then people begin to develop ad hoc hypotheses to try to explain the situation and have it still involve lipids in some way. I’m not a believer in the lipid hypothesis, so it can be twisted and diced and sliced all you want, and I still won’t believe it. Not until I see strong evidence that I’m wrong. And I don’t consider observational studies as strong evidence.

    Cheers–

    MRE

  53. Noah – that’s exactly what I have to contend with in regards to my fellow student naturopaths:
    “whole grain, veggie heavy, lots of chicken and fish, little red meat eating philosophy” and don’t forget the fruit and juice detox. The one I hate the most is everything in moderation! The cholesterol one is also annoying – none of them have ever read anything disputing the lipid hypothesis.

  54. I have finally decided to lose my current cardiologist and find another one with whom I can talk and advocate for my health. My current cardiologist has told me, “You’re going to fail”, when I told him I wanted to try losing weight and exercise to lower my blood pressure(which I have done, I might add). He recently prescribed Vytorin for my high cholesterol and when I asked him about the recent research regarding the drug(in the New England Journal of Medicine), regarding its efficacy and correlations with an increase in cancer, he told me that that was all coming from the New York Times and it had all been de-bunked. He even put down another cardiologist who was supporting further research of this medicine. The final stake in his heart was his departing comment for me to stop reading.

    He is probably in his early 30’s. The medical schools are still turning them out…

    I would appreciate any comments.

    What can I say? Your doc sounds all too typical. It’s a real shame.

  55. Funny how if I describe my diet as avoiding sugar and eating high quality protein and vegetables no one bats an eye, but the second I call it “low-carb” people start whipping out all of the vampire myths and LF propaganda statements (like how healthy the Chinese are) to try to argue with my choice of eating or stump me! This goes for medical as well as social situations. “Low-carb” simply conjures up the fad diet response in people, but “cutting sugar” seems to sound reasonable. I also don’t consider it a diet (like a previous poster mentioned), and if questioned I simply say I have to eat this way because of migraines. Invariably, I get an immediate slew of questions about how I eat because the questioner knows someone with migraines that they’d like to tell. Strange how we humans react to simple changes in presentation.

    Dr Mike – you say that Mg Citrate is a salt; does it absorb better than Mg Oxide? I’ve had good luck with it not causing stomach upset, but may switch if the chelates are substantially better.

    Mg Citrate definitely absorbs better than Mg Oxide. The chelates don’t necessarily absorb better than Mg Citrate, they just don’t compete with other elements for absorption.

  56. As an expert in cardiovascular risk assessment, prevention and the management of lipids, i agree only partially with Dr Garber’s metaphor about the # of vehicles rather than the passenger count as being important. We wish cardiovascular disease and the development of plaque was that simple. Dr. Garber is entirely correct that the particle # or Apo B reflect risk in a patient more than cholesterol content. However, it is a simplistic notion to believe that it is only particle number or Apo B that determines the damage to the artery wall. If one had 10 bombers filled with mega-ton weapons, it would do more damage than 20 light planes with unarmed commercial passengers. The point is this—it is the combination of # of lipid particles (NMR LDL-P) or Apo B (VAP) and the actual content of the particles. As an admittedly biased advocate of Atherotech, maker of the VAP test, we tell you the # of particles (Apo B–an international gold standard) and the composition of the particles. So, if one had a low # of particles by NMR but didn’t know that many of those particles are highly atherogenic particles like Lp(a), one would tell a patient their risk is low. The VAP test tells me everything i need to know…whereas with other tests, one would have to order other tests to get what one needs to know.

    So, it is the number of vehicles, the type of vehicle and the type of passenger that is critical. Particles don’t just take up room as in a traffic jam–they get into the arterial wall and based upon their characteristics, do damage.

    And as far as accuracy of a VAP-derived Apo B, it has been validated as accurate and may even be more accurate than immunoturbidometry for technical reasons. The NMR LDL-P is also a calculation (uses a formula). Finally, both LabCorp and Quest and all other labs report Apo B

    The number of vehicles, the type of vehicles and the type of passengers are simply putative risk factors – no one that I know of has shown that any of these are real (as opposed to putative) risk factors, so why spend a lot of time and money making the tests ever more accurate. Why not simply get a calcium score, which is a much more direct measure of plaque and quit fooling with putative risk factors? The literature is full of case reports of people who have low lipid levels and a lot of plaque and people with scary lipid levels with no plaque. So why not just measure the plaque and be done with it. An EBT scan for a calcium score can be had for about $400, which is about the same or even less than all the fancy lipid tests.

  57. I am a type 1 diabetic. I went low carb in March after having an A1C of 8.9, numerous episodes of crashing and rebounding with the blood sugar, weight gain, and generally feeling lousey. Before I was diagnoised diabetic, I did low carb for many years. Once diagnoised, the diabetic educator nearly had a heart attack when I ventured that low carb might be a good way of eating for this disease. I could swear I saw her cross herself..ha, ha. Anyway, luckily my local doctor is pro low carb and has supported my new regime which has lowered my weight by 22 lbs and my A1c to 6.0. Unfortunately, my latest cholestrol break down shows my total up from 200 to 249, HDL seady at 87, and LDL from 90 to 151. She wants to start me on a statin. I don’t want to go on one. The pressure is on since not only do I have diabetes, but my father died at 59 from a massive heart attack and all three of my brothers have had by-passes. My question is, what other tactics might I try to lower the LDL before considering a statin. Oh, I neglected to say I have been on a statin before and experienced the muscle aches…which have vanished since stopping the drug. I enjoy your blog.

    Why do you have to resort to other tactics to avoid the statin? The studies show that women of any age irrespective of their heart disease status gain no decrease in all-cause mortality by going on statins. So why go on them at all. Especially since you experience negative side effects. Ask your doctor to show you a study that is a double-blind, placebo-controlled study showing you will benefit from statin therapy in terms of a decrease in all-cause mortality. There is no such study.

  58. Hi Dr. Eades

    My mom needs to lose weight and get healthy and I recommend a low carb diet for her all the time. She now found out she has Diverticulosis. What would you say are the optimal foods she should eat with this condition? She’s just not sure what to eat in her condition.

    Most docs would recommend a high-fiber diet, but all my patients with diverticulosis have done fine on low-carb diets. Increasing the fat intake usually makes the colon work better anyway.

  59. I’m trying to learn about optimal nutrition for strength training and I keep coming across things like the text below that suggest low carb diets inhibit testosterone levels. Is this nonsense? I’ve been following a low carb diet and have gotten a little weaker, but I think that is mainly due to lowered overall calories while trying to get down to 4% BF, which I am now at.

    “Research suggests that eating a high-protein, low-carbohydrate diet can cramp your testosterone levels. High amounts of dietary protein in your blood can eventually lower the amount of testosterone produced in your testes, says Incledon, who observed this relationship in a Penn State study of 12 healthy, athletic men.”

    Whenever you see the words “research suggests” you’d better run. No, low-carb diets don’t “cramp” testosterone levels. In fact, it is just the opposite. The people who wrote this are probably the same kind of people who would finger low-carb diets as being too high in cholesterol. Well, cholesterol is the molecule from which testosterone is made. Cut cholesterol (think very low-fat, vegan diets) and you reduce testosterone. Also, it’s not just the overall amount of testosterone that’s important, it is the amount of free testosterone (that which isn’t bound to a binding protein making it unavailable for use), and it is well established that insulin resistance decreases free testosterone. How. Elevated levels of insulin drive the liver to make more SHBG (sex hormone-binding globulin), which binds more testosterone. More bound means less free. So a diet that reduces insulin levels (the low-carb diet is best at that) also reduces SHBG, which results in more free testosterone.

  60. Dr. Mike

    Another great post! I can’t thank you enough for all that you do, really! this blog is such a a God send. I read PP 10 years ago. Then PPLP, but it wasn’t until a year and half ago when my fasting blood glucose levels came at 125 that I took action. You see, I aways been a husky kind of guy, lift weights, jog a little, not your typical couch potato. I was really shocked when that FBG test stared at me, I decided to take action. Following the PPLP now my FBG is 102!
    I just got my blood test results and they are as follows:

    Fasting glucose——103, last time was 110
    HbA1c——————Not measured, last time was 5.6
    Total Chol————-303, up fom 260
    Direct LDL————-209
    Calculated LDL ——233
    HDL———————-56, up from 47
    Triglycerides———70, down from 88

    I am not concerned about the Chol. levels, but I am curious as to why my tot. Chol has increased.

    Maybe I am one of those individuals with less LDL-C receptors and thus have a higher LDL-C.

    It’s difficult to say why you total cholesterol increased. It could even be a lab error. My bet, based on observing the cholesterol levels of thousands of patients on low-carb diets, is that it will drop with time. It’ll probably be back to normal by your next lab test.

  61. Hello,
    I love your site and have made a few comments here and there. I read it a lot because I am trying to educate a lot of my friends and family about the dangers of too many carbs, and I need a lot of “ammunition” to be able to support my arguments. So far, it’s an uphill battle.

    Nonetheless, I need to tell you and all of your readers how much better I feel after reducing carbohydrate intake and eating lots meat and that oh-so-controversial nutrient, FAT! I am not overweight, not have I ever been (47 years old, 123 pounds, a lot of muscle). But I have blood sugar “issues”. In between meals (particularly high carb ones) and at the end of the day (pre-dinner), I have blood sugar “crashes” that make me irritable, anxious, etc…and can even result in binge-eating. I doubt seriously that I would qualify as hypoglycemic medically speaking, but I am sensitive to changes in blood sugar. The absolutely worst is eating cereal for breakfast…I have the shakes within a few hours and am ravenous. But NO MORE! I feel absolutely great–all day long.

    I am lucky enough to live in France–the French, with their low incidence of CVD eat a lot of charcuterie (sausages, meats, foie gras, etc…)…Their only sin is eating a lot of baguettes, which as Mary Enig suggests, contributes to a high rate of degenerative diseases. The sad part is that the French have bought into the low-fat mantra generated by the US medical establishment and are now abandoning their healthy ways. Hope that changes soon.

    Keep up the good work!

    And, sadly but predictably, since the French have abandoned their ways in favor of the US low-fat approach, obesity has been on the rise in France.