The rules of reversal

For the last few years, most practicing physicians have followed a rough blueprint for cholesterol management provided by the Adult Treatment Panel-III “consensus” guidelines, or ATP-III, a lengthy document last released in 2001, updated in 2004.

For instance, ATP-III suggests reducing LDL cholesterol to 100 mg/dl or less for those deemed to be at high risk for future heart disease, arbitrarily defined as a risk of 20% over a 10-year period. It also suggests that a desirable triglyceride level is no more than 150 mg/dl. The ATP-III guidelines have been the topic of discussion in thousands of medical meetings, editorials, and reports. They have served as the basis for many dinners at nice restaurants, weeks in Vegas or Honolulu, many, many lunches catered by pharmaceutical representatives. For most internists, family doctors, cardiologists, and lipid clinics, ATP-III is the Bible for cholesterol management.

AT-III has also become the de facto standard that could conceivably held up as the prevailing "standard of care" in a court of law in cases of presumed negligence to treat cholesterol values. “Doctor, would you agree that the consensus guidelines issued by the National Institutes of Health and endorsed by the American Heart Association state that LDL cholesterol should be reduced to 100? You do? Then why was Mr. Jones’ LDL not addressed according to these guidelines?”

Who was on the ATP-III panel and on what scientific evidence were the guidelines based? Several problems:

1) Of the 9 physician members of the panel, 8 had ties to industry, some of them quite intimate.

2) The studies upon which the guidelines were based and figure prominently, such as the Heart Protection Study, PROVE IT, and 4S, were all funded by the pharmaceutical industry. Of course, it would be unreasonable to expect anyone other than the pharmaceutical industry to fund drug studies. But prominently neglected or understated in the guidelines are all the other insights and treatments for coronary atherosclerotic risk available that were NOT funded by industry.

Of course, there’s money to be made in reducing LDL cholesterol. Lots of it--$23 billion last year alone, in fact. Just keeping that fact in mind makes the ATP-III guidelines make far better sense.

ATP-III is really not a blueprint for heart disease prevention. It is a blueprint--by industry, for industry--on how and when to treat LDL cholesterol.

But what if ATP-III had been a map for navigating coronary plaque reversal instead? What if it were not obsessed with just reducing LDL cholesterol, but was focused on providing the corner internist, family doctor, or cardiologist a roadmap for navigating the highways and byways of reversal?

That would be interesting. Mainstream reversal. Imagine that.

Among the difficulties is that the path to reversal is not lined with deep pockets. Treat LDL and who gains? That's easy. Reverse heart disease and who gains? Beyond LDL reduction, very few (beyond you and me, of course).

That’s why the call for a new Age of Self-Empowerment in healthcare is necessary now more than ever. In my view, in the foreseeable future, we will not have an ATP-III-like blueprint for heart disease control or reversal, nor will we witness a boom of nationwide appreciation that coronary atherosclerosis is a reversible process.

It’s time to take the control back and put it in our own hands. Don't expect the American Heart Association to do it. Don't expect the pharmaceutical industry to do it. If there's anyone who's going to do it, it's YOU.

Comments (12) -

  • gc

    11/3/2007 11:26:00 PM |

    Man oh man I wish I lived closer and you were my doc!!!!

    I try nicely to get docs to think that low carb and being off insulin is ok, that not being on a statin may be ok even though my ldl goes up but my lipoprotein a is low.....I don't know what to do about this new doc I am seeing as don't want to turn her off but want to turn her onto TYP.

  • G

    11/10/2007 4:05:00 PM |

    Unfortunately we all do have to be our own advocates... thanks for giving us the means and tools to do so for our family and friends (and patients)!

    The article you mentioned about MMPs (tissue metalloproteinases), CRP and D3 deficiency was quite frankly phenomenal.
    Q J Med: 2002;95:787-796.
    Cirgulating MMP9, vit D and variation in the TIMP-1 response with VDR genotype: mechanisms for inflammatory damage in chronic disorders?

    Again, I think you are correct, the implications revealed here and elsewhere are blatant omissions from discussion in the ATP guidelines (the 'bible' when I was in pharmacy school).  

    One-yr Post-supplementation with intra-muscular Vitamin D(from pre-8 to post-14 ng/ml) produced statistically reduced MMP9, as well as decreased CRP (another marker for chronic inflammation). These are all increased in acute MIs and unstable angina and in active arterial plaques. (unfortunately they did not raise the 25(OH)D levels sufficiently 50-70 ng/ml otherwise perhaps they might've seen substantial primary CAD prevention at the 5yr followup -- *bummer!*).

    Thank you for the info on Doxy. I remember reading > 10yrs ago how doxy helped in arithritis.  It makes sense now!!!

    With the role of D3 emerging that it's vital and affects all organ systems, do you think your TYP program is also treating and preventing ALL chronic conditions? Are you aware that you may be creating an immortal human subpopulation *ha haaa haa*. But alas, we are human...

    Do you think that perhaps since D3 is a steroid structure, D3 may be depleted in cortisol-driven activities (ie, chronic stress -- physical, mental, genetic)?  Perhaps a cascade of events occurs, triggered by (let's conjecture) a marginal reduction in sunlight (since we obtain naturally about 99% of D3 activation from sunlight) which leads to broad widespread decline in D3-dependent cellular activities. Unfortunately D3-dependent cell functions appear to me (from your blog and the literature) to be literally ALL functions...

    Immune cells--flu, infections, MS, lupus, asthma/copd, T1DM, RA
    Thyroid & parathyroid--TSH and PTH irregularities (then eventually Graves/Hashimotos), osteoporosis
    Bones/GI system--without D, GI incapable of absorbing calcium (absorb more Hg, Pb? ...autism spectrum?)
    Colon--cancer, mortality
    Cerebral arteries--migraines
    Brain--depression, less euphoria
    Nerve endings--peripheral neuropathy
    Kidney/renin--hypertention, pre-eclampsia (during pregnancy when E2 and P hormone production is ramped up)
    Pancreas/beta-islet--Metabolic Syndrome, glucose intolerance, Type 2 diabetes
    Liver--PPAR changes, high TG/low HDLs (less HDL to scavenge out LDL)
    Adipose--insulin resistance, weight gain
    Coronary arterial plaque--CAD, MI
    Nephrotic atherosclerosis--CKD, dialysis
    Cerebral vasculature--stroke
    Ovary, breast--infertility, PMS, cancer
    Hair follicles--male pattern baldness(?)
    Overused joints--osteoarithritis

    In the literature, D supplementation (sometimes with calcium, but I don't think it's necessarily relevant) improves all these chronic conditions. Is it all more interconnected then we suspect? I see all these conditions in the primary care setting, and I find that recently I'm giving the same 'dog-and-pony show' to all pts (migraines, perimenopause, T2DM, HTN, CKD, etc). 'fish oils, nuts/seeds, oat bran, relax, exercise, get some sunlight midday, low GI foods, Ezekiel bread, and on and on'.
    I wonder now...wouldn't it be just easier to put 'the D' in the water?  There are so many challenges in overcoming the havoc caused by MMP and other inflammatory constituents(ie,'target organ disease').  The TYP plan truly seems to offer vitality... and immortality! Another medical genius said ( Hippocrates) "your food is your medicine, and your medicine your food."  He was so right, after all these centuries. Keep up the strong work and don't stop the rhetoric!

  • G

    11/10/2007 4:13:00 PM |

    BTW, is there any tissue that is devoid of VDRs (vitamin D receptors)? toenails?  THANKS!!

  • G

    11/10/2007 5:41:00 PM |

    Additionally...i forgot several disease embryonic tissue in utero are affected too. does calcium modulation make such a difference at age 'zero'? there appears to be evidence. perhaps even for heart disease?

    Skin--psoriasis (treated w/Dovonex a D analogue)
    Maternal D nadirs--schizophrenia (in summer babies; see Oprah Nov's issue! *HA HAAA HAA*), Type 1 DM
    Brain--Alzheimers (D improved cognition, cheaper than Aricept)
    Muscles--chronic pain syndromes, fibromyalgia

    do you have a cure for addiction to reading about disease reversal?

  • Dr. Davis

    11/10/2007 11:07:00 PM |


    I've had the very same thoughts.

    Every day, I witness some new aspect of vitamin D replacement that I had not appreciated before. All of this needs to be systematically recorded and reported. Our first report on the effects of vitamin D, along with the Track Your Plaque program in all other aspects, will be reported next spring in the scientific literature.

    I'm seeing so many fabulous effects. We will follow our initial report with more on these issues, though little by little. That's how it works, though I tell you about these things before the official report hits the press.

  • Dr. Davis

    11/10/2007 11:08:00 PM |

    Curious thing, G: You will see accelerated growth of toenails and fingernails with vitamin D supplementation!

  • Dr. Davis

    11/10/2007 11:10:00 PM |


    Well, the enormous abyss of ignorance among physicians on these issues is a sobering thought.

  • G

    11/13/2007 3:24:00 AM |

    That's funny. You are so right again! I've always noticed my nails always grower faster in the summer!

    Did you get a chance to see Planet Earth on the Discovery channel?  AMAZING! Do you now what they focused on?!!!

    The sun and the earth...'Sunlight is the engine of life... whether on land or sea, sunlight shapes life... it triggers birth and death...'  

    I guess it's NO SURPRISE that VDRs are hinged next to other steroid receptors estrogen, progesterone,  and thyroid receptors (and possibly glucocortocoid and retinoic acid).
    (is that why TAN MUSCULAR athletes probably procreate more than cardiologists and pharmacists? *ha haaa haaa*)

    You notice and document here the tremendous disease reversal with testosterone, E2, vitamin D and DHEA...
    It A-L-L makes sense!!!!!

  • G

    11/13/2007 3:45:00 AM |

    can u translate?  I know this must mean something...

    Heterodimers of Retinoic Acid Receptors and Thyroid Hormone Receptors Display Unique Combinatorial Regulatory Properties

    There is an interesting discussion about PPAR and other nuclear steroid receptors. I think that Actos and Fibrates improve HDLs and TG and hence plaque reversal with their PPAR activities (gamma- and alpha- respectively).  Do you think that are other nuclear steroid receptors that can be explored for plaque reveral and ultimately reduction in chronic inflammation?

    my health food store nutritionist recommends cod liver because it includes Vitamin A which is a cofactor for D (he said) compared with D3 alone. I'm hesitant because I've read that A can block (perhaps through competition) D activity. I had a *bad* reaction with Chicken liver pate once... ate a whole chunk then drank ONE sip of beer and had the WORSE etoh-dehydrogenase reaction!  I worry about vitamin A toxicity... it also had worse mortality for lung CA patients.

  • Dr. Davis

    11/13/2007 4:04:00 AM |

    I wasn't aware of the proximity of those genes. Thanks, G.

  • Dr. Davis

    11/13/2007 4:07:00 AM |

    Hi, G-

    I'm afraid you've exceeded my scope of experience with that one.

    However, I know of no such vit A/vit D interaction. I prefer single supplement preparations, in general, because it allows independent adjustment of doses.

  • G

    11/13/2007 7:28:00 PM |

    I think you'll like this.  Bruce Ames discusses keeping mitochrondria happy (and preventing DNA damage and antagonistic pleiotropy). Vitamin D deficiency is mentioned as well.

    Low micronutrient intake may accelerate the degenerative diseases of aging through allocation of scarce micronutrients by triage

    Bruce N. Ames *
    Nutrition and Metabolism Center, Children's Hospital of Oakland Research Institute, 5700 Martin Luther King Jr. Way, Oakland, CA 94609

    Contributed by Bruce N. Ames, October 6, 2006 (sent for review September 20, 2006)

    Inadequate dietary intakes of vitamins and minerals are widespread, most likely due to excessive consumption of energy-rich, micronutrient-poor, refined food. Inadequate intakes may result in chronic metabolic disruption, including mitochondrial decay. Deficiencies in many micronutrients cause DNA damage, such as chromosome breaks, in cultured human cells or in vivo. Some of these deficiencies also cause mitochondrial decay with oxidant leakage and cellular aging and are associated with late onset diseases such as cancer. I propose DNA damage and late onset disease are consequences of a triage allocation response to micronutrient scarcity. Episodic shortages of micronutrients were common during evolution. Natural selection favors short-term survival at the expense of long-term health. I hypothesize that short-term survival was achieved by allocating scarce micronutrients by triage, in part through an adjustment of the binding affinity of proteins for required micronutrients. If this hypothesis is correct, micronutrient deficiencies that trigger the triage response would accelerate cancer, aging, and neural decay but would leave critical metabolic functions, such as ATP production, intact. Evidence that micronutrient malnutrition increases late onset diseases, such as cancer, is discussed. A multivitamin-mineral supplement is one low-cost way to ensure intake of the Recommended Dietary Allowance of micronutrients throughout life.